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Molina V, Hadid M, Miró J, Dahdah N. Left Pulmonary Artery Stenting for Left Pulmonary Artery Stenosis Following Patent Ductus Arteriosus Device Closure: Case Series and Review of the Literature. Case Rep Cardiol 2024; 2024:6690515. [PMID: 38957211 PMCID: PMC11217573 DOI: 10.1155/2024/6690515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 02/23/2024] [Accepted: 05/17/2024] [Indexed: 07/04/2024] Open
Abstract
Percutaneous device occlusion is currently the standard of care for most cases of patent ductus arteriosus (PDA). Albeit infrequent, device-related left pulmonary artery (LPA) stenosis is a known complication of this procedure, occasionally requiring stent placement to relieve the obstruction. We present a series of four patients who required left pulmonary stenting after ductus arteriosus device closure. A review of the current evidence is presented.
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Affiliation(s)
- Víctor Molina
- Division of Pediatric CardiologyCentre Hospitalier Universitaire Sainte-JustineUniversity of Montreal, Montreal, Canada
- Cardiology DepartmentDr. Luis Calvo Mackenna Hospital, Santiago, Chile
| | - Mehdi Hadid
- Division of Pediatric CardiologyCentre Hospitalier Universitaire Sainte-JustineUniversity of Montreal, Montreal, Canada
| | - Joaquim Miró
- Division of Pediatric CardiologyCentre Hospitalier Universitaire Sainte-JustineUniversity of Montreal, Montreal, Canada
| | - Nagib Dahdah
- Division of Pediatric CardiologyCentre Hospitalier Universitaire Sainte-JustineUniversity of Montreal, Montreal, Canada
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Gao B. Pulmonary Artery Stenosis in Tetralogy of Fallot. Cardiol Rev 2023:00045415-990000000-00172. [PMID: 37966279 DOI: 10.1097/crd.0000000000000627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2023]
Abstract
Tetralogy of Fallot (TOF) is the most common cyanotic congenital cardiac defect. The survival rate after primary complete repair is high (98-100%); however, pulmonary artery stenosis (PAS) is not uncommon after TOF repair, and severe PAS aggravates pulmonary regurgitation, resulting in right ventricle dilation, ventricular arrhythmia, and possibly death. PAS in TOF can be congenital due to hypoplasia or coarctation or can be acquired secondary to a surgical procedure. The latter may be caused by an exogenous conduit implant, compression from the adjacent enlarged ascending aorta, or outflow tract dilation after transannular patch repair. PAS can also be caused by the pulmonary artery plasty strategy itself. Here, the intrinsic mechanisms underlying PAS and pulmonary artery plasty techniques and strategies are reviewed to provide guidance for surgeons.
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Affiliation(s)
- Botao Gao
- From the Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
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Petit CJ, Glatz AC, Goldstone AB, Law MA, Romano JC, Maskatia SA, Chai PJ, Zampi JD, Meadows JJ, Nicholson GT, Shahanavaz S, Qureshi AM, McCracken CE, Mascio CE, Batlivala SP, Asztalos IB, Healan SJ, Smith JD, Pettus JA, Beshish A, Raulston JEB, Hock KM, Pajk AL, Goldstein BH. Pulmonary Artery Hypoplasia in Neonates With Tetralogy of Fallot. J Am Coll Cardiol 2023; 82:615-627. [PMID: 37558375 DOI: 10.1016/j.jacc.2023.05.051] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 04/27/2023] [Accepted: 05/22/2023] [Indexed: 08/11/2023]
Abstract
BACKGROUND Neonates with symptomatic tetralogy of Fallot (sTOF) with hypoplastic pulmonary arteries (hPA) are considered high risk. Data are needed to inform the impact of hPA on outcomes, and the ideal management strategy. OBJECTIVES The objectives of this study were to quantify the impact of hPA on outcomes in neonates with sTOF and measure the impact of strategy on pulmonary artery (PA) growth in this population. METHODS Neonates with sTOF from 2005 to 2017 were reviewed from the Congenital Cardiac Research Collaborative. Criteria for hPA included a unilateral PA z score <-2.0 and contralateral PA z score <0. Primary outcome was mortality. Secondary outcomes included reintervention and PA growth. RESULTS We included 542 neonates with sTOF, including 188 (35%) with hPA and 354 (65%) with normal PA, with median follow-up of 4.1 years. Median right and left hPA z scores were -2.19 (25th-75th percentile: -2.55 to -1.94) and -2.23 (25th-75th percentile: -2.64 to -1.91), respectively. Staged repair (vs primary TOF repair) was less common in the hPA cohort (36 vs 44%; P = 0.07). Survival was similar between groups (unadjusted P = 0.16; adjusted P = 0.25). Reintervention was more common in the hPA group (HR: 1.28; 95% CI: 1.01-1.63; P = 0.044); there was no difference after definitive repair (HR: 1.21; 95% CI: 0.93-1.58; P = 0.16). PA growth at 1 year was greater in the hPA cohort, particularly for the right PA (P < 0.001). CONCLUSIONS Despite perception, the presence of hPA in neonates with sTOF conferred no increase in overall hazard of mortality or reintervention after definitive repair. PA growth was superior in the hPA cohort. These findings suggest that the presence of hPA does not adversely impact outcomes in sTOF.
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Affiliation(s)
- Christopher J Petit
- Division of Cardiology, Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons, NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, New York, USA; Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia, USA.
| | - Andrew C Glatz
- Division of Pediatric Cardiology, Perelman School of Medicine at the University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA; Division of Pediatric Cardiology, Washington University School of Medicine and St Louis Children's Hospital, St Louis, Missouri, USA
| | - Andrew B Goldstone
- Division of Cardiology, Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons, NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, New York, USA
| | - Mark A Law
- University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA
| | - Jennifer C Romano
- University of Michigan School of Medicine, Mott Children's Hospital, Ann Arbor, Michigan, USA
| | - Shiraz A Maskatia
- University of California San Francisco School of Medicine, Benioff Children's Hospital, San Francisco, California, USA
| | - Paul J Chai
- Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Jeffrey D Zampi
- University of Michigan School of Medicine, Mott Children's Hospital, Ann Arbor, Michigan, USA
| | - Jeffery J Meadows
- University of California San Francisco School of Medicine, Benioff Children's Hospital, San Francisco, California, USA
| | - George T Nicholson
- Division of Cardiology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Shabana Shahanavaz
- Division of Pediatric Cardiology, Washington University School of Medicine and St Louis Children's Hospital, St Louis, Missouri, USA; Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Athar M Qureshi
- Baylor College of Medicine, Texas Children's Hospital, Waco, Texas, USA
| | - Courtney E McCracken
- Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Christopher E Mascio
- Division of Pediatric Cardiology, Perelman School of Medicine at the University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA; University of West Virginia School of Medicine, Morgantown, West Virginia, USA
| | | | - Ivor B Asztalos
- Division of Pediatric Cardiology, Perelman School of Medicine at the University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Steven J Healan
- Division of Cardiology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Justin D Smith
- University of Michigan School of Medicine, Mott Children's Hospital, Ann Arbor, Michigan, USA
| | - Joelle A Pettus
- Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Asaad Beshish
- Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - James E B Raulston
- University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA
| | - Krissie M Hock
- University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA
| | - Amy L Pajk
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Bryan H Goldstein
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA; University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Yin X, Wang Y. Effect of pulmonary regurgitation on cardiac functions based on a human bi-ventricle model. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2023; 238:107600. [PMID: 37285726 DOI: 10.1016/j.cmpb.2023.107600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 04/27/2023] [Accepted: 05/13/2023] [Indexed: 06/09/2023]
Abstract
BACKGROUND AND OBJECTIVE Assessing the severity of pulmonary regurgitation (PR) and identifying optimal clinically relevant indicators for its treatment is crucial, yet standards for quantifying PR remain unclear in clinical practice. Computational modelling of the heart is in the process of providing valuable insights and information for cardiovascular physiology research. However, the advancements of finite element computational models have not been widely applied to simulate cardiac outputs in patients with PR. Furthermore, a computational model that incorporates both the left ventricle (LV) and right ventricle (RV) can be valuable in assessing the relationship between left and right ventricular morphometry and septal motion in PR patients. To enhance our understanding of the effect of PR on cardiac functions and mechanical behaviour, we developed a human bi-ventricle model to simulate five cases with varying degrees of PR severity. METHODS This bi-ventricle model was built using a patient-specific geometry and a widely used myofibre architecture. The myocardial material properties were described by a hyperelastic passive constitutive law and a modified time-varying elastance active tension model. To simulate realistic cardiac functions and the dysfunction of the pulmonary valve in PR disease cases, open-loop lumped parameter models representing systemic and pulmonary circulatory systems were designed. RESULTS In the baseline case, pressures in the aorta and main pulmonary artery and ejection fractions of both the LV and RV were within normal physiological ranges reported in the literature. The end-diastolic volume (EDV) of the RV under varying degrees of PR was comparable to the reported cardiac magnetic resonance imaging data. Moreover, RV dilation and interventricular septum motion from the baseline to the PR cases were clearly observed through the long-axis and short-axis views of the bi-ventricle geometry. The RV EDV in the severe PR case increased by 50.3% compared to the baseline case, while the LV EDV decreased by 18.1%. The motion of the interventricular septum was consistent with the literature. Furthermore, ejection fractions of both the LV and RV decreased as PR became severe, with LV ejection fraction decreasing from 60.5% at baseline to 56.3% in the severe case and RV ejection fraction decreasing from 51.8% to 46.8%. Additionally, the average myofibre stress of the RV wall at end-diastole significantly increased due to PR, from 2.7±12.1 kPa at baseline to 10.9±26.5 kPa in the severe case. The average myofibre stress of the LV wall at end-diastole increased from 3.7±18.1 kPa to 4.3±20.3 kPa. CONCLUSIONS This study established a foundation for the computational modelling of PR. The simulated results showed that severe PR leads to reduced cardiac outputs in both the LV and RV, clearly observable septum motion, and a significant increase in the average myofibre stress in the RV wall. These findings demonstrate the potential of the model for further exploration of PR.
