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Kottmann P, Eildermann K, Murthi SR, Cleuziou J, Lemmer J, Vitanova K, von Stumm M, Lehmann L, Hörer J, Ewert P, Sigler M, Lange R, Lahm H, Dreßen M, Lichtner P, Wolf CM. EGFR and MMP-9 are associated with neointimal hyperplasia in systemic-to-pulmonary shunts in children with complex cyanotic heart disease. Mamm Genome 2023; 34:285-297. [PMID: 36867212 PMCID: PMC10290590 DOI: 10.1007/s00335-023-09982-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 01/31/2023] [Indexed: 03/04/2023]
Abstract
Systemic-to-pulmonary shunt malfunction contributes to morbidity in children with complex congenital heart disease after palliative procedure. Neointimal hyperplasia might play a role in the pathogenesis increasing risk for shunt obstruction. The aim was to evaluate the role of epidermal growth factor receptor (EGFR) and matrix-metalloproteinase 9 (MMP-9) in the formation of neointimal within shunts. Immunohistochemistry was performed with anti-EGFR and anti-MMP-9 on shunts removed at follow-up palliative or corrective procedure. Whole-genome single-nucleotide polymorphisms genotyping was performed on DNA extracted from patients´ blood samples and allele frequencies were compared between the group of patients with shunts displaying severe stenosis (≥ 40% of lumen) and the remaining group. Immunohistochemistry detected EGFR and MMP-9 in 24 of 31 shunts, located mainly in the luminal area. Cross-sectional area of EGFR and MMP-9 measured in median 0.19 mm2 (IQR 0.1-0.3 mm2) and 0.04 mm2 (IQR 0.03-0.09 mm2), respectively, and correlated positively with the area of neointimal measured on histology (r = 0.729, p < 0.001 and r = 0.0479, p = 0.018, respectively). There was a trend of inverse correlation between the dose of acetylsalicylic acid and the degree of EGFR, but not MMP-9, expression within neointima. Certain alleles in epidermal growth factor (EGF) and tissue inhibitor of metalloproteinases 1 (TIMP-1) were associated with increased stenosis and neointimal hyperplasia within shunts. EGFR and MMP-9 contribute to neointimal proliferation in SP shunts of children with complex cyanotic heart disease. SP shunts from patients carrying certain risk alleles in the genes encoding for EGF and TIMP-1 displayed increased neointima.
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Affiliation(s)
- Philip Kottmann
- Department of Congenital Heart Defects and Pediatric Cardiology, German Heart Center Munich, Technical University of Munich, School of Medicine & Health, Lazarettstrasse 36, 80636, Munich, Germany
| | - Katja Eildermann
- Department of Pediatrics and Adolescent Medicine-Paediatric Cardiology, Intensive Care Medicine and Pneumology, University Medical Center, Goettingen, Germany
| | - Sarala Raj Murthi
- Department of Congenital Heart Defects and Pediatric Cardiology, German Heart Center Munich, Technical University of Munich, School of Medicine & Health, Lazarettstrasse 36, 80636, Munich, Germany
| | - Julie Cleuziou
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technical University of Munich, School of Medicine & Health, Munich, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilian University Munich, Munich, Germany
- Institute for Translational Cardiac Surgery (INSURE), German Heart Center Munich, Technical University of Munich, School of Medicine & Health, Munich, Germany
| | - Julia Lemmer
- Department of Congenital Heart Defects and Pediatric Cardiology, German Heart Center Munich, Technical University of Munich, School of Medicine & Health, Lazarettstrasse 36, 80636, Munich, Germany
| | - Keti Vitanova
- Institute for Translational Cardiac Surgery (INSURE), German Heart Center Munich, Technical University of Munich, School of Medicine & Health, Munich, Germany
- Department of Cardiovascular Surgery, German Heart Center Munich, Technical University of Munich, School of Medicine & Health, Munich, Germany
