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Kochanski JJ, Feinstein JA, Ogawa M, Ritter V, Hopper RK, Adamson GT. Younger age at initiation of subcutaneous treprostinil is associated with better response in pediatric Group 1 pulmonary arterial hypertension. Pulm Circ 2024; 14:e12328. [PMID: 38348195 PMCID: PMC10860541 DOI: 10.1002/pul2.12328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 10/31/2023] [Accepted: 11/24/2023] [Indexed: 02/15/2024] Open
Abstract
Children with severe Group 1 pulmonary arterial hypertension (PAH) have an unpredictable response to subcutaneous treprostinil (TRE) therapy, which may be influenced by age, disease severity, or other unknown variables at time of initiation. In this retrospective single-center cohort study, we hypothesized that younger age at TRE initiation, early hemodynamic response (a decrease in pulmonary vascular resistance by ≥30% at follow-up catheterization), and less severe baseline hemodynamics (Rp:Rs < 1.1) would each be associated with better clinical outcomes. In 40 pediatric patients with Group I PAH aged 17 days-18 years treated with subcutaneous TRE, younger age (cut-off of 6-years of age, AUC 0.824) at TRE initiation was associated with superior 5-year freedom from adverse events (94% vs. 39%, p = 0.002), better WHO functional class (I or II: 88% vs. 39% p = 0.003), and better echocardiographic indices of right ventricular function at most recent follow-up. Neither early hemodynamic response nor less severe baseline hemodynamics were associated with better outcomes. Patients who did not have a significant early hemodynamic response to TRE by first follow-up catheterization were unlikely to show subsequent improvement in PVRi (1/8, 13%). These findings may help clinicians counsel families and guide clinical decision making regarding the timing of advanced therapies.
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Affiliation(s)
- Justin J. Kochanski
- Department of Pediatrics (Cardiology)Stanford University School of MedicinePalo AltoCaliforniaUSA
| | - Jeffrey A. Feinstein
- Department of Pediatrics (Cardiology)Stanford University School of MedicinePalo AltoCaliforniaUSA
| | - Michelle Ogawa
- Department of Pediatrics (Cardiology)Stanford University School of MedicinePalo AltoCaliforniaUSA
| | - Victor Ritter
- Stanford University School of MedicineQuantitative Sciences UnitPalo AltoCaliforniaUSA
| | - Rachel K. Hopper
- Department of Pediatrics (Cardiology)Stanford University School of MedicinePalo AltoCaliforniaUSA
| | - Gregory T. Adamson
- Department of Pediatrics (Cardiology)Stanford University School of MedicinePalo AltoCaliforniaUSA
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Hansen BE, Vandriel SM, Vig P, Garner W, Mogul DB, Loomes KM, Piccoli DA, Rand EB, Jankowska I, Czubkowski P, Gliwicz-Miedzińska D, Gonzales EM, Jacquemin E, Bouligand J, D'Antiga L, Nicastro E, Arnell H, Fischler B, Sokal É, Demaret T, Siew S, Stormon M, Karpen SJ, Romero R, Ebel NH, Feinstein JA, Roberts AJ, Evans HM, Sundaram SS, Chaidez A, Hardikar W, Shankar S, Fischer RT, Lacaille F, Debray D, Lin HC, Jensen MK, Jaramillo C, Karthikeyan P, Indolfi G, Verkade HJ, Larson-Nath C, Quiros-Tejeira RE, Valentino PL, Rogalidou M, Dezsőfi A, Squires JE, Schwarz K, Calvo PL, Bernabeu JQ, Zizzo AN, Nebbia G, Bulut P, Santos-Silva E, Fawaz R, Nastasio S, Karnsakul W, Tamara ML, Busoms CM, Kelly DA, Sandahl TD, Jimenez-Rivera C, Banales JM, Mujawar Q, Li LT, She H, Wang JS, Kim KM, Oh SH, Sanchez MC, Cavalieri ML, Lee WS, Hajinicolaou C, Lertudomphonwanit C, Waisbourd-Zinman O, Arikan C, Alam S, Carvalho E, Melere M, Eshun J, Önal Z, Desai DM, Wiecek S, Pinto RB, Wolters VM, Garcia J, Beretta M, Kerkar N, Brecelj J, Rock N, Lurz E, Blondet N, Shah U, Thompson RJ, Kamath BM. Event-free survival of maralixibat-treated patients with Alagille syndrome compared to a real-world cohort from GALA. Hepatology 2023:01515467-990000000-00695. [PMID: 38146932 DOI: 10.1097/hep.0000000000000727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 11/18/2023] [Indexed: 12/27/2023]
Abstract
BACKGROUND AND AIMS Alagille syndrome (ALGS) is characterized by chronic cholestasis with associated pruritus and extrahepatic anomalies. Maralixibat, an ileal bile acid transporter inhibitor, is an approved pharmacologic therapy for cholestatic pruritus in ALGS. Since long-term placebo-controlled studies are not feasible or ethical in children with rare diseases, a novel approach was taken comparing 6-year outcomes from maralixibat trials with an aligned and harmonized natural history cohort from the G lobal AL agille A lliance (GALA) study. APPROACH AND RESULTS Maralixibat trials comprise 84 patients with ALGS with up to 6 years of treatment. GALA contains retrospective data from 1438 participants. GALA was filtered to align with key maralixibat eligibility criteria, yielding 469 participants. Serum bile acids could not be included in the GALA filtering criteria as these are not routinely performed in clinical practice. Index time was determined through maximum likelihood estimation in an effort to align the disease severity between the two cohorts with the initiation of maralixibat. Event-free survival, defined as the time to first event of manifestations of portal hypertension (variceal bleeding, ascites requiring therapy), surgical biliary diversion, liver transplant, or death, was analyzed by Cox proportional hazards methods. Sensitivity analyses and adjustments for covariates were applied. Age, total bilirubin, gamma-glutamyl transferase, and alanine aminotransferase were balanced between groups with no statistical differences. Event-free survival in the maralixibat cohort was significantly better than the GALA cohort (HR, 0.305; 95% CI, 0.189-0.491; p <0.0001). Multiple sensitivity and subgroup analyses (including serum bile acid availability) showed similar findings. CONCLUSIONS This study demonstrates a novel application of a robust statistical method to evaluate outcomes in long-term intervention studies where placebo comparisons are not feasible, providing wide application for rare diseases. This comparison with real-world natural history data suggests that maralixibat improves event-free survival in patients with ALGS.
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Affiliation(s)
- Bettina E Hansen
- Department of Hepatology, Toronto General Hospital University Health Network, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Epidemiology, Erasmus MC, Rotterdam, The Netherlands
| | - Shannon M Vandriel
- Department of Paediatrics, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children and the University of Toronto, Toronto, Ontario, Canada
| | - Pamela Vig
- Department of Scientific and Medical Affairs, Mirum Pharmaceuticals, Inc., Foster City, California, USA
| | - Will Garner
- Department of Scientific and Medical Affairs, Mirum Pharmaceuticals, Inc., Foster City, California, USA
| | - Douglas B Mogul
- Department of Scientific and Medical Affairs, Mirum Pharmaceuticals, Inc., Foster City, California, USA
| | - Kathleen M Loomes
- Department of Pathology and Laboratory Medicine, Division of Gastroenterology, Hepatology and Nutrition, The Children's Hospital of Philadelphia and the University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - David A Piccoli
- Department of Pathology and Laboratory Medicine, Division of Gastroenterology, Hepatology and Nutrition, The Children's Hospital of Philadelphia and the University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Elizabeth B Rand
- Department of Pathology and Laboratory Medicine, Division of Gastroenterology, Hepatology and Nutrition, The Children's Hospital of Philadelphia and the University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Irena Jankowska
- Department of Gastroenterology, Hepatology, Nutrition Disturbances and Pediatrics, The Children's Memorial Health Institute, Warsaw, Poland
| | - Piotr Czubkowski
- Department of Gastroenterology, Hepatology, Nutrition Disturbances and Pediatrics, The Children's Memorial Health Institute, Warsaw, Poland
| | - Dorota Gliwicz-Miedzińska
- Department of Gastroenterology, Hepatology, Nutrition Disturbances and Pediatrics, The Children's Memorial Health Institute, Warsaw, Poland
| | - Emmanuel M Gonzales
- Department of Pediatric Hepatology and Liver Transplantation, Service d'Hépatologie et de Transplantation Hépatique Pédiatriques, Centre de Référence de l'Atrésie des Voies Biliaires et des Cholestases Génétiques (AVB-CG), FSMR FILFOIE, ERN RARE LIVER, Hôpital Bicêtre, AP-HP, Faculté de Médecine Paris-Saclay, Le Kremlin-Bicêtre, and Inserm U1193, Hépatinov, Université Paris-Saclay, Orsay, France
| | - Emmanuel Jacquemin
- Department of Pediatric Hepatology and Liver Transplantation, Service d'Hépatologie et de Transplantation Hépatique Pédiatriques, Centre de Référence de l'Atrésie des Voies Biliaires et des Cholestases Génétiques (AVB-CG), FSMR FILFOIE, ERN RARE LIVER, Hôpital Bicêtre, AP-HP, Faculté de Médecine Paris-Saclay, Le Kremlin-Bicêtre, and Inserm U1193, Hépatinov, Université Paris-Saclay, Orsay, France
| | - Jérôme Bouligand
- Department of Molecular Genetics, Pharmacogenetics and Hormonology, Service de Génétique Moléculaire, Pharmacogénétique et Hormonologie, Hôpitaux Universitaires Paris-Saclay, Assistance PubliqueHôpitaux de Paris, Centre Hospitalier Universitaire de Bicêtre, Le Kremlin-Bicêtre, France
| | - Lorenzo D'Antiga
- Department of Pediatric Hepatology, Gastroenterology, and Transplantation, Ospedale Papa Giovanni XXIII, Pediatric Hepatology, Gastroenterology and Transplantation, Bergamo, Italy
| | - Emanuele Nicastro
- Department of Pediatric Hepatology, Gastroenterology, and Transplantation, Ospedale Papa Giovanni XXIII, Pediatric Hepatology, Gastroenterology and Transplantation, Bergamo, Italy
| | - Henrik Arnell
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Astrid Lindgren Children's Hospital, Karolinska University Hospital and Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Björn Fischler
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Astrid Lindgren Children's Hospital, Karolinska University Hospital and CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - Étienne Sokal
- Department of Pediatric GI and Hepatology, Cliniques Universitaires Saint-Luc, Service De Gastroentérologie & Hépatologie Pédiatrique, Brussels, Belgium
| | - Tanguy Demaret
- Department of Pediatric GI and Hepatology, Cliniques Universitaires Saint-Luc, Service De Gastroentérologie & Hépatologie Pédiatrique, Brussels, Belgium
| | - Susan Siew
- Department of Gastroenterology, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Michael Stormon
- Department of Gastroenterology, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Saul J Karpen
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology & Nutrition, Children's Healthcare of Atlanta & Emory University School of Medicine, Atlanta, Georgia, USA
| | - Rene Romero
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology & Nutrition, Children's Healthcare of Atlanta & Emory University School of Medicine, Atlanta, Georgia, USA
| | - Noelle H Ebel
- Department of Pediatrics, Division of Gastroenterology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Jeffrey A Feinstein
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Lucile Packard Children's Hospital, Palo Alto, California, USA
| | - Amin J Roberts
- Starship Child Health, Department of Paediatric Gastroenterology, Auckland, New Zealand
| | - Helen M Evans
- Starship Child Health, Department of Paediatric Gastroenterology, Auckland, New Zealand
| | - Shikha S Sundaram
- Section of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics and the Digestive Health Institute, Children's Hospital of Colorado and University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Alexander Chaidez
- Section of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics and the Digestive Health Institute, Children's Hospital of Colorado and University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Winita Hardikar
- Department of Gastroenterology and Clinical Nutrition, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Sahana Shankar
- Department of Pediatrics, Mazumdar Shaw Medical Center, Narayana Health, Bangalore, Karnataka, India
| | - Ryan T Fischer
- Department of Gastroenterology, Children's Mercy Kansas City, Section of Hepatology, Kansas City, Missouri, USA
| | - Florence Lacaille
- Department of Pediatric Gastroenterology and Nutrition, Necker-Enfants Malades Hospital, University of Paris, Paris, France
| | - Dominique Debray
- Department of Pediatric Gastroenterology and Hepatology, Pediatric Liver Unit, National Reference Centre for Rare Pediatric Liver Diseases (Biliary Atresia and Genetic Cholestasis), FILFOIE, ERN RARE LIVER, Necker-Enfants Malades Hospital, University of Paris, Paris, France
| | - Henry C Lin
- Department of Pediatrics, Division of Pediatric Gastroenterology, Oregon Health and Science University, Portland, Oregon, USA
| | - M Kyle Jensen
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Primary Children's Hospital, University of Utah, Salt Lake City, Utah, USA
| | - Catalina Jaramillo
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Primary Children's Hospital, University of Utah, Salt Lake City, Utah, USA
| | - Palaniswamy Karthikeyan
- Department of Pediatrics, Leeds Teaching Hospitals NHS Trust, Leeds Children's Hospital, Leeds, UK
| | - Giuseppe Indolfi
- Department Neurofarba, University of Florence and Meyer Children's University Hospital, Paediatric and Liver Unit, Florence, Italy
| | - Henkjan J Verkade
- Department of Pediatrics, Center for Liver, Digestive, and Metabolic Diseases, University Medical Center Groningen, Groningen, The Netherlands
| | - Catherine Larson-Nath
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, Minnesota, USA
| | - Ruben E Quiros-Tejeira
- Department of Pediatrics, Children's Hospital & Medical Center and University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Pamela L Valentino
- Department of Pediatrics, Gastroenterology & Hepatology Division, University of Washington, Seattle Children's Hospital, Seattle, Washington, USA
| | - Maria Rogalidou
- First Department of Pediatrics, Division of Gastroenterology & Hepatology, "Agia Sofia" Children's Hospital, University of Athens, Athens, Greece
| | - Antal Dezsőfi
- First Department of Paediatrics, Semmelweis University, Budapest, Hungary
| | - James E Squires
- Department of Pediatrics, Division of Pediatric Gastroenterology and Hepatology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Kathleen Schwarz
- Department of Pediatrics, Division of Pediatric Gastroenterology, Rady Children's Hospital San Diego, University of California San Diego, San Diego, California, USA
| | - Pier Luigi Calvo
- Department of Pediatrics, Pediatric Gastroenterology Unit, Regina Margherita Children's Hospital, Azienda Ospedaliera-Universitaria Citta' della Salute e della Scienza, Turin, Italy
| | - Jesus Quintero Bernabeu
- Pediatric Hepatology and Liver Transplant Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Department of Liver and Gastrointestinal Diseases, Biodonostia Health Research Institute-Donostia University Hospital, University of the Basque Country (UPV/EHU), San Sebastian, Spain
| | - Andréanne N Zizzo
- Department of Paediatrics, Division of Paediatric Gastroenterology and Hepatology, London Health Sciences Centre, Children's Hospital, Western University, London, Ontario, Canada
| | - Gabriella Nebbia
- Department of Pediatric Hepatology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Servizio di Epatologia Pediatrica, Milan, Italy
| | - Pinar Bulut
- Department of Pediatrics, Division of Pediatric Gastroenterology and Hepatology, Phoenix Children's Hospital, Phoenix, Arizona, USA
| | - Ermelinda Santos-Silva
- Department of Pediatrics, Centro Hospitalar Universitário Do Porto, Pediatric Gastroenterology Unit, Porto, Portugal
| | - Rima Fawaz
- Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Silvia Nastasio
- Department of Pediatrics, Division of Gastroenterology, Hepatology, & Nutrition, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, US A
| | - Wikrom Karnsakul
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - María Legarda Tamara
- Department of Pediatrics, Paediatric Gastroenterology Unit, Cruces University Hospital, Bilbao, Spain
| | - Cristina Molera Busoms
- Department of Gastroenterology, Hepatology and Nutrition, Pediatric Gastroenterology Hepatology and Nutrition Unit, Hospital Sant Joan de Déu, Esplugues de Llobregat, Spain
| | - Deirdre A Kelly
- Department of Paediatric Hepatology, Liver Unit, Birmingham Women's & Children's Hospital NHS Trust and University of Birmingham, Birmingham, UK
| | | | - Carolina Jimenez-Rivera
- Department of Paediatrics, Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Jesus M Banales
- Department of Hepatology and Gastroenterology, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Biodonostia Health Research Institute-Donostia University Hospital, Universidad del País Vasco (UPV/EHU), San Sebastián, Spain
| | - Quais Mujawar
- Section of Pediatric Gastroenterology, Department of Pediatrics, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Li-Ting Li
- Department of Pediatric Gastroenterology, Children's Hospital of Fudan University, The Center for Pediatric Liver Diseases, Shanghai, China
| | - Huiyu She
- Department of Pediatric Gastroenterology, Children's Hospital of Fudan University, The Center for Pediatric Liver Diseases, Shanghai, China
| | - Jian-She Wang
- Department of Pediatric Gastroenterology, Children's Hospital of Fudan University, The Center for Pediatric Liver Diseases, Shanghai, China
| | - Kyung Mo Kim
- Department of Pediatrics, University of Ulsan College of Medicine, Asan Medical Center Children's Hospital, Seoul, South Korea
| | - Seak Hee Oh
- Department of Pediatrics, University of Ulsan College of Medicine, Asan Medical Center Children's Hospital, Seoul, South Korea
| | - Maria Camila Sanchez
- Department of Pediatric Gastroenterology, Pediatric Gastroenterology and Hepatology Division, Hospital Italiano Buenos Aires, Buenos Aires, Argentina
| | - Maria Lorena Cavalieri
- Department of Pediatric Gastroenterology, Pediatric Gastroenterology and Hepatology Division, Hospital Italiano Buenos Aires, Buenos Aires, Argentina
| | - Way Seah Lee
- Department of Paediatrics, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Christina Hajinicolaou
- Department of Paediatrics and Child Health, Division of Paediatric Gastroenterology, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Chatmanee Lertudomphonwanit
- Department of Pediatrics, Division of Gastroenterology, Ramathibodi Hospital Mahidol University, Bangkok, Thailand
| | - Orith Waisbourd-Zinman
- Department of Pediatrics, Schneider Children's Medical Center of Israel, Institute of Gastroenterology, Nutrition and Liver Diseases, Petah Tikva, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Cigdem Arikan
- Department of Pediatric Gastroenterology and Organ Transplant, Koç University School of Medicine, Istanbul, Turkey
| | - Seema Alam
- Department of Pediatric Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Elisa Carvalho
- Pediatric Gastroenterology Department, Hospital de Base do Distrito Federal, Hospital da Criança de Brasília, Centro Universitário de Brasília, Brasília, DF, Brazil
| | - Melina Melere
- Departamento de Gastroenterologia e Hepatologia Pediátrica, Pediatric Gastroenterology Service, Hospital da Criança Santo Antônio, Universidade Federal de Ciências da Saúde de Porto Alegre, Complexo Hospitalar Santa Casa, Porto Alegre, RS, Brazil
| | - John Eshun
- Department of Pediatric Gastroenterology, Le Bonheur Children's Hospital and The University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Zerrin Önal
- Pediatric Gastroenterology, Hepatology and Nutrition Department, Istanbul University Istanbul Medical Faculty, Istanbul, Turkey
| | - Dev M Desai
- Solid Organ Transplant Department, Children's Health-Children's Medical Center, Dallas, Texas, USA
| | - Sabina Wiecek
- Department of Pediatrics, Medical University of Silesia in Katowice, Katowice, Poland
| | - Raquel Borges Pinto
- Department of Pediatric Gastroenterology, Division of Pediatric Gastroenterology of Hospital da Criança Conceição do Grupo Hospitalar Conceição, Porto Alegre, RS, Brazil
| | - Victorien M Wolters
- Department of Pediatric Gastroenterology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jennifer Garcia
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition/Miami Transplant Institute, University of Miami, Miami, Florida, USA
| | - Marisa Beretta
- Department of Pediatric Intensive Care, Wits Donald Gordon Medical Centre, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Nanda Kerkar
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Rochester Medical Center, Rochester, New York, USA
| | - Jernej Brecelj
- Pediatric Gastroenterology, Hepatology and Nutrition, and Department of Pediatrics, Faculty of Medicine, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Nathalie Rock
- Department of Pediatrics, Gynecology, and Obstetrics, Division of Pediatric Specialties, Swiss Pediatric Liver Center, University Hospitals Geneva and University of Geneva, Geneva, Switzerland
| | - Eberhard Lurz
- Department of Pediatrics, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Munich, Germany
| | - Niviann Blondet
- Department of Pediatrics, Gastroenterology & Hepatology Division, University of Washington, Seattle Children's Hospital, Seattle, Washington, USA
| | - Uzma Shah
- Department of Pediatrics, Harvard Medical School, Massachusetts General Hospital for Children, Boston, Massachusetts, USA
| | - Richard J Thompson
- Department of Inflammation Biology, Institute of Liver Studies, King's College London, London, UK
| | - Binita M Kamath
- Department of Paediatrics, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children and the University of Toronto, Toronto, Ontario, Canada
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Szafron JM, Yang W, Feinstein JA, Rabinovitch M, Marsden AL. A computational growth and remodeling framework for adaptive and maladaptive pulmonary arterial hemodynamics. Biomech Model Mechanobiol 2023; 22:1935-1951. [PMID: 37658985 PMCID: PMC10929588 DOI: 10.1007/s10237-023-01744-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 07/05/2023] [Indexed: 09/05/2023]
Abstract
Hemodynamic loading is known to contribute to the development and progression of pulmonary arterial hypertension (PAH). This loading drives changes in mechanobiological stimuli that affect cellular phenotypes and lead to pulmonary vascular remodeling. Computational models have been used to simulate mechanobiological metrics of interest, such as wall shear stress, at single time points for PAH patients. However, there is a need for new approaches that simulate disease evolution to allow for prediction of long-term outcomes. In this work, we develop a framework that models the pulmonary arterial tree through adaptive and maladaptive responses to mechanical and biological perturbations. We coupled a constrained mixture theory-based growth and remodeling framework for the vessel wall with a morphometric tree representation of the pulmonary arterial vasculature. We show that non-uniform mechanical behavior is important to establish the homeostatic state of the pulmonary arterial tree, and that hemodynamic feedback is essential for simulating disease time courses. We also employed a series of maladaptive constitutive models, such as smooth muscle hyperproliferation and stiffening, to identify critical contributors to development of PAH phenotypes. Together, these simulations demonstrate an important step toward predicting changes in metrics of clinical interest for PAH patients and simulating potential treatment approaches.
