1
|
Nashat H, Montanaro C, Li W, Kempny A, Wort SJ, Dimopoulos K, Gatzoulis MA, Babu-Narayan SV. Atrial septal defects and pulmonary arterial hypertension. J Thorac Dis 2018; 10:S2953-S2965. [PMID: 30305956 PMCID: PMC6174141 DOI: 10.21037/jtd.2018.08.92] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2018] [Accepted: 08/20/2018] [Indexed: 12/19/2022]
Abstract
Atrial septal defects (ASD) are a common congenital heart defect. The majority of patient with ASDs often follow an uncomplicated course of events. However, a proportion of patients with ASDs, may have their condition complicated by pulmonary hypertension (PH), with a subsequent significant impact on management, morbidity and mortality. The presence of PH, influences the suitability for defect closure. In this review we describe the different types of ASDs, the classification of PH related to congenital heart disease (CHD), when ASD closure is contraindicated and the management of patients who develop pulmonary arterial hypertension (PAH), including the most extreme form, Eisenmenger syndrome (ES).
Collapse
Affiliation(s)
- Heba Nashat
- Department of Adult Congenital Heart Disease, Royal Brompton and Harefield NHS Foundation Trust, National Heart and Lung Institute, Imperial College London, London, UK
| | - Claudia Montanaro
- Department of Adult Congenital Heart Disease, Royal Brompton and Harefield NHS Foundation Trust, National Heart and Lung Institute, Imperial College London, London, UK
| | - Wei Li
- Department of Adult Congenital Heart Disease, Royal Brompton and Harefield NHS Foundation Trust, National Heart and Lung Institute, Imperial College London, London, UK
| | - Aleksander Kempny
- Department of Adult Congenital Heart Disease, Royal Brompton and Harefield NHS Foundation Trust, National Heart and Lung Institute, Imperial College London, London, UK
| | - Stephen J Wort
- Department of Adult Congenital Heart Disease, Royal Brompton and Harefield NHS Foundation Trust, National Heart and Lung Institute, Imperial College London, London, UK
| | - Konstantinos Dimopoulos
- Department of Adult Congenital Heart Disease, Royal Brompton and Harefield NHS Foundation Trust, National Heart and Lung Institute, Imperial College London, London, UK
| | - Michael A Gatzoulis
- Department of Adult Congenital Heart Disease, Royal Brompton and Harefield NHS Foundation Trust, National Heart and Lung Institute, Imperial College London, London, UK
| | - Sonya V Babu-Narayan
- Department of Adult Congenital Heart Disease, Royal Brompton and Harefield NHS Foundation Trust, National Heart and Lung Institute, Imperial College London, London, UK
| |
Collapse
|
2
|
Abstract
This review will outline the role of visiting cardiac surgical teams in low- and middle-income countries drawing on the collective experience of the authors in a wide range of locations. Requests for assistance can emerge from local programmes at a beginner or advanced stage. However, in all circumstances, careful pre-trip planning is necessary in conjunction with clinical and non-clinical local partners. The clinical evaluation, surgical procedures, and postoperative care all serve as a template for collaboration and education between the visiting and local teams in every aspect of care. Education focusses on both common and patient-specific issues. Case selection must appropriately balance the clinical priorities, safety, and educational objectives within the time constraints of trip duration. Considerable communication and practical challenges will present, and clinicians may need to make significant adjustments to their usual practice in order to function effectively in a resource-limited, unfamiliar, and multilingual environment. The effectiveness of visiting trips should be measured and constantly evaluated. Local and visiting teams should use data-driven evaluations of measurable outcomes and critical qualitative evaluation to repeatedly re-assess their interim goals. Progress invariably takes several years to achieve the final goal: an autonomous self-governing, self-financed, cardiac programme capable of providing care for children with complex CHD. This outcome is consistent with redundancy for the visiting trips model at the site, although fraternal, professional, and academic links will invariably remain for many years.