| | - Maria von Stumm
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technical University of Munich, School of Medicine & Health, Munich, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilian University Munich, Munich, Germany
| | - Luisa Lehmann
- Department of Congenital Heart Defects and Pediatric Cardiology, German Heart Center Munich, Technical University of Munich, School of Medicine & Health, Lazarettstrasse 36, 80636, Munich, Germany
| | - Jürgen Hörer
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technical University of Munich, School of Medicine & Health, Munich, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilian University Munich, Munich, Germany
| | - Peter Ewert
- Department of Congenital Heart Defects and Pediatric Cardiology, German Heart Center Munich, Technical University of Munich, School of Medicine & Health, Lazarettstrasse 36, 80636, Munich, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Matthias Sigler
- Department of Pediatrics and Adolescent Medicine-Paediatric Cardiology, Intensive Care Medicine and Pneumology, University Medical Center, Goettingen, Germany
| | - Rüdiger Lange
- Institute for Translational Cardiac Surgery (INSURE), German Heart Center Munich, Technical University of Munich, School of Medicine & Health, Munich, Germany
- Department of Cardiovascular Surgery, German Heart Center Munich, Technical University of Munich, School of Medicine & Health, Munich, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Harald Lahm
- Institute for Translational Cardiac Surgery (INSURE), German Heart Center Munich, Technical University of Munich, School of Medicine & Health, Munich, Germany
- Department of Cardiovascular Surgery, German Heart Center Munich, Technical University of Munich, School of Medicine & Health, Munich, Germany
| | - Martina Dreßen
- Institute for Translational Cardiac Surgery (INSURE), German Heart Center Munich, Technical University of Munich, School of Medicine & Health, Munich, Germany
- Department of Cardiovascular Surgery, German Heart Center Munich, Technical University of Munich, School of Medicine & Health, Munich, Germany
| | - Peter Lichtner
- Institute of Human Genetics, Helmholtz Centrum Munich, German Research Center for Environmental Health (GmbH), Neuherberg, Germany
| | - Cordula M Wolf
- Department of Congenital Heart Defects and Pediatric Cardiology, German Heart Center Munich, Technical University of Munich, School of Medicine & Health, Lazarettstrasse 36, 80636, Munich, Germany.
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany.
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Ferrigno F, Franceschini A, Kirk R, Amodeo A. Jacobsen Syndrome with Hypoplastic Left Heart Syndrome: Outcome after Cardiac Transplantation. J Cardiovasc Dev Dis 2022; 10:jcdd10010008. [PMID: 36661903 PMCID: PMC9864704 DOI: 10.3390/jcdd10010008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 12/14/2022] [Accepted: 12/22/2022] [Indexed: 12/28/2022] Open
Abstract
Jacobsen syndrome (JS) is a rare syndrome caused by a deletion of chromosome 11q. We report a patient with JS and hypoplastic left heart syndrome (HLHS) who required cardiac transplantation. She had many of the recognized morphological features in addition to immunological (lymphopenia) and hematological (thrombocytopenia) issues. The patient underwent a Norwood procedure with a modified Blalock-Taussig shunt (MBTS) and subsequently a Glenn procedure at six months of age. She developed desaturation, with severe tricuspid regurgitation and right ventricular dysfunction, and underwent heart transplantation at 7 months of age. After the transplant, she was hospitalized several times for severe infections. The diagnosis of Jacobsen syndrome came 2 months after transplant. Now, 5 years post-transplant, she is in relatively good health-her heart is functioning normally, her hospitalization rate is getting lower, and her immunological profile is stable.