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Affiliation(s)
- Jason M Szafron
- Department of Pediatrics (Cardiology), Stanford University, Stanford, CA, 94305, USA
- Cardiovascular Institute, Stanford University, Palo Alto, CA, 94305, USA
| | - Weiguang Yang
- Department of Pediatrics (Cardiology), Stanford University, Stanford, CA, 94305, USA
| | - Jeffrey A Feinstein
- Department of Pediatrics (Cardiology), Stanford University, Stanford, CA, 94305, USA
- Cardiovascular Institute, Stanford University, Palo Alto, CA, 94305, USA
| | - Marlene Rabinovitch
- Department of Pediatrics (Cardiology), Stanford University, Stanford, CA, 94305, USA
- Cardiovascular Institute, Stanford University, Palo Alto, CA, 94305, USA
| | - Alison L Marsden
- Department of Pediatrics (Cardiology), Stanford University, Stanford, CA, 94305, USA.
- Cardiovascular Institute, Stanford University, Palo Alto, CA, 94305, USA.
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Schramm JE, Dykes JC, Hopper RK, Feinstein JA, Rosenthal DN, Kameny RJ. Pulmonary Vasodilator Therapy in Pediatric Patients on Ventricular Assist Device Support: A Single-Center Experience and Proposal for Use. ASAIO J 2023; 69:1025-1030. [PMID: 37556563 DOI: 10.1097/mat.0000000000002023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/11/2023] Open
Abstract
Pediatric precapillary pulmonary hypertension can develop in response to systemic atrial hypertension. Systemic atrial decompression following ventricular assist device (VAD) implantation may not sufficiently lower pulmonary vascular resistance (PVR) to consider heart transplant candidacy. Prostacyclins have been used in adult VAD patients with success, but pediatric data on safety and efficacy in this population are limited. We sought to describe our center's experience to show its safety and to present our current protocol for perioperative use. We reviewed our use of prostacyclin therapy in pediatric patients on VAD support with high PVR from 2016 to 2021. Of the 17 patients who met inclusion, 12 survived to transplant and 1 is alive with VAD in situ . All patients survived posttransplant. With continuous intravenous (IV) epoprostenol or treprostinil therapy, there were no bleeding complications or worsening of end-organ function. A significant reduction was observed in vasoactive inotropic scores by 49% in the first 24 hours post-prostacyclin initiation. The proportion of patients surviving to transplant in this high-risk cohort is favorable. In conclusion, prostacyclins may be safe to use in patients with elevated PVR as part of their VAD and transplant course and may provide a transplant option in those otherwise not candidates.
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Affiliation(s)
- Jennifer E Schramm
- From the Department of Anesthesia and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - John C Dykes
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, California
| | - Rachel K Hopper
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, California
| | - Jeffrey A Feinstein
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, California
| | - David N Rosenthal
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, California
| | - Rebecca J Kameny
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, California
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Adamson GT, Yu J, Ramamoorthy C, Peng LF, Taylor A, Lennig M, Schmidt AR, Feinstein JA, Navaratnam M. Acute Hemodynamics in the Fontan Circulation: Open-Label Study of Vasopressin. Pediatr Crit Care Med 2023; 24:952-960. [PMID: 37462430 DOI: 10.1097/pcc.0000000000003326] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
OBJECTIVE To describe the acute hemodynamic effect of vasopressin on the Fontan circulation, including systemic and pulmonary pressures and resistances, left atrial pressure, and cardiac index. DESIGN Prospective, open-label, nonrandomized study (NCT04463394). SETTING Cardiac catheterization laboratory at Lucile Packard Children's Hospital, Stanford. PATIENTS Patients 3-50 years old with a Fontan circulation who were referred to the cardiac catheterization laboratory for hemodynamic assessment and/or intervention. INTERVENTIONS A 0.03 U/kg IV (maximum dose 1 unit) bolus of vasopressin was administered over 5 minutes, followed by a maintenance infusion of 0.3 mU/kg/min (maximum dose 0.03 U/min). MEASUREMENTS AND MAIN RESULTS Comprehensive cardiac catheterization measurements before and after vasopressin administration. Measurements included pulmonary artery, atrial, and systemic arterial pressures, oxygen saturations, and systemic and pulmonary flows and resistances. There were 28 patients studied. Median age was 13.5 (9.1, 17) years, and 16 (57%) patients had a single or dominant right ventricle. Following vasopressin administration, systolic blood pressure and systemic vascular resistance (SVR) increased by 17.5 (13.0, 22.8) mm Hg ( Z value -4.6, p < 0.001) and 3.8 (1.8, 7.5) Wood Units ( Z value -4.6, p < 0.001), respectively. The pulmonary vascular resistance (PVR) decreased by 0.4 ± 0.4 WU ( t statistic 6.2, p < 0.001), and the left atrial pressure increased by 1.0 (0.0, 2.0) mm Hg ( Z value -3.5, p < 0.001). The PVR:SVR decreased by 0.04 ± 0.03 ( t statistic 8.1, p < 0.001). Neither the pulmonary artery pressure (median difference 0.0 [-1.0, 1.0], Z value -0.4, p = 0.69) nor cardiac index (0.1 ± 0.3, t statistic -1.4, p = 0.18) changed significantly. There were no adverse events. CONCLUSIONS In Fontan patients undergoing cardiac catheterization, vasopressin administration resulted in a significant increase in systolic blood pressure, SVR, and left atrial pressure, decrease in PVR, and no change in cardiac index or pulmonary artery pressure. These findings suggest that in Fontan patients vasopressin may be an option for treating systemic hypotension during sedation or general anesthesia.
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Affiliation(s)
- Gregory T Adamson
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA
| | - Jane Yu
- Division of Pediatric Anesthesiology, Department of Anesthesia, Stanford University School of Medicine, Palo Alto, CA
| | - Chandra Ramamoorthy
- Division of Pediatric Anesthesiology, Department of Anesthesia, Stanford University School of Medicine, Palo Alto, CA
| | - Lynn F Peng
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA
| | - Anne Taylor
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA
| | - Michael Lennig
- Division of Pediatric Anesthesiology, Department of Anesthesia, Stanford University School of Medicine, Palo Alto, CA
| | - Alexander R Schmidt
- Division of Pediatric Anesthesiology, Department of Anesthesia, Stanford University School of Medicine, Palo Alto, CA
| | - Jeffrey A Feinstein
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA
| | - Manchula Navaratnam
- Division of Pediatric Anesthesiology, Department of Anesthesia, Stanford University School of Medicine, Palo Alto, CA
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6
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Motonaga KS, Sacks L, Olson I, Balasubramanian S, Chen S, Peng L, Feinstein JA, Silverman NH, Hanley FL, Axelrod DM, Krawczeski CD, Arunamata A, Kwiatkowski DM, Ceresnak SR. The development and efficacy of a paediatric cardiology fellowship online preparatory course. Cardiol Young 2023; 33:1975-1980. [PMID: 36440543 DOI: 10.1017/s1047951122003626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND The transition from residency to paediatric cardiology fellowship is challenging due to the new knowledge and technical skills required. Online learning can be an effective didactic modality that can be widely accessed by trainees. We sought to evaluate the effectiveness of a paediatric cardiology Fellowship Online Preparatory Course prior to the start of fellowship. METHODS The Online Preparatory Course contained 18 online learning modules covering basic concepts in anatomy, auscultation, echocardiography, catheterisation, cardiovascular intensive care, electrophysiology, pulmonary hypertension, heart failure, and cardiac surgery. Each online learning module included an instructional video with pre-and post-video tests. Participants completed pre- and post-Online Preparatory Course knowledge-based exams and surveys. Pre- and post-Online Preparatory Course survey and knowledge-based examination results were compared via Wilcoxon sign and paired t-tests. RESULTS 151 incoming paediatric cardiology fellows from programmes across the USA participated in the 3 months prior to starting fellowship training between 2017 and 2019. There was significant improvement between pre- and post-video test scores for all 18 online learning modules. There was also significant improvement between pre- and post-Online Preparatory Course exam scores (PRE 43.6 ± 11% versus POST 60.3 ± 10%, p < 0.001). Comparing pre- and post-Online Preparatory Course surveys, there was a statistically significant improvement in the participants' comfort level in 35 of 36 (97%) assessment areas. Nearly all participants (98%) agreed or strongly agreed that the Online Preparatory Course was a valuable learning experience and helped alleviate some anxieties (77% agreed or strongly agreed) related to starting fellowship. CONCLUSION An Online Preparatory Course prior to starting fellowship can provide a foundation of knowledge, decrease anxiety, and serve as an effective educational springboard for paediatric cardiology fellows.
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Affiliation(s)
- Kara S Motonaga
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University, Palo Alto, CA, USA
| | - Loren Sacks
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University, Palo Alto, CA, USA
| | - Inger Olson
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University, Palo Alto, CA, USA
| | - Sowmya Balasubramanian
- Department of Pediatrics, Division of Pediatric Cardiology, University of Michigan, Ann Arbor, MI, USA
| | - Sharon Chen
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University, Palo Alto, CA, USA
| | - Lynn Peng
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University, Palo Alto, CA, USA
| | - Jeffrey A Feinstein
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University, Palo Alto, CA, USA
| | - Norman H Silverman
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University, Palo Alto, CA, USA
| | - Frank L Hanley
- Department of Cardiothoracic Surgery, Division of Pediatric Cardiac Surgery, Stanford University, Palo Alto, CA, USA
| | - David M Axelrod
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University, Palo Alto, CA, USA
| | - Catherine D Krawczeski
- Department of Pediatrics, Division of Pediatric Cardiology, Nationwide Children's Hospital, Columbus, OH, USA
| | - Alisa Arunamata
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University, Palo Alto, CA, USA
| | - David M Kwiatkowski
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University, Palo Alto, CA, USA
| | - Scott R Ceresnak
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University, Palo Alto, CA, USA
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7
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Ridderbos FJS, Chan FP, van Melle JP, Ebels T, Feinstein JA, Berger RMF, Willems TP. Quantification of systemic-to-pulmonary collateral flow in univentricular physiology with 4D flow MRI. Cardiol Young 2023; 33:1634-1642. [PMID: 36120930 DOI: 10.1017/s1047951122002840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
PURPOSE Systemic-to-pulmonary collateral flow is a well-recognised phenomenon in patients with single ventricle physiology, but remains difficult to quantify. The aim was to compare the reported formula's that have been used for calculation of systemic-to-pulmonary-collateral flow to assess their consistency and to quantify systemic-to-pulmonary collateral flow in patients with a Glenn and/or Fontan circulation using four-dimensional flow MRI (4D flow MR). METHODS Retrospective case-control study of Glenn and Fontan patients who had a 4D flow MR study. Flows were measured at the ascending aorta, left and right pulmonary arteries, left and right pulmonary veins, and both caval veins. Systemic-to-pulmonary collateral flow was calculated using two formulas: 1) pulmonary veins - pulmonary arteries and 2) ascending aorta - caval veins. Anatomical identification of collaterals was performed using the 4D MR image set. RESULTS Fourteen patients (n = 11 Fontan, n = 3 Glenn) were included (age 26 [22-30] years). Systemic-to-pulmonary collateral flow was significantly higher in the patients than the controls (n = 10, age 31.2 [15.1-38.4] years) with both formulas: 0.28 [0.09-0.5] versus 0.04 [-0.66-0.21] l/min/m2 (p = 0.036, formula 1) and 0.67 [0.24-0.88] versus -0.07 [-0.16-0.08] l/min/m2 (p < 0.001, formula 2). In patients, systemic-to-pulmonary collateral flow differed significantly between formulas 1 and 2 (13% versus 26% of aortic flow, p = 0.038). In seven patients, veno-venous collaterals were detected and no aortopulmonary collaterals were visualised. CONCLUSION 4D flow MR is able to detect increased systemic-to-pulmonary collateral flow and visualise collaterals vessels in Glenn and Fontan patients. However, the amount of systemic-to-pulmonary collateral flow varies with the formula employed. Therefore, further research is necessary before it could be applied in clinical care.
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Affiliation(s)
- Floris-Jan S Ridderbos
- Department of Radiology, Stanford University Medical Center, Stanford University, Stanford, USA
- Department of Pediatric Cardiology, Center for Congenital Heart Diseases, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Frandics P Chan
- Department of Radiology, Stanford University Medical Center, Stanford University, Stanford, USA
| | - Joost P van Melle
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Tjark Ebels
- Department of Cardiothoracic Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
- Department of Cardiothoracic Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Jeffrey A Feinstein
- Department of Pediatrics (Cardiology), Stanford University Medical Center / Lucile Packard Children's Hospital, Stanford University, Stanford, USA
| | - Rolf M F Berger
- Department of Pediatric Cardiology, Center for Congenital Heart Diseases, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Tineke P Willems
- Department of Radiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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8
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Szafron JM, Yang W, Feinstein JA, Rabinovitch M, Marsden AL. A Computational Growth and Remodeling Framework for Adaptive and Maladaptive Pulmonary Arterial Hemodynamics. bioRxiv 2023:2023.04.20.537714. [PMID: 37131683 PMCID: PMC10153237 DOI: 10.1101/2023.04.20.537714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Hemodynamic loading is known to contribute to the development and progression of pulmonary arterial hypertension (PAH). This loading drives changes in mechanobiological stimuli that affect cellular phenotypes and lead to pulmonary vascular remodeling. Computational models have been used to simulate mechanobiological metrics of interest, such as wall shear stress, at single time points for PAH patients. However, there is a need for new approaches that simulate disease evolution to allow for prediction of long-term outcomes. In this work, we develop a framework that models the pulmonary arterial tree through adaptive and maladaptive responses to mechanical and biological perturbations. We coupled a constrained mixture theory-based growth and remodeling framework for the vessel wall with a morphometric tree representation of the pulmonary arterial vasculature. We show that non-uniform mechanical behavior is important to establish the homeostatic state of the pulmonary arterial tree, and that hemodynamic feedback is essential for simulating disease time courses. We also employed a series of maladaptive constitutive models, such as smooth muscle hyperproliferation and stiffening, to identify critical contributors to development of PAH phenotypes. Together, these simulations demonstrate an important step towards predicting changes in metrics of clinical interest for PAH patients and simulating potential treatment approaches.
