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Govindarajan V, Marshall L, Sahni A, Cetatoiu MA, Eickhoff EE, Davee J, St Clair N, Schulz NE, Hoganson DM, Hammer PE, Ghelani SJ, Prakash A, Del Nido PJ, Rathod RH. Impact of Age-Related Change in Caval Flow Ratio on Hepatic Flow Distribution in the Fontan Circulation. Circ Cardiovasc Imaging 2024; 17:e016104. [PMID: 38567518 PMCID: PMC11073583 DOI: 10.1161/circimaging.123.016104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 03/15/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND The Fontan operation is a palliative technique for patients born with single ventricle heart disease. The superior vena cava (SVC), inferior vena cava (IVC), and hepatic veins are connected to the pulmonary arteries in a total cavopulmonary connection by an extracardiac conduit or a lateral tunnel connection. A balanced hepatic flow distribution (HFD) to both lungs is essential to prevent pulmonary arteriovenous malformations and cyanosis. HFD is highly dependent on the local hemodynamics. The effect of age-related changes in caval inflows on HFD was evaluated using cardiac magnetic resonance data and patient-specific computational fluid dynamics modeling. METHODS SVC and IVC flow from 414 patients with Fontan were collected to establish a relationship between SVC:IVC flow ratio and age. Computational fluid dynamics modeling was performed in 60 (30 extracardiac and 30 lateral tunnel) patient models to quantify the HFD that corresponded to patient ages of 3, 8, and 15 years, respectively. RESULTS SVC:IVC flow ratio inverted at ≈8 years of age, indicating a clear shift to lower body flow predominance. Our data showed that variation of HFD in response to age-related changes in caval inflows (SVC:IVC, 2, 1, and 0.5 corresponded to ages, 3, 8, and 15+, respectively) was not significant for extracardiac but statistically significant for lateral tunnel cohorts. For all 3 caval inflow ratios, a positive correlation existed between the IVC flow distribution to both the lungs and the HFD. However, as the SVC:IVC ratio changed from 2 to 0.5 (age, 3-15+) years, the correlation's strength decreased from 0.87 to 0.64, due to potential flow perturbation as IVC flow momentum increased. CONCLUSIONS Our analysis provided quantitative insights into the impact of the changing caval inflows on Fontan's long-term HFD, highlighting the importance of SVC:IVC variations over time on Fontan's long-term hemodynamics. These findings broaden our understanding of Fontan hemodynamics and patient outcomes.
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Affiliation(s)
- Vijay Govindarajan
- Departments of Cardiovascular Surgery (V.G., L.M., A.S., M.A.C., E.E.E., J.D., N.S.C., N.E.S., D.M.H., P.E.H., S.J.G., A.P., P.J.d.N.), Boston Children's Hospital, MA
- Surgery (V.G., D.M.H., P.E.H.), Harvard Medical School, Boston, MA
- Department of Internal Medicine, University of Texas Health Science Center at Houston (V.G.)
| | - Lauren Marshall
- Departments of Cardiovascular Surgery (V.G., L.M., A.S., M.A.C., E.E.E., J.D., N.S.C., N.E.S., D.M.H., P.E.H., S.J.G., A.P., P.J.d.N.), Boston Children's Hospital, MA
| | - Akshita Sahni
- Departments of Cardiovascular Surgery (V.G., L.M., A.S., M.A.C., E.E.E., J.D., N.S.C., N.E.S., D.M.H., P.E.H., S.J.G., A.P., P.J.d.N.), Boston Children's Hospital, MA
| | - Maria A Cetatoiu
- Departments of Cardiovascular Surgery (V.G., L.M., A.S., M.A.C., E.E.E., J.D., N.S.C., N.E.S., D.M.H., P.E.H., S.J.G., A.P., P.J.d.N.), Boston Children's Hospital, MA
| | - Emily E Eickhoff
- Departments of Cardiovascular Surgery (V.G., L.M., A.S., M.A.C., E.E.E., J.D., N.S.C., N.E.S., D.M.H., P.E.H., S.J.G., A.P., P.J.d.N.), Boston Children's Hospital, MA
| | - Jocelyn Davee
- Departments of Cardiovascular Surgery (V.G., L.M., A.S., M.A.C., E.E.E., J.D., N.S.C., N.E.S., D.M.H., P.E.H., S.J.G., A.P., P.J.d.N.), Boston Children's Hospital, MA
| | - Nicole St Clair
- Departments of Cardiovascular Surgery (V.G., L.M., A.S., M.A.C., E.E.E., J.D., N.S.C., N.E.S., D.M.H., P.E.H., S.J.G., A.P., P.J.d.N.), Boston Children's Hospital, MA
| | - Noah E Schulz
- Departments of Cardiovascular Surgery (V.G., L.M., A.S., M.A.C., E.E.E., J.D., N.S.C., N.E.S., D.M.H., P.E.H., S.J.G., A.P., P.J.d.N.), Boston Children's Hospital, MA
| | - David M Hoganson
- Departments of Cardiovascular Surgery (V.G., L.M., A.S., M.A.C., E.E.E., J.D., N.S.C., N.E.S., D.M.H., P.E.H., S.J.G., A.P., P.J.d.N.), Boston Children's Hospital, MA
- Surgery (V.G., D.M.H., P.E.H.), Harvard Medical School, Boston, MA
| | - Peter E Hammer
- Departments of Cardiovascular Surgery (V.G., L.M., A.S., M.A.C., E.E.E., J.D., N.S.C., N.E.S., D.M.H., P.E.H., S.J.G., A.P., P.J.d.N.), Boston Children's Hospital, MA
- Surgery (V.G., D.M.H., P.E.H.), Harvard Medical School, Boston, MA
| | - Sunil J Ghelani
- Departments of Cardiovascular Surgery (V.G., L.M., A.S., M.A.C., E.E.E., J.D., N.S.C., N.E.S., D.M.H., P.E.H., S.J.G., A.P., P.J.d.N.), Boston Children's Hospital, MA
- Cardiology (S.J.G., A.P., P.J.d.N., R.H.R.), Boston Children's Hospital, MA
| | - Ashwin Prakash
- Departments of Cardiovascular Surgery (V.G., L.M., A.S., M.A.C., E.E.E., J.D., N.S.C., N.E.S., D.M.H., P.E.H., S.J.G., A.P., P.J.d.N.), Boston Children's Hospital, MA
- Cardiology (S.J.G., A.P., P.J.d.N., R.H.R.), Boston Children's Hospital, MA
| | - Pedro J Del Nido
- Departments of Cardiovascular Surgery (V.G., L.M., A.S., M.A.C., E.E.E., J.D., N.S.C., N.E.S., D.M.H., P.E.H., S.J.G., A.P., P.J.d.N.), Boston Children's Hospital, MA
- Cardiology (S.J.G., A.P., P.J.d.N., R.H.R.), Boston Children's Hospital, MA
| | - Rahul H Rathod
- Cardiology (S.J.G., A.P., P.J.d.N., R.H.R.), Boston Children's Hospital, MA
- Departments of Pediatrics (R.H.R.), Harvard Medical School, Boston, MA
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Govindarajan V, Marshall L, Sahni A, Cetatoiu M, Eickhoff E, Davee J, St Clair N, Schulz N, Hoganson DM, Hammer PE, Ghelani S, Prakash A, Del Nido PJ, Rathod RH. Impact of Age-related change in Caval Flow Ratio on Hepatic Flow Distribution in Fontan. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.09.06.23295166. [PMID: 37732201 PMCID: PMC10508792 DOI: 10.1101/2023.09.06.23295166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Abstract
Background The Fontan operation is a palliative technique for patients born with single ventricle heart disease. The superior vena cava (SVC), inferior vena cava (IVC), and hepatic veins are connected to the pulmonary arteries in a total cavopulmonary connection by an extracardiac (EC) conduit or a lateral tunnel (LT) connection. A balanced hepatic flow distribution (HFD) to both lungs is essential to prevent pulmonary arteriovenous malformations and cyanosis. HFD is highly dependent on the local hemodynamics. Objective The effect of age-related changes in caval inflows on HFD was evaluated using cardiac MRI (CMR) data and patient-specific computational fluid dynamics (CFD) modeling. Methods SVC and IVC flow from 414 Fontan patients were collected to establish a relationship between SVC:IVC flow ratio and age. CFD modeling was performed in 60 (30 EC and 30 LT) patient models to quantify the HFD that corresponded to patient ages of 3, 8, and 15 years, respectively. Results SVC:IVC flow ratio inverted at ∼8 years of age, indicating a clear shift to lower body flow predominance. Our data showed that variation of HFD in response to age-related changes in caval inflows (SVC:IVC = 2,1, and 0.5 corresponded to ages 3, 8, and 15+ respectively) was not significant for EC but statistically significant for LT cohorts. For all three caval inflow ratios, a positive correlation existed between the IVC flow distribution to both the lungs and the HFD. However, as the SVC:IVC ratio changed from 2→0.5 (age 3→15+), the correlation's strength decreased from 0.87→0.64, due to potential flow perturbation as IVC flow momentum increased. Conclusion Our analysis provided quantitative insights into the impact of the changing caval inflows on Fontan's long-term HFD, highlighting the importance of including SVC:IVC variations over time to understand Fontan's long-term hemodynamics. These findings broaden our understanding of Fontan hemodynamics and patient outcomes. Clinical Perspective With improvement in standard of care and management of single ventricle patients with Fontan physiology, the population of adults with Fontan circulation is increasing. Consequently, there is a clinical need to comprehend the impact of patient growth on Fontan hemodynamics. Using CMR data, we were able to quantify the relationship between changing caval inflows and somatic growth. We then used patient-specific computational flow modeling to quantify how this relationship affected the distribution of long-term hepatic flow in extracardiac and lateral tunnel Fontan types. Our findings demonstrated the significance of including SVC:IVC changes over time in CFD modeling to learn more about the long-term hemodynamics of Fontan. Fontan surgical approaches are increasingly planned and optimized using computational flow modeling. For a patient undergoing a Fontan procedure, the workflow presented in this study that takes into account the variations in Caval inflows over time can aid in predicting the long-term hemodynamics in a planned Fontan pathway.