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Affiliation(s)
- Federica Ferrigno
- The School of Pediatrics, University of Rome “Tor Vergata”, 00133 Rome, Italy
- Correspondence: ; Tel.: +39-3286426575
| | - Alessio Franceschini
- Department of Cardiosurgery, Cardiology, Heart and Lung Transplant, Bambino Gesù Children’s Hospital, IRCSS, 00165 Rome, Italy
| | - Richard Kirk
- Mechanical Circulatory Support Unit, Department of Cardiosurgery, Cardiology, Heart and Lung Transplant, Bambino Gesù Children’s Hospital, IRCSS, 00165 Rome, Italy
| | - Antonio Amodeo
- Mechanical Circulatory Support Unit, Department of Cardiosurgery, Cardiology, Heart and Lung Transplant, Bambino Gesù Children’s Hospital, IRCSS, 00165 Rome, Italy
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Broberg MCG, Cheifetz IM, Plummer ST. Current evidence for pharmacologic therapy following stage 1 palliation for single ventricle congenital heart disease. Expert Rev Cardiovasc Ther 2022; 20:627-636. [PMID: 35848073 DOI: 10.1080/14779072.2022.2103542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
INTRODUCTION Infants with single ventricle congenital heart disease are vulnerable to complications between stage 1 and stage 2 of palliation. Pharmaceutical treatment during this period is varied and often dependent on institutional practices as there is little evidence supporting a particular treatment path. AREAS COVERED This review focuses on medical management of patients following stage I palliation. We performed a scoping review of the current literature regarding angiotensin converting enzyme inhibitors and digoxin treatment in the interstage period. In addition, we discuss other medication classes frequently used in these patients. EXPERT OPINION Due to significant heterogeneity of anatomy, rarity of disease, and other confounding factors, there is limited evidence to support most commonly used medications within the interstage period. Digoxin is associated with improved mortality within the interstage period and should be considered; however, no large randomized controlled trial exists supporting its use. Prevention of thrombotic complication with aspirin is also associated with improved outcomes and should be considered unless a contraindication exists. The addition of other prescriptions in this patient population should be considered only after an evaluation of the risks and benefits of each medication, recognizing the burden and risk of polypharmacy in this fragile patient population.
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Affiliation(s)
- Meredith C G Broberg
- Department of Pediatrics, Division of Pediatric Cardiac Critical Care, University Hospitals Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Ira M Cheifetz
- Department of Pediatrics, Division of Pediatric Cardiac Critical Care, University Hospitals Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.,Department of Pediatrics, Division of Pediatric Cardiology, University Hospitals Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Sarah T Plummer
- Department of Pediatrics, Division of Pediatric Cardiology, University Hospitals Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
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Staehler H, Ono M, Schober P, Kido T, Heinisch PP, Strbad M, Vodiskar J, Cleuziou J, Lemmer J, Balling G, Hager A, Ewert P, Hörer J. Clinical and haemodynamic variables associated with intensive care unit length of stay and early adverse outcomes after the Norwood procedure. Eur J Cardiothorac Surg 2022; 61:1271-1280. [PMID: 35089334 DOI: 10.1093/ejcts/ezac014] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 11/07/2021] [Accepted: 01/06/2022] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVES This study was performed to determine the clinical and haemodynamic variables associated with early adverse outcomes after the neonatal Norwood procedure. METHODS Patients who underwent the neonatal Norwood procedure between 2001 and 2019 were included. The patient diagnosis, morphological characteristics and haemodynamic parameters were analysed to identify factors associated with length of stay (LOS) in the intensive care unit (ICU) and mortality during the stay. RESULTS A total of 322 patients were depicted. The median age and weight at the Norwood procedure were 9 days and 3.2 kg, respectively. Certain morphological and preoperative parameters, such as birth weight below 2.5 kg, restrictive atrial septal defect, extracardiac anomalies and the diameter of the ascending aorta, were found to be associated with the LOS in the ICU. Analysis using early postoperative haemodynamic variables revealed that systolic arterial pressure, diastolic arterial pressure, serum lactate levels and reduced ventricular function at 2 days postoperatively were associated with the LOS in the ICU. Birth weight <2.5 kg (P = 0.010), a restrictive atrial septal defect (P = 0.001) and smaller ascending aorta (P = 0.039) were associated with death in the ICU. Reduced ventricular function, lower systolic aortic pressure and higher lactate levels at various time points (P < 0.05) were also associated with ICU deaths. The LOS in the ICU was significantly associated with late mortality (P < 0.001, Hazard Ratio (HR) = 1.015). CONCLUSIONS The LOS in the ICU after the Norwood procedure was predicted by early postoperative haemodynamic variables, suggesting that good early postoperative haemodynamics determine early recovery. A prolonged stay in the ICU after the Norwood procedure was associated with late mortality.