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Affiliation(s)
- Xueqing Yin
- School of Mathematics and Statistics, University of Glasgow, Glasgow, United Kingdom
| | - Yingjie Wang
- School of Mathematics and Statistics, University of Glasgow, Glasgow, United Kingdom.
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Sun L, Li JJ, Xu YK, Xie YM, Wang SS, Zhang ZW. Initial status and 3-month results relating to the use of biodegradable nitride iron stents in children and the evaluation of right ventricular function. Front Cardiovasc Med 2022; 9:914370. [PMID: 35979021 PMCID: PMC9376250 DOI: 10.3389/fcvm.2022.914370] [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: 04/06/2022] [Accepted: 07/05/2022] [Indexed: 11/15/2022] Open
Abstract
Background Pulmonary artery stenosis is often associated with congenital heart disease. The aim of the study was to evaluate the efficacy and safety of stenting for branch pulmonary artery stenosis using a biodegradable nitride iron stent (IBS® Angel™) and right ventricular systolic and diastolic function. Methods From July 2021 to February 2022, a total of 11 cases (ages ranged from 36 to 86 months old) were included in this pre and post-intervention, prospective, cohort and preclinical study. All cases underwent transthoracic echocardiographic (TTE), chest radiography, along with computed tomography (256-slice scanner, multiple-detector) and right heart catheterization. Different types of biodegradable nitride iron stents were implanted. TTE was performed serially 1 day, 1 month and 3 months after the procedure to evaluate the rate of restenosis and right ventricular function. Results Stenting was successful in 11 patients. There were no major adverse cardiovascular events related to the device or to the procedure. Blood perfusion in the branch pulmonary artery was improved immediately. At follow-up, there was no significant restenosis that required re-intervention. None of the patients suffered from in-stent thrombosis, vascular embolism, stent displacement or heart failure. Compared with normal values, there were statistical with regards to FAC, E/A and E′/A′. Furthermore, we found that TAPSE correlated significantly with pulsed Doppler S wave (p = 0.008) and left ventricular ejection fraction (p < 0.01). The early trans-tricuspid inflow velocities E/E′ (tissue doppler at the lateral tricuspid annulus) correlated significantly with E′/A′ (p = 0.009). FAC and E′/A′ were statistically different from those prior to stenting (p = 0.041 and p = 0.035) when tested one month postoperatively. At three months postoperatively, only E/A showed a statistical difference (p = 0.015). Conclusion Our analysis suggests that biodegradable nitride iron stents are feasible, safe, and effective in children. Some small improvements were observed in right ventricular systolic and diastolic function after successful transcatheter intervention, although change was not statistically significant due to the small sample number. (A clinical Trial to Evaluate the Safety and Efficacy of IBS Angel in Patients With Pulmonary Artery Stenosis (IRIS); NCT04973540).
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Zhu Z, Gao B. Patch Enlargement May Not Be a Good Strategy for Tetralogy of Fallot with Unbalanced Pulmonary Artery Branches. Eur J Cardiothorac Surg 2022; 62:6594491. [PMID: 35640132 DOI: 10.1093/ejcts/ezac326] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 04/16/2022] [Accepted: 05/25/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To figure out the optimal strategy to manage Tetralogy of Fallot (TOF) with unbalanced pulmonary artery(PA) branches by investigating the different effects of PA plasty on the development of the hypoplastic PA (HPA). METHODS A single center, retrospective analysis was carried out to compare the outcome of different PA plasty methods on the development of HPA in patients of TOF with unbalanced PA branches. Size and balance of the PA branches were used to evaluate the outcome of PA plasty. RESULTS In the NATIVE group, 100% of the HPAs were well-developed and all the PA branches became balanced, while in the PATCH and EXTENSION groups, the percentage of well-developed HPAs was 40% and 33%, respectively, and none of the PA branches were balanced. In addition, HPAs became atretic in 28% of the patients in the patch enlargement group. CONCLUSIONS For TOF with unbalanced PA branches, patch enlargement may not be a good treatment strategy, as it reduces the growth potential of HPA and even causes iatrogenic atresia. Leaving the HPA in the native state without patch enlargement may be a good strategy.
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Affiliation(s)
- Zhongqun Zhu
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, 1678 Dongfang Road, Shanghai 200127, People's Republic of China
| | - Botao Gao
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, 1678 Dongfang Road, Shanghai 200127, People's Republic of China
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Abstract
OBJECTIVES Improved survival has led to a growing population of adults with congenital heart disease (CHD), followed by numerous reports of late complications. Liver disease is a known complication in some patients, with most studies focusing on Fontan associated liver disease. Whether liver disease also exists in other patients with CHD is not fully investigated. Elevated central venous pressure is considered pivotal in the development of liver disease in Fontan associated liver disease, and other patients with alterations in central venous pressure may also be at risk for developing liver fibrosis. We wanted to see if liver fibrosis is present in patients with tetralogy of Fallot. Many patients with tetralogy of Fallot have severe pulmonary regurgitation, which can lead to elevated central venous pressure. Patients with tetralogy of Fallot may be at risk of developing liver fibrosis. MATERIALS AND METHODS Ten patients (24-56 years) with tetralogy of Fallot and pulmonary regurgitation were investigated for liver fibrosis. All patients were examined with magnetic resonance elastography of liver, hepatobiliary iminodiacetic acid scan, indocyanine green elimination by pulse spectrophotometry, elastography via FibroScan, abdominal ultrasound including liver elastography, and blood samples including liver markers. RESULTS Three out of ten patients had findings indicating possible liver fibrosis. Two of these had a liver biopsy performed, which revealed fibrosis stage 1 and 2, respectively. The same three patients had an estimated elevated central venous pressure in previous echocardiograms. CONCLUSIONS Mild liver fibrosis was present in selected patients with tetralogy of Fallot and may be related to elevated central venous pressure.
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Boumpouli M, Sauvage EL, Capelli C, Schievano S, Kazakidi A. Characterization of Flow Dynamics in the Pulmonary Bifurcation of Patients With Repaired Tetralogy of Fallot: A Computational Approach. Front Cardiovasc Med 2021; 8:703717. [PMID: 34660711 PMCID: PMC8514754 DOI: 10.3389/fcvm.2021.703717] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 09/07/2021] [Indexed: 11/18/2022] Open
Abstract
The hemodynamic environment of the pulmonary bifurcation is of great importance for adult patients with repaired tetralogy of Fallot (rTOF) due to possible complications in the pulmonary valve and narrowing of the left pulmonary artery (LPA). The aim of this study was to computationally investigate the effect of geometrical variability and flow split on blood flow characteristics in the pulmonary trunk of patient-specific models. Data from a cohort of seven patients was used retrospectively and the pulmonary hemodynamics was investigated using averaged and MRI-derived patient-specific boundary conditions on the individualized models, as well as a statistical mean geometry. Geometrical analysis showed that curvature and tortuosity are higher in the LPA branch, compared to the right pulmonary artery (RPA), resulting in complex flow patterns in the LPA. The computational analysis also demonstrated high time-averaged wall shear stress (TAWSS) at the outer wall of the LPA and the wall of the RPA proximal to the junction. Similar TAWSS patterns were observed for averaged boundary conditions, except for a significantly modified flow split assigned at the outlets. Overall, this study enhances our understanding about the flow development in the pulmonary bifurcation of rTOF patients and associates some morphological characteristics with hemodynamic parameters, highlighting the importance of patient-specificity in the models. To confirm these findings, further studies are required with a bigger cohort of patients.
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Affiliation(s)
- Maria Boumpouli
- Department of Biomedical Engineering, University of Strathclyde, Glasgow, United Kingdom
| | - Emilie L. Sauvage
- Institute of Cardiovascular Science and Great Ormond Street Hospital for Children, NHS Foundation Trust, University College London, London, United Kingdom
| | - Claudio Capelli
- Institute of Cardiovascular Science and Great Ormond Street Hospital for Children, NHS Foundation Trust, University College London, London, United Kingdom
| | - Silvia Schievano
- Institute of Cardiovascular Science and Great Ormond Street Hospital for Children, NHS Foundation Trust, University College London, London, United Kingdom
| | - Asimina Kazakidi
- Department of Biomedical Engineering, University of Strathclyde, Glasgow, United Kingdom
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Boumpouli M, Danton MHD, Gourlay T, Kazakidi A. Blood flow simulations in the pulmonary bifurcation in relation to adult patients with repaired tetralogy of Fallot. Med Eng Phys 2020; 85:123-138. [PMID: 33081959 DOI: 10.1016/j.medengphy.2020.09.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 07/01/2020] [Accepted: 09/25/2020] [Indexed: 10/23/2022]
Abstract
Understanding the haemodynamic environment of the pulmonary bifurcation is important in adults with repaired conotruncal congenital heart disease. In these patients, dysfunction of the pulmonary valve and narrowing of the branch pulmonary arteries are common and can have serious clinical consequences. The aim of this study was to numerically investigate the underlying blood flow characteristics in the pulmonary trunk under a range of simplified conditions. For that, an in-depth analysis was conducted in idealised two-dimensional geometries that facilitate parametric investigation of healthy and abnormal conditions. Subtle variations in morphology influenced the haemodynamic environment and wall shear stress distribution. The pressure in the left pulmonary artery was generally higher than that in the right and main arteries, but was markedly reduced in the presence of a local stenosis. Different downstream pressure conditions altered the branch flow ratio, from 50:50% to more realistic 60:40% ratios in the right and left pulmonary artery, respectively. Despite some simplifications, this study highlights some previously undocumented aspects of the flow in bifurcating geometries, by clarifying the role of the stagnation point location on wall shear stress and differential branch pressures. In addition, measurements of the mean pressure ratios in the pulmonary bifurcation are discussed in the context of a new haemodynamic index which could potentially contribute to the assessment of left pulmonary artery stenosis in tetralogy of Fallot patients. Further studies are required to confirm the results in patient-specific models with personalised physiological flow conditions.