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Van De Bruaene A, Budts W. Collaterals in congenital heart disease: when and how to treat? Cardiovasc Diagn Ther 2023; 13:418-426. [PMID: 37583691 PMCID: PMC10423736 DOI: 10.21037/cdt-23-10] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 03/01/2023] [Indexed: 08/17/2023]
Abstract
The development of collateral circulation is not that rare in patients with congenital heart defects. These collaterals can affect cardiovascular hemodynamics and cause systemic arterial desaturation, which arises the question whether these should be closed. To date, few if any reports have been published on the therapeutic management of collaterals in adult patients with congenital heart disease in heart failure (HF). The focus of this article is to provide a pragmatic approach in the assessment of collateral circulation of the patient with HF. By considering the underlying hemodynamics and overall effects of the collateral circulation, we aim to provide a practical tool useful in clinical decision making. The paper highlights mainly the systemic venous to systemic venous collaterals, systemic venous to pulmonary venous (or pulmonary venous atrium) collaterals, and pulmonary arterio-venous malformations. Systemic venous anomalies are frequent and reported in 20% to 40% of patients who underwent Glenn or Fontan procedure. A reduction in effective pulmonary blood flow, coupled with increasing oxygen demands with growth, as well as a pressure difference between the higher pressure caval venous system and lower pressure atria (so called decompressing collaterals) are potential causes of collateral formation. Whether angiogenesis de novo or reappearance of embryological venous channels is responsible for collateral formation remains to be elucidated.
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Affiliation(s)
- Alexander Van De Bruaene
- Congenital and Structural Cardiology, University Hospitals Leuven, and Department of Cardiovascular Sciences, Catholic University Leuven, Leuven, Belgium
| | - Werner Budts
- Congenital and Structural Cardiology, University Hospitals Leuven, and Department of Cardiovascular Sciences, Catholic University Leuven, Leuven, Belgium
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Schafstedde M, Yevtushenko P, Nordmeyer S, Kramer P, Schleiger A, Solowjowa N, Berger F, Photiadis J, Mykychak Y, Cho MY, Ovroutski S, Kuehne T, Brüning J. Virtual treatment planning in three patients with univentricular physiology using computational fluid dynamics—Pitfalls and strategies. Front Cardiovasc Med 2022; 9:898701. [PMID: 35990961 PMCID: PMC9381838 DOI: 10.3389/fcvm.2022.898701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 07/18/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundUneven hepatic venous blood flow distribution (HFD) to the pulmonary arteries is hypothesized to be responsible for the development of intrapulmonary arteriovenous malformations (PAVM) in patients with univentricular physiology. Thus, achieving uniform distribution of hepatic blood flow is considered favorable. However, no established method for the prediction of the post-interventional hemodynamics currently exists. Computational fluid dynamics (CFD) offers the possibility to quantify HFD in patient-specific anatomies before and after virtual treatment. In this study, we evaluated the potential benefit of CFD-assisted treatment planning.Materials and methodsThree patients with total cavopulmonary connection (TCPC) and PAVM underwent cardiovascular magnetic resonance imaging (CMR) and computed tomography imaging (CT). Based on this imaging data, the patient-specific anatomy was reconstructed. These patients were considered for surgery or catheter-based intervention aiming at hepatic blood flow re-routing. CFD simulations were then performed for the untreated state as well as for different surgical and interventional treatment options. These treatment options were applied as suggested by treating cardiologists and congenital heart surgeons with longstanding experience in interventional and surgical treatment of patients with univentricular physiology. HFD was quantified for all simulations to identify the most viable treatment decision regarding redistribution of hepatic blood flow.ResultsFor all three patients, the complex TCPC anatomy could be reconstructed. However, due to the presence of metallic stent implants, hybrid models generated from CT as well as CMR data were required. Numerical simulation of pre-interventional HFD agreed well with angiographic assessment and physiologic considerations. One treatment option resulting in improvement of HFD was identified for each patient. In one patient follow-up data after treatment was available. Here, the virtual treatment simulation and the CMR flow measurements differed by 15%.ConclusionThe combination of modern computational methods as well as imaging methods for assessment of patient-specific anatomy and flow might allow to optimize patient-specific therapy planning in patients with pronounced hepatic flow mismatch and PAVM. In this study, we demonstrate that these methods can also be applied in patients with complex univentricular physiology and extensive prior interventions. However, in those cases, hybrid approaches utilizing information of different image modalities may be required.
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Affiliation(s)
- Marie Schafstedde
- Department of Congenital Heart Disease–Pediatric Cardiology, German Heart Center Berlin, Berlin, Germany
- Institute for Cardiovascular Computer-Assisted Medicine, Charité–Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
- German Centre for Cardiovascular Research, Partner Site Berlin, Berlin, Germany
- *Correspondence: Marie Schafstedde,
| | - Pavlo Yevtushenko
- Institute for Cardiovascular Computer-Assisted Medicine, Charité–Universitätsmedizin Berlin, Berlin, Germany
| | - Sarah Nordmeyer
- Department of Congenital Heart Disease–Pediatric Cardiology, German Heart Center Berlin, Berlin, Germany
- Institute for Cardiovascular Computer-Assisted Medicine, Charité–Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Kramer
- Department of Congenital Heart Disease–Pediatric Cardiology, German Heart Center Berlin, Berlin, Germany
| | - Anastasia Schleiger
- Department of Congenital Heart Disease–Pediatric Cardiology, German Heart Center Berlin, Berlin, Germany
| | - Natalia Solowjowa
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
| | - Felix Berger
- Department of Congenital Heart Disease–Pediatric Cardiology, German Heart Center Berlin, Berlin, Germany
- German Centre for Cardiovascular Research, Partner Site Berlin, Berlin, Germany
- Department of Pediatric Cardiology, Charité–Universitätsmedizin Berlin, Berlin, Germany
| | - Joachim Photiadis
- Department of Congenital Heart Surgery, German Heart Center Berlin, Berlin, Germany
| | - Yaroslav Mykychak
- Department of Congenital Heart Surgery, German Heart Center Berlin, Berlin, Germany
| | - Mi-Young Cho
- Department of Congenital Heart Surgery, German Heart Center Berlin, Berlin, Germany
| | - Stanislav Ovroutski
- Department of Congenital Heart Disease–Pediatric Cardiology, German Heart Center Berlin, Berlin, Germany
| | - Titus Kuehne
- Department of Congenital Heart Disease–Pediatric Cardiology, German Heart Center Berlin, Berlin, Germany
- Institute for Cardiovascular Computer-Assisted Medicine, Charité–Universitätsmedizin Berlin, Berlin, Germany
- German Centre for Cardiovascular Research, Partner Site Berlin, Berlin, Germany
| | - Jan Brüning
- Institute for Cardiovascular Computer-Assisted Medicine, Charité–Universitätsmedizin Berlin, Berlin, Germany
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Ohuchi H, Mori A, Nakai M, Fujimoto K, Iwasa T, Sakaguchi H, Kurosaki K, Shiraishi I. Pulmonary Arteriovenous Fistulae After Fontan Operation: Incidence, Clinical Characteristics, and Impact on All-Cause Mortality. Front Pediatr 2022; 10:713219. [PMID: 35757115 PMCID: PMC9218217 DOI: 10.3389/fped.2022.713219] [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: 05/22/2021] [Accepted: 02/28/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The Fontan operation is a surgical procedure used in children with univentricular hearts. Pulmonary arteriovenous fistulae (PAVF) is a major complication after a Fontan operation. However, the incidence and related clinical pathophysiology of PAVF remain unclear. PURPOSE This study aimed to clarify the incidence of PAVF, its clinical characteristics, and its influence on all-cause mortality. METHODS AND RESULTS We serially assessed the presence of PAVF using pulmonary artery angiography and/or contrast echocardiography during catheterization in 391 consecutive patients who underwent the Fontan procedure and compared the results with the Fontan pathophysiology and all-cause mortality. PAVF developed in 36 patients (9.2%), including 30 diffuse- and six discrete-PAVF types. The PAVF-free rates at 1, 5, 10, 15, 20, and ≥25 years after Fontan operation were 97, 96, 93, 88, 87, and 83%, respectively. The mean arterial blood oxygen saturation (SaO2) in patients with diffuse PAVF at each corresponding postoperative stage were 90, 91, 91, 91, 89, and 88%, respectively, indicating lower SaO2 levels than those in patients without PAVF (all p < 0.01). However, there was no difference in the SaO2 levels between patients with discrete PAVF and those without PAVF. During a median follow-up period of 2.9 years after the last catheterization, 31 patients, including 12 patients with PAVF, died. Patients with PAVF, especially those with diffuse PAVF, had a higher mortality rate (p = 0.01) than those without PAVF (hazard ratio: 3.6, 95% confidence interval: 1.6-7.8, p = 0.0026). CONCLUSION Patients who underwent Fontan surgery had an increased incidence of PAVF as they aged. Discrete PAVF did not influence SaO2 or mortality, whereas the presence of diffuse PAVF caused hypoxia and was associated with all-cause mortality.