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Affiliation(s)
- Helena Staehler
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany.,Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Masamichi Ono
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany.,Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Patrick Schober
- Department of Anesthesiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Takashi Kido
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany.,Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Paul Philipp Heinisch
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany.,Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Martina Strbad
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany.,Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Janez Vodiskar
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany.,Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Julie Cleuziou
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany.,Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Julia Lemmer
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Center Munich at the Technical University of Munich, Munich, Germany
| | - Gunter Balling
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Center Munich at the Technical University of Munich, Munich, Germany
| | - Alfred Hager
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Center Munich at the Technical University of Munich, Munich, Germany
| | - Peter Ewert
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Center Munich at the Technical University of Munich, Munich, Germany
| | - Jürgen Hörer
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany.,Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
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5
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Van De Bruaene A, Claessen G, Salaets T, Gewillig M. Late Fontan Circulatory Failure. What Drives Systemic Venous Congestion and Low Cardiac Output in Adult Fontan Patients? Front Cardiovasc Med 2022; 9:825472. [PMID: 35360011 PMCID: PMC8964135 DOI: 10.3389/fcvm.2022.825472] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 02/02/2022] [Indexed: 12/23/2022] Open
Abstract
The Fontan circulation provides definite palliation for children born with a single anatomical or functional ventricle by diverting systemic venous blood directly to the pulmonary arteries, effectively rendering systemic venous return into portal vessels to the lung. Although this restores pulmonary blood flow and avoids the mixture of oxygenated and deoxygenated blood, it also results in elevated systemic venous pressures and low cardiac output. These are the two hallmarks of any Fontan circulation and the cause of Fontan circulatory failure later in life. We highlight the determinants of systemic venous return, its changed relationship with the pulmonary circulation, how it affects preload, and the changed role of the heart (myocardium, valves, and heart rate). By critically evaluating the components of the Fontan circulation, we hope to give some clues in how to optimize the Fontan circulation and avenues for future research.
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Affiliation(s)
- Alexander Van De Bruaene
- Division of Cardiology, Department of Cardiovascular Sciences, University Hospitals Leuven, KU Leuven, Leuven, Belgium
- *Correspondence: Alexander Van De Bruaene
| | - Guido Claessen
- Division of Cardiology, Department of Cardiovascular Sciences, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Thomas Salaets
- Division of Pediatric Cardiology, Department of Cardiovascular Sciences, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Marc Gewillig
- Division of Pediatric Cardiology, Department of Cardiovascular Sciences, University Hospitals Leuven, KU Leuven, Leuven, Belgium
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Impact of Medical Interventions and Comorbidities on Norwood Admission for Patients with Hypoplastic Left Heart Syndrome. Pediatr Cardiol 2022; 43:267-278. [PMID: 35034159 DOI: 10.1007/s00246-022-02818-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 01/06/2022] [Indexed: 10/19/2022]
Abstract
The purpose of these analyses was to determine how specific comorbidities and medical interventions impact risk of inpatient mortality in those with hypoplastic left heart syndrome undergoing Norwood procedure. The secondary aims were to determine the impact of these on billed charges, postoperative length of stay, and risk of cardiac arrest. Admissions from 2004 to 2015 in the Pediatric Health Information System database with hypoplastic left heart syndrome and Norwood procedure were identified. Admission characteristics, patient interventions, and the presence of comorbidities were captured. A total of 5,138 admissions were identified meeting inclusion criteria. Of these 829 (16.1%) experienced inpatient mortality, and 352 (6.7%) experienced cardiac arrest. The frequency of inpatient mortality did not significantly change over the course of the study era. The frequency of cardiac arrest significantly decreased from 7.4% in 2004 to 4.3% in 2015 (p = 0.04). The frequency of pharmacologic therapies, particularly vasoactive use, decreased as the study period progressed. Regression analyses demonstrated a significant association between cardiac arrest and inpatient mortality with arrhythmias, acute kidney injury, and pulmonary hypertension. Similarly, regression analyses demonstrated a significant association between increase in billed charges and length of stay with year of surgery, presence of heart failure, syndromes, and acute kidney injury. For patients with hypoplastic left heart syndrome undergoing the Norwood procedure, the frequency of pharmacologic therapies and cardiac arrest has decreased over time. There are significant associations between acute kidney injury, arrythmias, and pulmonary hypertension with cardiac arrest and mortality.