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Affiliation(s)
- Maria Boumpouli
- Department of Biomedical Engineering, University of Strathclyde, 106 Rottenrow East, Glasgow G4 0NW, United Kingdom
| | - Mark H D Danton
- Department of Biomedical Engineering, University of Strathclyde, 106 Rottenrow East, Glasgow G4 0NW, United Kingdom; Scottish Adult Congenital Cardiac Service, Golden Jubilee National Hospital, Clydebank G81 4DY, United Kingdom
| | - Terence Gourlay
- Department of Biomedical Engineering, University of Strathclyde, 106 Rottenrow East, Glasgow G4 0NW, United Kingdom
| | - Asimina Kazakidi
- Department of Biomedical Engineering, University of Strathclyde, 106 Rottenrow East, Glasgow G4 0NW, United Kingdom.
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Outflow tract geometries are associated with adverse outcome indicators in repaired tetralogy of Fallot. J Thorac Cardiovasc Surg 2020; 162:196-205. [PMID: 33097218 DOI: 10.1016/j.jtcvs.2020.09.072] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Revised: 08/25/2020] [Accepted: 09/10/2020] [Indexed: 11/23/2022]
Abstract
OBJECTIVES A wide variety of right ventricular outflow tract (RVOT) and pulmonary artery (PA) geometries has been reported in patients with repaired tetralogy of Fallot (rTOF). We aimed to investigate the associations between RVOT/PA geometries and outcome indicators in a large rTOF cohort receiving non-conduit repair. METHODS Three-dimensional magnetic resonance angiographic images of 206 patients with rTOF who had a pulmonary regurgitation (PR) fraction ≥20% were reviewed. Patients' RVOT geometry was quantitatively classified into 4 distinct shapes (tubular, hourglass, pyramid, and inverted trapezoid). Bilateral PA size discrepancy was defined as the diameter of the smaller side being less than 70% of that of the bigger side. RESULTS Based on lateral projection of the 3-dimensional images, patients with an inverted trapezoid-shaped RVOT had the smallest RV end-diastolic volume index (EDVi) (108.7 ± 24.3 mL/m2) and pulmonary valve annulus diameter, and shortest QRS duration, whereas those with a pyramid-shaped RVOT had the largest RV EDVi (161.0 ± 44.6 mL/m2) and pulmonary valve annulus diameter. Similar trends of differences were also observed if such classifications were based on the frontal projections. Multivariable analysis revealed that RVOT shapes, subvalvular diameter, PR fraction, QRS duration, and the presence of bilateral PA size discrepancy were independent determinants of RV EDVi. Furthermore, having bilateral PA size discrepancy (25.2%) was independently associated with lower peak oxygen consumption (P = .041). CONCLUSIONS Distinct RVOT morphologies and branch PA size discrepancy are associated with variations in RV remodeling and exercise capacity in patients with rTOF. These findings may aid decision-making regarding reintervention for PR and branch PA size discrepancy.
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Fujii T, Tomita H, Kobayashi T, Kato H, Sugiyama H, Mizukami A, Ueda H. Clinical trial of the CP stent for pulmonary artery stenosis: the first investigator-initiated clinical trial for pediatric interventional cardiology in Japan. Heart Vessels 2020; 36:291-296. [PMID: 32889644 DOI: 10.1007/s00380-020-01691-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 08/28/2020] [Indexed: 11/24/2022]
Abstract
Stenting is an important treatment option for pulmonary artery stenosis (PS) associated with congenital heart disease (CHD). However, no stent has been approved for this indication in Japan, despite negotiation between academia and the regulatory bodies for longer than 20 years. To evaluate efficacy and safety of the CP stent, we performed the first investigator-initiated clinical trial for pediatric interventional cardiology in Japan. This trial was designed as a single-arm, prospective, clinical trial. Patients who had postoperative PS associated with CHD were included. Stenting was attempted in 24 cases and succeeded in 22 cases. The median age of the patients was 11 years (3-36 years) and weight was 38 kg (12-69 kg), while follow-up for 12 months was completed. In all 22 cases, stenting was successful, with a 50% increase in the minimum lumen diameter (MLD) in 86.4% of patients (90% confidence interval, 68.4-96.2%). The mean percent change in MLD was 119.3 ± 52.5%. In two-ventricle repair, the mean percent change in systolic right ventricular/aortic pressure was - 8.5 ± 16.1%, while that of pressure gradient was - 55.9 ± 41.7%. In single-ventricle repair, the percent change in the mean pressure gradient was - 100.0 ± 0%, while that of SaO2 was 1.4 ± 1.7%. No serious adverse events or significant restenosis was reported. The CP stent is highly effective and safe for PS associated with CHD. This study has significant importance in not only scientific but also social considerations.
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Affiliation(s)
- Takanari Fujii
- Pediatric Heart Disease and Adult Congenital Heart Disease Center, Showa University Hospital, 1-5-8, Hatanodai, Shinagawa-Ku, Tokyo, 142-8666, Japan.
| | - Hideshi Tomita
- Pediatric Heart Disease and Adult Congenital Heart Disease Center, Showa University Hospital, 1-5-8, Hatanodai, Shinagawa-Ku, Tokyo, 142-8666, Japan
| | - Toshiki Kobayashi
- Department of Pediatric Cardiology, Saitama Medical University International Medical Center, Hidaka, Japan
| | - Hitoshi Kato
- Department of Pediatric Cardiology, National Center for Child Health and Development, Tokyo, Japan
| | - Hisashi Sugiyama
- Department of Pediatric Cardiology and Adult Congenital Cardiology, Tokyo Women's Medical University, Tokyo, Japan
| | - Ayumi Mizukami
- Department of Pediatrics, National Center for Global Health and Medicine, Tokyo, Japan
| | - Hideaki Ueda
- Department of Cardiology, Kanagawa Children's Medical Center, Yokohama, Japan
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Gufler H, Wagner S, Niefeldt S, Klopsch C, Brill R, Wohlgemuth WA, Yerebakan C. Levels of agreement between cardiac magnetic resonance and conductance catheter measurements of right ventricular volumes after pulmonary artery banding. Acta Radiol 2020; 61:894-902. [PMID: 31752497 DOI: 10.1177/0284185119886318] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Pressure-volume analysis is the gold standard for quantifying pump function of the right ventricle (RV); however, volume measurements based on a conductive catheter may be imprecise. The reference method for volume assessment is cardiac magnetic resonance (CMR). PURPOSE To determine the levels of agreement between RV volume measurements obtained by cine CMR, phase-contrast CMR (PC CMR), and a conductance catheter in an animal model. MATERIAL AND METHODS CMR was performed in 20 sheep three months after pulmonary artery banding. Ejection fraction (EF), end-diastolic (EDV), end-systolic (ESV), and stroke volumes (SV) were obtained by cine CMR and conductance catheter. RESULTS Statistically significant differences between cine CMR and conductance catheter derived volume measurements were found for EDV (P < 0.001), ESV (P < 0.05), and SV (P < 0.05). Bland-Altman analysis showed very poor agreement between the two methods: EDV, bias 36.27 mL, agreement of limits 1.96-70.57 mL; ESV, bias 15.33 mL, agreement of limits -6.89-37.55 mL; and SV, bias 20.69 mL, agreement of limits 8.01-49.10 mL. Good agreement was found for SV between cine CMR and PC CMR (bias -7.0 mL, agreement of limits -24.01-9.98 mL), while SV derived from PC CMR measurements showed poor agreement with conductance catheter (bias 27.76 mL, agreement of limits -3.84-59.26 mL). CONCLUSION Poor agreement between the conductance catheter and CMR RV volume measurements was found. PC CMR and cine CMR measurements of SV agreed well.
