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Bassareo PP. Innominate Vein Turndown Procedure as Another Option for Lymphatic Abnormalities in Fontan Patients. Radiol Cardiothorac Imaging 2024; 6:e240257. [PMID: 39115408 PMCID: PMC11369645 DOI: 10.1148/ryct.240257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/06/2024]
Affiliation(s)
- Pier Paolo Bassareo
- University College of Dublin School of Medicine, Mater Misericordiae University Hospital and Children’s Health Ireland Crumlin, Eccles Street, Dublin, Ireland D07 R2WY
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Smood B, Smith C, Dori Y, Mavroudis CD, Fuller S, Gaynor JW, Maeda K. Lymphatic failure and lymphatic interventions: Knowledge gaps and future directions for a new frontier in congenital heart disease. Semin Pediatr Surg 2024; 33:151426. [PMID: 38820801 PMCID: PMC11229519 DOI: 10.1016/j.sempedsurg.2024.151426] [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] [Indexed: 06/02/2024]
Abstract
Lymphatic failure is a broad term that describes the lymphatic circulation's inability to adequately transport fluid and solutes out of the interstitium and into the systemic venous circulation, which can result in dysfunction and dysregulation of immune responses, dietary fat absorption, and fluid balance maintenance. Several investigations have recently elucidated the nexus between lymphatic failure and congenital heart disease, and the associated morbidity and mortality is now well-recognized. However, the precise pathophysiology and pathogenesis of lymphatic failure remains poorly understood and relatively understudied, and there are no targeted therapeutics or interventions to reliably prevent its development and progression. Thus, there is growing enthusiasm towards the development and application of novel percutaneous and surgical lymphatic interventions. Moreover, there is consensus that further investigations are needed to delineate the underlying mechanisms of lymphatic failure, which could help identify novel therapeutic targets and develop innovative procedures to improve the overall quality of life and survival of these patients. With these considerations, this review aims to provide an overview of the lymphatic circulation and its vasculature as it relates to current understandings into the pathophysiology and pathogenesis of lymphatic failure in patients with congenital heart disease, while also summarizing strategies for evaluating and managing lymphatic complications, as well as specific areas of interest for future translational and clinical research efforts.
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Affiliation(s)
- Benjamin Smood
- Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, United States of America; Division of Cardiovascular Surgery, Department of Surgery, The University of Pennsylvania, Philadelphia, Pennsylvania, 19104, United States of America.
| | - Christopher Smith
- Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, Philadelphia, PA, United States; Department of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, 19104 United States of America
| | - Yoav Dori
- Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, Philadelphia, PA, United States; Department of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, 19104 United States of America
| | - Constantine D Mavroudis
- Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, United States of America; Division of Cardiovascular Surgery, Department of Surgery, The University of Pennsylvania, Philadelphia, Pennsylvania, 19104, United States of America
| | - Stephanie Fuller
- Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, United States of America; Division of Cardiovascular Surgery, Department of Surgery, The University of Pennsylvania, Philadelphia, Pennsylvania, 19104, United States of America
| | - J William Gaynor
- Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, United States of America; Division of Cardiovascular Surgery, Department of Surgery, The University of Pennsylvania, Philadelphia, Pennsylvania, 19104, United States of America
| | - Katsuhide Maeda
- Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, United States of America; Division of Cardiovascular Surgery, Department of Surgery, The University of Pennsylvania, Philadelphia, Pennsylvania, 19104, United States of America; Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, Philadelphia, PA, United States
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Juaneda I, Kreutzer C, Jatene MB. Fifth "Jatene Lecture on Surgical Innovation": Innovation in Congenital Heart Surgery: Contributions From South America. World J Pediatr Congenit Heart Surg 2024; 15:265-269. [PMID: 38404004 DOI: 10.1177/21501351241227881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Abstract
We present the fifth "Jatene Lecture on Surgical Innovation" on Innovation in Congenital Heart Surgery, given at the Eighth Scientific Meeting of the World Society for Pediatric and Congenital Heart Surgery and Eighth World Congress of Pediatric Cardiology and Cardiac Surgery in Washington DC in 2023. We highlight what surgical innovation is and how innovation was accomplished in cardiac surgery and particularly in congenital heart surgery. A brief history of the development of congenital heart surgery across the world is summarized and we finally illustrate the South American contributions to congenital heart surgery, acknowledging the great innovations of Adib Jatene and Guillermo Kreutzer to our field.