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Affiliation(s)
- Jason M. Szafron
- Department of Pediatrics (Cardiology), Stanford University
- Cardiovascular Institute, Stanford University
| | - Weiguang Yang
- Department of Pediatrics (Cardiology), Stanford University
| | - Jeffrey A. Feinstein
- Department of Pediatrics (Cardiology), Stanford University
- Cardiovascular Institute, Stanford University
| | - Marlene Rabinovitch
- Department of Pediatrics (Cardiology), Stanford University
- Cardiovascular Institute, Stanford University
| | - Alison L. Marsden
- Department of Pediatrics (Cardiology), Stanford University
- Cardiovascular Institute, Stanford University
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9
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Wise-Faberowski L, Long J, Ma M, Nadel HR, Shek J, Feinstein JA, Martin E, Hanley FL, McElhinney DB. Serial Lung Perfusion Scintigraphy After Unifocalization and Repair of Tetralogy of Fallot With Major Aortopulmonary Collaterals. World J Pediatr Congenit Heart Surg 2023; 14:261-272. [PMID: 36972512 DOI: 10.1177/21501351231162959] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
Background In patients with tetralogy of Fallot and major aortopulmonary collaterals (MAPCAs), pulmonary blood supply is highly variable. Our approach to this condition emphasizes complete unifocalization of the pulmonary circulation, incorporating all lung segments and addressing stenoses out to the segmental level. Post-repair, we recommend serial lung perfusion scintigraphy (LPS) to assess short-term changes in pulmonary blood flow distribution. Methods We reviewed post-discharge and follow-up LPS performed through three years post-repair and analyzed serial changes in perfusion, risk factors for change, and the relationship between LPS parameters and pulmonary artery reintervention. Results Of 543 patients who had postoperative LPS results in our system, 317 (58%) had only a predischarge LPS available for review, while 226 had 1 (20%) or more (22%) follow-up scans within three years. Overall, pulmonary flow distribution prior to discharge was balanced, and there was minimal change over time; however, there was considerable patient-to-patient variation in both metrics. On multivariable mixed modeling, time after repair ( P = .025), initial anatomy consisting of a ductus arteriosus to one lung ( P < .001), and age at repair ( P = .014) were associated with changes on serial LPS. Patients who had follow-up LPS were more likely to undergo pulmonary artery reintervention, but within that cohort, LPS parameters were not associated with reintervention risk. Conclusion Serial LPS during the first year after MAPCAs repair is a noninvasive method of screening for significant post-repair pulmonary artery stenosis that occurs in a small but important minority of patients. In patients who received follow-up LPS beyond the perioperative period, there was minimal change over time in the population overall, but large changes in some patients and considerable variability. There was no statistical association between LPS findings and pulmonary artery reintervention.
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Affiliation(s)
| | - Jin Long
- Department of Pediatrics, Stanford University, Stanford, CA, USA
| | - Michael Ma
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, USA
| | - Helen R Nadel
- Department of Radiology, Lucile Packard Children's Hospital Children's Heart Center, Stanford University, Stanford, CA, USA
| | - Jennifer Shek
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, USA
| | | | - Elisabeth Martin
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, USA
| | - Frank L Hanley
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, USA
| | - Doff B McElhinney
- Department of Pediatrics, Stanford University, Stanford, CA, USA
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, USA
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10
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Hopper RK, van der Have O, Hollander SA, Dipchand AI, Perez de Sa V, Feinstein JA, Tran-Lundmark K. International practice heterogeneity in pre-transplant management of pulmonary hypertension related to pediatric left heart disease. Pediatr Transplant 2023; 27:e14461. [PMID: 36593638 DOI: 10.1111/petr.14461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Revised: 12/12/2022] [Accepted: 12/14/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND Elevated pulmonary vascular resistance (PVR) in the setting of left heart failure may contribute to poor outcomes after pediatric heart transplant (HTx), but peri-transplant management is variable. METHODS We sought to characterize international practice by surveying physicians at pediatric HTx centers. RESULTS We received 49 complete responses from 39 centers in 16 countries. Most respondents are pediatric cardiologists (90%), practice at centers offering heart (86%) and lung (55%) transplant, and perform pre-HTx acute vasoreactivity testing (AVT, 88%) in patients with elevated PVR. Half (51%) reported defining a PVR cutoff for HTx eligibility as ≤6 WU m2 (56%) post-AVT (84%). The highest post-AVT PVR ever accepted for HTx ranged from 3-14.4 (median 6) WU m2 . To treat elevated pre-transplant PVR, phosphodiesterase type 5 inhibitors are most common (65%) followed by oxygen (31%), nitric oxide (14%), endothelin receptor antagonists (11%), and prostacyclins (6%). Nearly a third (31%) do not routinely use pulmonary vasodilators without implantation of a left ventricular assist device (LVAD). Case scenarios highlight treatment variability: in a restrictive cardiomyopathy scenario, HTx listing with post-transplant vasodilator therapy was favored, whereas in a Shone's complex patient with fixed PVR, LVAD ± pulmonary vasodilators followed by repeat catheterization was most common. Management of dilated cardiomyopathy with reactive PVR was variable. Most continue vasodilator therapy until HTx (16%), PVR normalizes (16%) or ≤6 months. CONCLUSIONS Management of elevated PVR in children awaiting HTx is heterogenous. Evidence-based guidelines are needed to allow for longitudinal determination of optimal outcomes and standardized care.
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Affiliation(s)
- Rachel K Hopper
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, California, USA
| | - Oscar van der Have
- Department of Experimental Medical Science, Wallenberg Center for Molecular Medicine, Lund University, Lund, Sweden.,The Pediatric Heart Center, Skane University Hospital, Lund, Sweden
| | - Seth A Hollander
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, California, USA
| | - Anne I Dipchand
- Department of Pediatrics, Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Valeria Perez de Sa
- Department of Clinical Sciences, Anesthesiology and Intensive Care, Lund University, Lund, Sweden
| | - Jeffrey A Feinstein
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, California, USA
| | - Karin Tran-Lundmark
- Department of Experimental Medical Science, Wallenberg Center for Molecular Medicine, Lund University, Lund, Sweden.,The Pediatric Heart Center, Skane University Hospital, Lund, Sweden
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11
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Vandriel SM, Li L, She H, Wang J, Gilbert MA, Jankowska I, Czubkowski P, Gliwicz‐Miedzińska D, Gonzales EM, Jacquemin E, Bouligand J, Spinner NB, Loomes KM, Piccoli DA, D'Antiga L, Nicastro E, Sokal É, Demaret T, Ebel NH, Feinstein JA, Fawaz R, Nastasio S, Lacaille F, Debray D, Arnell H, Fischler B, Siew S, Stormon M, Karpen SJ, Romero R, Kim KM, Baek WY, Hardikar W, Shankar S, Roberts AJ, Evans HM, Jensen MK, Kavan M, Sundaram SS, Chaidez A, Karthikeyan P, Sanchez MC, Cavalieri ML, Verkade HJ, Lee WS, Squires JE, Hajinicolaou C, Lertudomphonwanit C, Fischer RT, Larson‐Nath C, Mozer‐Glassberg Y, Arikan C, Lin HC, Bernabeu JQ, Alam S, Kelly DA, Carvalho E, Ferreira CT, Indolfi G, Quiros‐Tejeira RE, Bulut P, Calvo PL, Önal Z, Valentino PL, Desai DM, Eshun J, Rogalidou M, Dezsőfi A, Wiecek S, Nebbia G, Pinto RB, Wolters VM, Tamara ML, Zizzo AN, Garcia J, Schwarz K, Beretta M, Sandahl TD, Jimenez‐Rivera C, Kerkar N, Brecelj J, Mujawar Q, Rock N, Busoms CM, Karnsakul W, Lurz E, Santos‐Silva E, Blondet N, Bujanda L, Shah U, Thompson RJ, Hansen BE, Kamath BM. Natural history of liver disease in a large international cohort of children with Alagille syndrome: Results from the GALA study. Hepatology 2023; 77:512-529. [PMID: 36036223 PMCID: PMC9869940 DOI: 10.1002/hep.32761] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 07/20/2022] [Accepted: 07/21/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND AND AIMS Alagille syndrome (ALGS) is a multisystem disorder, characterized by cholestasis. Existing outcome data are largely derived from tertiary centers, and real-world data are lacking. This study aimed to elucidate the natural history of liver disease in a contemporary, international cohort of children with ALGS. APPROACH AND RESULTS This was a multicenter retrospective study of children with a clinically and/or genetically confirmed ALGS diagnosis, born between January 1997 and August 2019. Native liver survival (NLS) and event-free survival rates were assessed. Cox models were constructed to identify early biochemical predictors of clinically evident portal hypertension (CEPH) and NLS. In total, 1433 children (57% male) from 67 centers in 29 countries were included. The 10 and 18-year NLS rates were 54.4% and 40.3%. By 10 and 18 years, 51.5% and 66.0% of children with ALGS experienced ≥1 adverse liver-related event (CEPH, transplant, or death). Children (>6 and ≤12 months) with median total bilirubin (TB) levels between ≥5.0 and <10.0 mg/dl had a 4.1-fold (95% confidence interval [CI], 1.6-10.8), and those ≥10.0 mg/dl had an 8.0-fold (95% CI, 3.4-18.4) increased risk of developing CEPH compared with those <5.0 mg/dl. Median TB levels between ≥5.0 and <10.0 mg/dl and >10.0 mg/dl were associated with a 4.8 (95% CI, 2.4-9.7) and 15.6 (95% CI, 8.7-28.2) increased risk of transplantation relative to <5.0 mg/dl. Median TB <5.0 mg/dl were associated with higher NLS rates relative to ≥5.0 mg/dl, with 79% reaching adulthood with native liver ( p < 0.001). CONCLUSIONS In this large international cohort of ALGS, only 40.3% of children reach adulthood with their native liver. A TB <5.0 mg/dl between 6 and 12 months of age is associated with better hepatic outcomes. These thresholds provide clinicians with an objective tool to assist with clinical decision-making and in the evaluation of therapies.
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Affiliation(s)
- Shannon M. Vandriel
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children and the University of Toronto, Toronto, Canada
| | - Li‐Ting Li
- The Center for Pediatric Liver Diseases, Children's Hospital of Fudan University, Shanghai, China
| | - Huiyu She
- The Center for Pediatric Liver Diseases, Children's Hospital of Fudan University, Shanghai, China
| | - Jian‐She Wang
- The Center for Pediatric Liver Diseases, Children's Hospital of Fudan University, Shanghai, China
| | - Melissa A. Gilbert
- Division of Genomic Diagnostics, Department of Pathology and Laboratory Medicine, The Children’s Hospital of Philadelphia and the University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Irena Jankowska
- Department of Gastroenterology, Hepatology, Nutrition Disturbances and Pediatrics, The Children's Memorial Health Institute, Warsaw, Poland
| | - Piotr Czubkowski
- Department of Gastroenterology, Hepatology, Nutrition Disturbances and Pediatrics, The Children's Memorial Health Institute, Warsaw, Poland
| | - Dorota Gliwicz‐Miedzińska
- Department of Gastroenterology, Hepatology, Nutrition Disturbances and Pediatrics, The Children's Memorial Health Institute, Warsaw, Poland
| | - Emmanuel M. Gonzales
- Pediatric Hepatology and Liver Transplantation Unit, National Reference Centre for Rare Pediatric Liver Diseases (Biliary Atresia and Genetic Cholestasis), FILFOIE, ERN RARE LIVER, Bicêtre Hospital, AP‐HP and Inserm U1193, Hepatinov, Université Paris‐Saclay, Le Kremlin‐Bicêtre, France
| | - Emmanuel Jacquemin
- Pediatric Hepatology and Liver Transplantation Unit, National Reference Centre for Rare Pediatric Liver Diseases (Biliary Atresia and Genetic Cholestasis), FILFOIE, ERN RARE LIVER, Bicêtre Hospital, AP‐HP and Inserm U1193, Hepatinov, Université Paris‐Saclay, Le Kremlin‐Bicêtre, France
| | - Jérôme Bouligand
- Service de Génétique Moléculaire, Pharmacogénétique et Hormonologie, Hôpitaux Universitaires Paris‐Saclay, Assistance Publique‐Hôpitaux de Paris, Centre Hospitalier Universitaire de Bicêtre, Le Kremlin‐Bicêtre, France
| | - Nancy B. Spinner
- Division of Genomic Diagnostics, Department of Pathology and Laboratory Medicine, The Children’s Hospital of Philadelphia and the University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Kathleen M. Loomes
- Division of Gastroenterology, Hepatology and Nutrition, The Children's Hospital of Philadelphia and the University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - David A. Piccoli
- Division of Gastroenterology, Hepatology and Nutrition, The Children's Hospital of Philadelphia and the University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Lorenzo D'Antiga
- Pediatric Hepatology, Gastroenterology and Transplantation, Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | - Emanuele Nicastro
- Pediatric Hepatology, Gastroenterology and Transplantation, Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | - Étienne Sokal
- Service De Gastroentérologie & Hépatologie Pédiatrique, Cliniques Universitaires Saint‐Luc, Brussels, Belgium
| | - Tanguy Demaret
- Service De Gastroentérologie & Hépatologie Pédiatrique, Cliniques Universitaires Saint‐Luc, Brussels, Belgium
| | - Noelle H. Ebel
- Division of Gastroenterology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
| | - Jeffrey A. Feinstein
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Lucile Packard Children's Hospital, Palo Alto, California, USA
| | - Rima Fawaz
- Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Silvia Nastasio
- Division of Gastroenterology, Hepatology, & Nutrition, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Florence Lacaille
- Department of Pediatric Gastroenterology, and Nutrition, Necker‐Enfants Malades Hospital, University of Paris, Paris, France
| | - Dominique Debray
- Pediatric Liver Unit, National Reference Centre for Rare Pediatric Liver Diseases (Biliary Atresia and Genetic Cholestasis), FILFOIE, ERN RARE LIVER, Necker‐Enfants Malades Hospital, University of Paris, Paris, France
| | - Henrik Arnell
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Björn Fischler
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
- CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - Susan Siew
- Department of Gastroenterology, The Children's Hospital at Westmead, Sydney, Australia
| | - Michael Stormon
- Department of Gastroenterology, The Children's Hospital at Westmead, Sydney, Australia
| | - Saul J. Karpen
- Division of Pediatric Gastroenterology, Hepatology & Nutrition, Children's Healthcare of Atlanta & Emory University School of Medicine, Atlanta, Georgia, USA
| | - Rene Romero
- Division of Pediatric Gastroenterology, Hepatology & Nutrition, Children's Healthcare of Atlanta & Emory University School of Medicine, Atlanta, Georgia, USA
| | - Kyung Mo Kim
- Department of Pediatrics, University of Ulsan College of Medicine, Asan Medical Center Children's Hospital, Seoul, Republic of Korea
| | - Woo Yim Baek
- Department of Pediatrics, University of Ulsan College of Medicine, Asan Medical Center Children's Hospital, Seoul, Republic of Korea
| | - Winita Hardikar
- Department of Gastroenterology and Clinical Nutrition, Royal Children's Hospital, Melbourne, Australia
| | - Sahana Shankar
- Mazumdar Shaw Medical Center, Narayana Health, Bangalore, India
| | - Amin J. Roberts
- Department of Paediatric Gastroenterology, Starship Child Health, Auckland, New Zealand
| | - Helen M. Evans
- Department of Paediatric Gastroenterology, Starship Child Health, Auckland, New Zealand
| | - M. Kyle Jensen
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Utah, Salt Lake City, Utah, USA
| | - Marianne Kavan
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Utah, Salt Lake City, Utah, USA
| | - Shikha S. Sundaram
- Section of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics and the Digestive Health Institute, Children's Hospital of Colorado and University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Alexander Chaidez
- Section of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics and the Digestive Health Institute, Children's Hospital of Colorado and University of Colorado School of Medicine, Aurora, Colorado, USA
| | | | - Maria Camila Sanchez
- Pediatric Gastroenterology and Hepatology Division, Hospital Italiano Buenos Aires, Buenos Aires, Argentina
| | - Maria Lorena Cavalieri
- Pediatric Gastroenterology and Hepatology Division, Hospital Italiano Buenos Aires, Buenos Aires, Argentina
| | - Henkjan J. Verkade
- Department of Pediatrics, Center for Liver, Digestive, and Metabolic Diseases, University Medical Center Groningen, Groningen, The Netherlands
| | - Way Seah Lee
- Faculty of Medicine, Department of Paediatrics, University of Malaya, Kuala Lumpur, Malaysia
| | - James E. Squires
- Division of Pediatric Gastroenterology and Hepatology, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Christina Hajinicolaou
- Division of Paediatric Gastroenterology, Department of Paediatrics and Child Health, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Chatmanee Lertudomphonwanit
- Division of Gastroenterology, Department of Pediatrics, Ramathibodi Hospital Mahidol University, Bangkok, Thailand
| | - Ryan T. Fischer
- Department of Gastroenterology, Section of Hepatology, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | - Catherine Larson‐Nath
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, Minnesota, USA
| | - Yael Mozer‐Glassberg
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Cigdem Arikan
- Department of Pediatric Gastroenterology and Organ Transplant, Koc University School of Medicine, Istanbul, Turkey
| | - Henry C. Lin
- Division of Pediatric Gastroenterology, Department of Pediatrics, Oregon Health and Science University, Portland, Oregon, USA
| | - Jesus Quintero Bernabeu
- Pediatric Hepatology and Liver Transplant Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Seema Alam
- Department of Pediatric Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Deirdre A. Kelly
- Liver Unit, Birmingham Women's & Children's Hospital NHS Trust, University of Birmingham, Birmingham, UK
| | - Elisa Carvalho
- Pediatric Gastroenterology Department, Hospital da Criança de Brasília, Centro Universitário de Brasília, Brasília, Brazil
| | - Cristina Targa Ferreira
- Pediatric Gastroenterology Service, Hospital da Criança Santo Antôni, Universidade Federal de Ciências da Saúde de Porto Alegre, Complexo Hospitalar Santa Casa, Porto Alegre, RS, Brazil
| | - Giuseppe Indolfi
- Paediatric and Liver Unit, Department Neurofarba, University of Florence and Meyer Children's University Hospital, Florence, Italy