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7
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Risk Factors of Thrombotic Complications and Antithrombotic Therapy in Paediatric Cardiosurgical Patients. ACTA BIOMEDICA SCIENTIFICA 2021. [DOI: 10.29413/abs.2021-6.2.9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
The development of cardiosurgical care for paediatric and neonatal patients is undergoing the rapid growth. Complex, multi-stage reconstructive operations and the use of invasive monitoring are associated with high risk of venous and arterial thrombosis.The cardiac surgery patient is inherently unique, since it requires controlled anticoagulation during cardiopulmonary bypass. Moreover, the most cardiovascular pediatric patients require antithrombotic measures over the perioperative period. In addition to medication support with the use of various groups of antithrombotic agents, vascular access management is justified in order to minimize the risk of thromboembolic complications, which can affect both the functional status, and common and inter-stage mortality.The purpose of this review was to systematize the available data on risk factors contributing to the development of thrombotic complications in patients with congenital heart disease.An information search was carried out using Internet resources (PubMed, Web of Science, eLibrary.ru); literature sources for period 2015–2020 were analysed. As a result of the analysis of the literature data age-dependent features of the haemostatic system, and associated with the defect pathophysiology, and undergone reconstructive interventions were described. The issues of pathophysiology of univentricular heart defects and risk factors associated with thrombosis were also covered.Moreover, aspects of intraoperative anti-thrombotic support are discussed, as well as measures to prevent thromboembolic complications in this population.Coordinated actions of haematologists, cardiologists, anaesthesiologists, intensivists, and cardiac surgeons will allow achieving a fine balance between risks of bleeding and thrombosis in the population of paediatric patients undergoing cardiovascular surgery.
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Vargas D, Zhou H, Yu X, Diamond S, Yeh J, Allada V, Krishnamurthy G, Price M, Allen B, Alexander J, Schmidhofer J, Kreutzer J, Vincent J, Morell V, Bacha E, Diacovo T. Cangrelor PK/PD analysis in post-operative neonatal cardiac patients at risk for thrombosis. J Thromb Haemost 2021; 19:202-211. [PMID: 33078501 DOI: 10.1111/jth.15141] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 10/07/2020] [Accepted: 10/12/2020] [Indexed: 01/18/2023]
Abstract
Essentials An optimal therapeutic strategy has yet to be established to prevent early shunt thrombosis. A phase 1 study of cangrelor was performed in neonates after palliation of congenital heart disease. PD endpoint of >90% platelet inhibition in 60% of patients was achieved at 0.5 µg/kg/min dosing. No serious adverse events related to drug administration were observed, including bleeding. ABSTRACT: Background Systemic-to-pulmonary artery shunt thrombosis is a significant cause of early postoperative mortality in neonates after palliation of congenital heart disease. In the context of thromboprophylaxis, an optimal therapeutic strategy has yet to be established before aspirin administration. Cangrelor, a fast-acting, reversible P2Y12 inhibitor, may fill this unmet need. Objectives To evaluate the pharmacokinetics (PK), pharmacodynamics (PD), and safety of cangrelor in neonates undergoing stage 1 palliation. Methods This prospective, open-label, single-arm study evaluated two cangrelor dosing cohorts following placement of a systemic-to-pulmonary artery shunt, right ventricle-to-pulmonary artery shunt, or ductal stent. Drug concentrations and platelet reactivity, assessed by light transmission aggregometry and in microfluidic assays (MF), were measured. Results Twenty-two patients were consented and 15 received a 1-hour infusion of cangrelor at either 0.5 µg/kg/min (cohort 1) or 0.25 µg/kg/min (cohort 2). Whereas the primary PD endpoint was achieved at the higher dose (ie, reduction in maximal platelet aggregation by ≥90% in 60% of participants), only 29% of those in cohort 2 attained this goal. Comparable and statistically significant results were obtained in MF assays (P < .0001 vs. baseline). Drug levels during infusion were 3-fold higher in cohort 1 vs. cohort 2 (P < .001). Most participants (70%) had undetectable drug levels by 10 minutes postinfusion with full recovery in platelet function at 1 hour. No drug-related bleeding events occurred. Conclusions Favorable PK/PD properties of cangrelor 0.5 µg/kg/min dosing and safety profile warrant further evaluation in neonates following palliative cardiac procedures.