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Affiliation(s)
- Hideo Ohuchi
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Suita, Japan.,Adult Congenital Heart Disease, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Aki Mori
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Michikazu Nakai
- Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kazuto Fujimoto
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Toru Iwasa
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Heima Sakaguchi
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kenichi Kurosaki
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Isao Shiraishi
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Suita, Japan
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Nickel NP, Galura GM, Zuckerman MJ, Hakim MN, Alkhateeb H, Mukherjee D, Austin ED, Heresi GA. Liver abnormalities in pulmonary arterial hypertension. Pulm Circ 2021; 11:20458940211054304. [PMID: 34707859 PMCID: PMC8544777 DOI: 10.1177/20458940211054304] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 09/13/2021] [Indexed: 12/17/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is a cardiopulmonary disease with high mortality. In recent years, it has been recognized that PAH is a multi-organ system disease, involving the systemic circulation, kidneys, skeletal muscles, and the central nervous system, among others. Right heart failure produces congestive hepatopathy, a disease state that has direct consequences on liver biochemistry, histology, and systemic glucose and lipid metabolism. This article aims to summarize the consequences of congestive hepatopathy with an emphasis on liver biochemistry, histology, and PAH-targeted therapy. Furthermore, PAH-specific changes in glucose and lipid metabolism will be discussed.
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Affiliation(s)
- Nils P. Nickel
- Division of Pulmonary and Critical Care Medicine, Texas Tech
University Health Sciences Center, El Paso, TX, USA
| | - Gian M. Galura
- Division of Gastroenterology, Texas Tech University Health
Sciences Center, El Paso, TX, USA
| | - Marc J. Zuckerman
- Division of Gastroenterology, Texas Tech University Health
Sciences Center, El Paso, TX, USA
| | - M. Nawar Hakim
- Department of Pathology, Texas Tech University Health Sciences
Center, El Paso, TX, USA
| | - Haider Alkhateeb
- Division of Cardiovascular Medicine, Texas Tech University
Health Sciences Center, El Paso, TX, USA
| | - Debabrata Mukherjee
- Division of Cardiovascular Medicine, Texas Tech University
Health Sciences Center, El Paso, TX, USA
| | - Eric D. Austin
- Division of Pediatric Pulmonary Medicine, Vanderbilt University,
Nashville, TN, USA
| | - Gustavo A. Heresi
- Division of Pulmonary and Critical Care Medicine, Cleveland
Clinic, OH, USA
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van der Woude SFS, Rijnberg FM, Hazekamp MG, Jongbloed MRM, Kenjeres S, Lamb HJ, Westenberg JJM, Roest AAW, Wentzel JJ. The Influence of Respiration on Blood Flow in the Fontan Circulation: Insights for Imaging-Based Clinical Evaluation of the Total Cavopulmonary Connection. Front Cardiovasc Med 2021; 8:683849. [PMID: 34422920 PMCID: PMC8374887 DOI: 10.3389/fcvm.2021.683849] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 07/05/2021] [Indexed: 12/18/2022] Open
Abstract
Congenital heart disease is the most common birth defect and functionally univentricular heart defects represent the most severe end of this spectrum. The Fontan circulation provides an unique solution for single ventricle patients, by connecting both caval veins directly to the pulmonary arteries. As a result, the pulmonary circulation in Fontan palliated patients is characterized by a passive, low-energy circulation that depends on increased systemic venous pressure to drive blood toward the lungs. The absence of a subpulmonary ventricle led to the widely believed concept that respiration, by sucking blood to the pulmonary circulation during inspiration, is of great importance as a driving force for antegrade blood flow in Fontan patients. However, recent studies show that respiration influences pulsatility, but has a limited effect on net forward flow in the Fontan circulation. Importantly, since MRI examination is recommended every 2 years in Fontan patients, clinicians should be aware that most conventional MRI flow sequences do not capture the pulsatility of the blood flow as a result of the respiration. In this review, the unique flow dynamics influenced by the cardiac and respiratory cycle at multiple locations within the Fontan circulation is discussed. The impact of (not) incorporating respiration in different MRI flow sequences on the interpretation of clinical flow parameters will be covered. Finally, the influence of incorporating respiration in advanced computational fluid dynamic modeling will be outlined.
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Affiliation(s)
- Séline F S van der Woude
- Department of Cardiology, Biomedical Engineering, Biomechanics Laboratory, Rotterdam, Netherlands
| | - Friso M Rijnberg
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands
| | - Mark G Hazekamp
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands
| | - Monique R M Jongbloed
- Department of Anatomy, Embryology and Cardiology, Leiden University Medical Center, Leiden, Netherlands
| | - Sasa Kenjeres
- Department of Chemical Engineering, Faculty of Applied Sciences, Delft University of Technology and J. M. Burgerscentrum Research School for Fluid Mechanics, Delft, Netherlands
| | - Hildo J Lamb
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | - Jos J M Westenberg
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | - Arno A W Roest
- Department of Pediatric Cardiology, Leiden University Medical Center, Leiden, Netherlands
| | - Jolanda J Wentzel
- Department of Cardiology, Biomedical Engineering, Biomechanics Laboratory, Rotterdam, Netherlands
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Escher A, Strauch C, Hubmann EJ, Hübler M, Bortis D, Thamsen B, Mueller M, Kertzscher U, Thamsen PU, Kolar JW, Zimpfer D, Granegger M. A Cavopulmonary Assist Device for Long-Term Therapy of Fontan Patients. Semin Thorac Cardiovasc Surg 2021; 34:238-248. [PMID: 34166811 DOI: 10.1053/j.semtcvs.2021.06.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 06/04/2021] [Indexed: 12/22/2022]
Abstract
Treatment of univentricular hearts remains restricted to palliative surgical corrections (Fontan pathway). The established Fontan circulation lacks a subpulmonary pressure source and is commonly accompanied by progressively declining hemodynamics. A novel cavopulmonary assist device (CPAD) may hold the potential for improved therapeutic management of Fontan patients by chronic restoration of biventricular equivalency. This study aimed at translating clinical objectives toward a functional CPAD with preclinical proof regarding hydraulic performance, hemocompatibility and electric power consumption. A prototype composed of hemocompatible titanium components, ceramic bearings, electric motors, and corresponding drive unit was manufactured for preclinical benchtop analysis: hydraulic performance in general and hemocompatibility characteristics in particular were analyzed in-silico (computational fluid dynamics) and validated in-vitro. The CPAD's power consumption was recorded across the entire operational range. The CPAD delivered pressure step-ups across a comprehensive operational range (0-10 L/min, 0-50 mm Hg) with electric power consumption below 1.5 W within the main operating range. In-vitro hemolysis experiments (N = 3) indicated a normalized index of hemolysis of 3.8 ± 1.6 mg/100 L during design point operation (2500 rpm, 4 L/min). Preclinical investigations revealed the CPAD's potential for low traumatic and thrombogenic support of a heterogeneous Fontan population (pediatric and adult) with potentially accompanying secondary disorders (e.g., elevated pulmonary vascular resistance or systemic ventricular insufficiency) at distinct physical activities. The low power consumption implied adequate settings for a small, fully implantable system with transcutaneous energy transfer. The successful preclinical proof provides the rationale for acute and chronic in-vivo trials aiming at the confirmation of laboratory findings and verification of hemodynamic benefit.