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Affiliation(s)
- Hubert Gufler
- Department of Diagnostic and Interventional Radiology, University Clinic, Rostock, Germany
- Clinic and Policlinic of Diagnostic Radiology, Martin-Luther University Halle-Wittenberg, 01620, Germany
| | - Sabine Wagner
- Department of Diagnostic and Interventional Radiology, University Clinic, Rostock, Germany
| | - Sabine Niefeldt
- Department of Cardiac Surgery, University Clinic, Rostock, Germany*Equal contributors
| | - Christian Klopsch
- Department of Cardiac Surgery, University Clinic, Rostock, Germany*Equal contributors
| | - Richard Brill
- Clinic and Policlinic of Diagnostic Radiology, Martin-Luther University Halle-Wittenberg, 01620, Germany
| | | | - Can Yerebakan
- Department of Cardiac Surgery, University Clinic, Rostock, Germany*Equal contributors
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13
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Vandenheuvel M, Bouchez S, Wouters P, Mauermann E. Assessing Right Ventricular Function in the Perioperative Setting, Part II: What About Catheters? Anesthesiol Clin 2019; 37:697-712. [PMID: 31677686 DOI: 10.1016/j.anclin.2019.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
An-depth assessment of right ventricular function is important in a many perioperative settings. After exploring 2-dimensional echo-based evaluation, other proposed monitoring modalities are discussed. Pressure-based methods of right ventricular appraisal is discussed. Flow-based assessment is reviewed. An overview of the state of current right ventricular 3-dimensional echocardiography and its potential to construct clinical pressure-volume loops in conjunction with pressure measurements is provided. An overview of right ventricular assessment modalities that do not rely on 2-dimensional echocardiography is discussed. Tailored selection of monitoring modalities can be of great benefit for the perioperative physician. Integrating modalities offers optimal estimations of right ventricular function.
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Affiliation(s)
- Michael Vandenheuvel
- Department of Anesthesiology and Perioperative Medicine, Ghent University Hospital, C. Heymanslaan 10, Ghent 9000, Belgium
| | - Stefaan Bouchez
- Department of Anesthesiology and Perioperative Medicine, Ghent University Hospital, C. Heymanslaan 10, Ghent 9000, Belgium
| | - Patrick Wouters
- Department of Anesthesiology and Perioperative Medicine, Ghent University Hospital, C. Heymanslaan 10, Ghent 9000, Belgium
| | - Eckhard Mauermann
- Department of Anesthesiology and Perioperative Medicine, Ghent University Hospital, C. Heymanslaan 10, Ghent 9000, Belgium; Department for Anesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, Basel University Hospital, Spitalstrasse 21, Basel 4031, Switzerland.
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14
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Voges I, Al-Mallah MH, Scognamiglio G, Di Salvo G. Right Heart-Pulmonary Circulation Unit in Congenital Heart Diseases. Heart Fail Clin 2018; 14:283-295. [PMID: 29966627 DOI: 10.1016/j.hfc.2018.02.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The right ventricle plays a major role in congenital heart disease. This article describes the right ventricular mechanics in some selected congenital heart diseases affecting the right ventricle in different ways: tetralogy of Fallot, Ebstein anomaly, and the systemic right ventricle.
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Affiliation(s)
- Inga Voges
- Royal Brompton and Harefield Trust, London, UK
| | - Mouaz H Al-Mallah
- National Guard Health Affairs, Riyadh King Abdulaziz Cardiac Center, Riyadh, Saudi Arabia
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15
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Standard and Strain Measurements by Echocardiography Detect Early Overloaded Right Ventricular Dysfunction: Validation against Hemodynamic and Myocyte Contractility Changes in a Large Animal Model. J Am Soc Echocardiogr 2017; 30:1138-1147.e4. [DOI: 10.1016/j.echo.2017.07.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Indexed: 11/22/2022]
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16
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Kim YY, Ruckdeschel E. Approach to residual pulmonary valve dysfunction in adults with repaired tetralogy of Fallot. Heart 2016; 102:1520-6. [DOI: 10.1136/heartjnl-2015-309067] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2016] [Accepted: 05/23/2016] [Indexed: 12/28/2022] Open
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17
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Zhang W, Liu J, Yan Q, Liu J, Hong H, Mao L. Computational haemodynamic analysis of left pulmonary artery angulation effects on pulmonary blood flow. Interact Cardiovasc Thorac Surg 2016; 23:519-25. [DOI: 10.1093/icvts/ivw179] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Accepted: 04/19/2016] [Indexed: 11/12/2022] Open
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18
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Fujii T, Tomita H, Fujimoto K, Otsuki S, Kobayashi T, Ono Y, Yazaki S, Kim SH, Nakanishi T. Morphological and Hemodynamic Effectiveness of Stenting for Pulmonary Artery Stenosis – Subanalysis of JPIC Stent Survey –. Circ J 2016; 80:1852-6. [DOI: 10.1253/circj.cj-15-1196] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Takanari Fujii
- Cardiovascular Center, Showa University Northern Yokohama Hospital
| | - Hideshi Tomita
- Cardiovascular Center, Showa University Northern Yokohama Hospital
| | - Kazuto Fujimoto
- Cardiovascular Center, Showa University Northern Yokohama Hospital
| | - Shinichi Otsuki
- Division of Pediatric Cardiology, Department of Pediatrics, Okayama University
| | - Toshiki Kobayashi
- Department of Pediatric Cardiology, Saitama Medical University International Medical Center
| | - Yasuo Ono
- Department of Cardiology, Shizuoka Children’s Hospital
| | - Satoshi Yazaki
- Department of Pediatric Cardiology, Sakakibara Heart Institute
| | - Sung-Hae Kim
- Department of Cardiology, Shizuoka Children’s Hospital
| | - Toshio Nakanishi
- Department of Pediatric Cardiology, Tokyo Women’s Medical University
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19
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DeCampli WM. Pulmonary Regurgitation in Tetralogy of Fallot: Can Circulatory Modeling Help Us Avert Right Ventricular Failure? World J Pediatr Congenit Heart Surg 2015; 6:511-3. [PMID: 26467863 DOI: 10.1177/2150135115601727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- William M DeCampli
- Pediatric Cardiovascular Surgery, Arnold Palmer Hospital for Children, University of Central Florida College of Medicine, Orlando, FL, USA
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Ko Y, Morita K, Abe T, Nakao M, Hashimoto K. Variability of Pulmonary Regurgitation in Proportion to Pulmonary Vascular Resistance in a Porcine Model of Total Resection of the Pulmonary Valve: Implications for Early- and Long-Term Postoperative Management of Right Ventricular Outflow Tract Reconstruction With Resulting Pulmonary Valve Incompetence. World J Pediatr Congenit Heart Surg 2015; 6:502-10. [PMID: 26467862 DOI: 10.1177/2150135115598209] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Pulmonary regurgitation (PR) is a major concern after right ventricular (RV) outflow tract surgery. We assessed the impact of physiological changes in pulmonary vasculature on hemodynamic severity of PR and RV function and their potential clinical implications for postoperative management using a porcine model with severe PR. MATERIALS AND METHODS Eight porcine models of acute PR were established by means of resection of pulmonary valve on cardiopulmonary bypass. After separation from bypass and stabilization, blood flow in the main pulmonary artery was measured by a pulsed Doppler flowmeter, and RV systolic function was assessed on the basis of RV segment shortening (RVSS), which was analyzed by sonomicrometry. In the acute PR model, we verified the impact of pulmonary vascular resistance (Rp) on pulmonary regurgitant fraction (PRF) and RV function. Pulmonary vascular resistance was changed by manipulating the level of PaCo 2 and by inhalation of nitric oxide (NO). RESULTS After bypass, the mean PRF was 40% ± 5%, and there was a deterioration of RV function. Under each ventilation condition (high CO2, low CO2, and NO 20 ppm), Rp was 836 ± 207 dyne × s × cm(-5), 499 ± 125 dyne × s × cm(-5), and 340 ± 102 dyne × s × cm(-5), respectively, and PRF was 60% ± 10%, 37% ± 5%, and 24% ± 4%, respectively, under each condition. They also showed a positive correlation in all animals. Cardiac output and RVSS were decreased by hypercapnia, while they were significantly improved after NO inhalation. CONCLUSIONS This study indicates that low Rp after right ventricular outflow tract reconstruction (RVOTR) resulting in acute PR is advantageous in reducing the severity of PR and RV volume load. These findings may have clinical implications for early and long-term postoperative management of patients subjected to RVOTR with resulting pulmonary valve incompetence.