| | - Ruben E. Quiros‐Tejeira
- Department of Pediatrics, Children's Hospital & Medical Center and University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Pinar Bulut
- Division of Pediatric Gastroenterology and Hepatology, Phoenix Children's Hospital, Phoenix, USA
| | - Pier Luigi Calvo
- Pediatric Gastroenterology Unit, Regina Margherita Children's Hospital, Azienda Ospedaliera‐Universitaria Citta' della Salute e della Scienza, Turin, Italy
| | - Zerrin Önal
- Pediatric Gastroenterology, Hepatology and Nutrition Department, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Pamela L. Valentino
- Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Dev M. Desai
- Solid Organ Transplant Department, Children's Health – Children's Medical Center, Dallas, Texas, USA
| | - John Eshun
- Department of Pediatric Gastroenterology, Le Bonheur Children's Hospital, The University of Tennessee Health Science Center, Memphis, Texas, USA
| | - Maria Rogalidou
- Division of Gastroenterology & Hepatology, First Department of Pediatrics, “Agia Sofia” Children's Hospital, University of Athens, Athens, Greece
| | - Antal Dezsőfi
- First Department of Paediatrics, Semmelweis University, Budapest, Hungary
| | - Sabina Wiecek
- Department of Pediatrics, Medical University of Silesia in Katowice, Katowice, Poland
| | - Gabriella Nebbia
- Servizio di Epatologia Pediatrica, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Raquel Borges Pinto
- Division of Pediatric Gastroenterology of Hospital da Criança Conceição do Grupo Hospitalar Conceição, Porto Alegre, RS, Brazil
| | - Victorien M. Wolters
- Department of Pediatric Gastroenterology, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Andréanne N. Zizzo
- Division of Paediatric Gastroenterology and Hepatology, London Health Sciences Centre, Children's Hospital, Western University, London, Ontario, Canada
| | - Jennifer Garcia
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Miami Transplant Institute, University of Miami, Miami, Florida, USA
| | - Kathleen Schwarz
- Division of Pediatric Gastroenterology, University of California San Diego, Rady Children's Hospital San Diego, San Diego, California, USA
| | - Marisa Beretta
- Faculty of Health Sciences, Wits Donald Gordon Medical Centre, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Carolina Jimenez‐Rivera
- Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Eastern Ontario, Ottawa, Canada
| | - Nanda Kerkar
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Rochester Medical Center, Rochester, New York, USA
| | - Jernej Brecelj
- Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Faculty of Medicine, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Quais Mujawar
- Section of Pediatric Gastroenterology, Department of Pediatrics, University of Manitoba, Winnipeg, Canada
| | - Nathalie Rock
- Department of Paediatrics, Gynaecology and Obstetrics, Geneva University Hospitals, University of Geneva, Geneva, Switzerland
| | - Cristina Molera Busoms
- Pediatric Gastroenterology Hepatology and Nutrition Unit, Hospital Sant Joan de Déu, Esplugues de Llobregat, Spain
| | - Wikrom Karnsakul
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Eberhard Lurz
- Department of Pediatrics, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Munich, Germany
| | - Ermelinda Santos‐Silva
- Pediatric Gastroenterology Unit, Centro Hospitalar Universitário Do Porto, Porto, Portugal
| | - Niviann Blondet
- Gastroenterology and Hepatology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Luis Bujanda
- Department of Hepatology and Gastroenterology, Biodonostia Health Research Institute, Donostia University Hospital, Universidad del País Vasco (UPV/EHU), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), San Sebastián, Spain
| | - Uzma Shah
- Harvard Medical School, Massachusetts General Hospital for Children, Boston, Massachusetts, USA
| | | | - Bettina E. Hansen
- Toronto General Hospital University Health Network, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, Toronto, Ontario, Canada
| | - Binita M. Kamath
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children and the University of Toronto, Toronto, Canada
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12
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Dong ML, Azarine A, Haddad F, Amsallem M, Kim YW, Yang W, Fadel E, Aubrege L, Loecher M, Ennis D, Pavec JL, Vignon-Clementel I, Feinstein JA, Mercier O, Marsden AL. 4D flow cardiovascular magnetic resonance recovery profiles following pulmonary endarterectomy in chronic thromboembolic pulmonary hypertension. J Cardiovasc Magn Reson 2022; 24:59. [PMID: 36372884 PMCID: PMC9661778 DOI: 10.1186/s12968-022-00893-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 10/04/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Four-dimensional flow cardiovascular magnetic resonance imaging (4D flow CMR) allows comprehensive assessment of pulmonary artery (PA) flow dynamics. Few studies have characterized longitudinal changes in pulmonary flow dynamics and right ventricular (RV) recovery following a pulmonary endarterectomy (PEA) for patients with chronic thromboembolic pulmonary hypertension (CTEPH). This can provide novel insights of RV and PA dynamics during recovery. We investigated the longitudinal trajectory of 4D flow metrics following a PEA including velocity, vorticity, helicity, and PA vessel wall stiffness. METHODS Twenty patients with CTEPH underwent pre-PEA and > 6 months post-PEA CMR imaging including 4D flow CMR; right heart catheter measurements were performed in 18 of these patients. We developed a semi-automated pipeline to extract integrated 4D flow-derived main, left, and right PA (MPA, LPA, RPA) volumes, velocity flow profiles, and secondary flow profiles. We focused on secondary flow metrics of vorticity, volume fraction of positive helicity (clockwise rotation), and the helical flow index (HFI) that measures helicity intensity. RESULTS Mean PA pressures (mPAP), total pulmonary resistance (TPR), and normalized RV end-systolic volume (RVESV) decreased significantly post-PEA (P < 0.002). 4D flow-derived PA volumes decreased (P < 0.001) and stiffness, velocity, and vorticity increased (P < 0.01) post-PEA. Longitudinal improvements from pre- to post-PEA in mPAP were associated with longitudinal decreases in MPA area (r = 0.68, P = 0.002). Longitudinal improvements in TPR were associated with longitudinal increases in the maximum RPA HFI (r=-0.85, P < 0.001). Longitudinal improvements in RVESV were associated with longitudinal decreases in MPA fraction of positive helicity (r = 0.75, P = 0.003) and minimum MPA HFI (r=-0.72, P = 0.005). CONCLUSION We developed a semi-automated pipeline for analyzing 4D flow metrics of vessel stiffness and flow profiles. PEA was associated with changes in 4D flow metrics of PA flow profiles and vessel stiffness. Longitudinal analysis revealed that PA helicity was associated with pulmonary remodeling and RV reverse remodeling following a PEA.
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Affiliation(s)
- Melody L Dong
- Department of Bioengineering, Stanford University, Stanford, CA, USA
| | - Arshid Azarine
- Department of Radiology, Groupe Hospitalier Paris Saint-Joseph, Paris, France
- Pulmonary Hypertension: Pathophysiology and Novel Therapies, Marie Lannelongue Hospital, INSERM UMR-S 999, Le Plessis Robinson, France
| | - Francois Haddad
- Division of Cardiovascular Medicine, Stanford University, Stanford, CA, USA
| | - Myriam Amsallem
- Division of Cardiovascular Medicine, Stanford University, Stanford, CA, USA
| | - Young-Wouk Kim
- Department of Radiology, Groupe Hospitalier Paris Saint-Joseph, Paris, France
| | - Weiguang Yang
- Department of Pediatric Cardiology, Stanford University, Stanford, CA, USA
| | - Elie Fadel
- Biomedical Engineering Lab, Groupe Hospitalier Paris Saint-Joseph, Paris, France
- Department of Thoracic Surgery, Marie Lannelongue Hospital, Université Paris-Saclay, Le Plessis Robinson, France
- Pulmonary Hypertension: Pathophysiology and Novel Therapies, Marie Lannelongue Hospital, INSERM UMR-S 999, Le Plessis Robinson, France
| | - Laure Aubrege
- Biomedical Engineering Lab, Groupe Hospitalier Paris Saint-Joseph, Paris, France
| | - Michael Loecher
- Department of Radiology, Stanford University, Stanford, CA, USA
| | - Daniel Ennis
- Department of Radiology, Stanford University, Stanford, CA, USA
| | - Jérôme Le Pavec
- Department of Respirology, Marie Lannelongue Hospital, Le Plessis Robinson, France
- Pulmonary Hypertension: Pathophysiology and Novel Therapies, Marie Lannelongue Hospital, INSERM UMR-S 999, Le Plessis Robinson, France
| | | | | | - Olaf Mercier
- Biomedical Engineering Lab, Groupe Hospitalier Paris Saint-Joseph, Paris, France
- Department of Thoracic Surgery, Marie Lannelongue Hospital, Université Paris-Saclay, Le Plessis Robinson, France
- Pulmonary Hypertension: Pathophysiology and Novel Therapies, Marie Lannelongue Hospital, INSERM UMR-S 999, Le Plessis Robinson, France
| | - Alison L Marsden
- Department of Bioengineering, Stanford University, Stanford, CA, USA.
- Department of Pediatric Cardiology, Stanford University, Stanford, CA, USA.
- Department of Bioengineering and Pediatric Cardiology, Stanford University, Stanford, CA, USA.
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13
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Sullivan RT, Handler SS, Feinstein JA, Ogawa M, Liu E, Ma M, Hopper RK, Norris J, Hollander SA, Chen S. Subcutaneous Treprostinil Improves Surgical Candidacy for Next Stage Palliation in Single Ventricle Patients With High-Risk Hemodynamics. Semin Thorac Cardiovasc Surg 2022; 35:733-743. [PMID: 35931345 DOI: 10.1053/j.semtcvs.2022.07.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 07/26/2022] [Indexed: 11/11/2022]
Abstract
Single ventricle (SV) patients with pulmonary vascular disease (SV-PVD) are considered poor surgical candidates for Glenn or Fontan palliation. Given limited options for Stage 1 (S1) and Stage 2 (S2) SV patients with SV-PVD, we report on the use of subcutaneous treprostinil (TRE) to treat SV-PVD in this population. This single-center, retrospective cohort study examined SV patients who were not candidates for subsequent surgical palliation due to SV-PVD and were treated with TRE. The primary outcome was ability to progress to the next surgical stage; secondary outcomes included changes in hemodynamics after TRE initiation. Between 3/2014 and 8/2021, 17 SV patients received TRE for SV-PVD: 11 after S1 and 6 after S2 (median PVR 4.1 [IQR 3.2-4.8] WU*m2 and 5.0 [IQR 1.5-6.1] WU*m2, respectively). Nine of 11 (82%) S1 progressed to S2, and 2 (18%) underwent heart transplant (HTx). Three of 6 (50%) S2 progressed to Fontan, 1 underwent HTx and 2 are awaiting Fontan on TRE. TRE significantly decreased PVR in S1 patients with median post-treatment PVR of 2.0 (IQR 1.5-2.6) WU*m2. TRE can allow for further surgical palliation in select pre-Fontan patients with SV-PVD, obviating the need for HTx. Improvement in PVR was significant in S1 patients and persisted beyond discontinuation of therapy for most patients.
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Affiliation(s)
- Rachel T Sullivan
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California
| | - Stephanie S Handler
- Department of Pediatrics, Division of Pediatric Cardiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jeffrey A Feinstein
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California
| | - Michelle Ogawa
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California
| | - Esther Liu
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California
| | - Michael Ma
- Department of Cardiothoracic Surgery, Division of Pediatric Cardiac Surgery, Stanford University School of Medicine, Palo Alto, California
| | - Rachel K Hopper
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California
| | - Jana Norris
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California
| | - Seth A Hollander
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California
| | - Sharon Chen
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California..
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14
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Dual SA, Verdonk C, Amsallem M, Pham J, Obasohan C, Nataf P, McElhinney DB, Arunamata A, Kuznetsova T, Zamanian R, Feinstein JA, Marsden A, Haddad F. Elucidating tricuspid Doppler signal interpolation and its implication for assessing pulmonary hypertension. Pulm Circ 2022; 12:e12125. [PMID: 36016669 PMCID: PMC9395694 DOI: 10.1002/pul2.12125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 07/07/2022] [Accepted: 08/02/2022] [Indexed: 11/06/2022] Open
Abstract
Doppler echocardiography plays a central role in the assessment of pulmonary hypertension (PAH). We aim to improve quality assessment of systolic pulmonary arterial pressure (SPAP) by applying a cubic polynomial interpolation to digitized tricuspid regurgitation (TR) waveforms. Patients with PAH and advanced lung disease were divided into three cohorts: a derivation cohort (n = 44), a validation cohort (n = 71), an outlier cohort (n = 26), and a non-PAH cohort (n = 44). We digitized TR waveforms and analyzed normalized duration, skewness, kurtosis, and first and second derivatives of pressure. Cubic polynomial interpolation was applied to three physiology-driven phases: the isovolumic phase, ejection phase, and "shoulder" point phase. Coefficients of determination and a Bland-Altman analysis was used to assess bias between methods. The cubic polynomial interpolation of the TR waveform correlated strongly with expert read right ventricular systolic pressure (RVSP) with R 2 > 0.910 in the validation cohort. The biases when compared to invasive SPAP measured within 24 h were 6.03 [4.33; 7.73], -2.94 [1.47; 4.41], and -3.11 [-4.52; -1.71] mmHg, for isovolumic, ejection, and shoulder point interpolations, respectively. In the outlier cohort with more than 30% difference between echocardiographic estimates and invasive SPAP, cubic polynomial interpolation significantly reduced underestimation of RVSP. Cubic polynomial interpolation of the TR waveform based on isovolumic or early ejection phase may improve RVSP estimates.
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Affiliation(s)
- Seraina A. Dual
- Department of Cardiothoracic SurgeryStanford University School of MedicineStanfordCaliforniaUSA
- Cardiovascular InstituteStanford UniversityStanfordCaliforniaUSA
| | - Constance Verdonk
- Department of Medicine, Division of Cardiovascular MedicineStanford University School of MedicineStanfordCaliforniaUSA
- Department of Cardiothoracic SurgeryHospital BichatParisFrance
- INSERM U1148, Cardiovascular BioengineeringParisFrance
| | - Myriam Amsallem
- Cardiovascular InstituteStanford UniversityStanfordCaliforniaUSA
- Department of Medicine, Division of Cardiovascular MedicineStanford University School of MedicineStanfordCaliforniaUSA
- KU Leuven Department of Cardiovascular Sciences, Research Unit Hypertension and Cardiovascular EpidemiologyUniversity of LeuvenLeuvenBelgium
| | - Jonathan Pham
- Department of PediatricsDivision of Pediatric Cardiology, Stanford University School of MedicinePalo AltoCaliforniaUSA
- Department of BioengineeringStanford University School of MedicineStanfordCaliforniaUSA
| | - Courtney Obasohan
- Department of MedicineDivision of Pulmonary and Critical Care Medicine, Stanford University School of MedicineStanfordCaliforniaUSA
| | - Patrick Nataf
- Department of Cardiothoracic SurgeryHospital BichatParisFrance
- INSERM U1148, Cardiovascular BioengineeringParisFrance
| | - Doff B. McElhinney
- Department of Cardiothoracic SurgeryStanford University School of MedicineStanfordCaliforniaUSA
- Cardiovascular InstituteStanford UniversityStanfordCaliforniaUSA
| | - Alisa Arunamata
- Department of PediatricsDivision of Pediatric Cardiology, Stanford University School of MedicinePalo AltoCaliforniaUSA
| | - Tatiana Kuznetsova
- KU Leuven Department of Cardiovascular Sciences, Research Unit Hypertension and Cardiovascular EpidemiologyUniversity of LeuvenLeuvenBelgium
| | - Roham Zamanian
- Department of Mechanical EngineeringStanford UniversityCaliforniaStanfordUSA
- Vera Moulton Wall Center for Pulmonary Vascular Disease at StanfordStanfordCaliforniaUSA
| | - Jeffrey A. Feinstein
- Department of PediatricsDivision of Pediatric Cardiology, Stanford University School of MedicinePalo AltoCaliforniaUSA
- Department of BioengineeringStanford University School of MedicineStanfordCaliforniaUSA
- Department of Mechanical EngineeringStanford UniversityCaliforniaStanfordUSA
| | - Alison Marsden
- Cardiovascular InstituteStanford UniversityStanfordCaliforniaUSA
- Department of PediatricsDivision of Pediatric Cardiology, Stanford University School of MedicinePalo AltoCaliforniaUSA
- Department of BioengineeringStanford University School of MedicineStanfordCaliforniaUSA
- Department of Mechanical EngineeringStanford UniversityCaliforniaStanfordUSA
| | - François Haddad
- Cardiovascular InstituteStanford UniversityStanfordCaliforniaUSA
- Department of Medicine, Division of Cardiovascular MedicineStanford University School of MedicineStanfordCaliforniaUSA
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15
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Handler SS, Jin J, Ogawa MT, Feinstein JA, Lo C. Abnormal Platelet Aggregation in Pediatric Pulmonary Hypertension. Pulm Circ 2022; 12:e12104. [PMID: 35864911 PMCID: PMC9294293 DOI: 10.1002/pul2.12104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 05/24/2022] [Accepted: 06/16/2022] [Indexed: 11/14/2022] Open
Abstract
Endogenous prostacyclin stimulates pulmonary vasodilation and inhibits platelet aggregation. For the synthetic analog treprostinil, used in the treatment of pulmonary hypertension (PH), conflicting, anecdotal evidence exists regarding its effects on clinically relevant platelet function. This study investigated whether treprostinil therapy results in inhibition of platelet aggregation in pediatric PH patients. This is a single institution, prospective, cohort study. Pediatric patients ≤18 years of age on medical therapy for PH underwent platelet function testing by light transmission aggregometry with U‐46619—a stable analog of endoperoxide prostaglandin H2, exhibiting properties similar to thromboxane A2 (TXA2). Results were compared for those on continuous treprostinil therapy (TRE) versus those on other, non‐prostacyclin therapies (non‐TRE). Thirty‐five patients were enrolled: 18 in the TRE group and 17 in the non‐TRE group. There was no difference in platelet aggregation abnormalities between the two groups: 44% (n = 8) in the TRE group and 41% (n = 7) in the non‐TRE group were abnormal. Furthermore, subgroup analysis showed no difference based on treprostinil dosing. This study demonstrated similar, moderately high rates of abnormal platelet aggregation in pediatric PH patients on continuous treprostinil therapy compared to those on other, non‐prostacyclin therapies. The high rate of abnormal platelet aggregation in the entire cohort, however, warrants follow‐up study to identify a potential inherent risk in this population.