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Affiliation(s)
- Andreas Escher
- Biofluid Mechanics Laboratory, Institute for Imaging Science and Computational Modelling in Cardiovascular Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany; Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Carsten Strauch
- Fachgebiet für Fluidsystemdynamik, Technische Universität Berlin, Berlin, Germany
| | - Emanuel J Hubmann
- Power Electronic Systems Laboratory, ETH Zurich, Zurich, Switzerland
| | - Michael Hübler
- University Heart & Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Dominik Bortis
- Power Electronic Systems Laboratory, ETH Zurich, Zurich, Switzerland
| | - Bente Thamsen
- Biofluid Mechanics Laboratory, Institute for Imaging Science and Computational Modelling in Cardiovascular Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Marc Mueller
- Institute for Multiphase Processes, Leibniz University Hannover, Hannover, Germany
| | - Ulrich Kertzscher
- Biofluid Mechanics Laboratory, Institute for Imaging Science and Computational Modelling in Cardiovascular Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Paul U Thamsen
- Fachgebiet für Fluidsystemdynamik, Technische Universität Berlin, Berlin, Germany
| | - Johann W Kolar
- Power Electronic Systems Laboratory, ETH Zurich, Zurich, Switzerland
| | - Daniel Zimpfer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Marcus Granegger
- Biofluid Mechanics Laboratory, Institute for Imaging Science and Computational Modelling in Cardiovascular Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany; Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria.
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9
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Kramdhari H, Valakkada J, Ayyappan A. Diagnosis and endovascular management of pulmonary arteriovenous malformations. Br J Radiol 2021; 94:20200695. [PMID: 34038182 DOI: 10.1259/bjr.20200695] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Pulmonary arteriovenous malformations (PAVM) are abnormal communication of a branch of the pulmonary artery and pulmonary vein circumventing the intervening pulmonary capillaries. This results in a right-to-left (R-L) shunt and its related manifestations, which include hampered gas exchange leading to hypoxaemia, dyspnoea, paradoxical emboli leading to stroke, cerebral abscess, myocardial infarction and pulmonary haemorrhage due to rupture of the PAVM. Endovascular transcatheter embolization of the feeding vessels with coils or occlusion devices is the current standard care of treatment and preferred treatment modality. The articles aim to provide insights into the current trends in diagnosis, the current recommendations, approach and management options for patients with PAVM.
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Affiliation(s)
- Harshit Kramdhari
- Department of imaging sciences and interventional radiology, Sreechitra institute of medical sciences and technology, Trivandrum - 695011, Kerala, India
| | - Jineesh Valakkada
- Department of imaging sciences and interventional radiology, Sreechitra institute of medical sciences and technology, Trivandrum - 695011, Kerala, India
| | - Anoop Ayyappan
- Department of imaging sciences and interventional radiology, Sreechitra institute of medical sciences and technology, Trivandrum - 695011, Kerala, India
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10
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Rijnberg FM, van der Woude SFS, van Assen HC, Juffermans JF, Hazekamp MG, Jongbloed MRM, Kenjeres S, Lamb HJ, Westenberg JJM, Wentzel JJ, Roest AAW. Non-uniform mixing of hepatic venous flow and inferior vena cava flow in the Fontan conduit. J R Soc Interface 2021; 18:20201027. [PMID: 33823607 PMCID: PMC8086942 DOI: 10.1098/rsif.2020.1027] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Fontan patients require a balanced hepatic blood flow distribution (HFD) to prevent pulmonary arteriovenous malformations. Currently, HFD is quantified by tracking Fontan conduit flow, assuming hepatic venous (HV) flow to be uniformly distributed within the Fontan conduit. However, this assumption may be unvalid leading to inaccuracies in HFD quantification with potential clinical impact. The aim of this study was to (i) assess the mixing of HV flow and inferior vena caval (IVC) flow within the Fontan conduit and (ii) quantify HFD by directly tracking HV flow and quantitatively comparing results with the conventional approach. Patient-specific, time-resolved computational fluid dynamic models of 15 total cavopulmonary connections were generated, including the HV and subhepatic IVC. Mixing of HV and IVC flow, on a scale between 0 (no mixing) and 1 (perfect mixing), was assessed at the caudal and cranial Fontan conduit. HFD was quantified by tracking particles from the caudal (HFDcaudal conduit) and cranial (HFDcranial conduit) conduit and from the hepatic veins (HFDHV). HV flow was non-uniformly distributed at both the caudal (mean mixing 0.66 ± 0.13) and cranial (mean 0.79 ± 0.11) level within the Fontan conduit. On a cohort level, differences in HFD between methods were significant but small; HFDHV (51.0 ± 20.6%) versus HFDcaudal conduit (48.2 ± 21.9%, p = 0.033) or HFDcranial conduit (48.0 ± 21.9%, p = 0.044). However, individual absolute differences of 8.2–14.9% in HFD were observed in 4/15 patients. HV flow is non-uniformly distributed within the Fontan conduit. Substantial individual inaccuracies in HFD quantification were observed in a subset of patients with potential clinical impact.
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Affiliation(s)
- Friso M Rijnberg
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Hans C van Assen
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Joe F Juffermans
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Mark G Hazekamp
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Monique R M Jongbloed
- Department of Cardiology and Anatomy and Embryology, Leiden University Medical Center, Leiden, The Netherlands
| | - Sasa Kenjeres
- Department of Chemical Engineering, Faculty of Applied Sciences, Delft University of Technology and J. M. Burgerscentrum Research School for Fluid Mechanics, Delft, The Netherlands
| | - Hildo J Lamb
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jos J M Westenberg
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jolanda J Wentzel
- Department of Cardiology, Biomedical Engineering, Erasmus MC, Rotterdam, The Netherlands
| | - Arno A W Roest
- Department of Pediatric Cardiology, Leiden University Medical Center, Leiden, The Netherlands
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11
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Onay ZR, Ramasli Gursoy T, Aslan AT, Sismanlar Eyuboglu T, Akkan K. Hepatopulmonary Syndrome and Multiple Arteriovenous Fistulas in a Child with Niemann-Pick Disease. PEDIATRIC ALLERGY, IMMUNOLOGY, AND PULMONOLOGY 2021; 34:30-32. [PMID: 33734872 PMCID: PMC8082032 DOI: 10.1089/ped.2020.1244] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 11/18/2020] [Indexed: 05/31/2023]
Abstract
Background: Niemann-Pick disease (NPD) is caused by abnormal storage of sphingomyelin. NPD may affect the pulmonary system and cause hypoxia. In the present case, both hepatopulmonary syndrome (HPS) and pulmonary arteriovenous fistulas (PAVFs) developed in a child with NPD and were successfully treated with repeated embolization. Case Presentation: We have reported the case of a 16-year-old-girl with NPD who suffered severe hypoxia, dyspnea, fatigue, had multiple PAVFs, and was diagnosed with type 2 HPS. To improve oxygenation, 10 PAVFs were embolized. She needed re-embolization after 9 months because of hypoxia redevelopment. Conclusions: Pulmonary involvement, HPS, and/or PAVFs could be responsible for hypoxemia in patients with NPD, who should, therefore, be investigated for HPS and PAVFs. Embolization could be beneficial. Some patients may need repeated embolization.