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Affiliation(s)
- Diana Vargas
- Department of Pediatrics, Columbia University Medical Center, New York, NY, USA
| | - Hairu Zhou
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Xinren Yu
- Department of Chemical and Biomolecular Engineering, University of Pennsylvania, Philadelphia, PA, USA
| | - Scott Diamond
- Department of Chemical and Biomolecular Engineering, University of Pennsylvania, Philadelphia, PA, USA
| | - Justin Yeh
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Vivekanand Allada
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Ganga Krishnamurthy
- Department of Pediatrics, Columbia University Medical Center, New York, NY, USA
| | | | | | | | - Joseph Schmidhofer
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jacqueline Kreutzer
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Julie Vincent
- Department of Pediatrics, Columbia University Medical Center, New York, NY, USA
| | - Victor Morell
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Emile Bacha
- Department of Surgery, Columbia University School of Medicine, New York, NY, USA
| | - Thomas Diacovo
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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9
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McVea S, McGettrick A. Fifteen-minute consultation: Assessing the child with a Blalock-Taussig shunt who is unwell in a district general hospital. Arch Dis Child Educ Pract Ed 2020; 105:142-146. [PMID: 31278077 DOI: 10.1136/archdischild-2018-315875] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Revised: 06/20/2019] [Accepted: 06/22/2019] [Indexed: 12/28/2022]
Abstract
Univentricular heart disease accounts for ~1.25% of all congenital heart disease. Such cases remain among the most challenging to manage, typically requiring a three-staged palliation. The first stage involves placement of a systemic to pulmonary shunt. While a variety of shunt types, including ductal stenting, can be used to manage univentricular conditions, the archetype remains the Blalock-Taussig (BT) shunt. While waiting future palliative intervention at home, intercurrent illness may necessitate presentation to a district general hospital where subspecialist advice and assessment is remote. This review aims to present the general paediatrician with a straightforward BT shunt physiology overview highlighting unique complications which may complicate intercurrent illness.
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Affiliation(s)
- Steven McVea
- Paediatric Intensive Care, Royal Hospital for Children Glasgow, Glasgow, UK
| | - Anne McGettrick
- Paediatric Critical Care, Royal Hospital for Children Glasgow, Glasgow, UK
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10
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Schlueter SM, Wilhelm M, Anagnostopoulos PV, Al-Subu AM. Pulmonary Embolism in a Neonate Following Modified Norwood Procedure With Sano Shunt. World J Pediatr Congenit Heart Surg 2020; 10:638-640. [PMID: 31496419 DOI: 10.1177/2150135119853283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Pulmonary embolism is a rare but potentially fatal complication in neonates with congenital heart disease. The authors report a case of pulmonary embolism in the immediate postoperative period following modified Norwood procedure with Sano shunt. In addition, this report discusses the initial evaluation and available anticoagulation options to treat pulmonary embolism in children with congenital heart disease.
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Affiliation(s)
- Sarah M Schlueter
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Michael Wilhelm
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Petros V Anagnostopoulos
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Awni M Al-Subu
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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11
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Bautista-Hernandez V, Avila-Alvarez A, Marx GR, Del Nido PJ. [Current surgical options and outcomes for newborns with hypoplastic left heart syndrome]. An Pediatr (Barc) 2019; 91:352.e1-352.e9. [PMID: 31694800 DOI: 10.1016/j.anpedi.2019.09.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 09/09/2019] [Indexed: 02/02/2023] Open
Abstract
Since the first successful palliation was performed by Norwood et al. in 1983, there have been substantial changes in diagnosis, management, and outcomes of hypoplastic left heart syndrome, Survival for stage 1 palliation has increased to 90% in many centres, with patients potentially surviving into adulthood. However, the associated morbidity and mortality remain substantial. Although the principles of staged surgical palliation of hypoplastic left heart syndrome are well established, there is significant variability in surgical procedure and management between centres, and several controversial aspects remain unresolved. In this review, we summarize the current surgical and management options for newborns with hypoplastic left heart syndrome and their outcomes.