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Affiliation(s)
- Yoshihiro Ko
- Department of Cardiovascular Surgery, Jikei University School of Medicine, Tokyo, Japan
| | - Kiyozo Morita
- Department of Cardiovascular Surgery, Jikei University School of Medicine, Tokyo, Japan
| | - Takayuki Abe
- Department of Cardiovascular Surgery, Jikei University School of Medicine, Tokyo, Japan
| | - Mitsutaka Nakao
- Department of Cardiovascular Surgery, Jikei University School of Medicine, Tokyo, Japan
| | - Kazuhiro Hashimoto
- Department of Cardiovascular Surgery, Jikei University School of Medicine, Tokyo, Japan
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Rommel JJ, Yadav PK, Stouffer GA. Causes and hemodynamic findings in chronic severe pulmonary regurgitation. Catheter Cardiovasc Interv 2015; 92:E197-E203. [DOI: 10.1002/ccd.26073] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Accepted: 05/23/2015] [Indexed: 11/08/2022]
Affiliation(s)
- John J. Rommel
- Division of Cardiology; University of North Carolina; Chapel Hill North Carolina
| | - Pradeep K. Yadav
- Division of Cardiology; University of North Carolina; Chapel Hill North Carolina
| | - George A. Stouffer
- Division of Cardiology; University of North Carolina; Chapel Hill North Carolina
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Maskatia SA, Morris SA, Spinner JA, Krishnamurthy R, Altman CA. Echocardiographic Parameters of Right Ventricular Diastolic Function in Repaired Tetralogy of Fallot Are Associated with Important Findings on Magnetic Resonance Imaging. CONGENIT HEART DIS 2015; 10:E113-22. [PMID: 25916551 DOI: 10.1111/chd.12265] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/26/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Right ventricular (RV) dilation, RV dysfunction, RV outflow tract obstruction, and branch pulmonary artery stenosis are risk factors associated with the need for future surgical or catheter-based intervention commonly assessed by cardiac magnetic resonance in patients with tetralogy of Fallot who have undergone initial repair. The ability of echocardiography to predict the presence of these risk factors is limited. OBJECTIVE We aimed to determine the association between echocardiographic parameters of right ventricular diastolic dysfunction and risk factors for intervention as identified on cardiac magnetic resonance imaging (CMR). DESIGN We reviewed all echocardiograms and CMRs performed at our institution within 1 year of each other in patients with repaired tetralogy of Fallot. We evaluated patients for the following: RV systolic dysfunction (RV ejection fraction <45%), RV dilation (right ventricular end-diastolic volume ≥ 160 mL/m(2)), and RV obstruction (RV outflow tract gradient ≥ 3 m/s by echocardiogram or branch pulmonary artery stenosis assessed by CMR). We evaluated for associations between the above CMR findings and echocardiographic parameters of diastolic function. RESULTS CMR and echocardiographic images performed between March 2007 and March 2012 were available in 99 patients. RV obstruction was associated with lower E/A ratio (P = .02), E/A reversal (P = .02), and prograde end diastolic pulmonary flow (P < .01). Low tricuspid annular a' and low septal s' were associated with lower RV ejection fraction (P < .01, P < .01). Elevated E/e' was associated with higher RV end diastolic volume (P = .04). In predicting the presence of any of the evaluated risk factors for future intervention, TV E/e' ≥ 4.7 had positive predictive value (PPV) of 86% and negative predictive value (NPV) of 50%, TV E/A reversal had PPV of 89% and NPV of 34, and prograde end diastolic pulmonary flow on echocardiogram had PPV of 91% and NPV of 38%. CONCLUSIONS Echocardiographic parameters of diastolic dysfunction have a reasonable PPV but poor NPV for predicting clinically significant risk factors identified by CMR.
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Affiliation(s)
- Shiraz A Maskatia
- Section of Pediatric Cardiology, Baylor College of Medicine, Texas Children's Hospital, Houston, Tex, USA
| | - Shaine A Morris
- Section of Pediatric Cardiology, Baylor College of Medicine, Texas Children's Hospital, Houston, Tex, USA
| | - Joseph A Spinner
- Section of Pediatric Cardiology, Baylor College of Medicine, Texas Children's Hospital, Houston, Tex, USA
| | - Rajesh Krishnamurthy
- Department of Radiology, Baylor College of Medicine, Texas Children's Hospital, Houston, Tex, USA
| | - Carolyn A Altman
- Section of Pediatric Cardiology, Baylor College of Medicine, Texas Children's Hospital, Houston, Tex, USA
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23
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Lynch W, Boekholdt SM, Hazekamp MG, de Winter RJ, Koolbergen DR. Hybrid branch pulmonary artery stent placement in adults with congenital heart disease. Interact Cardiovasc Thorac Surg 2015; 20:499-503. [DOI: 10.1093/icvts/ivu435] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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24
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25
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Lee C, Lee CH, Kwak JG, Kim SH, Shim WS, Lee SY, Jang SI, Park SJ, Kim YM. Factors associated with right ventricular dilatation and dysfunction in patients with chronic pulmonary regurgitation after repair of tetralogy of Fallot: analysis of magnetic resonance imaging data from 218 patients. J Thorac Cardiovasc Surg 2014; 148:2589-95. [PMID: 25173118 DOI: 10.1016/j.jtcvs.2014.07.051] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Revised: 07/09/2014] [Accepted: 07/14/2014] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The aim of the present study was to identify the factors associated with right ventricular (RV) dilatation and dysfunction in patients with chronic pulmonary regurgitation (PR) after repair of tetralogy of Fallot. METHODS From April 2002 to June 2013, 218 patients with repaired tetralogy of Fallot underwent magnetic resonance imaging; 165 (76%) underwent transannular repair and 36 (17%) underwent nontransannular repair. Linear regression analyses were used to identify the predictors for RV end-diastolic volume index (EDVI), end-systolic volume index (ESVI), and ejection fraction. RESULTS On univariable analysis, male sex, ventricular septal defect (VSD) closure through the right ventricle, larger pulmonary artery index, and greater PR fraction were associated with greater RV volume indexes. Multivariable analyses identified male sex (β = 17.55, P < .001 for RV EDVI; β = 14.08, P = .001 for RV ESVI), VSD closure through RV (β = 8.49, P = .048 for RV ESVI), longer interval since repair (β = 1.29, P = .014 for RV EDVI), and greater PR fraction (β = 1.92, P < .001 for RV EDVI; β = 1.38, P < .001 for RV ESVI) as independent predictors for greater RV volume indexes. On univariable analysis, male sex, VSD closure through the right ventricle, and greater PR fraction were associated with a lower RV ejection fraction. Multivariable analysis identified male sex (β = -3.10, P = .018), VSD closure through the right ventricle (β = -3.05, P = .020), and greater PR fraction (β = -0.27, P < .001) as independent predictors for a lower RV ejection fraction. CONCLUSIONS Male sex, VSD closure through the right ventricle, longer interval since repair, and greater PR fraction were independent predictors of RV dilatation after tetralogy of Fallot repair. Male sex, VSD closure through the right ventricle, and greater PR fraction were also independent predictors of RV dysfunction.
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Affiliation(s)
- Cheul Lee
- Department of Thoracic and Cardiovascular Surgery, Cardiovascular Center, Sejong General Hospital, Bucheon, Republic of Korea.
| | - Chang-Ha Lee
- Department of Thoracic and Cardiovascular Surgery, Cardiovascular Center, Sejong General Hospital, Bucheon, Republic of Korea
| | - Jae Gun Kwak
- Department of Thoracic and Cardiovascular Surgery, Cardiovascular Center, Sejong General Hospital, Bucheon, Republic of Korea
| | - Seong-Ho Kim
- Department of Pediatric Cardiology, Cardiovascular Center, Sejong General Hospital, Bucheon, Republic of Korea
| | - Woo-Sup Shim
- Department of Pediatric Cardiology, Cardiovascular Center, Sejong General Hospital, Bucheon, Republic of Korea
| | - Sang Yun Lee
- Department of Pediatric Cardiology, Cardiovascular Center, Sejong General Hospital, Bucheon, Republic of Korea
| | - So-Ick Jang
- Department of Pediatric Cardiology, Cardiovascular Center, Sejong General Hospital, Bucheon, Republic of Korea
| | - Su-Jin Park
- Department of Pediatric Cardiology, Cardiovascular Center, Sejong General Hospital, Bucheon, Republic of Korea
| | - Yang Min Kim
- Department of Radiology, Cardiovascular Center, Sejong General Hospital, Bucheon, Republic of Korea
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Ing FF, Khan A, Kobayashi D, Hagler DJ, Forbes TJ. Pulmonary artery stents in the recent era: Immediate and intermediate follow-up. Catheter Cardiovasc Interv 2014; 84:1123-30. [PMID: 24910458 DOI: 10.1002/ccd.25567] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2013] [Revised: 04/09/2014] [Accepted: 05/31/2014] [Indexed: 11/06/2022]
Abstract
BACKGROUND Long-term follow-up after stent dilation of native and acquired pulmonary artery stenosis is scarce in the pediatric population. Most cohorts include a myriad of anatomies and associated conditions. METHOD In order to establish objective performance criteria, we performed a retrospective review of all patients who underwent unilateral pulmonary artery stenting in biventricular physiology at three centers from June 2006 to June 2011. RESULTS Fifty-eight patients received 60 stents with Palmaz Genesis stent used most commonly (78%). Average age at implantation was 10.4 ± 10.3 years and weight 31.6 ± 21.8 kg. The immediate success rate was 98%, with improvement in minimal diameter from 5.1 ± 2 cm to 10.6 ± 3 cm (P < 0.01). There were 10 complications (7 major and 3 minor) and no acute mortality. One-year follow-up studies were available in 48 patients (83%), including echocardiogram (60%), catheterization (28%), MRI (29%), and lung perfusion (31%). Follow-up echocardiogram showed mild increase in stent gradient, from 5.7 ± 6.7 mm Hg post-procedure to 17.1 ± 11.7 mm Hg. Follow-up catheterization showed no significant change in minimal stent diameter (8.8 ± 2.6 to 7.8 ± 2.3 mm), gradient (7.7 ± 8.4 to 12.6 ± 12.2 mm Hg), or right ventricular pressures (43.7 ± 9 to 47.7 ± 10.5 mm Hg). Nine patients (16%) underwent scheduled stent redilation over a period of 12 days to 25 months. CONCLUSION In conclusion, stent implantation shows excellent immediate and 1-year follow-up results with maintenance of improved caliber of the stented vessel and lowered right ventricular systolic pressures.
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Affiliation(s)
- Frank F Ing
- Division of Cardiology, Children's Hospital Los Angeles, Los Angeles, California
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27
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Swamy P, Bharadwaj A, Varadarajan P, Pai RG. Echocardiographic evaluation of tetralogy of Fallot. Echocardiography 2014; 32 Suppl 2:S148-56. [PMID: 24888422 DOI: 10.1111/echo.12437] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Tetralogy of Fallot (TOF) is a cyanotic heart disease consisting of nonrestrictive ventricular septal defect, overriding aorta, pulmonary stenosis, and right ventricular hypertrophy. Early total correction is the treatment of choice and these patients with repaired TOF are increasingly seen in adult practice. This review addresses echocardiographic evaluation of TOF, corrected TOF, its sequelae and various complications. A working knowledge of TOF assessment is essential for all adult cardiologists and sonographers.