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Affiliation(s)
- Zeynep Reyhan Onay
- Department of Pediatric Pulmonology, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Tugba Ramasli Gursoy
- Department of Pediatric Pulmonology, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Ayse Tana Aslan
- Department of Pediatric Pulmonology, Faculty of Medicine, Gazi University, Ankara, Turkey
| | | | - Koray Akkan
- Department of Interventional Radiology, Faculty of Medicine, Gazi University, Ankara, Turkey
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12
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Ng LQ, Choo JT, Fortier MV, Chiou FK. Variceal Hemorrhage in Two Children With Congenital Heart Disease and Long-Term Pulmonary Venous Obstruction. JPGN REPORTS 2021; 2:e028. [PMID: 37206944 PMCID: PMC10191530 DOI: 10.1097/pg9.0000000000000028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 10/29/2020] [Indexed: 05/21/2023]
Affiliation(s)
- Lay Queen Ng
- From the Gastroenterology, Hepatology and Nutrition Service, Pediatric Medicine, KK Women’s and Children’s Hospital, Singapore
| | - Jonathan T.L. Choo
- Cardiology Service, Department of Pediatric Subspecialties, KK Women’s and Children’s Hospital, Singapore
| | - Marielle V. Fortier
- Department of Diagnostic and Interventional Imaging, KK Women’s and Children’s Hospital, Singapore
| | - Fang Kuan Chiou
- From the Gastroenterology, Hepatology and Nutrition Service, Pediatric Medicine, KK Women’s and Children’s Hospital, Singapore
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13
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Veronese L, Swanevelder J, Brooks A. Anaesthesia for the child with a univentricular heart: a practical approach. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2021. [DOI: 10.36303/sajaa.2021.27.3.2572] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
| | - J Swanevelder
- Red Cross War Memorial Children’s Hospital, University of Cape Town,
South Africa
| | - A Brooks
- Red Cross War Memorial Children’s Hospital, University of Cape Town,
South Africa
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14
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Tariq M, Zahid I, Hashmi S, Amanullah M, Shahabuddin S. The Glenn procedure: Clinical outcomes in patients with congenital heart disease in pakistan. Ann Card Anaesth 2021; 24:30-35. [PMID: 33938828 PMCID: PMC8081130 DOI: 10.4103/aca.aca_85_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Objectives: Congenital heart defects (CHDs) affect more than 40,000 children annually in Pakistan. Approximately 80% of patients require at least one surgical intervention to achieve a complete or palliative cardiac repair. The Glenn shunt, a palliative procedure is established between superior vena cava (SVC) and the right pulmonary artery to provide an anastomosis offering minimal risk to patients with univentricular heart disease. The aim of this study was to assess the clinical outcomes of the Glenn shunt procedure in patients with complex congenital heart diseases in a developing country like Pakistan. Materials and Methods: A retrospective chart review was conducted on patients who underwent a bidirectional Glenn shunt procedure from July 2006 to June 2017. Data were collected on a structured questionnaire and analyses performed on SPSS version 22. Frequencies and percentages were computed for categorical variables while mean and standard deviation for continuous variables where appropriate. Results: A total of 79 patients underwent the Glenn shunt procedures. The median age was 1.9 years and 54.5% were male. Tricuspid atresia was the primary diagnosis in 30.4% of the patients. Common morbidities included arrhythmias (6.3%), pleural effusion (8.9%), wound infection (3.8%), pneumonia (2.5%), and seizures (3.8%); reopening was required in 2.5% of the patients and 8.8% were readmitted within 30 days of index operation. There were three (3.8%) deaths in total. Conclusions: Bidirectional Glenn shunt procedure can be performed safely in patients with ideal characteristics as the first stage palliation and has favorable results with acceptable rate of complications.
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Affiliation(s)
- Muhammad Tariq
- Cardiothoracic Section, Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan
| | - Ibrahim Zahid
- Dow University of Health Sciences, Karachi, Pakistan
| | - Shiraz Hashmi
- Cardiothoracic Section, Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan
| | - Muneer Amanullah
- Cardiothoracic Surgery, National Institute of Cardiovascular Diseases, Karachi, Pakistan
| | - Syed Shahabuddin
- Cardiothoracic Section, Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan
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15
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Putotto C, Marino B, Versacci P. Commentary: sVEGFR1 Is Enriched in Hepatic Vein Blood-Evidence for a Provisional Hepatic Factor Candidate? Front Pediatr 2021; 9:782779. [PMID: 34820346 PMCID: PMC8606681 DOI: 10.3389/fped.2021.782779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 10/19/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Carolina Putotto
- Department of Pediatrics, Obstetrics and Gynecology, "Sapienza" University of Rome, Rome, Italy
| | - Bruno Marino
- Department of Pediatrics, Obstetrics and Gynecology, "Sapienza" University of Rome, Rome, Italy
| | - Paolo Versacci
- Department of Pediatrics, Obstetrics and Gynecology, "Sapienza" University of Rome, Rome, Italy
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16
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Khetan A, Salehian O, Karbassi A. Asking Bubbles for Direction: Assessment of a Classic Glenn Shunt Using Agitated Saline Contrast Echocardiography. CASE 2020; 4:485-489. [PMID: 33376839 PMCID: PMC7756162 DOI: 10.1016/j.case.2020.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Glenn shunt is a common palliative surgery for congenital heart disease. PAVMs are a frequent complication. A saline contrast study can show bubbles first appearing in the left atrium. Treatment options include coil embolization and surgery.
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17
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Joshi K, Sharma C, Misra N, Kholwadwala D, Georgekutty J, Friedman R, Parnell V. A unique approach to Fontan revision in a cyanotic patient. PROGRESS IN PEDIATRIC CARDIOLOGY 2020. [DOI: 10.1016/j.ppedcard.2020.101298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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18
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Alibrahim IJ, Mohammed MHA, Kabbani MS, Jijeh AMZ, Tamimi OR, Alghamdi AA, Alhabshan F. Pulmonary arteriovenous malformations in children after the Kawashima procedure: Risk factors and midterm outcome. Ann Pediatr Cardiol 2020; 14:10-17. [PMID: 33679056 PMCID: PMC7918011 DOI: 10.4103/apc.apc_144_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Revised: 12/05/2019] [Accepted: 08/05/2020] [Indexed: 11/28/2022] Open
Abstract
Background: Pulmonary arteriovenous malformations (PAVMs) are the major cause of progressive cyanosis in patients palliated with bidirectional cavopulmonary connection (BCPC). The aim of our study is to analyze the occurrence of PAVMs in patients after Kawashima procedure, to study the effect of total cavopulmonary connection (TCPC) on PAVMs, to evaluate the effect of axillary arteriovenous fistula (AAVF) creation on PAVMs, and to study the risk factors for PAVMs. Methods: In this retrospective cohort study, all patients with left isomerism and azygous continuation of an interrupted inferior vena cava who underwent Kawashima procedure from July 2001 to December 2017 were included. Results: Twenty.six patients after Kawashima procedure were included in our study. PAVMs were diagnosed in 12 patients (46%). Five of these 12 patients underwent TCPC with complete resolution of hypoxemia. Three patients underwent AAVF creation, 2 had complete resolution, while 1 had partial resolution of hypoxemia. Fourteen patients (54%) did not develop PAVMs. Nakata index below 267 mm2/m2and McGoon ratio below 1.9 predicted the development of PAVMs with high sensitivity and specificity. Conclusions: PAVMs represent a serious complication in patients who undergo Kawashima procedure. Small size of pulmonary arteries is an important risk factor for the development of PAVMs. Resolution of hypoxemia after TCPC completion supports the hepatic factor hypothesis. Early TCPC completion in these patients may help to avoid the development of PAVMs by restoring the hepatic factor. Resolution of hypoxemia after AAVF creation may support the lack of pulsatile flow hypothesis.
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Affiliation(s)
- Ibrahim J Alibrahim
- Department of Cardiac Sciences, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Mohammed H A Mohammed
- Department of Cardiac Sciences, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Mohamad S Kabbani
- Department of Cardiac Sciences, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia.,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.,College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Abdulraouf M Z Jijeh
- Department of Cardiac Sciences, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Omar R Tamimi
- Department of Cardiac Sciences, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia.,College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Abdullah A Alghamdi
- Department of Cardiac Sciences, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia.,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.,College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Fahad Alhabshan
- Department of Cardiac Sciences, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia.,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.,College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
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19
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Hepatic to azygos connection by autologous pericardial roll for Fontan completion. Cardiol Young 2020; 30:1356-1357. [PMID: 32662366 DOI: 10.1017/s1047951120001961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Techniques for performing the Fontan completion procedure after Kawashima procedure have developed in recent years. This paper presents a case in which we performed an off-pump hepatic-to-azygos connection by autologous pericardial roll via thoracotomy as a modified Fontan completion. The operation wound was limited, and the short-term follow-up was satisfactory. Notably, it was found that the autologous pericardium might require a shorter period of anticoagulation treatment than what is needed for artificial prosthetic materials.