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Affiliation(s)
| | - Jing Jin
- Stanford Health Care, Clinical Laboratories
| | | | - Jeffrey A Feinstein
- Stanford UniversityDepartment of Pediatrics (Cardiology)
- Stanford UniversityDepartment of Bioengineering
| | - Clara Lo
- Stanford UniversityDepartment of Pediatrics (Hematology)
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16
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Gillich A, Brownfield DG, Travaglini KJ, Zhang F, Farmer CG, St. Julien KR, Tan SY, Gu M, Zhou B, Feinstein JA, Metzger RJ, Krasnow MA. Dissecting alveolar patterning and maintenance at single‐cell resolution. FASEB J 2022. [DOI: 10.1096/fasebj.2022.36.s1.i7444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Astrid Gillich
- BiochemistryStanford University School of MedicineStanfordCA
- Howard Hughes Medical InstituteStanfordCA
| | - Douglas G. Brownfield
- BiochemistryStanford University School of MedicineStanfordCA
- Howard Hughes Medical InstituteStanfordCA
| | - Kyle J. Travaglini
- BiochemistryStanford University School of MedicineStanfordCA
- Howard Hughes Medical InstituteStanfordCA
| | - Fan Zhang
- Vera Moulton Wall Center for Pulmonary Vascular DiseaseStanford University School of MedicineStanfordCA
| | | | - Krystal R. St. Julien
- BiochemistryStanford University School of MedicineStanfordCA
- Howard Hughes Medical InstituteStanfordCA
| | - Serena Y. Tan
- PathologyStanford University School of MedicineStanfordCA
| | - Mingxia Gu
- PediatricsStanford University School of MedicineStanfordCA
| | - Bin Zhou
- Chinese Academy of SciencesShanghai
| | | | | | - Mark A. Krasnow
- BiochemistryStanford University School of MedicineStanfordCA
- Howard Hughes Medical InstituteStanfordCA
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17
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Lan IS, Yang W, Feinstein JA, Kreutzer J, Collins RT, Ma M, Adamson GT, Marsden AL. Virtual Transcatheter Interventions for Peripheral Pulmonary Artery Stenosis in Williams and Alagille Syndromes. J Am Heart Assoc 2022; 11:e023532. [PMID: 35253446 PMCID: PMC9075299 DOI: 10.1161/jaha.121.023532] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background
Despite favorable outcomes of surgical pulmonary artery (PA) reconstruction, isolated proximal stenting of the central PAs is common clinical practice for patients with peripheral PA stenosis in association with Williams and Alagille syndromes. Given the technical challenges of PA reconstruction and the morbidities associated with transcatheter interventions, the hemodynamic consequences of all treatment strategies must be rigorously assessed. Our study aims to model, assess, and predict hemodynamic outcomes of transcatheter interventions in these patients.
Methods and Results
Isolated proximal and “extensive” interventions (stenting and/or balloon angioplasty of proximal and lobar vessels) were performed in silico on 6 patient‐specific PA models. Autoregulatory adaptation of the cardiac output and downstream arterial resistance was modeled in response to intervention‐induced hemodynamic perturbations. Postintervention computational fluid dynamics predictions were validated in 2 stented patients and quantitatively assessed in 4 surgical patients. Our computational methods accurately predicted postinterventional PA pressures, the primary indicators of success for treatment of peripheral PA stenosis. Proximal and extensive treatment achieved median reductions of 14% and 40% in main PA systolic pressure, 27% and 56% in pulmonary vascular resistance, and 10% and 45% in right ventricular stroke work, respectively.
Conclusions
In patients with Williams and Alagille syndromes, extensive transcatheter intervention is required to sufficiently reduce PA pressures and right ventricular stroke work. Transcatheter therapy was shown to be ineffective for long‐segment stenosis and pales hemodynamically in comparison with published outcomes of surgical reconstruction. Regardless of the chosen strategy, a virtual treatment planning platform could identify lesions most critical for optimizing right ventricular afterload.
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Affiliation(s)
- Ingrid S. Lan
- Department of Bioengineering Stanford University Stanford CA
| | - Weiguang Yang
- Department of Pediatrics (Cardiology) Stanford University Stanford CA
| | - Jeffrey A. Feinstein
- Department of Bioengineering Stanford University Stanford CA
- Department of Pediatrics (Cardiology) Stanford University Stanford CA
| | - Jacqueline Kreutzer
- Department of Pediatrics (Cardiology) University of Pittsburgh Pittsburgh PA
| | - R. Thomas Collins
- Department of Pediatrics (Cardiology) Stanford University Stanford CA
- Department of Medicine (Cardiovascular Medicine) Stanford University Stanford CA
| | - Michael Ma
- Department of Cardiothoracic Surgery Stanford University Stanford CA
| | | | - Alison L. Marsden
- Department of Bioengineering Stanford University Stanford CA
- Department of Pediatrics (Cardiology) Stanford University Stanford CA
- Institute for Computational and Mathematical Engineering Stanford University Stanford CA
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18
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Dong ML, Lan IS, Yang W, Rabinovitch M, Feinstein JA, Marsden AL. Computational simulation-derived hemodynamic and biomechanical properties of the pulmonary arterial tree early in the course of ventricular septal defects. Biomech Model Mechanobiol 2021; 20:2471-2489. [PMID: 34585299 DOI: 10.1007/s10237-021-01519-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 09/12/2021] [Indexed: 01/15/2023]
Abstract
Untreated ventricular septal defects (VSDs) can lead to pulmonary arterial hypertension (PAH) characterized by elevated pulmonary artery (PA) pressure and vascular remodeling, known as PAH associated with congenital heart disease (PAH-CHD). Though previous studies have investigated hemodynamic effects on vascular mechanobiology in late-stage PAH, hemodynamics leading to PAH-CHD initiation have not been fully quantified. We hypothesize that abnormal hemodynamics from left-to-right shunting in early stage VSDs affects PA biomechanical properties leading to PAH initiation. To model PA hemodynamics in healthy, small, moderate, and large VSD conditions prior to the onset of vascular remodeling, computational fluid dynamics simulations were performed using a 3D finite element model of a healthy 1-year-old's proximal PAs and a body-surface-area-scaled 0D distal PA tree. VSD conditions were modeled with increased pulmonary blood flow to represent degrees of left-to-right shunting. In the proximal PAs, pressure, flow, strain, and wall shear stress (WSS) increased with increasing VSD size; oscillatory shear index decreased with increasing VSD size in the larger PA vessels. WSS was higher in smaller diameter vessels and increased with VSD size, with the large VSD condition exhibiting WSS >100 dyn/cm[Formula: see text], well above values typically used to study dysfunctional mechanotransduction pathways in PAH. This study is the first to estimate hemodynamic and biomechanical metrics in the entire pediatric PA tree with VSD severity at the stage leading to PAH initiation and has implications for future studies assessing effects of abnormal mechanical stimuli on endothelial cells and vascular wall mechanics that occur during PAH-CHD initiation and progression.
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Affiliation(s)
- Melody L Dong
- Department of Bioengineering, Stanford University, Stanford, CA, USA
| | - Ingrid S Lan
- Department of Bioengineering, Stanford University, Stanford, CA, USA
| | - Weiguang Yang
- Department of Pediatrics, Stanford University, Stanford, CA, USA
| | | | - Jeffrey A Feinstein
- Department of Pediatrics and Bioengineering, Stanford University, Stanford, CA, USA
| | - Alison L Marsden
- Department of Pediatrics and Bioengineering, Stanford University, Stanford, CA, USA.
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19
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Harrod KK, Rogers JL, Feinstein JA, Marsden AL, Schiavazzi DE. Predictive Modeling of Secondary Pulmonary Hypertension in Left Ventricular Diastolic Dysfunction. Front Physiol 2021; 12:666915. [PMID: 34276397 PMCID: PMC8281259 DOI: 10.3389/fphys.2021.666915] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 04/16/2021] [Indexed: 12/03/2022] Open
Abstract
Diastolic dysfunction is a common pathology occurring in about one third of patients affected by heart failure. This condition may not be associated with a marked decrease in cardiac output or systemic pressure and therefore is more difficult to diagnose than its systolic counterpart. Compromised relaxation or increased stiffness of the left ventricle induces an increase in the upstream pulmonary pressures, and is classified as secondary or group II pulmonary hypertension (2018 Nice classification). This may result in an increase in the right ventricular afterload leading to right ventricular failure. Elevated pulmonary pressures are therefore an important clinical indicator of diastolic heart failure (sometimes referred to as heart failure with preserved ejection fraction, HFpEF), showing significant correlation with associated mortality. However, accurate measurements of this quantity are typically obtained through invasive catheterization and after the onset of symptoms. In this study, we use the hemodynamic consistency of a differential-algebraic circulation model to predict pulmonary pressures in adult patients from other, possibly non-invasive, clinical data. We investigate several aspects of the problem, including the ability of model outputs to represent a sufficiently wide pathologic spectrum, the identifiability of the model's parameters, and the accuracy of the predicted pulmonary pressures. We also find that a classifier using the assimilated model parameters as features is free from the problem of missing data and is able to detect pulmonary hypertension with sufficiently high accuracy. For a cohort of 82 patients suffering from various degrees of heart failure severity, we show that systolic, diastolic, and wedge pulmonary pressures can be estimated on average within 8, 6, and 6 mmHg, respectively. We also show that, in general, increased data availability leads to improved predictions.
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Affiliation(s)
- Karlyn K Harrod
- Department of Applied and Computational Mathematics and Statistics, University of Notre Dame, Notre Dame, IN, United States
| | - Jeffrey L Rogers
- Department of Digital Health, T.J. Watson Research Center, International Business Machines Corporation, Yorktown Heights, NY, United States
| | - Jeffrey A Feinstein
- Department of Pediatrics and Bioengineering, Stanford University, Stanford, CA, United States
| | - Alison L Marsden
- Department of Pediatrics, Bioengineering and Institute for Computational and Mathematical Engineering, Stanford University, Stanford, CA, United States
| | - Daniele E Schiavazzi
- Department of Applied and Computational Mathematics and Statistics, University of Notre Dame, Notre Dame, IN, United States
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20
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Luong R, Feinstein JA, Ma M, Ebel NH, Wise-Faberowski L, Zhang Y, Peng LF, Yarlagadda VV, Shek J, Hanley FL, McElhinney DB. Outcomes in Patients with Alagille Syndrome and Complex Pulmonary Artery Disease. J Pediatr 2021; 229:86-94.e4. [PMID: 32980376 DOI: 10.1016/j.jpeds.2020.09.053] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 09/17/2020] [Accepted: 09/21/2020] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To assess outcomes in a large cohort of patients with Alagille syndrome (ALGS) who underwent pulmonary artery reconstruction surgery for complex pulmonary artery disease. STUDY DESIGN Patients with ALGS who underwent pulmonary artery reconstruction surgery at Lucile Packard Children's Hospital Stanford were reviewed. Patients were examined as an overall cohort and based on the primary cardiovascular diagnosis: severe isolated branch pulmonary artery stenosis, tetralogy of Fallot (TOF) without major aortopulmonary collateral arteries (MAPCAs), or TOF with MAPCAs. RESULTS Fifty-one patients with ALGS underwent pulmonary artery surgery at our center, including 22 with severe branch pulmonary artery stenosis, 9 with TOF without MAPCAs, and 20 with TOF and MAPCAs. Forty-one patients (80%) achieved a complete repair. Five of the patients with TOF with MAPCAs (25%) underwent complete repair at the first surgery, compared with 8 (89%) with TOF without MAPCAs and 19 (86%) with isolated branch pulmonary artery stenosis. At a median follow-up of 1.7 years after the first surgery, 39 patients (76%) were alive, 36 with a complete repair and a median pulmonary artery:aortic systolic pressure of 0.38. Nine patients (18%), including 8 with isolated branch pulmonary artery stenosis, underwent liver transplantation. CONCLUSIONS Most patients with ALGS and complex pulmonary artery disease can undergo complete repair with low postoperative right ventricular pressure. Patients with TOF/MAPCAs had the worst outcomes, with higher mortality and more frequent pulmonary artery interventions compared with patients with TOF without MAPCAs or isolated branch pulmonary artery stenosis. Complex pulmonary artery disease is not a contraindication to liver transplantation in patients with ALGS.
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Affiliation(s)
- Roger Luong
- Department of Pediatrics, Lucille Packard Children's Hospital Stanford and Stanford University, Palo Alto, CA.
| | - Jeffrey A Feinstein
- Department of Pediatrics, Lucille Packard Children's Hospital Stanford and Stanford University, Palo Alto, CA
| | - Michael Ma
- Department of Cardiothoracic Surgery, Lucille Packard Children's Hospital Stanford and Stanford University, Palo Alto, CA
| | - Noelle H Ebel
- Department of Pediatrics, Lucille Packard Children's Hospital Stanford and Stanford University, Palo Alto, CA
| | - Lisa Wise-Faberowski
- Department of Anesthesia, Lucille Packard Children's Hospital Stanford and Stanford University, Palo Alto, CA
| | - Yulin Zhang
- Department of Cardiothoracic Surgery, Lucille Packard Children's Hospital Stanford and Stanford University, Palo Alto, CA
| | - Lynn F Peng
- Department of Pediatrics, Lucille Packard Children's Hospital Stanford and Stanford University, Palo Alto, CA
| | - Vamsi V Yarlagadda
- Department of Pediatrics, Lucille Packard Children's Hospital Stanford and Stanford University, Palo Alto, CA
| | - Jennifer Shek
- Department of Cardiothoracic Surgery, Lucille Packard Children's Hospital Stanford and Stanford University, Palo Alto, CA
| | - Frank L Hanley
- Department of Cardiothoracic Surgery, Lucille Packard Children's Hospital Stanford and Stanford University, Palo Alto, CA
| | - Doff B McElhinney
- Department of Pediatrics, Lucille Packard Children's Hospital Stanford and Stanford University, Palo Alto, CA; Department of Cardiothoracic Surgery, Lucille Packard Children's Hospital Stanford and Stanford University, Palo Alto, CA
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21
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Amsallem M, Bagherzadeh SP, Boulate D, Sweatt AJ, Kudelko KT, Sung YK, Feinstein JA, Fadel E, Mercier O, Denault A, Haddad F, Zamanian R. Hemodynamic trajectories and outcomes in patients with pulmonary arterial hypertension. Pulm Circ 2020; 10:2045894020941343. [PMID: 33335708 PMCID: PMC7724418 DOI: 10.1177/2045894020941343] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 06/18/2020] [Indexed: 12/02/2022] Open
Abstract
The relative pulmonary to systemic pressure ratio (mean pulmonary arterial
pressure/mean arterial pressure) has been proven to be valuable in cardiac
surgery. Little is known on the prognostic value of baseline and trajectory of
mean pulmonary arterial pressure/mean arterial pressure in pulmonary arterial
hypertension. Patients with confirmed idiopathic, familial, drug and toxins, or
connective tissue disease-related pulmonary arterial hypertension and at least
one complete right heart catheterization were included and prospectively
followed-up for 5.9 ± 4.03 years. Correlates of the primary end point (i.e.
death or lung transplant need) during follow-up were determined using Cox
regression modeling. Results showed that among the 308 patients included, 187
had at least one follow-up catheterization (median time between
catheterizations: 2.16 (1.16–3.19) years). In the total cohort (mean age
47.3 ± 14.9 years, 82.8% of female and 58.1% in New York Heart Association class
3 or 4), mean pulmonary arterial pressure/mean arterial pressure (1.38
(1.07–1.77)) was associated with outcome (p = 0.01). Mean
pulmonary arterial pressure/mean arterial pressure was incremental to a basic
model (including right atrial pressure, systolic blood pressure, New York Heart
Association class 3 or 4, and connective tissue disease) for outcome prediction,
while mean pulmonary arterial pressure was not. In the 187 patients with a
follow-up catheterization, both delta mean pulmonary arterial pressure and delta
mean pulmonary arterial pressure/mean arterial pressure were associated with
outcome (1.32 (1.11–1.58) and 1.31 (1.1–1.57) respectively,
p < 0.01). Mean pulmonary arterial pressure and mean
pulmonary arterial pressure/mean arterial pressure were both incremental to the
basic model, while worsening in mean pulmonary arterial pressure or mean
pulmonary arterial pressure/mean arterial pressure did not reach significance.
In conclusion, mean pulmonary arterial pressure/mean arterial pressure at
baseline prognosticates long-term outcome with a significant, albeit modest,
incremental value to basic variables.
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Affiliation(s)
- Myriam Amsallem
- Division of Cardiovascular Medicine, Stanford University, Stanford, CA, USA.,Stanford Cardiovascular Institute, Stanford University, Stanford, CA, USA
| | | | - David Boulate
- INSERM UMR S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Andrew J Sweatt
- Division of Pulmonary and Critical Care Medicine, Stanford University, Stanford, CA, USA.,Vera Moulton Wall Center for Pulmonary Vascular Disease at Stanford, CA, USA
| | - Kristina T Kudelko
- Division of Pulmonary and Critical Care Medicine, Stanford University, Stanford, CA, USA.,Vera Moulton Wall Center for Pulmonary Vascular Disease at Stanford, CA, USA
| | - Yon K Sung
- Division of Pulmonary and Critical Care Medicine, Stanford University, Stanford, CA, USA.,Vera Moulton Wall Center for Pulmonary Vascular Disease at Stanford, CA, USA
| | - Jeffrey A Feinstein
- Department of Pediatrics (Cardiology), and by courtesy Bioengineering, Stanford University, Stanford, CA, USA
| | - Elie Fadel
- INSERM UMR S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Olaf Mercier
- INSERM UMR S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Andre Denault
- Division of Anesthesiology and Critical Care, Université de Montréal, Montreal, QC, Canada
| | - Francois Haddad
- Division of Cardiovascular Medicine, Stanford University, Stanford, CA, USA.,Stanford Cardiovascular Institute, Stanford University, Stanford, CA, USA
| | - Roham Zamanian
- Division of Pulmonary and Critical Care Medicine, Stanford University, Stanford, CA, USA.,Vera Moulton Wall Center for Pulmonary Vascular Disease at Stanford, CA, USA
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22
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Adamson GT, McElhinney DB, Zhang Y, Feinstein JA, Peng LF, Ma M, Algaze CA, Hanley FL, Perry SB. Angiographic Anatomy of Major Aortopulmonary Collateral Arteries and Association With Early Surgical Outcomes in Tetralogy of Fallot. J Am Heart Assoc 2020; 9:e017981. [PMID: 33283588 PMCID: PMC7955371 DOI: 10.1161/jaha.120.017981] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Due in part to the heterogeneity of the pulmonary circulation in patients with tetralogy of Fallot and major aortopulmonary collateral arteries (MAPCAs), research on this condition has focused on relatively basic anatomic characteristics. We aimed to detail pulmonary artery (PA) and MAPCA anatomy in a large group of infants, assess relationships between anatomy and early surgical outcomes, and consider systems for classifying MAPCAs. Methods and Results All infants ( <1 year of age) undergoing first cardiac surgery for tetralogy of Fallot/MAPCAs from 2001 to 2019 at Stanford University were identified. Preoperative angiograms delineating supply to all 18 pulmonary segments were reviewed for details of each MAPCA and the arborization and size of central PAs. We studied 276 patients with 1068 MAPCAs and the following PA patterns: 152 (55%) incompletely arborizing PAs, 48 (17%) normally arborizing PAs, 45 (16%) absent PAs, and 31 (11%) unilateral MAPCAs. There was extensive anatomic variability, but no difference in early outcomes according to PA arborization or the predominance of PAs or MAPCAs. Patients with low total MAPCA and/or PA cross-sectional area were less likely to undergo complete repair. Conclusions MAPCA anatomy is highly variable and essentially unique for each patient. Though each pulmonary segment can be supplied by a MAPCA, central PA, or both, all anatomic combinations are similarly conducive to a good repair. Total cross-sectional area of central PA and MAPCA material is an important driver of outcome. We elucidate a number of novel associations between anatomic features, but the extreme variability of the pulmonary circulation makes a granular tetralogy of Fallot/MAPCA classification system unrealistic.