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Affiliation(s)
- Pooja Swamy
- Department of Cardiology, Loma Linda University Medical Center, Loma Linda, CA
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Kadner A, Tulevski II, Bauersfeld U, Prêtre R, Valsangiacomo-Buechel ER, Dodge-Khatami A. Chronic pulmonary valve insufficiency after repaired Tetralogy of Fallot: diagnostics, reoperations and reconstruction possibilities. Expert Rev Cardiovasc Ther 2014; 5:221-30. [PMID: 17338667 DOI: 10.1586/14779072.5.2.221] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Complete correction of Tetralogy of Fallot, the most common cyanotic congenital heart defect, has now become routine. However, late residual lesions, primarily chronic pulmonary valve insufficiency, may have a negative impact on right-ventricular function, leading to the need for reoperation to insert a competent valve at the right-ventricular outflow. The diagnostic modalities pertaining to the failing right ventricle, the timing for eventual reintervention and the various surgical reconstruction possibilities of the right-ventricular outflow tract are still controversial and evolving, and are reviewed with a brief overview on current trends and future outlooks.
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Affiliation(s)
- Alexander Kadner
- University of Zürich, Division of Congenital Cardiovascular Surgery, University Children's Hospital, Steinwiesstrasse 75, CH-8032 Zürich, Switzerland.
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McCabe C, White PA, Hoole SP, Axell RG, Priest AN, Gopalan D, Taboada D, MacKenzie Ross R, Morrell NW, Shapiro LM, Pepke-Zaba J. Right ventricular dysfunction in chronic thromboembolic obstruction of the pulmonary artery: a pressure-volume study using the conductance catheter. J Appl Physiol (1985) 2013; 116:355-63. [PMID: 24356516 DOI: 10.1152/japplphysiol.01123.2013] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Pressure-volume loops describe dynamic ventricular performance, relevant to patients with and at risk of pulmonary hypertension. We used conductance catheter-derived pressure-volume loops to measure right ventricular (RV) mechanics in patients with chronic thromboembolic pulmonary arterial obstruction at different stages of pathological adaptation. Resting conductance catheterization was performed in 24 patients: 10 with chronic thromboembolic pulmonary hypertension (CTEPH), 7 with chronic thromboembolic disease without pulmonary hypertension (CTED), and 7 controls. To assess the validity of conductance measurements, RV volumes were compared in a subset of 8 patients with contemporaneous cardiac magnetic resonance (CMR). Control, CTED, and CTEPH groups showed different pressure-volume loop morphology, most notable during systolic ejection. Prolonged diastolic relaxation was seen in patients with CTED and CTEPH [tau = 56.2 ± 6.7 (controls) vs. 69.7 ± 10.0 (CTED) vs. 67.9 ± 6.2 ms (CTEPH), P = 0.02]. Control and CTED groups had lower afterload (Ea) and contractility (Ees) compared with the CTEPH group (Ea = 0.30 ± 0.10 vs. 0.52 ± 0.24 vs. 1.92 ± 0.70 mmHg/ml, respectively, P < 0.001) (Ees = 0.44 ± 0.20 vs. 0.59 ± 0.15 vs. 1.13 ± 0.43 mmHg/ml, P < 0.01) with more efficient ventriculoarterial coupling (Ees/Ea = 1.46 ± 0.30 vs. 1.27 ± 0.36 vs. 0.60 ± 0.18, respectively, P < 0.001). Stroke volume assessed by CMR and conductance showed closest agreement (mean bias +9 ml, 95% CI -1 to +19 ml) compared with end-diastolic volume (+48 ml, -16 to 111 ml) and end-systolic volume (+37 ml, -21 to 94 ml). RV conductance catheterization detects novel alteration in pressure-volume loop morphology and delayed RV relaxation in CTED, which distinguish this group from controls. The observed agreement in stroke volume assessed by CMR and conductance suggests RV mechanics are usefully measured by conductance catheter in chronic thromboembolic obstruction.
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Affiliation(s)
- Colm McCabe
- Pulmonary Vascular Disease Unit, Papworth Hospital, Cambridge, United Kingdom
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Sasikumar N, Ramanan S, Rema KMS, Kumar RS, Subramanyan R, Cherian KM. Prosthetic reconstruction of bicuspid pulmonary valve in tetralogy of Fallot. Asian Cardiovasc Thorac Ann 2013; 22:436-41. [PMID: 24771732 DOI: 10.1177/0218492313496416] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Various techniques have been described for preserving pulmonary valve function in tetralogy of Fallot repair. In selected substrates, the pulmonary valve can be bicuspidized and preserved using polytetrafluoroethylene pericardial membrane. METHODS This study was a retrospective review of 20 patients aged 11 months to 31 years with tetralogy of Fallot and a bicuspid pulmonary valve (with anteroposterior cusps) who underwent intracardiac repair from August 2010 to January 2013. The anterior cusp was augmented using polytetrafluoroethylene pericardial membrane to preserve the valve hinge. A transannular patch was used in all cases. Data relating to surgical outcome, intensive care unit course, pulmonary regurgitation, and right ventricular outflow tract gradient were collected. RESULTS There was no mortality. Predischarge pulmonary regurgitation was ≤grade 2 in 18 (90%) patients. One patient had an outflow gradient >40 mm Hg. On follow-up of 3-24 months, there was no increase in outflow gradient; 18.7% had progression of pulmonary regurgitation. CONCLUSION In selected substrates, this technique is associated with minimization of pulmonary regurgitation and an excellent functional outcome. The utility of this technique needs to be validated over a longer time scale in a larger series.
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Affiliation(s)
- Navaneetha Sasikumar
- Department of Pediatric Cardiology and Pediatric Cardiac Surgery, Frontier Lifeline Hospital, Chennai, India
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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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Unilateral pulmonary artery branch stenosis: diastolic prolongation of forward flow appears to maintain flow to the affected lung if the pulmonary valve is competent. Int J Cardiol 2013; 168:3698-703. [PMID: 23849966 DOI: 10.1016/j.ijcard.2013.06.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2012] [Revised: 05/13/2013] [Accepted: 06/15/2013] [Indexed: 11/23/2022]
Abstract
BACKGROUND We sought to improve understanding of the diastolic prolongation of forward flow seen through a unilateral branch pulmonary artery (PA) stenosis. METHODS AND RESULTS Of patients studied by cardiovascular magnetic resonance (CMR) for congenital heart disease, we reviewed right and left PA flow to find 10 cases with a diastolic prolongation of flow in a stenosed branch PA. They were aged 20 years (median, range = 14-40 years, 7 males). Seven had transposition of the great arteries corrected by arterial switch (TGA-AS) and 3 had repaired tetralogy of Fallot (rToF). All had at least moderate unilateral stenosis and competent pulmonary valves. For comparison, we identified 10 patients with unilateral stenosis and at least moderate pulmonary regurgitation, 9 rTOF and 1 TGA-AS, aged 23.5 years (range = 14-42 years, 6 males). Flow in each PA was measured, and in 10 healthy volunteers aged 27 years (range = 20-42 years, 5 males). The curves of flow through stenosed and non-stenosed arteries were averaged for each patient group and compared with those from controls. In competent pulmonary valve patients, the minimum diameters of the stenosed versus non-stenosed branches were as follows (median [range]): 4 [3-8] mm versus 13.5 [10-28] mm, p<0.001, although their flows differed a little: 2.5 [1.5-6.8] L/min versus 3.2 [1.2-8.8] L/min, p=0.6. No diastolic tail was identifiable in the patients with unilateral PA stenosis and pulmonary regurgitation, where stenosed versus non-stenosed diameters were 7 [4-12] mm versus 20.5 [13-33] mm, p<0.001, and flows differed: 1.3 [0.4-2.9] L/min versus 3.8 [3.0-5.0] L/min, p<0.001. No controls showed stenosis or diastolic tail. CONCLUSIONS Beyond a competent pulmonary valve, flow through a unilateral PA stenosis, although limited in systole, can continue into diastole, maintaining flow to the lung.
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Yoo BW, Park HK. Pulmonary stenosis and pulmonary regurgitation: both ends of the spectrum in residual hemodynamic impairment after tetralogy of Fallot repair. KOREAN JOURNAL OF PEDIATRICS 2013; 56:235-41. [PMID: 23807889 PMCID: PMC3693041 DOI: 10.3345/kjp.2013.56.6.235] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/26/2012] [Accepted: 04/14/2013] [Indexed: 11/27/2022]
Abstract
Repair of tetralogy of Fallot (TOF) has shown excellent outcomes. However it leaves varying degrees of residual hemodynamic impairment, with severe pulmonary stenosis (PS) and free pulmonary regurgitation (PR) at both ends of the spectrum. Since the 1980s, studies evaluating late outcomes after TOF repair revealed the adverse impacts of residual chronic PR on RV volume and function; thus, a turnaround of operational strategies has occurred from aggressive RV outflow tract (RVOT) reconstruction for complete relief of RVOT obstruction to conservative RVOT reconstruction for limiting PR. This transformation has raised the question of how much residual PS after conservative RVOT reconstruction is acceptable. Besides, as pulmonary valve replacement (PVR) increases in patients with RV deterioration from residual PR, there is concern regarding when it should be performed. Regarding residual PS, several studies revealed that PS in addition to PR was associated with less PR and a small RV volume. This suggests that PS combined with PR makes RV diastolic property to protect against dilatation through RV hypertrophy and supports conservative RVOT enlargement despite residual PS. Also, several studies have revealed the pre-PVR threshold of RV parameters for the normalization of RV volume and function after PVR, and based on these results, the indications for PVR have been revised. Although there is no established strategy, better understanding of RV mechanics, development of new surgical and interventional techniques, and evidence for the effect of PVR on RV reverse remodeling and its late outcome will aid us to optimize the management of TOF.