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20
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Rochon ER, Krowka MJ, Bartolome S, Heresi GA, Bull T, Roberts K, Hemnes A, Forde KA, Krok KL, Patel M, Lin G, McNeil M, Al-Naamani N, Roman BL, Yu PB, Fallon MB, Gladwin MT, Kawut SM. BMP9/10 in Pulmonary Vascular Complications of Liver Disease. Am J Respir Crit Care Med 2020; 201:1575-1578. [PMID: 32083953 DOI: 10.1164/rccm.201912-2514le] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Affiliation(s)
| | | | | | | | - Todd Bull
- University of ColoradoDenver, Colorado
| | | | | | - Kimberly A Forde
- Perelman School of Medicine at the University of PennsylvaniaPhiladelphia, Pennsylvania
| | - Karen L Krok
- Penn State College of MedicineHershey, Pennsylvania
| | - Mamta Patel
- Perelman School of Medicine at the University of PennsylvaniaPhiladelphia, Pennsylvania
| | | | - Megan McNeil
- Penn State College of MedicineHershey, Pennsylvania.,Brigham and Women's HospitalBoston, Massachusetts
| | - Nadine Al-Naamani
- Perelman School of Medicine at the University of PennsylvaniaPhiladelphia, Pennsylvania
| | - Beth L Roman
- University of Pittsburgh Graduate School of Public HealthPittsburgh, Pennsylvania
| | - Paul B Yu
- Penn State College of MedicineHershey, Pennsylvania.,Harvard Medical SchoolBoston, Massachusettsand
| | | | | | - Steven M Kawut
- Perelman School of Medicine at the University of PennsylvaniaPhiladelphia, Pennsylvania
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21
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Choi RS, DiNardo JA, Brown ML. Superior Cavopulmonary Connection: Its Physiology, Limitations, and Anesthetic Implications. Semin Cardiothorac Vasc Anesth 2020; 24:337-348. [PMID: 32646291 DOI: 10.1177/1089253220939361] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The superior cavopulmonary connection (SCPC) or "bidirectional Glenn" is an integral, intermediate stage in palliation of single ventricle patients to the Fontan procedure. The procedure, normally performed at 3 to 6 months of life, increases effective pulmonary blood flow and reduces the ventricular volume load in patients with single ventricle (parallel circulation) physiology. While the SCPC, with or without additional sources of pulmonary blood flow, cannot be considered a long-term palliation strategy, there are a subset of patients who require SCPC palliation for a longer interval than the typical patient. In this article, we will review the physiology of SCPC, the consequences of prolonged SCPC palliation, and modes of failure. We will also discuss strategies to augment pulmonary blood flow in the presence of an SCPC. The anesthetic considerations in SCPC patients will also be discussed, as these patients may present for noncardiac surgery from infancy to adulthood.
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Affiliation(s)
- Ray S Choi
- Children's Hospital Colorado, Denver, CO, USA.,Boston Children's Hospital, Boston, MA, USA
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22
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Conversion of prior univentricular repairs to septated circulation: Case selection, challenges, and outcomes. Indian J Thorac Cardiovasc Surg 2020; 37:91-103. [PMID: 33603287 DOI: 10.1007/s12055-020-00938-9] [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] [Received: 11/15/2019] [Revised: 02/05/2020] [Accepted: 02/07/2020] [Indexed: 10/23/2022] Open
Abstract
Objectives Complex congenital heart defects that present earlier in life are sometimes channelled in the single ventricle pathway, because of anatomical or logistic challenges involved in biventricular correction. Given the long-term functional and survival advantage, and with the surgeons' improved understanding of the cardiac anatomy, we have consciously explored the feasibility of a biventricular repair in these patients when they presented later for Fontan completion. We present a single institution's 10-year experience in achieving biventricular septation of prior univentricular repairs, the technical and physiological challenges and the surgical outcomes. Methods Between June 2010 and December 2019, 246 patients were channelized in the single ventricle pathway, of which 32 patients were identified as potential biventricular candidates at the time of evaluation for Fontan palliation, considering their anatomic feasibility. The surgical technique involves routing of the left ventricle to the aorta across the ventricular septal defect, ensuring an adequate sized right ventricular cavity, establishing right ventricle-pulmonary artery continuity and taking down the Glenn shunt with rerouting of the superior vena cava to the right atrium. This is a retrospective study where we reviewed the unique physiological and surgical characteristics of this subset of patients and analysed their surgical outcomes and complications. Results Biventricular conversion was achieved in all cases except in 3 patients, who had the Glenn shunt retained leading to a one and a half ventricle repair. The average age of the patients was 4.9 years of whom 18 were male. The average cardiopulmonary bypass time was 371 min with an average cross clamp time of 162 min. There was one mortality in a patient with corrected transposition of great arteries (c-TGA) with extensive arterio-venous malformations (AVMs). At a median follow-up of 60 months, all patients remained symptom free except two with NYHA II symptoms, one being treated for branch pulmonary artery stenosis with balloon dilatation and the other with multiple AVMs who needed coil closure. One patient with branch pulmonary artery (PA) stenosis required balloon dilatation and stent placement. Conclusion The possibility of achieving the surgical goal in this unique subset of patients evolves with the progressive experience of the congenital heart surgeon. Case selection is a crucial aspect in achieving the desired outcome, and this 'borderline' substrate is often recognized at the time of evaluation for the Fontan completion. A comprehensive preoperative imaging and planning helps in achieving the surgical septation and reconnection to achieve the desired physiological circulation. Though technically challenging, the surgery has excellent short- and mid-term outcomes as evidenced by our 10-year experience.
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23
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Broda CR, Downing TE, John AS. Diagnosis and management of the adult patient with a failing Fontan circulation. Heart Fail Rev 2020; 25:633-646. [DOI: 10.1007/s10741-020-09932-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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24
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Granegger M, Thamsen B, Hubmann EJ, Choi Y, Beck D, Valsangiacomo Buechel E, Voutat M, Schweiger M, Meboldt M, Hübler M. A long-term mechanical cavopulmonary support device for patients with Fontan circulation. Med Eng Phys 2019; 70:9-18. [DOI: 10.1016/j.medengphy.2019.06.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 06/15/2019] [Accepted: 06/19/2019] [Indexed: 12/28/2022]
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25
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McLennan D, Schäfer M, Mitchell MB, Morgan GJ, Ivy D, Barker AJ, Jacobsen R. Usefulness of 4D-Flow MRI in Mapping Flow Distribution Through Failing Fontan Circulation Prior to Cardiac Intervention. Pediatr Cardiol 2019; 40:1093-1096. [PMID: 30982076 DOI: 10.1007/s00246-019-02101-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 03/29/2019] [Indexed: 11/29/2022]
Abstract
We report a case of a 23-year-old male with failing Fontan circulation who was taken to the catheterization lab to better evaluate the Fontan circulation and hemodynamics. Catheterization revealed arteriovenous malformations exclusively present in the right lung leading to the consideration of placing stents to direct the inferior vena cava flow through the Fontan circuit to the right pulmonary artery (RPA), thus increasing the RPA concentration of the hepatic factor. However, comprehensive 4D-Flow MRI analyses indicated sufficient distribution of the hepatic flow between branch pulmonary arteries, and consequently no further invasive intervention to redirect hepatic flow was performed.
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Affiliation(s)
- Daniel McLennan
- Division of Cardiology, Heart Institute, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, 13123 E 16th Ave, Aurora, CO, 80045-2560, USA.
| | - Michal Schäfer
- Division of Cardiology, Heart Institute, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, 13123 E 16th Ave, Aurora, CO, 80045-2560, USA
| | - Max B Mitchell
- Section of Congenital Heart Surgery, Heart Institute, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
| | - Gareth J Morgan
- Division of Cardiology, Heart Institute, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, 13123 E 16th Ave, Aurora, CO, 80045-2560, USA
| | - Dunbar Ivy
- Division of Cardiology, Heart Institute, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, 13123 E 16th Ave, Aurora, CO, 80045-2560, USA
| | - Alex J Barker
- Division of Cardiology, Heart Institute, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, 13123 E 16th Ave, Aurora, CO, 80045-2560, USA
| | - Roni Jacobsen
- Division of Cardiology, Heart Institute, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, 13123 E 16th Ave, Aurora, CO, 80045-2560, USA
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Ugurlucan M, Oztas DM, Bahseliyev S, Aliyev B, Yozgat Y, Tireli E, Alpagut U. Glenn Procedure in a Baby with Single Pulmonary Artery and Single Lung. Heart Views 2019; 19:106-108. [PMID: 31007860 PMCID: PMC6448474 DOI: 10.4103/heartviews.heartviews_19_18] [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] [Indexed: 11/10/2022] Open
Abstract
Glenn followed by Fontan are still the main two procedures for the treatment of patients with single ventricle. Some patients may be challenging due to unfavorable cardiopulmonary anatomy. In this report, we present Glenn shunt procedure in a patient with single pulmonary artery and congenitally agenetic lung.