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Affiliation(s)
- Gregory T Adamson
- Division of Pediatric Cardiology Department of Pediatrics Stanford University School of Medicine Palo Alto CA
| | - Doff B McElhinney
- Division of Pediatric Cardiology Department of Pediatrics Stanford University School of Medicine Palo Alto CA.,Division of Pediatric Cardiac Surgery Department of Cardiothoracic Surgery Stanford University School of Medicine Palo Alto CA.,Clinical and Translational Research Program Lucile Packard Children's Hospital Heart CenterStanford University School of Medicine Palo Alto CA
| | - Yulin Zhang
- Clinical and Translational Research Program Lucile Packard Children's Hospital Heart CenterStanford University School of Medicine Palo Alto CA
| | - Jeffrey A Feinstein
- Division of Pediatric Cardiology Department of Pediatrics Stanford University School of Medicine Palo Alto CA
| | - Lynn F Peng
- Division of Pediatric Cardiology Department of Pediatrics Stanford University School of Medicine Palo Alto CA
| | - Michael Ma
- Division of Pediatric Cardiac Surgery Department of Cardiothoracic Surgery Stanford University School of Medicine Palo Alto CA
| | - Claudia A Algaze
- Division of Pediatric Cardiology Department of Pediatrics Stanford University School of Medicine Palo Alto CA
| | - Frank L Hanley
- Division of Pediatric Cardiac Surgery Department of Cardiothoracic Surgery Stanford University School of Medicine Palo Alto CA
| | - Stanton B Perry
- Division of Pediatric Cardiology Department of Pediatrics Stanford University School of Medicine Palo Alto CA
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23
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Gillich A, Zhang F, Farmer CG, Travaglini KJ, Tan SY, Gu M, Zhou B, Feinstein JA, Krasnow MA, Metzger RJ. Capillary cell-type specialization in the alveolus. Nature 2020; 586:785-789. [PMID: 33057196 PMCID: PMC7721049 DOI: 10.1038/s41586-020-2822-7] [Citation(s) in RCA: 158] [Impact Index Per Article: 39.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 07/22/2020] [Indexed: 01/01/2023]
Abstract
In the mammalian lung, an apparently homogenous mesh of capillary vessels surrounds each alveolus, forming the vast respiratory surface across which oxygen transfers to the blood1. Here we use single-cell analysis to elucidate the cell types, development, renewal and evolution of the alveolar capillary endothelium. We show that alveolar capillaries are mosaics; similar to the epithelium that lines the alveolus, the alveolar endothelium is made up of two intermingled cell types, with complex 'Swiss-cheese'-like morphologies and distinct functions. The first cell type, which we term the 'aerocyte', is specialized for gas exchange and the trafficking of leukocytes, and is unique to the lung. The other cell type, termed gCap ('general' capillary), is specialized to regulate vasomotor tone, and functions as a stem/progenitor cell in capillary homeostasis and repair. The two cell types develop from bipotent progenitors, mature gradually and are affected differently in disease and during ageing. This cell-type specialization is conserved between mouse and human lungs but is not found in alligator or turtle lungs, suggesting it arose during the evolution of the mammalian lung. The discovery of cell type specialization in alveolar capillaries transforms our understanding of the structure, function, regulation and maintenance of the air-blood barrier and gas exchange in health, disease and evolution.
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Affiliation(s)
- Astrid Gillich
- Department of Biochemistry and Howard Hughes Medical Institute, Stanford University School of Medicine, Stanford, CA, USA
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA
- Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford University School of Medicine, Stanford, CA, USA
| | - Fan Zhang
- Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford University School of Medicine, Stanford, CA, USA
| | - Colleen G Farmer
- Department of Biology, University of Utah, Salt Lake City, UT, USA
| | - Kyle J Travaglini
- Department of Biochemistry and Howard Hughes Medical Institute, Stanford University School of Medicine, Stanford, CA, USA
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA
- Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford University School of Medicine, Stanford, CA, USA
| | - Serena Y Tan
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA
| | - Mingxia Gu
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA
- Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford University School of Medicine, Stanford, CA, USA
- Department of Pediatrics, Division of Cardiology, Stanford University School of Medicine, Stanford, CA, USA
| | - Bin Zhou
- The State Key Laboratory of Cell Biology, CAS Center for Excellence on Molecular Cell Science, Shanghai Institute of Biochemistry and Cell Biology, University of Chinese Academy of Sciences, Chinese Academy of Sciences, Shanghai, China
| | - Jeffrey A Feinstein
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA
- Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford University School of Medicine, Stanford, CA, USA
- Department of Pediatrics, Division of Cardiology, Stanford University School of Medicine, Stanford, CA, USA
| | - Mark A Krasnow
- Department of Biochemistry and Howard Hughes Medical Institute, Stanford University School of Medicine, Stanford, CA, USA.
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA.
- Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford University School of Medicine, Stanford, CA, USA.
| | - Ross J Metzger
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA.
- Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford University School of Medicine, Stanford, CA, USA.
- Department of Pediatrics, Division of Cardiology, Stanford University School of Medicine, Stanford, CA, USA.
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24
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Dong M, Yang W, Tamaresis JS, Chan FP, Zucker EJ, Kumar S, Rabinovitch M, Marsden AL, Feinstein JA. Image-based scaling laws for somatic growth and pulmonary artery morphometry from infancy to adulthood. Am J Physiol Heart Circ Physiol 2020; 319:H432-H442. [PMID: 32618514 DOI: 10.1152/ajpheart.00123.2020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Pulmonary artery (PA) morphometry has been extensively explored in adults, with particular focus on intra-acinar arteries. However, scaling law relationships for length and diameter of extensive preacinar PAs by age have not been previously reported for in vivo human data. To understand preacinar PA growth spanning children to adults, we performed morphometric analyses of all PAs visible in the computed tomography (CT) and magnetic resonance (MR) images from a healthy subject cohort [n = 16; age: 1-51 yr; body surface area (BSA): 0.49-2.01 m2]. Subject-specific anatomic PA models were constructed from CT and MR images, and morphometric information-diameter, length, tortuosity, bifurcation angle, and connectivity-was extracted and sorted into diameter-defined Strahler orders. Validation of Murray's law, describing optimal scaling exponents of radii for branching vessels, was performed to determine how closely PAs conform to this classical relationship. Using regression analyses of vessel diameters and lengths against orders and patient metrics (BSA, age, height), we found that diameters increased exponentially with order and allometrically with patient metrics. Length increased allometrically with patient metrics, albeit weakly. The average tortuosity index of all vessels was 0.026 ± 0.024, average bifurcation angle was 28.2 ± 15.1°, and average Murray's law exponent was 2.92 ± 1.07. We report a set of scaling laws for vessel diameter and length, along with other morphometric information. These provide an initial understanding of healthy structural preacinar PA development with age, which can be used for computational modeling studies and comparison with diseased PA anatomy.NEW & NOTEWORTHY Pulmonary artery (PA) morphometry studies to date have focused primarily on large arteries and intra-acinar arteries in either adults or children, neglecting preacinar arteries in both populations. Our study is the first to quantify in vivo preacinar PA morphometry changes spanning infants to adults. For preacinar arteries > 1 mm in diameter, we identify scaling laws for vessel diameters and lengths with patient metrics of growth and establish a healthy PA morphometry baseline for most preacinar PAs.
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Affiliation(s)
- Melody Dong
- Department of Bioengineering, Stanford University, Stanford, California
| | - Weiguang Yang
- Department of Pediatrics-Cardiology, Stanford University, Stanford, California
| | - John S Tamaresis
- Department of Biomedical Data Science, Stanford University, Stanford, California
| | - Frandics P Chan
- Department of Radiology, Stanford University, Stanford, California
| | - Evan J Zucker
- Department of Radiology, Stanford University, Stanford, California
| | - Sahana Kumar
- Department of Pediatrics-Cardiology, Stanford University, Stanford, California
| | - Marlene Rabinovitch
- Department of Pediatrics-Cardiology, Stanford University, Stanford, California
| | - Alison L Marsden
- Department of Bioengineering, Stanford University, Stanford, California.,Department of Pediatrics-Cardiology, Stanford University, Stanford, California
| | - Jeffrey A Feinstein
- Department of Bioengineering, Stanford University, Stanford, California.,Department of Pediatrics-Cardiology, Stanford University, Stanford, California
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25
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Hollander SA, Ogawa MT, Hopper RK, Liu E, Chen S, Rosenthal DN, Feinstein JA. Treprostinil improves hemodynamics and symptoms in children with mild pulmonary hypertension awaiting heart transplantation. Pediatr Transplant 2020; 24:e13742. [PMID: 32428328 DOI: 10.1111/petr.13742] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 03/05/2020] [Accepted: 04/24/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Treprostinil, a prostacyclin analog, is a safe and effective therapy for children with PAH; however, the use of this agent in children with mild PVR elevations related to HF, including those with SV congenital heart disease awaiting HT, is understudied. We describe the hemodynamic and symptomatic changes in pediatric patients awaiting HT treated with treprostinil. METHODS Single-center retrospective review of all patients was listed for HT who received treprostinil during the listing period. Changes in hemodynamic and functional indices between the baseline catheterization (prior to drug initiation), and prior to HT, and patient outcomes were analyzed. RESULTS Among 16/17 (94%) who survived to HT, 8 (50%) were female, and 10 (63%) had SV physiology. The median age at drug initiation was 9 (IQR: 1, 14) years. The median duration of therapy prior to HT was 253 (IQR: 148, 504) days. Treprostinil significantly decreased PVR (3.8 vs 3.1 WU, P = .03), while mLA or mPCW pressure did not change (11 vs 13 mm Hg, P = .9). HF symptoms improved in 9/15 (60%) patients without VAD support prior to drug initiation, including 4/10 (40%) who did not receive a VAD any point while awaiting HT. CONCLUSIONS Treprostinil may be used safely in patients with mild PAH awaiting HT, including those with SV disease. PVR falls without substantial increases in mLA/mPCW pressure. HF symptoms improve in some patients.
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Affiliation(s)
- Seth A Hollander
- Department of Pediatrics (Cardiology), Stanford University, Palo Alto, California, USA
| | - Michelle T Ogawa
- Department of Pediatrics (Cardiology), Stanford University, Palo Alto, California, USA
| | - Rachel K Hopper
- Department of Pediatrics (Cardiology), Stanford University, Palo Alto, California, USA
| | - Esther Liu
- Department of Pediatrics (Cardiology), Stanford University, Palo Alto, California, USA
| | - Sharon Chen
- Department of Pediatrics (Cardiology), Stanford University, Palo Alto, California, USA
| | - David N Rosenthal
- Department of Pediatrics (Cardiology), Stanford University, Palo Alto, California, USA
| | - Jeffrey A Feinstein
- Department of Pediatrics (Cardiology), Stanford University, Palo Alto, California, USA
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26
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Adamson GT, Peng LF, Feinstein JA, Yarlagadda VV, Lin A, Wise-Faberowski L, McElhinney DB. Pulmonary hemorrhage in children with Alagille syndrome undergoing cardiac catheterization. Catheter Cardiovasc Interv 2019; 95:262-269. [PMID: 31584246 DOI: 10.1002/ccd.28508] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 04/26/2019] [Accepted: 09/14/2019] [Indexed: 11/09/2022]
Abstract
OBJECTIVES To evaluate the incidence, severity, and outcomes of pulmonary hemorrhage in children with Alagille syndrome (AGS) undergoing cardiac catheterization, and to find variables associated with hemorrhage in this population. BACKGROUND Children with AGS have a high incidence of bleeding complications during invasive procedures. It has been our impression that catheterization-associated pulmonary hemorrhage is more common in children with AGS, but there are no published data on this topic. METHODS This was a retrospective single institution study of children with AGS undergoing catheterization from 2010 to 2018. Pulmonary hemorrhage was defined as angiographic or fluoroscopic evidence of extravasated blood in the lung parenchyma, or blood suctioned from the endotracheal tube with documentation of pulmonary hemorrhage by the anesthesiologist or intensivist. Univariate comparisons were made between catheterizations that did and did not have pulmonary hemorrhage. RESULTS Thirty children with AGS underwent 87 catheterizations, 32 (37%) with interventions on the branch pulmonary arteries (PA). There were 26 (30%) procedures with hemorrhage, the majority (65%) of which were self-limited or required less than 24 hr of mechanical ventilation. Moderate and severe hemorrhage occurred only in children with tetralogy of Fallot (TOF; 5 of 14, 36%). A higher right ventricle to aorta systolic pressure ratio (1.0 [0.85-1.1] vs. 0.88 [0.59-1.0], p = .029) and interventions on the branch PAs (14 of 26, 54% vs. 18 of 61, 30%, p = .032) were associated with hemorrhage. CONCLUSIONS Pulmonary hemorrhage was common in children with AGS undergoing both intervention and diagnostic cardiac catheterization, and was associated with TOF, higher RV to aorta pressure ratio, and interventions on the branch PAs.
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Affiliation(s)
- Gregory T Adamson
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
| | - Lynn F Peng
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
| | - Jeffrey A Feinstein
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California.,Department of Bioengineering, Stanford University, Palo Alto, California
| | - Vamsi V Yarlagadda
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
| | - Amy Lin
- Clinical and Translational Research Program, Betty Irene Moore Children's Heart Center, Stanford University School of Medicine, Palo Alto, California
| | - Lisa Wise-Faberowski
- Division of Pediatric Anesthesiology, Department of Anesthesia, Stanford University School of Medicine, Palo Alto, California
| | - Doff B McElhinney
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California.,Clinical and Translational Research Program, Betty Irene Moore Children's Heart Center, Stanford University School of Medicine, Palo Alto, California.,Division of Pediatric Cardiac Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Palo Alto, California
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Ivy DD, Feinstein JA, Yung D, Mullen MP, Kirkpatrick EC, Hirsch R, Austin ED, Fineman J, Truong U, Solum D, Deng CQ, Hopper RK. Oral treprostinil in transition or as add-on therapy in pediatric pulmonary arterial hypertension. Pulm Circ 2019; 9:2045894019856471. [PMID: 31215336 PMCID: PMC6628532 DOI: 10.1177/2045894019856471] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Treprostinil, a prostacyclin analogue, is approved for the treatment of pulmonary
arterial hypertension (PAH) in adults. Transition from parenteral to oral
treprostinil has been successfully accomplished in adults with PAH but not in
children. In this multicenter study, pediatric patients treated with parenteral
(Cohort 1) or inhaled (Cohort 2) treprostinil were transitioned to oral
treprostinil. Prostacyclin-naïve individuals on background oral PAH therapy
received oral treprostinil as add-on therapy (Cohort 3). Successful transition
was oral treprostinil dose maintenance through week 24. Patients were monitored
for adverse events (AEs), 6-min walk distance (6MWD), PAH symptoms, World Health
Organization (WHO) Functional Class (FC), cardiac magnetic resonance imaging
(cMRI), cardiopulmonary exercise testing (CPET), and quality of life through 24
weeks. A total of 32 patients were enrolled in the study; 23 (72%) were girls
(mean age = 12.2 years). All patients were on background oral PAH therapy.
Overall, patients (96.9%) maintained transition to oral treprostinil; one
patient (Cohort 1) transitioned to oral treprostinil, then back to parenteral
after experiencing syncope and WHO FC change from II to III. Cohorts 1, 2, and 3
received a final mean oral treprostinil dose of 5.6, 3.3, and 4.5 mg t.i.d.,
respectively. All cohorts had variable changes in 6MWD, cMRI, and CPET. Overall,
12 serious AEs were reported. All patients had drug-related AEs including
headache (81%), diarrhea (69%), nausea (66%), vomiting (66%), and flushing
(56%). Pediatric patients maintained transition to oral treprostinil with
preservation of exercise capacity and WHO FC. Prostanoid-related AEs were most
common and similar to those reported in adults.