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Affiliation(s)
- Byung Won Yoo
- Department of Clinical Pharmacology, Clinical Trial Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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Maskatia SA, Spinner JA, Morris SA, Petit CJ, Krishnamurthy R, Nutting AC. Effect of branch pulmonary artery stenosis on right ventricular volume overload in patients with tetralogy of fallot after initial surgical repair. Am J Cardiol 2013; 111:1355-60. [PMID: 23411101 DOI: 10.1016/j.amjcard.2013.01.278] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2012] [Revised: 01/02/2013] [Accepted: 01/02/2013] [Indexed: 10/27/2022]
Abstract
Right ventricular (RV) volume overload secondary to pulmonary regurgitation is common in patients after initial repair of tetralogy of Fallot (TOF) and is associated with adverse long-term outcomes. The objective of the present study was to determine the effect of branch pulmonary artery stenosis on the RV volume in patients with repaired TOF. We reviewed 178 cardiac magnetic resonance imaging studies in patients with repaired TOF. We defined bilateral stenosis as a Nakata index of ≤200 mm(2)/m(2) and concordant branch pulmonary artery cross-sectional area, unilateral stenosis as 1 branch pulmonary artery cross-sectional area ≤100 mm(2)/m(2) and 1 branch pulmonary artery cross-sectional area >100 mm(2)/m(2), and restrictive physiology as prograde main pulmonary artery diastolic flow. Of the 178 patients, 20 (11%) had bilateral stenosis, 47 (26%) unilateral stenosis, and 111 (63%) had no stenosis. The RV end-diastolic volume was lower in patients with bilateral (125 ± 27 ml/m(2)) or unilateral (131 ± 43 ml/m(2)) stenosis than in those without stenosis (149 ± 35 ml/m(2), p = 0.021 and p = 0.019, respectively). The main pulmonary artery regurgitant fraction was greater in patients without stenosis (47%, range 2% to 69%) than in those with bilateral (33%, range 9% to 59%; p = 0.009) or unilateral stenosis (40%, range 0% to 71%; p = 0.033). Restrictive physiology was more common in patients with bilateral (13 of 15, 87%) or unilateral (21 of 38, 55%) stenosis than in those without stenosis (28 of 85, 33%; p <0.001 and p = 0.017, respectively). In conclusion, in patients with repaired TOF, bilateral and unilateral branch pulmonary artery stenosis was associated with a greater main pulmonary artery regurgitant fraction and smaller RV end-diastolic volume than those in patients without stenosis, likely owing to the development of restrictive physiology. Branch pulmonary artery stenosis might effectively delay the referral for pulmonary valve replacement.
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Impact of pressure load caused by right ventricular outflow tract obstruction on right ventricular volume overload in patients with repaired tetralogy of Fallot. J Thorac Cardiovasc Surg 2012; 143:1299-304. [DOI: 10.1016/j.jtcvs.2011.12.033] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2011] [Revised: 11/18/2011] [Accepted: 12/14/2011] [Indexed: 11/20/2022]
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Ko HK, Kim YH, Yu JJ, Ko JK, Park IS, Seo DM, Yun TJ, Park JJ, Jang WS. Effectiveness and safety of percutaneous transcatheter implantation of pulmonary arterial stent in congenital heart disease. Korean Circ J 2012; 42:40-5. [PMID: 22363382 PMCID: PMC3283753 DOI: 10.4070/kcj.2012.42.1.40] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2011] [Accepted: 09/21/2011] [Indexed: 11/12/2022] Open
Abstract
Background and Objectives Pulmonary arterial stenosis is a relatively common complication after corrective operation of congenital heart disease. Unilateral stenosis of pulmonary arteries could result in decrease perfusion of affected lung, pulmonary regurgitation, or elevation of right ventricular pressure. Eventually there are increasing risks of right ventricular failure, arrhythmia, or sudden death. However we have limited data of pulmonary arterial stent in paediatric population as the treatment of branch pulmonary stenosis. This study aimed at validating the effectiveness and investigating complications of pulmonary arterial stent implantation in a single institution during mid-term follow up period. Subjects and Methods A total of 42 patients (50 stents) were implanted for treating branch pulmonary arterial stenosis. We used cardiac catheterization for comparing diameter after stent implantation directly and lung perfusion scan indirectly. We also investigated any adverse effect relating the procedure. Results Percent stenosis of stenotic lesions were decreased from 54.1±10.7% to 22.8±12.5% (p<0.001) and degree of decrement in affected lung perfusion was declined from 22.7±8.0% to 10.3±9.0% (p<0.001) immediately and lasts during mid-term follow up period. Complication rate relating the procedure was 12% (6 out of 12) and there was no mortality case. Conclusion This series showed immediate and short term effectiveness of pulmonary arterial stent in congenital heart defects. We concluded that percutaneous transcatheter implantation of pulmonary arterial stent was safe and effective during short and mid-term follow up period.
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Affiliation(s)
- Hong Ki Ko
- Department of Pediatric Cardiology, Ulsan of Unversity College of Medicine, Asan Medical Center, Seoul, Korea
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Surgical Management of Pulmonary Atresia With Ventricular Septal Defect: Early Total Correction Versus Shunt. Ann Thorac Surg 2011; 91:1928-34; discussion 1934-5. [DOI: 10.1016/j.athoracsur.2011.01.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2010] [Revised: 01/03/2011] [Accepted: 01/04/2011] [Indexed: 11/19/2022]
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KENNY DAMIEN, AMIN ZAHID, SLYDER SHARI, HIJAZI ZIYADM. Medium-Term Outcomes for Peripheral Pulmonary Artery Stenting in Adults with Congenital Heart Disease. J Interv Cardiol 2011; 24:373-7. [DOI: 10.1111/j.1540-8183.2011.00638.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Abstract
The long-term outcome of patients with congenitally malformed hearts involving abnormal right ventricular morphology and haemodynamics is variable. In most instances, the patients are at risk for right ventricular failure, in part due to morphological differences between the right and left ventricles and their response to chronic volume and pressure overload. In patients after repair of tetralogy of Fallot, and after balloon valvotomy for valvar pulmonary stenosis, pulmonary regurgitation is the most significant risk factor for right ventricular dysfunction. In patients with a dominant right ventricle after Fontan palliation, and in those with systemic right ventricles in association with surgically or congenitally corrected transposition, the right ventricle is not morphologically capable of dealing with chronic exposure to the high afterload of the systemic circulation. In patients with Ebstein's malformation of the tricuspid valve, the degree of atrialisation of the right ventricle determines how well the right ventricle will function as the pump for the pulmonary vascular bed.
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Lambert V, Capderou A, Le Bret E, Rücker-Martin C, Deroubaix E, Gouadon E, Raymond N, Stos B, Serraf A, Renaud JF. Right ventricular failure secondary to chronic overload in congenital heart disease: an experimental model for therapeutic innovation. J Thorac Cardiovasc Surg 2010; 139:1197-204, 1204.e1. [PMID: 20412956 DOI: 10.1016/j.jtcvs.2009.11.028] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2009] [Revised: 10/07/2009] [Accepted: 11/14/2009] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Mortality and morbidity related to right ventricular failure remain a problem for the long-term outcome of congenital heart diseases. Therapeutic innovation requires establishing an animal model reproducing right ventricular dysfunction secondary to chronic pressure-volume overload. METHODS Right ventricular tract enlargement by transvalvular patch and pulmonary artery banding were created in 2-month-old piglets (n = 6) to mimic repaired tetralogy of Fallot. Age-matched piglets were used as controls (n = 5). Right ventricular function was evaluated at baseline and 3 and 4 months of follow-up by hemodynamic parameters and electrocardiography. Right ventricular tissue remodeling was characterized using cellular electrophysiologic and histologic analyses. RESULTS Four months after surgery, right ventricular peak pressure increased to 75% of systemic pressure and pulmonary regurgitation significantly progressed, end-systolic and end-diastolic volumes significantly increased, and efficient ejection fraction significantly decreased compared with controls. At 3 months, the slope of the end-systolic pressure-volume relationship was significantly elevated compared with baseline and controls; a significant rightward shift of the slope, returning to the baseline value, was observed at 4 months, whereas stroke work progressed at each step and was significantly higher than in controls. Four months after surgery, QRS duration was significantly prolonged as action potential duration. Significant fibrosis and myocyte hypertrophy without myolysis and inflammation were observed in the operated group at 4 months. CONCLUSION Various aspects of early right ventricular remodeling were analyzed in this model. This model reproduced evolving right ventricular alterations secondary to chronic volumetric and barometric overload, as observed in repaired tetralogy of Fallot with usual sequelae, and can be used for therapeutic innovation.