Collapse
|
3
|
Gerrah R, Haller SJ, George I. Mechanical Concepts Applied in Congenital Heart Disease and Cardiac Surgery. Ann Thorac Surg 2017; 103:2005-2014. [DOI: 10.1016/j.athoracsur.2017.01.068] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Revised: 01/04/2017] [Accepted: 01/16/2017] [Indexed: 11/30/2022]
|
4
|
The Changing Landscape of Pulmonary Arterial Hypertension in the Adult with Congenital Heart Disease. J Clin Med 2017; 6:jcm6040040. [PMID: 28358329 PMCID: PMC5406772 DOI: 10.3390/jcm6040040] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 03/09/2017] [Accepted: 03/23/2017] [Indexed: 01/09/2023] Open
Abstract
Pulmonary arterial hypertension associated with congenital heart disease (PAH-CHD) is a common type of pulmonary arterial hypertension (PAH) and a frequent complication of congenital heart disease (CHD). PAH-CHD represents a heterogeneous patient population and it is important to distinguish between the underlying cardiac defects considering the prognostic and therapeutic implications. Improved interventional techniques have enabled repair or palliation of most cardiac defects, though a substantial number of patients remain at high risk for PAH after closure. Traditionally, the treatment and management of PAH-CHD patients has been limited to palliative and supportive care, and based on expert opinion rather than clinical trials. Recently, however, the availability of advanced PAH-specific treatment has opened up a new field for the clinical management of this condition. Nevertheless, there is limited evidence on the optimal therapeutic approach for PAH-CHD. Herein, we discuss the current and novel therapeutic options for PAH-CHD as well as highlight several challenges in the clinical management at present.
Collapse
|
5
|
Makhija N, Narula J, Keshri VK, Gupta SK, Talwar S. Unidirectional ventricular septal valved patch for repair of late presenting ventricular septal defect with aortopulmonary window. Ann Pediatr Cardiol 2016; 9:90-3. [PMID: 27011704 PMCID: PMC4782481 DOI: 10.4103/0974-2069.171404] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Management of long standing left to right shunt lesion resulting in elevated pulmonary vascular resistance (PVR) is challenging. Limited surgical options are further complicated by an unpredictable postoperative period. Unidirectional valve patch (UVP) closure has shown to be useful in cases of the large ventricular septal defect (VSD) who present late. We report a case of large aortopulmonary window coexisting with a large VSD with severe pulmonary artery hypertension and significantly elevated PVR that was managed surgically by closure of the window by sandwich technique and closure of the septal defect with a UVP. This report emphasizes the importance of UVP in the management of such patients.
Collapse
Affiliation(s)
- Neeti Makhija
- Cardiothoracic Sciences Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Jitin Narula
- Cardiothoracic Sciences Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Vikas Kumar Keshri
- Cardiothoracic Sciences Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Saurabh Kumar Gupta
- Cardiothoracic Sciences Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Sachin Talwar
- Cardiothoracic Sciences Centre, All India Institute of Medical Sciences, New Delhi, India
| |
Collapse
|
6
|
Talwar S, Keshri VK, Choudhary SK, Gupta SK, Ramakrishnan S, Juneja R, Saxena A, Kothari SS, Airan B. Surgical strategies for patients with congenital heart disease and severe pulmonary hypertension in low/middle-income countries. HEART ASIA 2015; 7:31-7. [PMID: 27326218 DOI: 10.1136/heartasia-2015-010645] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 08/02/2015] [Accepted: 09/18/2015] [Indexed: 11/04/2022]
Abstract
In this review, we discuss specific surgical strategies that are used in patients with congenital heart disease and severe pulmonary arterial hypertension. Our own experience, with the use of unidirectional valved patches in managing these patients, is also discussed in detail.