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Affiliation(s)
- Ignacio Juaneda
- Congenital Heart Surgery, Hospital Privado Universitario de Córdoba, Cordoba, Argentina
- Congenital Heart Surgery, Hospital de Niños de Córdoba, Cordoba, Argentina
| | - Christian Kreutzer
- Congenital Heart Surgery, Hospital Privado Universitario de Córdoba, Cordoba, Argentina
- Congenital Heart Surgery, Hospital Universitario Austral, Pilar, Argentina
| | - Marcelo B Jatene
- Congenital Heart Surgery, Instituto do Coração, Hospital das Clínicas, Universidade de São Paulo, São Paulo, Brazil
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Smith CL, Dori Y, O'Byrne ML, Glatz AC, Gillespie MJ, Rome JJ. Transcatheter Thoracic Duct Decompression for Multicompartment Lymphatic Failure After Fontan Palliation. Circ Cardiovasc Interv 2022; 15:e011733. [PMID: 35708032 DOI: 10.1161/circinterventions.121.011733] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Lymphatic embolization therapy has proven effective for Fontan failure from plastic bronchitis or protein-losing enteropathy but not when multiple lymphatic compartments are involved; furthermore, embolization does not alter the underlying pathophysiology of lymphatic dysfunction. A technique for transcatheter thoracic duct decompression (TDD), rerouting the thoracic duct to the pulmonary venous atrium to treat multicompartment lymphatic failure is described and early outcomes presented. METHODS Initially covered stents were used to channel the innominate vein flow inside of the cavopulmonary pathway into the pulmonary venous atrium. A modified approach was developed where covered stents redirected innominate vein directly to the left atrium via an extravascular course. Baseline and follow-up data on all patients undergoing TDD were reviewed. RESULTS Twelve patients underwent TDD between March 2018 and February 2021 at a median age of 12 (range: 2-22) years. Lymphatic failure occurred in median of 3 compartments per patient (protein-losing enteropathy, ascites, pleural effusions, plastic bronchitis); 10 patients had lymphatic embolizations before TDD. TDD method was intra-Fontan tunnel in 4, direct approach in 7, and other in 1. There were no major procedural complications; 6 patients underwent subsequent procedures, most commonly to treat endoleaks. Lymphatic failure resolved in 6 patients, improved in 2, and was unchanged in 4 at 6 (range: 1-20) months follow-up. One patient died after TDD from Fontan failure. CONCLUSIONS TDD is a promising new treatment for the failing Fontan physiology from multicompartment lymphatic failure. Additional work is needed to refine the technique and define optimal candidates.
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Affiliation(s)
- Christopher L Smith
- Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania
| | - Yoav Dori
- Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania
| | - Michael L O'Byrne
- Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania
| | - Andrew C Glatz
- Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania
| | - Matthew J Gillespie
- Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania
| | - Jonathan J Rome
- Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania
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Protein-losing enteropathy in Fontan circulation: Pathophysiology, outcome and treatment options of a complex condition. INTERNATIONAL JOURNAL OF CARDIOLOGY CONGENITAL HEART DISEASE 2022. [DOI: 10.1016/j.ijcchd.2022.100322] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
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Mackie AS, Veldtman GR, Thorup L, Hjortdal VE, Dori Y. Plastic Bronchitis and Protein-Losing Enteropathy in the Fontan Patient: Evolving Understanding and Emerging Therapies. Can J Cardiol 2022; 38:988-1001. [DOI: 10.1016/j.cjca.2022.03.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 03/08/2022] [Accepted: 03/12/2022] [Indexed: 12/17/2022] Open
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Dori Y, Smith CL. Lymphatic Disorders in Patients With Single Ventricle Heart Disease. Front Pediatr 2022; 10:828107. [PMID: 35757132 PMCID: PMC9226478 DOI: 10.3389/fped.2022.828107] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 05/11/2022] [Indexed: 11/13/2022] Open
Abstract
Lymphatic abnormalities in patients with single ventricle physiology can lead to early Fontan failure and severe Fontan complications, such as protein-losing enteropathy (PLE), plastic bronchitis (PB), chylothorax, and edema. Recent developments in lymphatic imaging and interventions have shed new light on the lymphatic dysfunction in this patient population and the role of the lymphatic circulation in PLE, PB, and chylothorax. In this study, we reviewed some of the latest developments in this field and discuss new treatment options for these patients.