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Affiliation(s)
- D Dunbar Ivy
- 1 Children's Hospital of Colorado, Aurora, CO, USA
| | - Jeffrey A Feinstein
- 2 Lucile Packard Children's Hospital Stanford and Stanford University School of Medicine, Palo Alto, CA, USA
| | | | | | | | - Russel Hirsch
- 6 Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Eric D Austin
- 7 Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
| | - Jeffrey Fineman
- 8 University of California San Francisco, San Francisco, CA, USA
| | - Uyen Truong
- 1 Children's Hospital of Colorado, Aurora, CO, USA
| | - Derek Solum
- 9 United Therapeutics, Research Triangle Park, NC, USA
| | - C Q Deng
- 9 United Therapeutics, Research Triangle Park, NC, USA
| | - Rachel K Hopper
- 2 Lucile Packard Children's Hospital Stanford and Stanford University School of Medicine, Palo Alto, CA, USA.,10 Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Shang JK, Esmaily M, Verma A, Reinhartz O, Figliola RS, Hsia TY, Feinstein JA, Marsden AL. Patient-Specific Multiscale Modeling of the Assisted Bidirectional Glenn. Ann Thorac Surg 2018; 107:1232-1239. [PMID: 30471273 DOI: 10.1016/j.athoracsur.2018.10.024] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 10/05/2018] [Accepted: 10/08/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND First-stage palliation of neonates with single-ventricle physiology is associated with poor outcomes and challenging clinical management. Prior computational modeling and in vitro experiments introduced the assisted bidirectional Glenn (ABG), which increased pulmonary flow and oxygenation over the bidirectional Glenn (BDG) and the systemic-to-pulmonary shunt in idealized models. In this study, we demonstrate that the ABG achieves similar performance in patient-specific models and assess the influence of varying shunt geometry. METHODS In a small cohort of single-ventricle prestage 2 patients, we constructed three-dimensional in silico models and tuned lumped parameter networks to match clinical measurements. Each model was modified to produce virtual BDG and ABG surgeries. We simulated the hemodynamics of the stage 1 procedure, BDG, and ABG by using multiscale computational modeling, coupling a finite-element flow solver to the lumped parameter network. Two levels of pulmonary vascular resistances (PVRs) were investigated: baseline (low) PVR of the patients and doubled (high) PVR. The shunt nozzle diameter, anastomosis location, and shape were also manipulated. RESULTS The ABG increased the pulmonary flow rate and pressure by 15% to 20%, which was accompanied by a rise in superior vena caval pressure (2 to 3 mm Hg) at both PVR values. Pulmonary flow rate and superior vena caval pressures were most sensitive to the shunt nozzle diameter. CONCLUSIONS Patient-specific ABG performance was similar to prior idealized simulations and experiments, with good performance at lower PVR values in the range of measured clinical data. Larger shunt outlet diameters and lower PVR led to improved ABG performance.
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Affiliation(s)
- Jessica K Shang
- Department of Mechanical Engineering, University of Rochester, Rochester, New York.
| | - Mahdi Esmaily
- Department of Mechanical and Aerospace Engineering, Cornell University, Ithaca, New York
| | - Aekaansh Verma
- Department of Mechanical Engineering, Stanford University, Stanford, California
| | - Olaf Reinhartz
- Department of Cardiothoracic Surgery, Stanford University, Stanford, California
| | - Richard S Figliola
- Department of Mechanical Engineering, Clemson University, Clemson, South Carolina
| | - Tian-Yen Hsia
- Pediatric Cardiac Surgery, Yale New Haven Children's Hospital, New Haven, Connecticut
| | - Jeffrey A Feinstein
- Department of Pediatrics, Stanford University School of Medicine, Lucile Salter Packard Children's Hospital, Palo Alto, California; Department of Bioengineering, Stanford University, Stanford, California
| | - Alison L Marsden
- Department of Pediatrics, Bioengineering and ICME, Stanford University, Stanford, California
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Yang W, Marsden AL, Ogawa MT, Sakarovitch C, Hall KK, Rabinovitch M, Feinstein JA. Right ventricular stroke work correlates with outcomes in pediatric pulmonary arterial hypertension. Pulm Circ 2018; 8:2045894018780534. [PMID: 29767574 PMCID: PMC6432686 DOI: 10.1177/2045894018780534] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Pulmonary arterial hypertension (PAH) is characterized by elevated pulmonary artery pressures (PAP) and pulmonary vascular resistance (PVR). Optimizing treatment strategies and timing for transplant remains challenging. Thus, a quantitative measure to predict disease progression would be greatly beneficial in treatment planning. We devised a novel method to assess right ventricular (RV) stroke work (RVSW) as a potential biomarker of the failing heart that correlates with clinical worsening. Pediatric patients with idiopathic PAH or PAH secondary to congenital heart disease who had serial, temporally matched cardiac catheterization and magnetic resonance imaging (MRI) data were included. RV and PA hemodynamics were numerically determined by using a lumped parameter (circuit analogy) model to create pressure-volume (P-V) loops. The model was tuned using optimization techniques to match MRI and catheterization derived RV volumes and pressures for each time point. RVSW was calculated from the corresponding P-V loop and indexed by ejection fraction and body surface area (RVSWEF) to compare across patients. Seventeen patients (8 boys; median age = 9.4 years; age range = 4.4–16.3 years) were enrolled. Nine were clinically stable; the others had clinical worsening between the time of their initial matched studies and their most recent follow-up (mean time = 3.9 years; range = 1.1–8.0 years). RVSWEF and the ratio of pulmonary to systemic resistance (Rp:Rs) values were found to have more significant associations with clinical worsening within one, two, and five years following the measurements, when compared with PVR index (PVRI). A receiver operating characteristic analysis showed RVSWEF outperforms PVRI, Rp:Rs and ejection fraction for predicting clinical worsening. RVSWEF correlates with clinical worsening in pediatric PAH, shows promising results towards predicting adverse outcomes, and may serve as an indicator of future clinical worsening.
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Affiliation(s)
- Weiguang Yang
- 1 Department of Pediatrics (Cardiology), Stanford University, Stanford, CA, USA
| | - Alison L Marsden
- 1 Department of Pediatrics (Cardiology), Stanford University, Stanford, CA, USA.,2 Department of Bioengineering, Stanford University, Stanford, CA, USA
| | - Michelle T Ogawa
- 1 Department of Pediatrics (Cardiology), Stanford University, Stanford, CA, USA
| | | | - Keeley K Hall
- 1 Department of Pediatrics (Cardiology), Stanford University, Stanford, CA, USA
| | - Marlene Rabinovitch
- 1 Department of Pediatrics (Cardiology), Stanford University, Stanford, CA, USA
| | - Jeffrey A Feinstein
- 1 Department of Pediatrics (Cardiology), Stanford University, Stanford, CA, USA.,2 Department of Bioengineering, Stanford University, Stanford, CA, USA
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Altit G, Lee HC, Hintz S, Tacy TA, Feinstein JA, Bhombal S. Practices surrounding pulmonary hypertension and bronchopulmonary dysplasia amongst neonatologists caring for premature infants. J Perinatol 2018; 38:361-367. [PMID: 29234146 DOI: 10.1038/s41372-017-0025-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Revised: 11/20/2017] [Accepted: 11/28/2017] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Pulmonary hypertension (PH) is associated with bronchopulmonary dysplasia (BPD). Screening strategies, a thorough investigation of co-morbidities, and multidisciplinary involvement prior to anti-PH medications have been advocated by recent guidelines. We sought to evaluate current practices of neonatologists caring for premature infants with PH. DESIGN Electronic survey of American Academy of Pediatrics neonatology members. RESULTS Among 306 neonatologist respondents, 38% had an institutional screening protocol for patients with BPD; 83% screened at 36 weeks for premature neonates on oxygen/mechanical ventilation. In those practicing more than 5 years, 54% noted increasing numbers of premature infants diagnosed with PH. Evaluation for PH in BPD patients included evaluations for micro-aspiration (41%), airways anomalies (29%), and catheterization (10%). Some degree of acquired pulmonary vein stenosis was encountered in 47%. A majority (90%) utilized anti-PH medications during the neonatal hospitalization. CONCLUSIONS Screening for PH in BPD, and subsequent evaluation and management is highly variable.
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Affiliation(s)
- Gabriel Altit
- Neonatology, Montreal Children's Hospital, McGill University, Montreal, QC, Canada. .,Pediatric Cardiology and Neonatal and Developmental Medicine at Stanford University, Lucile Packard Children's Hospital, Palo Alto, CA, USA.
| | - Henry C Lee
- Neonatal and Developmental Medicine, Stanford University, Lucile Packard Children's Hospital, Palo Alto, CA, USA
| | - Susan Hintz
- Obstetrics and Gynecology, Neonatologist, Professor in Neonatal and Developmental Medicine, Stanford University, Lucile Packard Children's Hospital, Palo Alto, CA, USA
| | - Theresa A Tacy
- Echocardiography Laboratory, Stanford University, Lucile Packard Children's Hospital, Palo Alto, CA, USA
| | - Jeffrey A Feinstein
- Bioengineering, Pediatric Cardiologist, Stanford University, Lucile Packard Children's Hospital, Palo Alto, CA, USA
| | - Shazia Bhombal
- Neonatal and Developmental Medicine, Stanford University, Lucile Packard Children's Hospital, Palo Alto, CA, USA
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Verma A, Esmaily M, Shang J, Figliola R, Feinstein JA, Hsia TY, Marsden AL. Optimization of the Assisted Bidirectional Glenn Procedure for First Stage Single Ventricle Repair. World J Pediatr Congenit Heart Surg 2018; 9:157-170. [PMID: 29544408 PMCID: PMC6668725 DOI: 10.1177/2150135117745026] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND First-stage single-ventricle palliation is challenging to manage, and significant interstage morbidity and mortality remain. Prior computational and in vitro studies of the assisted bidirectional Glenn (ABG), a novel first-stage procedure that has shown potential for early conversion to a more stable augmented Glenn physiology, demonstrated increased pulmonary flow and oxygen delivery while decreasing cardiac work, as compared to conventional stage-1 alternatives. This study aims to identify optimal shunt designs for the ABG to improve pulmonary flow while maintaining or decreasing superior vena caval (SVC) pressure. METHODS A representative three-dimensional model of a neonatal bidirectional Glenn (BDG) was created, with a shunt connecting the innominate artery to the SVC. The shunt design was studied as a six-parameter constrained shape optimization problem. We simulated hemodynamics for each candidate designs using a multiscale finite element flow solver and compared performance against designs with taper-less shunts, the standalone BDG, and a simplified control volume model. Three values of pulmonary vascular resistance (PVR) of 2.3, 4.3, and 7.1 WUm2 were studied. RESULTS Increases in pulmonary flow were generally accompanied by increases in SVC pressure, except at low PVR (2.3 WUm2), where the optimal shunt geometry achieved a 13% increase in pulmonary flow without incurring any increase in SVC pressure. Shunt outlet area was the most influential design parameter, while others had minimal effect. CONCLUSION Assisted bidirectional Glenn performance is sensitive to PVR and shunt outlet diameter. An increase in pulmonary flow without a corresponding increase in SVC pressure is possible only when PVR is low.
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Affiliation(s)
- Aekaansh Verma
- Department of Mechanical Engineering, Stanford University, Stanford, CA, USA
| | - Mahdi Esmaily
- Center for Turbulence Research, Stanford University, Stanford, CA, USA
- Sibley School of Mechanical and Aerospace Engineering, Cornell University, Ithaca, NY, USA
| | - Jessica Shang
- Department of Mechanical Engineering, University of Rochester, Rochester, NY, USA
| | - Richard Figliola
- Department of Mechanical Engineering, Clemson University, Clemson, SC, USA
| | - Jeffrey A. Feinstein
- Department of Pediatrics, Stanford University School of Medicine, Lucile Salter Packard Children’s Hospital, Palo Alto, CA, USA
- Department of Bioengineering, Stanford University, Stanford, CA, USA
| | - Tain-Yen Hsia
- Cardiothoracic Unit, Great Ormond Street Hospital for Children NHS-Trust, London, UK
| | - Alison L. Marsden
- Department of Pediatrics, Stanford University School of Medicine, Lucile Salter Packard Children’s Hospital, Palo Alto, CA, USA
- Department of Bioengineering, Stanford University, Stanford, CA, USA
- Institute for Computational and Mathematical Engineering, Stanford University, CA, USA
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McCarthy EK, Ogawa MT, Hopper RK, Feinstein JA, Gans HA. Central line replacement following infection does not improve reinfection rates in pediatric pulmonary hypertension patients receiving intravenous prostanoid therapy. Pulm Circ 2018; 8:2045893218754886. [PMID: 29309237 PMCID: PMC5826011 DOI: 10.1177/2045893218754886] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Treatment of pediatric pulmonary hypertension (PH) with IV prostanoids has greatly improved outcomes but requires a central line, posing inherent infection risk. This study examines the types of infections, infection rates, and importantly the effect of line management strategies on reinfection in children receiving IV prostanoids for PH. This study is a retrospective review of all pediatric PH patients receiving intravenous epoprostenol (EPO) or treprostinil (TRE) at one academic tertiary care center between 2000 and 2014. No patients declined participation in the study or were otherwise excluded. Infectious complications were characterized by organism(s), infection rates, time to next infection, and line management decisions (salvage vs. replace). Of the 40 patients followed, 13 sustained 38 infections involving 49 pathogens, with a predominance of gram-positive (GP) organisms (n = 35). The pooled infection rate was 1.06 per 1000 prostanoid days with no difference between EPO and TRE. No significant difference in reinfection rate was observed when comparing line salvage to replacement, regardless of organism type. Both overall and organism-type comparisons suggest longer time between line infections following line salvage compared with line replacement (732 vs. 410 days overall; 793 vs. 363 days for GP; 611 vs. 581 days for gram-negative [GN]; P > 0.05 for all comparisons). Central line replacement following blood stream infections in pediatric PH patients does not improve subsequent infection rates or time to next infection, and may lead to unnecessary risks associated with line replacement, including potential loss of vascular access. A revised approach to central line infections in pediatric PH is proposed.
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Affiliation(s)
- Elisa K McCarthy
- 1 12248 School of Medicine, Loyola Stritch School of Medicine, Maywood , IL, USA
| | - Michelle T Ogawa
- 2 24349 Department of Pediatrics, Division of Pediatric Cardiology, Stanford University Medical Center , Stanford, CA, USA
| | - Rachel K Hopper
- 2 24349 Department of Pediatrics, Division of Pediatric Cardiology, Stanford University Medical Center , Stanford, CA, USA
| | - Jeffrey A Feinstein
- 2 24349 Department of Pediatrics, Division of Pediatric Cardiology, Stanford University Medical Center , Stanford, CA, USA
| | - Hayley A Gans
- 3 10624 Department of Pediatrics, Division of Pediatric Infectious Diseases, Stanford University Medical Center , Stanford, CA, USA
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Yang W, Hanley FL, Chan FP, Marsden AL, Vignon-Clementel IE, Feinstein JA. Computational simulation of postoperative pulmonary flow distribution in Alagille patients with peripheral pulmonary artery stenosis. CONGENIT HEART DIS 2017; 13:241-250. [PMID: 29194961 DOI: 10.1111/chd.12556] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2017] [Revised: 10/24/2017] [Accepted: 10/28/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Up to 90% of individuals with Alagille syndrome have congenital heart diseases. Peripheral pulmonary artery stenosis (PPS), resulting in right ventricular hypertension and pulmonary flow disparity, is one of the most common abnormalities, yet the hemodynamic effects are ill-defined, and optimal patient management and treatment strategies are not well established. The purpose of this pilot study is to use recently refined computational simulation in the setting of multiple surgical strategies, to examine the influence of pulmonary artery reconstruction on hemodynamics in this population. MATERIALS AND METHODS Based on computed tomography angiography and cardiac catheterization data, preoperative pulmonary artery models were constructed for 4 patients with Alagille syndrome with PPS (all male, age range: 0.6-2.9 years), and flow simulations with deformable walls were performed. Surgeon directed virtual surgery, mimicking the surgical procedure, was then performed to derive postoperative models. Postoperative simulation-derived hemodynamics and blood flow distribution were then compared with the clinical results. RESULTS Simulations confirmed substantial resistance, resulting from preoperative severe ostial stenoses, and the use of newly developed adaptive outflow boundary conditions led to excellent agreement with in vivo measurements. Relief of PPS decreased pulmonary artery pressures and improved pulmonary flow distribution both in vivo and in silico with good correlation. CONCLUSIONS Using adaptive outflow boundary conditions, computational simulations can estimate postoperative overall pulmonary flow distribution in patients with Alagille syndrome after pulmonary artery reconstruction. Obstruction relief along with pulmonary artery vasodilation determines postoperative pulmonary flow distribution and newer methods can incorporate these physiologic changes. Evolving blood flow simulations may be useful in surgical or transcatheter planning and in understanding the complex interplay among various obstructions in patients with peripheral pulmonary stenosis.
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Affiliation(s)
- Weiguang Yang
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Stanford, California, USA
| | - Frank L Hanley
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California, USA
| | - Frandics P Chan
- Department of Radiology, Stanford University School of Medicine, Stanford, California, USA
| | - Alison L Marsden
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Stanford, California, USA.,Department of BioEngineering, Stanford University School of Medicine, Stanford, California, USA
| | - Irene E Vignon-Clementel
- INRIA and Sorbonne Universités UPMC, Univ. Paris 6, Laboratoire Jacques-Louis Lions, Paris, France
| | - Jeffrey A Feinstein
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Stanford, California, USA.,Department of BioEngineering, Stanford University School of Medicine, Stanford, California, USA
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Handler SS, Ogawa MT, Hopper RK, Sakarovitch C, Feinstein JA. Subcutaneous treprostinil in pediatric patients with failing single-ventricle physiology. J Heart Lung Transplant 2017; 37:S1053-2498(17)31993-9. [PMID: 29126699 DOI: 10.1016/j.healun.2017.09.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Revised: 08/15/2017] [Accepted: 09/11/2017] [Indexed: 11/28/2022] Open
Affiliation(s)
- Stephanie S Handler
- Division of Cardiology, Department of Pediatrics, Stanford University, Palo Alto, California, USA
| | - Michelle T Ogawa
- Division of Cardiology, Department of Pediatrics, Stanford University, Palo Alto, California, USA
| | - Rachel K Hopper
- Division of Cardiology, Department of Pediatrics, Stanford University, Palo Alto, California, USA
| | - Charlotte Sakarovitch
- Division of Biomedical Informatics Research, Department of Medicine, Quantitative Sciences Unit, Stanford University, Palo Alto, California, USA
| | - Jeffrey A Feinstein
- Division of Cardiology, Department of Pediatrics, Stanford University, Palo Alto, California, USA; Department of Bioengineering, Stanford University, Palo Alto, California, USA.