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Affiliation(s)
- Virginie Lambert
- Département de Recherche Médicale, CNRS UMR 8162, Centre Chirurgical Marie Lannelongue, Le Plessis Robinson, France.
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MRI and Computed Tomography of Cardiac and Pulmonary Complications of Tetralogy of Fallot in Adults. J Thorac Imaging 2010; 25:183-90. [DOI: 10.1097/rti.0b013e31819d14fe] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Luijnenburg SE, Vliegen HW, Mulder BJ, Helbing WA. Tetralogy of Fallot — Does MR imaging have the answers? PROGRESS IN PEDIATRIC CARDIOLOGY 2010. [DOI: 10.1016/j.ppedcard.2009.10.004] [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: 10/20/2022]
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Bédard E, McCarthy KP, Dimopoulos K, Giannakoulas G, Gatzoulis MA, Ho SY. Structural abnormalities of the pulmonary trunk in tetralogy of Fallot and potential clinical implications: a morphological study. J Am Coll Cardiol 2009; 54:1883-90. [PMID: 19892240 DOI: 10.1016/j.jacc.2009.06.040] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2009] [Revised: 05/19/2009] [Accepted: 06/01/2009] [Indexed: 10/20/2022]
Abstract
OBJECTIVES The purpose of this study was to determine whether intrinsic histological abnormalities of the pulmonary trunk (PT) are present from birth and interact with palliative surgery and/or repair. BACKGROUND Little is known about PT histology in patients with tetralogy of Fallot (TOF), especially in the era of surgical intervention in childhood. METHODS We studied 39 formalin-fixed necropsy heart specimens with TOF and compared them with 17 normal control heart specimens. Sections of the PT and aorta were studied by light microscopy using various stains; histological findings were graded according to severity. RESULTS Among the TOF group (1 fetus, 11 infants, 14 children, and 13 adults), 11 patients had undergone palliative and 10 patients had undergone reparative surgery at a median age of 8 years (range 2.5 to 18 years). Histological changes of grade 2 or higher were present in 59% (medionecrosis), 36% (fibrosis), 56% (cystlike formation), and 56% (abnormal elastic tissue configuration) of TOF patients. Total histology grading scores were higher in TOF hearts (median 6, range 1 to 9) compared with controls (median 1, range 0 to 6; p < 0.0001). Histological abnormalities were present among infants (median score 3.5, range 1 to 9) and after palliative surgery (median score 5, range 2 to 9) or repair (median score 7.5, range 4 to 9). CONCLUSIONS Marked histological abnormalities in the PT of hearts with TOF exist compared with controls. These changes were present from infancy and among patients who had undergone palliative or reparative surgery, although operations in this cohort were performed late. Our data suggest that structural abnormalities of the PT, similar to these recently shown in the aorta, are intrinsic.
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Affiliation(s)
- Elisabeth Bédard
- Adult Congenital Heart Centre/Centre for Pulmonary Hypertension and Unit of Cardiac Morphology, Royal Brompton Hospital and the National Heart and Lung Institute, Imperial College London, London, United Kingdom
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Law MA, Shamszad P, Nugent AW, Justino H, Breinholt JP, Mullins CE, Ing FF. Pulmonary artery stents: Long-term follow-up. Catheter Cardiovasc Interv 2009; 75:757-64. [DOI: 10.1002/ccd.22356] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Abstract
Tetralogy of Fallot is the most common form of cyanotic congenital heart disease, and one of the first to be successfully repaired by congenital heart surgeons. Since the first procedures in the 1950s, advances in the diagnosis, perioperative and surgical treatment, and postoperative care have been such that almost all those born with tetralogy of Fallot can now expect to survive to adulthood. The startling improvement in outcomes for babies born with congenital heart disease in general-and for those with tetralogy of Fallot in particular-is one of the success stories of modern medicine. Indeed, in many countries adults with tetralogy of Fallot outnumber children. Consequently, new issues have emerged, ranging from hitherto unpredicted medical complications to issues with training for caregivers and resource allocation for this population of survivors. Therefore, evolution of treatment, recognition of late complications, research on disease mechanisms and therapies-with feedback to changes in care of affected children born nowadays-are templates on which the timely discussion of organisation of care of those affected by congenital heart diseases from the fetus to the elderly can be based. Here, we focus on new developments in the understanding of the causes, diagnosis, early treatment, and late outcomes of tetralogy of Fallot, emphasising the continuum of multidisciplinary care that is necessary for best possible lifelong treatment of the 1% of the population born with congenital heart diseases.
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Affiliation(s)
- Christian Apitz
- Division of Cardiology, Labatt Family Heart Centre, Hospital for Sick Children, Toronto, ON, Canada
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Right ventricular dysfunction and B-type natriuretic peptide in asymptomatic patients after repair for tetralogy of Fallot. Pediatr Cardiol 2009; 30:898-904. [PMID: 19475443 DOI: 10.1007/s00246-009-9453-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2008] [Revised: 02/19/2009] [Accepted: 04/16/2009] [Indexed: 10/20/2022]
Abstract
Early detection of right ventricular (RV) dysfunction is essential in the assessment of patients with repaired tetralogy of Fallot (TOF). This study aimed to assess latent RV dysfunction in asymptomatic patients with TOF and to determine the predictive value of B-type natriuretic peptide (BNP). Pressure-volume loops were recorded for 16 young patients (New York Heart Association class 1 or Ross class 0; median age, 14.2 years) using the conductance catheter technique. All the patients had RV dilation secondary to pulmonary regurgitation after surgical repair of TOF. Indexes of RV function were derived at baseline level and during dobutamine infusion. Contractility was calculated by the slope of the end-systolic pressure-volume relation (ESPVR). An increase in ESPVR during dobutamine infusion was considered to indicate contractile reserve as a marker for latent RV dysfunction. The median ESPVR significantly increased from 0.32 mmHg/ml (0.13-0.72 mmHg/ml) at baseline to 0.57 mmHg/ml (0.24-1.55 mmHg/ml) during dobutamine infusion (p = 0.005). However, for five patients, no relevant increase in contractility was found, indicating impaired RV contractile reserve. There was only a weak inverse correlation between impaired contractile reserve and BNP (r = -0.28). Even asymptomatic patients with only a mildly enlarged right ventricle can have impaired RV function. Early RV dysfunction cannot be predicted accurately with BNP.
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Petit CJ, Gillespie MJ, Harris MA, Seymour TL, Liu TY, Khan A, Gaynor JW, Rome JJ. Relief of branch pulmonary artery stenosis reduces pulmonary valve insufficiency in a swine model. J Thorac Cardiovasc Surg 2009; 138:382-9. [DOI: 10.1016/j.jtcvs.2009.02.030] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2008] [Revised: 01/12/2009] [Accepted: 02/16/2009] [Indexed: 11/30/2022]
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Risk factors for early pulmonary valve replacement after valve disruption in congenital pulmonary stenosis and tetralogy of Fallot. J Thorac Cardiovasc Surg 2009; 138:103-8. [DOI: 10.1016/j.jtcvs.2009.02.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2008] [Revised: 12/11/2008] [Accepted: 02/02/2009] [Indexed: 11/22/2022]
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Kilner PJ, Balossino R, Dubini G, Babu-Narayan SV, Taylor AM, Pennati G, Migliavacca F. Pulmonary regurgitation: the effects of varying pulmonary artery compliance, and of increased resistance proximal or distal to the compliance. Int J Cardiol 2008; 133:157-66. [PMID: 18722025 DOI: 10.1016/j.ijcard.2008.06.078] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2008] [Revised: 06/11/2008] [Accepted: 06/28/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND Pulmonary regurgitation is common after repair of tetralogy of Fallot, predisposing to right ventricular dilatation and potentially fatal arrhythmias. Magnetic resonance studies of such patients led us to hypothesize that the amount of regurgitation, in the absence of an effective valve, depends on pulmonary arterial compliance and on the location of resistance relative to the compliance. METHODS AND RESULTS Using a pre-existing mathematical model representing the cardiovascular system, removal of the virtual pulmonary valve gave a triphasic pulmonary artery flow curve similar in shape to those recorded in patients with free regurgitation, with a regurgitant fraction of 30%. There was no reversal of flow at pulmonary capillary level, the regurgitant volume originating entirely from the compliance of the virtual pulmonary arteries and arterioles. Doubling their compliance increased regurgitation to 35%, whereas halving it decreased regurgitation to 23%. Doubling the total pulmonary vascular resistance by increasing arteriolar resistance increased regurgitation to 46%, whereas doubling it by simulating pulmonary annular stenosis proximal to the compliance limited regurgitation to 10%, but at the cost of a 32 mmHg peak systolic pressure drop. CONCLUSIONS The model supported our hypotheses, indicating the relevance to pulmonary regurgitation of previously overlooked variables. The virtual pulmonary regurgitation was exacerbated by pulmonary artery compliance and by elevated resistance distal to it, but was limited by more proximal resistance. These relationships merit careful clinical investigation as they would have implications for the initial management, subsequent investigation and decisions on re-intervention in patients with pulmonary regurgitation.
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Affiliation(s)
- Philip J Kilner
- CMR Unit, Royal Brompton Hospital and Imperial College, London, UK.
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Ammash NM, Dearani JA, Burkhart HM, Connolly HM. Pulmonary Regurgitation after Tetralogy of Fallot Repair: Clinical Features, Sequelae, and Timing of Pulmonary Valve Replacement. CONGENIT HEART DIS 2007; 2:386-403. [DOI: 10.1111/j.1747-0803.2007.00131.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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