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Affiliation(s)
- Murat Ugurlucan
- Department of Cardiovascular Surgery, Istanbul University Istanbul Medical Faculty, Istanbul, Turkey
| | - Didem Melis Oztas
- Department of Cardiovascular Surgery, Istanbul University Istanbul Medical Faculty, Istanbul, Turkey
| | - Shiraslan Bahseliyev
- Department of Cardiovascular Surgery, Istanbul University Istanbul Medical Faculty, Istanbul, Turkey
| | - Bahruz Aliyev
- Department of Pediatric Cardiology, Istanbul University Istanbul Medical Faculty, Istanbul, Turkey
| | - Yilmaz Yozgat
- Department of Pediatric Cardiology, Bezmialem University Hospital, Istanbul, Turkey
| | - Emin Tireli
- Department of Cardiovascular Surgery, Istanbul University Istanbul Medical Faculty, Istanbul, Turkey
| | - Ufuk Alpagut
- Department of Cardiovascular Surgery, Istanbul University Istanbul Medical Faculty, Istanbul, Turkey
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Yi T, Fan G, Xing Y, Zhao W, Zhang L, Fan F, Jiang X, Ma Z, Yan J, Li S, Wang Q. Impact of Time Interval Between Glenn and Fontan Procedures on Fontan Operative and Long-Term Follow-up Results. Pediatr Cardiol 2019; 40:705-712. [PMID: 30652193 DOI: 10.1007/s00246-018-2049-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 12/18/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The bidirectional cavopulmonary shunt (BCPS) is an effective palliative procedure which has been widely used to boost outcome of the Fontan procedure. However, there is no standard duration time between these two procedures. Therefore, we investigated whether different time intervals between BCPS and Fontan procedure affects morbidity and mortality of Fontan patients. METHODS Between 2004 and 2016, 210 post-BCPS patients underwent Fontan operation at Fuwai Hospital. The median interval between BCPS and Fontan procedure was 3.7 years (range 0.55-11.86 years) and this was used to divide study cohort into Group 1 (< 3.7 years; n = 124) and Group 2 (> 3.7 years; n = 86). We analyzed these patients retrospectively in terms of their preoperative characteristics and post-operative and follow-up results. RESULTS Weight z-scores for age at BCPS (- 0.73 ± 1.39 vs - 1.17 ± 1.60, p < 0.05) was significantly higher in Group 2. However, saturation at room air before Fontan (76.42 ± 20.01 vs 82.85 ± 9.69, p < 0.001) was significantly higher in Group 1. The morbidity and mortality were similar between two groups. There were twelve hospital deaths (5.7%): eight (8/124, 6.5%) presented in Group 1 and four (4/86, 4.7%) in Group 2. On multi-variable analysis, risk factors for death were prolonged mechanical ventilation [hazard ratio (HR) 1.02, p = 0.004] and single right ventricle (HR 7.17, p = 0.03). After a mean follow-up of 4.95 years (range 0.74-13.62 years), one patient in Group 1 died of heart failure 13 months after Fontan procedure. The overall Fontan failure in Group 1 was similar to that in Group 2 (2.7% vs 2.6%, p = 0.985). The incidence of arrhythmias and re-intervention were not different between the two groups. CONCLUSIONS Fontan procedure could be performed safely in patient who stayed in long duration between Fontan procedure and BCPS without affecting the operative and long-term follow-up results. However, for post-BCPS patients with severe hypoxemia, earlier age at Fontan might be a good choice.
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Affiliation(s)
- Tong Yi
- Department of Congenital Heart Disease, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 North Lishi Road, Xicheng District, Beijing, China
| | - Guohui Fan
- Institute of Clinical Medical Sciences, China-Japan Friendship Hospital, Beijing, China
| | - Yunchao Xing
- Department of Congenital Heart Disease, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 North Lishi Road, Xicheng District, Beijing, China
| | - Wei Zhao
- Department of Congenital Heart Disease, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 North Lishi Road, Xicheng District, Beijing, China
| | - Liang Zhang
- Department of Congenital Heart Disease, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 North Lishi Road, Xicheng District, Beijing, China
| | - Fan Fan
- Center for Infant Heart, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xianchao Jiang
- Department of Congenital Heart Disease, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 North Lishi Road, Xicheng District, Beijing, China
| | - Zhiling Ma
- Department of Congenital Heart Disease, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 North Lishi Road, Xicheng District, Beijing, China
| | - Jun Yan
- Department of Congenital Heart Disease, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 North Lishi Road, Xicheng District, Beijing, China
| | - Shoujun Li
- Department of Congenital Heart Disease, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 North Lishi Road, Xicheng District, Beijing, China
| | - Qiang Wang
- Department of Congenital Heart Disease, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 North Lishi Road, Xicheng District, Beijing, China.
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Wilder TJ. Commentary: Individualized surgery for patients with single-ventricle physiology. J Thorac Cardiovasc Surg 2019; 158:e173-e174. [PMID: 30902464 DOI: 10.1016/j.jtcvs.2019.02.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 02/05/2019] [Indexed: 11/18/2022]
Affiliation(s)
- Travis J Wilder
- Department of Cardiothoracic Surgery, University of Utah, Salt Lake City, Utah.
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29
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Anesthetic Considerations for Pediatric Patients With Fontan Physiology Undergoing Noncardiac Surgery. Int Anesthesiol Clin 2019; 57:42-60. [DOI: 10.1097/aia.0000000000000250] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Successful use of calcium channel blocker for management of arterio-venous malformations following Fontan procedure. Cardiol Young 2018; 28:1468-1470. [PMID: 30156174 DOI: 10.1017/s1047951118001488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
In diffuse forms of arteriovenous malformation following Fontan procedure, "classical" medical therapy, inhaled nitric oxide and sildenafil, may play a role, until re-direction of hepatic flow to pulmonary circulation cures it. However, in refractory cases, as reported in our 2-year-old patient, unusual medications such as calcium channel blockers can be tried and continued if patients respond adequately.
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Chacon-Portillo MA, Zea-Vera R, Zhu H, Dickerson HA, Adachi I, Heinle JS, Fraser CD, Mery CM. Pulsatile Glenn as long-term palliation for single ventricle physiology patients. CONGENIT HEART DIS 2018; 13:927-934. [PMID: 30280502 DOI: 10.1111/chd.12664] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 07/16/2018] [Accepted: 07/18/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVE There are limited studies analyzing pulsatile Glenn as a long-term palliation strategy for single ventricle patients. This study sought to determine their outcomes at a single institution. DESIGN A retrospective review was performed. SETTING Study performed at a single pediatric hospital. PATIENTS All single ventricle patients who underwent pulsatile Glenn from 1995 to 2016 were included. OUTCOME MEASURES Pulsatile Glenn failure was defined as takedown, transplant, or death. Further palliation was defined as Fontan, 1.5, or biventricular repair. Risk factors were assessed by Cox multivariable competing risk analyses. RESULTS Seventy-eight patients underwent pulsatile Glenn at age 9 months (interquartile range, 5-14). In total, 28% had heterotaxy, 18% had a genetic syndrome, and 24% had an abnormal inferior vena cava. There were 3 (4%) perioperative mortalities. Further palliation was performed in 41 (53%) patients with a median time-to-palliation of 4 years (interquartile range, 3-5). Pulsatile Glenn failure occurred in 10 (13%) patients with 8 total mortalities. Five- and 10-year transplant-free survival were 91% and 84%, respectively. At a median follow-up of 6 years (interquartile range, 2-8), 27 patients (35%) remained with PG (age 7 years [interquartile range, 3-11], oxygen saturation 83% ± 4%). Preoperative moderate-severe atrioventricular valve regurgitation (AVVR) (hazard ratio 7.77; 95% confidence interval 1.80-33.43; P =.005) and higher pulmonary vascular resistance (hazard ratio 2.59; 95% confidence interval 1.08-6.15; P =.031) were predictors of pulsatile Glenn failure after adjusting for covariates. Reaching further palliation was less likely in patients with preoperative moderate-severe AVVR (hazard ratio 0.22, 95% confidence interval 0.08-0.59; P =.002). CONCLUSION Pulsatile Glenn can be an effective tool to be used in challenging circumstances, these patients can have a favorable long-term prognosis without reducing their suitability for further palliation.
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Affiliation(s)
- Martin A Chacon-Portillo
- Division of Congenital Heart Surgery, Texas Children's Hospital, Houston, Texas.,Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Rodrigo Zea-Vera
- Division of Congenital Heart Surgery, Texas Children's Hospital, Houston, Texas.,Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Huirong Zhu
- Outcomes and Impact Service, Texas Children's Hospital, Houston, Texas
| | - Heather A Dickerson
- Division of Pediatric Cardiology, Texas Children's Hospital, Houston, Texas.,Baylor College of Medicine, Houston, Texas
| | - Iki Adachi
- Division of Congenital Heart Surgery, Texas Children's Hospital, Houston, Texas.,Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Jeffrey S Heinle
- Division of Congenital Heart Surgery, Texas Children's Hospital, Houston, Texas.,Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Charles D Fraser
- Division of Congenital Heart Surgery, Texas Children's Hospital, Houston, Texas.,Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Carlos M Mery
- Division of Congenital Heart Surgery, Texas Children's Hospital, Houston, Texas.,Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
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Mosca RS. Super Glenn: Able to Defeat Recalcitrant Pulmonary Vascular Adversaries? Semin Thorac Cardiovasc Surg 2018; 30:189-190. [PMID: 29684550 DOI: 10.1053/j.semtcvs.2018.04.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/13/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Ralph S Mosca
- Department of Cardiac Surgery, NYU Langone Health, New York, New York.