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Affiliation(s)
- Victor Bautista-Hernandez
- Servicio de Cirugía Cardiovascular, Complexo Hospitalario Universitario de A Coruña (CHUAC), A Coruña, España; Cardiopatía Estructural y Congénita, Instituto de Investigación Biomédica A Coruña (INIBIC), A Coruña, España.
| | - Alejandro Avila-Alvarez
- Cardiopatía Estructural y Congénita, Instituto de Investigación Biomédica A Coruña (INIBIC), A Coruña, España; Unidad de Neonatología, Servicio de Pediatría, Complexo Hospitalario Universitario de A Coruña (CHUAC), A Coruña, España
| | - Gerald R Marx
- Servicio de Cardiología, Boston Children'S Hospital/Harvard Medical School, Boston, Estados Unidos
| | - Pedro J Del Nido
- Servicio de Cirugía Cardíaca, Boston Children's Hospital/Harvard Medical School, Boston, Estados Unidos
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12
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Current surgical options and outcomes for newborns with hypoplastic left heart syndrome. An Pediatr (Barc) 2019. [DOI: 10.1016/j.anpede.2019.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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13
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Abstract
OBJECTIVE Shunt-related adverse events are frequent in infants after modified Blalock-Taussig despite use of acetylsalicylic acid prophylaxis. A higher incidence of acetylsalicylic acid-resistance and sub-therapeutic acetylsalicylic acid levels has been reported in infants. We evaluated whether using high-dose acetylsalicylic acid can decrease shunt-related adverse events in infants after modified Blalock-Taussig. METHODS In this single-centre retrospective cohort study, we included infants ⩽1-year-old who underwent modified Blalock-Taussig placement and received acetylsalicylic acid in the ICU. We defined acetylsalicylic acid treatment groups as standard dose (⩽7 mg/kg/day) and high dose (⩾8 mg/kg/day) based on the initiating dose. RESULTS There were 34 infants in each group. Both groups were similar in age, gender, cardiac defect type, ICU length of stay, and time interval to second stage or definitive repair. Shunt interventions (18 versus 32%, p=0.16), shunt thrombosis (14 versus 17%, p=0.74), and mortality (9 versus 12%, p=0.65) were not significantly different between groups. On multiple logistic regression analysis, single-ventricle morphology (odds ratio 5.2, 95% confidence interval of 1.2-23, p=0.03) and post-operative red blood cells transfusion ⩾24 hours [odds ratio 15, confidence interval of (3-71), p<0.01] were associated with shunt-related adverse events. High-dose acetylsalicylic acid treatment [odds ratio 2.6, confidence interval of (0.7-10), p=0.16] was not associated with decrease in these events. CONCLUSIONS High-dose acetylsalicylic acid may not be sufficient in reducing shunt-related adverse events in infants after modified Blalock-Taussig. Post-operative red blood cells transfusion may be a modifiable risk factor for these events. A randomised trial is needed to determine appropriate acetylsalicylic acid dosing in infants with modified Blalock-Taussig.
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Agarwal A, Firdouse M, Brar N, Yang A, Lambiris P, Chan AK, Mondal TK. Incidence and Management of Thrombotic and Thromboembolic Complications Following the Superior Cavopulmonary Anastomosis Procedure: A Literature Review. Clin Appl Thromb Hemost 2017; 24:405-415. [PMID: 29277101 PMCID: PMC6714653 DOI: 10.1177/1076029617739702] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The objective of this literature review was to estimate the incidence of thrombosis and thromboembolism associated with the superior cavopulmonary anastomosis (SCPA) procedure and its variants and to examine current thromboprophylaxis regimens utilized. MEDLINE and EMBASE were searched from inception to August 2017 for all prospective and retrospective cohort studies explicitly reporting incidence of thrombosis, thromboembolism, or shunt occlusion in neonates, infants, and children undergoing 1 or more variants of the SCPA procedure. End points included thrombotic events and thromboembolic events (strokes and pulmonary embolisms) as primary outcomes, and overall mortality as a secondary outcome, at the last available follow-up time point. Of 1303 unique references identified, 13 cohort studies were deemed eligible. Reported incidence of thrombosis and thromboembolic events ranged from 0% to 28.0% and from 0% to 12.5%, respectively. Reported incidence of major bleeding events ranged from 0% to 2.9%. Reported overall mortality ranged from 2.5% to 50.5% across studies. Thromboprophylaxis protocols varied across institutions and studies, most commonly involving unfractionated heparin (UFH), warfarin, enoxaparin, acetylsalicylic acid (ASA), or combinations of ASA and warfarin, ASA and low-molecular-weight heparin (LMWH), UFH and LMWH, and UFH and ASA; several studies did not specify a protocol. Due to substantial variability in reported event rates, no clear correlation was identified between prophylaxis protocols and postoperative thrombotic complications. Despite guidance recommending postoperative UFH as standard practice, thromboprophylaxis protocols varied across institutions and studies. More robust trials evaluating different thromboprophylaxis regimens for the management of these patients are warranted.