Collapse
Affiliation(s)
- Sachin Talwar
- Cardiothoracic Centre, All India Institute of Medical Sciences , New Delhi , India
| | - Vikas Kumar Keshri
- Cardiothoracic Centre, All India Institute of Medical Sciences , New Delhi , India
| | - Shiv Kumar Choudhary
- Cardiothoracic Centre, All India Institute of Medical Sciences , New Delhi , India
| | - Saurabh Kumar Gupta
- Cardiothoracic Centre, All India Institute of Medical Sciences , New Delhi , India
| | | | - Rajnish Juneja
- Cardiothoracic Centre, All India Institute of Medical Sciences , New Delhi , India
| | - Anita Saxena
- Cardiothoracic Centre, All India Institute of Medical Sciences , New Delhi , India
| | - Shyam Sunder Kothari
- Cardiothoracic Centre, All India Institute of Medical Sciences , New Delhi , India
| | - Balram Airan
- Cardiothoracic Centre, All India Institute of Medical Sciences , New Delhi , India
| |
Collapse
|
7
|
D'Alto M, Merola A, Dimopoulos K. Pulmonary hypertension related to congenital heart disease: A comprehensive review. Glob Cardiol Sci Pract 2015. [DOI: 10.5339/gcsp.2015.42] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
|
8
|
Talwar S, Keshri VK, Choudhary SK, Gupta SK, Ramakrishnan S, Saxena A, Kothari SS, Juneja R, Kumar G, Airan B. Unidirectional valved patch closure of ventricular septal defects with severe pulmonary arterial hypertension: hemodynamic outcomes. J Thorac Cardiovasc Surg 2014; 148:2570-5. [PMID: 24332111 DOI: 10.1016/j.jtcvs.2013.10.052] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2013] [Revised: 09/13/2013] [Accepted: 10/29/2013] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The purpose of the present study was to study the midterm hemodynamic outcomes of unidirectional valved patch closure of ventricular septal defects (VSDs) in patients with VSD and pulmonary arterial hypertension (PAH). METHODS From January 2006 to January 2012, 20 patients with VSD with PAH and a pulmonary vascular resistance index >8 Wood units underwent VSD closure with a unidirectional valved patch using the technique previously described by us. Of these, 13 patients agreed to follow-up cardiac catheterization and were studied at a mean follow-up of 34.7 ± 18.6 months (range, 2-56). The mean age of these 13 patients was 8.5 ± 4.4 years (range, 2-19; median, 9), and the mean preoperative systemic saturation was 94.1% ± 3.4% (range, 87-99; median, 95.0) The mean preoperative pulmonary artery systolic pressure was 96.2 ± 13.6 mm Hg (range, 75-115; median, 103.0), and the mean preoperative pulmonary vascular resistance index was 10.0 ± 2.1 Wood units (range, 8.0-15.1; median, 9.3). RESULTS At follow-up cardiac catheterization, the mean systemic saturation had increased to 98.92%. The pulmonary vascular resistance index had decreased significantly to 5.8 ± 2.1 Wood units (P = .02). A significant decrease was seen in the pulmonary artery systolic, diastolic, and mean pressures (P = .000), and none of the patients had severe PAH. No patients died, and all patients were in New York Heart Association class I. CONCLUSIONS Unidirectional valved patch closure of VSD is a promising technique for patients with a large VSD and severe PAH. It had a favorable effect on the immediate, early, and midterm clinical outcomes and hemodynamic parameters.
Collapse
Affiliation(s)
- Sachin Talwar
- Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India.
| | - Vikas Kumar Keshri
- Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Shiv Kumar Choudhary
- Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Saurabh Kumar Gupta
- Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India
| | | | - Anita Saxena
- Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Shyam Sunder Kothari
- Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Rajnish Juneja
- Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Guresh Kumar
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
| | - Balram Airan
- Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India
| |
Collapse
|
9
|
Khanna SN, Paul M, Bhan S, Sharma KK. Surgical correction of Lutembacher's syndrome in a patient with severe pulmonary artery hypertension. J Card Surg 2014; 29:569-71. [PMID: 24827112 DOI: 10.1111/jocs.12340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Lutembacher's syndrome is an uncommon combination of a congenital ostium secundum atrial septal defect (ASD) with acquired mitral stenosis (MS). The incidence of this condition is very rare. The symptoms are dependent upon the size of the ASD, severity of the MS, compliance of the right ventricle and pulmonary artery hypertension. We describe a patient with Lutembacher's syndrome with severe pulmonary hypertension who underwent successful surgical repair.