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Trezzi M, Cetrano E, Giannico S, Iorio FS, Albanese SB, Carotti A. Long-Term Outcomes After Extracardiac Fontan Takedown to an Intermediate Palliative Circulation. Ann Thorac Surg 2018; 105:599-605. [DOI: 10.1016/j.athoracsur.2017.05.068] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Revised: 05/16/2017] [Accepted: 05/16/2017] [Indexed: 11/29/2022]
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Wisotzkey BL, Magyar DL, Jones TK, Boucek RJ, Permut LC, Kemna MS, Law YM. A tale of two cases of pulmonary arteriovenous malformation: How they fared after cardiac transplantation. Clin Transplant 2017; 32. [PMID: 29277952 DOI: 10.1111/ctr.13183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/19/2017] [Indexed: 12/01/2022]
Abstract
BACKGROUND In single ventricle patients, aortopulmonary collaterals (APCs) and pulmonary arteriovenous malformations (PAVMs) following superior cavopulmonary shunt (CPS) can complicate orthotopic heart transplant (OHT) by cyanosis and hemoptysis. Although PAVMs can regress with the restoration of hepatic venous flow to the pulmonary circulation, the effects of hypoxemia on the "unconditioned" allograft are not known. CASES Two patients with significant PAVMs after CPS were cyanotic following OHT. One patient with predominantly unilateral left PAVMs had arterial saturation levels less than 70% despite pulmonary vasodilators and ventilation. A custom flow restrictor-covered stent was deployed in the pulmonary artery of the affected side, redirecting the blood flow to the contralateral lung, immediately improving cyanosis. When the PAVMs regressed, the flow restrictor stent was dilated to eliminate the constriction. The second patient with PAVMs had cyanosis and severe hemoptysis from APCs post-OHT. The APCs required an extensive coil embolization, while the cyanosis responded to oxygen and pulmonary vasodilators. Both recipients did well with gradual resolution of PAVMs within 8 months. CONCLUSIONS Despite cyanosis from right-to-left intrapulmonary shunting, allograft function recovered. Novel transcatheter interventions can play a role in patients with significant APCs or PAVM following cardiac transplantation.
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Affiliation(s)
- Bethany L Wisotzkey
- Department of Pediatrics, Division of Pediatric Cardiology, Johns Hopkins All Children's Hospital, Saint Petersburg, FL, USA
| | - Dari L Magyar
- Department of Pediatrics, Seattle Children's Hospital, Seattle, WA, USA
| | - Thomas K Jones
- Department of Pediatrics, Division of Pediatric Cardiology, Seattle Children's Hospital, Seattle, WA, USA
| | - Robert J Boucek
- Department of Pediatrics, Division of Pediatric Cardiology, Seattle Children's Hospital, Seattle, WA, USA
| | - Lester C Permut
- Department of Pediatrics, Division of Pediatric Cardiothoracic Surgery, Seattle Children's Hospital, Seattle, WA, USA
| | - Mariska S Kemna
- Department of Pediatrics, Division of Pediatric Cardiology, Seattle Children's Hospital, Seattle, WA, USA
| | - Yuk M Law
- Department of Pediatrics, Division of Pediatric Cardiology, Seattle Children's Hospital, Seattle, WA, USA
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Al-Dairy A, Dehaki MG, Omrani G, Sadeghpour A, Jalali AH, Afjehi RS, Mahdavi M, Salesi M. The Outcomes of Superior Cavopulmonary Connection Operation: a Single Center Experience. Braz J Cardiovasc Surg 2017; 32:503-507. [PMID: 29267614 PMCID: PMC5731310 DOI: 10.21470/1678-9741-2017-0025] [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: 02/03/2017] [Accepted: 05/18/2017] [Indexed: 11/26/2022] Open
Abstract
Introduction The superior cavopulmonary connection operation is one of the stages of the
palliative surgical management for patients with functionally single
ventricle. After surviving this stage, the patients are potential candidates
for the final palliative procedure: the Fontan operation. Objectives This study aimed to analyze the outcomes of superior cavopulmonary connection
operations in our center and to identify factors affecting the survival and
the progression to Fontan stage. Methods The outcomes of 161 patients were retrospectively analyzed after undergoing
superior cavopulmonary connection operation in our center between 2005 and
2015. Results The early mortality rate was 2.5%. Five (3.1%) patients underwent takedown of
the superior cavopulmonary connection. The rate of exclusion from the Fontan
stage was 8.3%. Statistical analysis revealed that elevated mean pulmonary
artery pressure preoperatively and the prior palliation with pulmonary
artery banding were risk factors for both early mortality and takedown;
however, the age, the morphology of the single ventricle and the type of
operation were not considered risk factors. Conclusion The superior cavopulmonary connection operation can be performed with low
rate mortality and morbidity; however, the elevated mean pulmonary artery
pressure preoperatively and the prior pulmonary artery banding are
associated with poor outcomes.
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Affiliation(s)
- Alwaleed Al-Dairy
- Department of Cardiovascular Surgery, Division of Congenital Cardiac Surgery of Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Maziar Gholampour Dehaki
- Department of Cardiovascular Surgery, Division of Congenital Cardiac Surgery of Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Gholamreza Omrani
- Department of Cardiovascular Surgery, Division of Congenital Cardiac Surgery of Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Ali Sadeghpour
- Department of Cardiovascular Surgery, Division of Congenital Cardiac Surgery of Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Amir Hossein Jalali
- Department of Cardiovascular Surgery, Division of Congenital Cardiac Surgery of Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Reza Sadat Afjehi
- Department of Cardiovascular Surgery, Division of Congenital Cardiac Surgery of Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammad Mahdavi
- Department of Pediatric Cardiology, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Mahmood Salesi
- Atherosclerosis Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
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Raees MA, Mazhar D, Christensen JT, Parra DA, Killen S, Bichell DP. Bidirectional Inferior Cavopulmonary Anastomosis: Pre-Fontan Interim Palliation. Ann Thorac Surg 2017; 104:e329-e331. [PMID: 28935329 DOI: 10.1016/j.athoracsur.2017.04.056] [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] [Received: 03/01/2017] [Revised: 04/07/2017] [Accepted: 04/22/2017] [Indexed: 10/18/2022]
Abstract
We report a novel method of constructing an extracardiac bidirectional inferior cavopulmonary anastomosis. Our patient was a 4-month-old girl with complex single-ventricle anatomy and a small-caliber superior vena cava. A direct anastomosis from the inferior vena cava to the main pulmonary artery was constructed by using all autologous tissue. The resulting pathway remained patent and exhibited growth with age. Furthermore, a pulmonary arteriovenous malformation did not develop. This case demonstrates how a bidirectional inferior cavopulmonary anastomosis is feasible in the human and can provide similar hemodynamic results as the bidirectional superior cavopulmonary anastomosis.
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Affiliation(s)
- Muhammad Aanish Raees
- Division of Pediatric Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Driss Mazhar
- Faculté de Médecine, Université Paris Sud, Orsay, Paris, France
| | - Jason T Christensen
- Division of Pediatric Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David Andres Parra
- Division of Pediatric Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Stacy Killen
- Division of Pediatric Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David P Bichell
- Division of Pediatric Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.
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Kim SY, Kim ER, Bang JH, Kim WH. Development of a Pulmonary Arteriovenous Fistula after a Modified Glenn Shunt in Tetralogy of Fallot and Its Resolution after Shunt Takedown in a 57-Year-Old Patient. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2017; 50:215-219. [PMID: 28593160 PMCID: PMC5460971 DOI: 10.5090/kjtcs.2017.50.3.215] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Revised: 09/17/2016] [Accepted: 09/18/2016] [Indexed: 11/29/2022]
Abstract
Pulmonary arteriovenous fistula (PAVF) is a complication of the Glenn shunt. A 57-year-old tetralogy of Fallot (TOF) patient, who had undergone a Glenn shunt and TOF total correction, complained of dyspnea and cyanosis. PAVFs were present in the right lung, and right lung perfusion was nearly absent. After coil embolization, takedown of the Glenn shunt, and reconstruction of the right pulmonary artery, the patient’s symptoms were relieved. Extrapulmonary radioisotope uptake caused by the PAVFs shown in lung perfusion scans decreased, and right lung perfusion increased gradually. Although the development and resolution of PAVFs after a Glenn shunt have been reported in the pediatric population, this may be the first report on this change in old age.
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Affiliation(s)
- Sang Yoon Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital
| | - Eung Rae Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital
| | - Ji Hyun Bang
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital
| | - Woong-Han Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital
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Ghelani SJ, Rathod RH. Pulmonary arteriovenous malformations: The consequences of bypassing the capillary bed. J Thorac Cardiovasc Surg 2015; 150:717-9. [PMID: 26095622 DOI: 10.1016/j.jtcvs.2015.05.055] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Accepted: 05/21/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Sunil J Ghelani
- Department of Cardiology, Boston Children's Hospital, Boston, Mass
| | - Rahul H Rathod
- Department of Cardiology, Boston Children's Hospital, Boston, Mass.
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