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Affiliation(s)
- Arnav Agarwal
- 1 Department of Pediatrics, McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada.,2 School of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Mohammed Firdouse
- 1 Department of Pediatrics, McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada.,2 School of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Nishaan Brar
- 2 School of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Andy Yang
- 3 Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Panos Lambiris
- 4 University Health Network Library and Information Services, Toronto General Hospital, Toronto, Ontario, Canada
| | - Anthony K Chan
- 1 Department of Pediatrics, McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada
| | - Tapas Kumar Mondal
- 1 Department of Pediatrics, McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada
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Kaza EA, Egalka MC, Zhou H, Chen J, Evans D, Prats J, Li R, Diamond SL, Vincent JA, Bacha EA, Diacovo TG. P2Y 12 Receptor Function and Response to Cangrelor in Neonates With Cyanotic Congenital Heart Disease. JACC Basic Transl Sci 2017; 2:465-476. [PMID: 29057376 PMCID: PMC5646421 DOI: 10.1016/j.jacbts.2017.04.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Platelets from neonatal patients with cyanotic congenital heart disease have a nearly identical response to adenosine diphosphate activation and P2Y12 receptor blockade with cangrelor as their adult counterparts. Integrating high-throughput technologies with unique biological platforms can provide considerable insight into the potential clinical use of antiplatelet agents for neonatal and pediatric patients at risk for thrombosis. Cangrelor may prove to be an effective antithrombotic drug with pharmacological properties well suited for use in the immediate post-operative period for neonates palliated with systemic-to-pulmonary artery shunts.
Shunt thrombosis remains a major cause of morbidity and mortality, especially during the initial palliation for single-ventricle physiology. The authors present evidence that the P2Y12 inhibitor cangrelor may fill a therapeutic void in thromboprophylaxis. They base this theory on results showing that platelets from neonatal patients with cyanotic congenital heart disease have a robust response to adenosine diphosphate and are amenable to P2Y12 inhibition with cangrelor. Unique to this study was their ability to establish drug efficacy in an avatar mouse model that permits the in vivo evaluation of human platelet–mediated thrombus formation illustrating that this P2Y12 inhibitor yields the intended biological response.
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Affiliation(s)
- Elisabeth A Kaza
- Division of Neonatology, Columbia University Medical Center, New York, New York
| | - Matthew C Egalka
- Division of Neonatology, Columbia University Medical Center, New York, New York
| | - Hairu Zhou
- Division of Neonatology, Columbia University Medical Center, New York, New York
| | - Jianchun Chen
- Division of Neonatology, Columbia University Medical Center, New York, New York
| | | | - Jayne Prats
- The Medicines Company, Parsippany, New Jersey
| | - Ruizhi Li
- Department of Chemical and Biomolecular Engineering, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Scott L Diamond
- Department of Chemical and Biomolecular Engineering, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Julie A Vincent
- Division of Cardiology, Columbia University Medical Center, New York, New York.,Department of Pediatrics, Columbia University Medical Center, New York, New York
| | - Emile A Bacha
- Department of Surgery, Columbia University Medical Center, New York, New York
| | - Thomas G Diacovo
- Division of Neonatology, Columbia University Medical Center, New York, New York.,Department of Pediatrics, Columbia University Medical Center, New York, New York.,Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York
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