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Affiliation(s)
- Yoav Dori
- Department of Cardiology, Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Christopher L Smith
- Department of Cardiology, Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, Philadelphia, PA, United States
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Alsaied T, Lubert AM, Goldberg DJ, Schumacher K, Rathod R, Katz DA, Opotowsky AR, Jenkins M, Smith C, Rychik J, Amdani S, Lanford L, Cetta F, Kreutzer C, Feingold B, Goldstein BH. Protein losing enteropathy after the Fontan operation. INTERNATIONAL JOURNAL OF CARDIOLOGY CONGENITAL HEART DISEASE 2022. [DOI: 10.1016/j.ijcchd.2022.100338] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Juaneda E, Catalfamo D, Fregapani JP, Peirone A, Juaneda I, Kreutzer C, Lucino S. Magnetic resonance lymphangiography in group 1 paediatric pulmonary arterial hypertension. Pulm Circ 2021; 11:20458940211004777. [PMID: 33868641 PMCID: PMC8020108 DOI: 10.1177/20458940211004777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 03/04/2021] [Indexed: 11/17/2022] Open
Abstract
Pulmonary hypertension could have thoracic lymphatic abnormalities caused by
right ventricular failure. Since there is no description of such abnormalities,
the purpose of this study was to investigate them with magnetic resonance.
Prospective review magnetic resonance T2-weighted lymphangiography was performed
between January 2017 and October 2019 through quantitative thoracic duct
diameter, diameter index and qualitative lymphatic abnormalities types: 1 –
little or none abnormalities, 2 – abnormalities in supraclavicular region, 3 –
abnormalities extending into the mediastinum and 4 – abnormalities extending
into the lung. Five patients with group 1 pulmonary arterial hypertension
participated in this study. The mean age was 12.44 ± 4.92 years, three male and
two female. The quantitative analysis yielded the following results: mean
thoracic duct diameter of 2.92 ± 0.16 mm and thoracic duct index 2.28 ± 1.03
mm/m2. Qualitative lymphangiography abnormalities were type 1 in
three patients, type 2 in one, all with low-risk determinants, and type 3 in one
with high-risk determinants and right ventricular failure. Magnetic resonance
T2-weighted lymphangiography in group 1 paediatric pulmonary arterial
hypertension allowed for the identification of the thoracic duct, which was used
to perform both quantitative and qualitative analysis of thoracic lymphatic
abnormalities, in particular when increased high-risk determinants and right
ventricular failure were present. These features represent an extracardiac
finding useful to understand systemic venous congestion impact on lymphatic
system.
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Affiliation(s)
- Ernesto Juaneda
- Hospital de Niños, Hospital Privado Universitario and Instituto Oulton-Catholic University of Córdoba, Córdoba, Argentina
| | - Danilo Catalfamo
- Instituto Oulton, Catholic University of Córdoba, Córdoba, Argentina
| | - Juan P Fregapani
- Instituto Oulton, Catholic University of Córdoba, Córdoba, Argentina
| | - Alejandro Peirone
- Hospital de Niños and Hospital Privado Universitario de Córdoba, Córdoba, Argentina
| | - Ignacio Juaneda
- Hospital de Niños and Hospital Privado Universitario de Córdoba, Córdoba, Argentina
| | | | - Sergio Lucino
- Instituto Oulton, Catholic University of Córdoba, Córdoba, Argentina
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Hraska V, Hjortdal VE, Dori Y, Kreutzer C. Innominate vein turn-down procedure: Killing two birds with one stone. JTCVS Tech 2021; 7:253-260. [PMID: 34318266 PMCID: PMC8312117 DOI: 10.1016/j.xjtc.2021.01.045] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 01/19/2021] [Indexed: 11/18/2022] Open
Affiliation(s)
- Viktor Hraska
- Division of Pediatric Cardiothoracic Surgery, Herma Heart Institute, Children's Wisconsin, Milwaukee, Wis
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wis
- Address for reprints: Viktor Hraska, MD, PhD, Division of Pediatric Cardiothoracic Surgery, Herma Heart Institute, Children's Wisconsin, 9000 W. Wisconsin Ave, B730, Milwaukee, WI 53226.
| | - Vibeke E. Hjortdal
- Department of Cardiothoracic Surgery, Rigshospitalet, Copenhagen, Denmark
| | - Yoav Dori
- Jill and Mark Fishman Center for Lymphatic Disorders and Lymphatic Research, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Christian Kreutzer
- Division of Pediatric Cardiovascular Surgery, Hospital Universitario Austral, Universidad Austral, Pilar, Buenos Aires, Argentina
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