Collapse
|
10
|
Talwar S, Choudhary SK, Garg S, Saxena A, Ramakrishnan S, Kothari SS, Juneja R, Airan B. Unidirectional valved patch closure of ventricular septal defects with severe pulmonary arterial hypertension. Interact Cardiovasc Thorac Surg 2012; 14:699-702. [PMID: 22402503 DOI: 10.1093/icvts/ivs044] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Delayed presentation of ventricular septal defect (VSD) is common in developing countries. Such patients often have severe pulmonary arterial hypertension (PAH), which increases post-operative morbidity and mortality. To address these problems, we used our technique of unidirectional valved patch (UVP) for closure of VSD. Between January 2006 and December 2010, 17 patients (age 2-23 years, median 9 years) with a large VSD and severe PAH underwent VSD closure with UVP. Pre-operative mean indexed pulmonary vascular resistance (PVRI) was 10.9 ± 2.2 Wood units and mean pre-operative systemic saturation was 93.4 ± 2.6%. Shunt was bidirectional in 15 patients and predominantly right to left in two. After VSD closure, intra-operative transoesophageal echocardiography revealed a right to left shunt across the patch in three patients 2, 7 and 9 years of age who had pre-operative PVRI of 9.5, 9.8 and 11.1 Wood units, respectively. There were no in-hospital deaths and all patients had uneventful recovery. Mean follow-up was 30 ± 14.7 months and all patients are well without cyanosis. Echocardiography showed no shunt across the patch and all have systemic saturation >95%. We conclude that UVP is a promising technique in patients with large VSD and severe PAH.
Collapse
Affiliation(s)
- Sachin Talwar
- Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India.
| | | | | | | | | | | | | | | |
Collapse
|
11
|
Talwar S, Choudhary SK, Nair VV, Chauhan S, Kothari SS, Juneja R, Saxena A, Airan B. Arterial switch operation with unidirectional valved patch closure of ventricular septal defect in patients with transposition of great arteries and severe pulmonary hypertension. World J Pediatr Congenit Heart Surg 2012; 3:21-5. [PMID: 23804680 DOI: 10.1177/2150135111421939] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE For patients with dextro-transposition of great arteries (d-TGAs), ventricular septal defect (VSD), and severe pulmonary arterial hypertension (PAH), the common surgical options are palliative arterial switch operation (ASO) or palliative atrial switch operation leaving the VSD open. We evaluated the role of ASO with VSD closure using a fenestrated unidirectional valved patch (UVP). METHODS Between July 2009 and February 2011, six patients with TGAs, VSD, and severe PAH (mean age 39.8 ± 47.4 months, median 21, range 8-132 months), weighing 10.7 ± 9.2 kg (median 8.6, range 4.3-29 kg), underwent ASO with VSD closure using our simple technique of UVP. Mean pulmonary artery systolic pressure before the operation was 106 ± 12.7 mm Hg (median 107.5, range 95-126 mm Hg) and pulmonary vascular resistance was 9.5 ± 4.22 units (median 9.5, range 6.6-17.1 Wood units). RESULTS There were no deaths. All patients had a postoperative systemic arterial saturation of more than 95%, although there were frequent episodes of systemic desaturation due to right-to-left shunt across the valved VSD patch (as seen on transesophageal and transthoracic echocardiograms). Mean follow-up was 10 ± 7.6 months (median 7.5, range 1-22 months). At most recent follow-up, all patients had systemic arterial saturation of more than 95% and no right-to-left shunt through the VSD patch. In one patient, the follow-up cardiac catheterization showed a fall in pulmonary artery systolic pressure to 49 mm Hg. CONCLUSION Arterial switch operation with UVP VSD closure is feasible with acceptable early results. It avoids complications of palliative atrial switch (arrhythmia and baffle obstruction) and partially or completely open VSD.
Collapse
Affiliation(s)
- Sachin Talwar
- Cardiothoracic Center, All India Institute of Medical Sciences, New Delhi, India
| | | | | | | | | | | | | | | |
Collapse
|
12
|
Talwar S, Kothari SS, Ahmed T, Choudhary SK, Airan B. Unidirectional valved patch closure of ventricular septal defect with arterial switch operation in a patient with d-transposition of great arteries with severe pulmonary hypertension. J Card Surg 2011; 26:234-6. [PMID: 21395688 DOI: 10.1111/j.1540-8191.2010.01184.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
We report our experience with a five-year-old child with d-transposition of great arteries (d-TGA), ventricular septal defect (VSD), and severe pulmonary arterial hypertension (PAH). A fenestrated unidirectional-valved patch was used to close the VSD and a standard arterial witch operation (ASO) was performed. Difficulties in assessment of operability and the choice of procedures in such patients are briefly discussed.
Collapse
Affiliation(s)
- Sachin Talwar
- Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India.
| | | | | | | | | |
Collapse
|