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35
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Austin ED, Feinstein JA. Accelerometry: Improving Objective Assessments of Therapeutic Impact in Pediatric Pulmonary Arterial Hypertension. Am J Respir Crit Care Med 2017; 196:127-129. [PMID: 28707968 DOI: 10.1164/rccm.201702-0409ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Eric D Austin
- 1 Department of Pediatrics Vanderbilt University Medical Center Nashville, Tennessee and
| | - Jeffrey A Feinstein
- 2 Department of Pediatrics (Cardiology) Stanford University Medical Center Palo Alto, California
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Kinsella JP, Steinhorn RH, Krishnan US, Feinstein JA, Adatia I, Austin ED, Rosenzweig EB, Everett AD, Fineman JR, Hanna BD, Hopper RK, Humpl T, Ivy DD, Keller RL, Mullen MP, Raj JU, Wessel DL, Abman SH. Recommendations for the Use of Inhaled Nitric Oxide Therapy in Premature Newborns with Severe Pulmonary Hypertension. J Pediatr 2016; 170:312-4. [PMID: 26703869 DOI: 10.1016/j.jpeds.2015.11.050] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Revised: 10/30/2015] [Accepted: 11/17/2015] [Indexed: 12/27/2022]
Affiliation(s)
- John P Kinsella
- Section of Neonatology, University of Colorado School of Medicine-Children's Hospital Colorado, Aurora, CO.
| | | | - Usha S Krishnan
- New York-Presbyterian/Columbia University Medical Center, New York, NY
| | | | - Ian Adatia
- University of Alberta-Edmonton, Edmonton, Alberta, Canada
| | - Eric D Austin
- Vanderbilt University Medical Center-Vanderbilt Children's Hospital, Nashville, TN
| | | | | | - Jeffrey R Fineman
- Section of Pediatric Critical Care, University of California San Francisco-Benioff Children's Hospital, San Francisco, CA
| | - Brian D Hanna
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Rachel K Hopper
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Tilman Humpl
- The Hospital for Sick Children-University of Toronto, Toronto, Ontario, Canada
| | - D Dunbar Ivy
- Section of Cardiology, University of Colorado School of Medicine-Children's Hospital Colorado, Aurora, CO
| | - Roberta L Keller
- Section of Neonatology, University of California San Francisco-Benioff Children's Hospital, San Francisco, CA
| | | | - J Usha Raj
- University of Illinois-Chicago, Chicago, IL
| | | | - Steven H Abman
- Section of Pulmonary Medicine, University of Colorado School of Medicine-Children's Hospital Colorado, Aurora, CO
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Abman SH, Hansmann G, Archer SL, Ivy DD, Adatia I, Chung WK, Hanna BD, Rosenzweig EB, Raj JU, Cornfield D, Stenmark KR, Steinhorn R, Thébaud B, Fineman JR, Kuehne T, Feinstein JA, Friedberg MK, Earing M, Barst RJ, Keller RL, Kinsella JP, Mullen M, Deterding R, Kulik T, Mallory G, Humpl T, Wessel DL. Pediatric Pulmonary Hypertension: Guidelines From the American Heart Association and American Thoracic Society. Circulation 2015; 132:2037-99. [PMID: 26534956 DOI: 10.1161/cir.0000000000000329] [Citation(s) in RCA: 660] [Impact Index Per Article: 73.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Pulmonary hypertension is associated with diverse cardiac, pulmonary, and systemic diseases in neonates, infants, and older children and contributes to significant morbidity and mortality. However, current approaches to caring for pediatric patients with pulmonary hypertension have been limited by the lack of consensus guidelines from experts in the field. In a joint effort from the American Heart Association and American Thoracic Society, a panel of experienced clinicians and clinician-scientists was assembled to review the current literature and to make recommendations on the diagnosis, evaluation, and treatment of pediatric pulmonary hypertension. This publication presents the results of extensive literature reviews, discussions, and formal scoring of recommendations for the care of children with pulmonary hypertension.
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MESH Headings
- Cardiovascular Agents/therapeutic use
- Child
- Child, Preschool
- Combined Modality Therapy
- Diagnostic Imaging/methods
- Disease Management
- Extracorporeal Membrane Oxygenation
- Genetic Counseling
- Heart Defects, Congenital/complications
- Heart Defects, Congenital/therapy
- Hernias, Diaphragmatic, Congenital/complications
- Hernias, Diaphragmatic, Congenital/therapy
- Humans
- Hypertension, Pulmonary/diagnosis
- Hypertension, Pulmonary/etiology
- Hypertension, Pulmonary/genetics
- Hypertension, Pulmonary/therapy
- Infant
- Infant, Newborn
- Lung/embryology
- Lung Transplantation
- Nitric Oxide/administration & dosage
- Nitric Oxide/therapeutic use
- Oxygen Inhalation Therapy
- Persistent Fetal Circulation Syndrome/diagnosis
- Persistent Fetal Circulation Syndrome/therapy
- Postoperative Complications/therapy
- Respiration, Artificial/adverse effects
- Respiration, Artificial/methods
- Ventilator-Induced Lung Injury/prevention & control
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Webber SA, Hsu DT, Ivy DD, Kulik TJ, Pahl E, Rosenthal DN, Morrow WR, Feinstein JA. Task Force 7: Pediatric Cardiology Fellowship Training in Pulmonary Hypertension, Advanced Heart Failure, and Transplantation. J Am Coll Cardiol 2015; 66:732-9. [DOI: 10.1016/j.jacc.2015.03.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Ross RD, Brook M, Koenig P, Feinstein JA, Lang P, Spicer RL, Vincent JA. 2015 SPCTPD/ACC/AAP/AHA Training Guidelines for Pediatric Cardiology Fellowship Programs (Revision of the 2005 Training Guidelines for Pediatric Cardiology Fellowship Programs): Introduction. J Am Coll Cardiol 2015; 66:672-6. [DOI: 10.1016/j.jacc.2015.03.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Ross RD, Brook M, Feinstein JA, Koenig P, Lang P, Spicer R, Vincent JA, Lewis AB, Martin GR, Bartz PJ, Fischbach PS, Fulton DR, Matherne GP, Reinking B, Srivastava S, Printz B, Geva T, Shirali GS, Weinberg P, Wong PC, Armsby LB, Vincent RN, Foerster SR, Holzer RJ, Moore JW, Marshall AC, Latson L, Dubin AM, Walsh EP, Franklin W, Kanter RJ, Saul JP, Shah MJ, Van Hare GF, Feltes TF, Roth SJ, Almodovar MC, Andropoulos DB, Bohn DJ, Costello JM, Gajarski RJ, Mott AR, Stout K, Valente AM, Cook S, Gurvitz M, Saidi A, Webber SA, Hsu DT, Ivy DD, Kulik TJ, Pahl E, Rosenthal DN, Morrow R, Mahle WT, Murphy AM, Li JS, Law YM, Newburger JW, Daniels SR, Bernstein D, Marino BS. 2015 SPCTPD/ACC/AAP/AHA Training Guidelines for Pediatric Cardiology Fellowship Programs (Revision of the 2005 Training Guidelines for Pediatric Cardiology Fellowship Programs). J Am Coll Cardiol 2015; 66:S0735-1097(15)00809-8. [PMID: 25777637 DOI: 10.1016/j.jacc.2015.03.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Ross RD, Brook M, Koenig P, Feinstein JA, Lang P, Spicer RL, Vincent JA. 2015 SPCTPD/ACC/AAP/AHA Training Guidelines for Pediatric Cardiology Fellowship Programs (Revision of the 2005 Training Guidelines for Pediatric Cardiology Fellowship Programs): Introduction. Circulation 2015; 132:e43-7. [PMID: 25769639 DOI: 10.1161/cir.0000000000000191] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Hopper RK, Feinstein JA, Manning MA, Benitz W, Hudgins L. Neonatal pulmonary arterial hypertension and Noonan syndrome: two fatal cases with a specific RAF1 mutation. Am J Med Genet A 2015; 167A:882-5. [PMID: 25706034 DOI: 10.1002/ajmg.a.37024] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2014] [Accepted: 02/02/2015] [Indexed: 11/10/2022]
Abstract
Mutations in RAF1 are associated with Noonan syndrome and hypertrophic cardiomyopathy. We present two infants with Noonan syndrome and an identical RAF1 mutation, p.Ser257Leu (c.770C>T), who developed severe pulmonary arterial hypertension (PAH) that proved to be fatal. The RAF1 gene encodes Raf-1 kinase, part of the Ras/mitogen-activated kinase (MAPK) signaling pathway, which has been linked to the development of PAH. This specific mutation has been associated with dephosphorylation of a critical serine residue and constitutive activation of the Raf-1 kinase. These two cases suggest that abnormal activation of the Ras/MAPK pathway may play a significant role in the development of pulmonary vascular disease in the subset of patients with Noonan syndrome and a specific RAF1 mutation.
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Affiliation(s)
- Rachel K Hopper
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
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Martin MH, Feinstein JA, Chan FP, Marsden AL, Yang W, Reddy VM. Technical feasibility and intermediate outcomes of using a handcrafted, area-preserving, bifurcated Y-graft modification of the Fontan procedure. J Thorac Cardiovasc Surg 2015; 149:239-45.e1. [DOI: 10.1016/j.jtcvs.2014.08.058] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Revised: 08/16/2014] [Accepted: 08/23/2014] [Indexed: 11/16/2022]
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Abstract
BACKGROUND Sildenafil, a phosphodiestase type 5 inhibitor, was approved in 2005 for the treatment of pulmonary arterial hypertension (PAH) in adults and is commonly used off-label for pediatric patients. Little is known, however, about sildenafil's side effects in this population. METHODS Single institution, longitudinal survey-based study performed in an outpatient pediatric cardiology clinic. Pediatric patients on sildenafil [alone or in combination with other pulmonary hypertension (PH) therapies] completed questionnaires regarding frequency of vascular, gastrointestinal, neurologic, and hematologic side effects. RESULTS Between January 2011 and May 2014, 66 pediatric patients with PH on sildenafil filled out 214 surveys, 32 patients (96 surveys) on monotherapy, and 43 patients (118 surveys) on sildenafil plus an endothelin receptor antagonist (ERA) (bosentan or ambrisentan) and/or a prostacyclin (epoprostenol or treprostinil). Overall, 30% of respondents identified at least one side effect. For all patients on sildenafil, incidence of side effects by system was 37% gastrointestinal, 35% vascular, and 22% neurologic. For patients on sildenafil monotherapy, incidence of side effects by system was 24% gastrointestinal, 21% vascular, and 18% neurologic compared to patients on combination therapy who reported an incidence of 48% gastrointestinal, 45% vascular, and 25% neurologic. CONCLUSION Incidence of vascular, gastrointestinal, and neurologic side effect in pediatric patients on sildenafil therapy for PAH was 30%. Side effects were more common in patients on combination therapy with an ERA and/or prostacyclin than in patients on sildenafil monotherapy.
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Affiliation(s)
- Stephanie L Siehr
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University , Palo Alto, CA , USA
| | - Elisa K McCarthy
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University , Palo Alto, CA , USA
| | - Michelle T Ogawa
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University , Palo Alto, CA , USA
| | - Jeffrey A Feinstein
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University , Palo Alto, CA , USA
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Kwon S, Feinstein JA, Dholakia RJ, LaDisa JF. Quantification of local hemodynamic alterations caused by virtual implantation of three commercially available stents for the treatment of aortic coarctation. Pediatr Cardiol 2014; 35:732-40. [PMID: 24259013 PMCID: PMC3959287 DOI: 10.1007/s00246-013-0845-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2013] [Accepted: 11/06/2013] [Indexed: 12/18/2022]
Abstract
Patients with coarctation of the aorta (CoA) are prone to morbidity including atherosclerotic plaque that has been shown to correlate with altered wall shear stress (WSS) in the descending thoracic aorta (dAo). We created the first patient-specific computational fluid dynamics (CFD) model of a CoA patient treated by Palmaz stenting to date, and compared resulting WSS distributions to those from virtual implantation of Genesis XD and modified NuMED CP stents, also commonly used for CoA. CFD models were created from magnetic resonance imaging, fluoroscopy and blood pressure data. Simulations incorporated vessel deformation, downstream vascular resistance and compliance to match measured data and generate blood flow velocity and time-averaged WSS (TAWSS) results. TAWSS was quantified longitudinally and circumferentially in the stented region and dAo. While modest differences were seen in the distal portion of the stented region, marked differences were observed downstream along the posterior dAo and depended on stent type. The Genesis XD model had the least area of TAWSS values exceeding the threshold for platelet aggregation in vitro, followed by the Palmaz and NuMED CP stents. Alterations in local blood flow patterns and WSS imparted on the dAo appear to depend on the type of stent implanted for CoA. Following confirmation in larger studies, these findings may aid pediatric interventional cardiologists in selecting the most appropriate stent for each patient, and ultimately reduce long-term morbidity following treatment for CoA by stenting.
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Affiliation(s)
- Sung Kwon
- Department of Biomedical Engineering, Marquette University
| | - Jeffrey A. Feinstein
- Department of Bioengineering, Stanford University,Department of Pediatrics, Lucile Packard Children’s Hospital
| | | | - John F. LaDisa
- Department of Biomedical Engineering, Marquette University,Herma Heart Center, Children’s Hospital of Wisconsin,Department of Medicine, Medical College of Wisconsin
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Villafañe J, Feinstein JA, Jenkins KJ, Vincent RN, Walsh EP, Dubin AM, Geva T, Towbin JA, Cohen MS, Fraser C, Dearani J, Rosenthal D, Kaufman B, Graham TP. Hot Topics in Tetralogy of Fallot. J Am Coll Cardiol 2013; 62:2155-66. [DOI: 10.1016/j.jacc.2013.07.100] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2013] [Revised: 06/26/2013] [Accepted: 07/01/2013] [Indexed: 12/13/2022]
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Maxey DM, Ivy DD, Ogawa MT, Feinstein JA. Food and Drug Administration (FDA) postmarket reported side effects and adverse events associated with pulmonary hypertension therapy in pediatric patients. Pediatr Cardiol 2013; 34:1628-36. [PMID: 23532466 PMCID: PMC3783558 DOI: 10.1007/s00246-013-0688-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2013] [Accepted: 02/25/2013] [Indexed: 10/27/2022]
Abstract
Because most medications for pediatric pulmonary hypertension (PH) are used off label and based on adult trials, little information is available on pediatric-specific adverse events (AEs). Although drug manufacturers are required to submit postmarket AE reports to the Food and Drug Administration (FDA), this information is rarely transmitted to practitioners. In the setting of a recent FDA warning for sildenafil, the authors sought to give a better description of the AEs associated with current therapies in pediatric PH. In January 2010, a written request was made to the Food and Drug Administration for AE records of commonly used PH medications. Reports were screened for pediatric patients, analyzed in terms of AEs, and compared with the medical literature. Arbitrarily, AEs that could be attributed to concomitant medications were not attributed to the PH medication in question. Adverse events occurring in more than 5 % of events for each drug were assumed to be associated with the targeted PH medication. Between November 1997 and December 2009, 588 pediatric AE reports (death in 257 cases) were reported for the three most commonly used therapies: bosentan, epoprostenol, and sildenafil. Many of the AEs were similar to those reported previously. However, 27 AEs not previously reported in the literature (e.g., pulmonary hemorrhage, hemoptysis, and pneumonia) were found. The FDA postmarket records for PH medications in pediatric patients show a significant number of AEs. The discovery of AEs not previously reported will better inform those caring for these complex and critically ill children, and the large number of deaths suggest they may be underreported in current literature.
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Affiliation(s)
- Dawn M. Maxey
- Department of Pediatrics (Cardiology), Stanford University Medical Center/Lucile Packard Children’s Hospital, 750 Welch Road, Suite 305, Palo Alto, CA 94304, USA
| | - D. Dunbar Ivy
- Division of Pediatric Cardiology, Department of Pediatrics, University of Colorado, 13123 E. 16th Avenue B100, Aurora, CO 80045-7106, USA
| | - Michelle T. Ogawa
- Department of Pediatrics (Cardiology), Stanford University Medical Center/Lucile Packard Children’s Hospital, 750 Welch Road, Suite 305, Palo Alto, CA 94304, USA
| | - Jeffrey A. Feinstein
- Department of Pediatrics (Cardiology), Stanford University Medical Center/Lucile Packard Children’s Hospital, 750 Welch Road, Suite 305, Palo Alto, CA 94304, USA
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Sheth SS, Maxey DM, Drain AE, Feinstein JA. Validation of the Innocor device for noninvasive measurement of oxygen consumption in children and adults. Pediatr Cardiol 2013; 34:847-52. [PMID: 23108483 DOI: 10.1007/s00246-012-0555-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2012] [Accepted: 10/04/2012] [Indexed: 11/29/2022]
Abstract
Outpatient measurements of oxygen consumption (VO2) and cardiac output (CO) are valuable in the management of pediatric cardiac disease. Current methods are inaccurate and cumbersome or require invasive procedures. New devices to measure these variables in adults have not been rigorously tested for children. The Innocor system uses a photoacoustic analyzer to measure gas content for noninvasive measurement of VO2 and CO. This study sought to validate Innocor-derived VO2 measurements in children and adults by comparing them against the gold standard Douglas bag method. Subjects were tested in an outpatient setting. Adaptations were made for pediatric patients based on weight. Resting VO2 measurements were obtained simultaneously by the Innocor system and Douglas bag during 3 min. The study enrolled 31 children (mean age, 12.2 years; range, 7-17 years, 17 girls) and 29 adults (mean age, 36.7 years; range, 19-57 years; 17 women). Strong correlation between the two techniques was seen for both the adults (R (2) = 0.88) and the children (R (2) = 0.82). The average discrepancy between the Innocor and Douglas bag measurements was 1.7 % (range, 0.6-19.1 %) for the adults, and 5.4 % (range, 0.1-32.2 %) for the children. The discrepancy was more than 15 % for 17 % of the adults and 22 % of the children, with the Innocor device tending to overestimate VO2 in children compared with the Douglas bag. This trend was not seen in adults. The Innocor system has excellent correlation with the Douglas bag and shows promise for noninvasive measurement of VO2 and CO in the school-age pediatric population.
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Affiliation(s)
- Shreya S Sheth
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Stanford, CA, USA.
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Algaze CA, Peng LF, Feinstein JA, Reddy VM, Hanley FL, Perry SB. MAJOR AORTOPULMONARY COLLATERAL ARTERY NOMENCLATURE. J Am Coll Cardiol 2013. [DOI: 10.1016/s0735-1097(13)60543-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Siehr SL, Ivy DD, Miller-Reed K, Ogawa M, Rosenthal DN, Feinstein JA. Children with pulmonary arterial hypertension and prostanoid therapy: long-term hemodynamics. J Heart Lung Transplant 2013; 32:546-52. [PMID: 23453572 DOI: 10.1016/j.healun.2013.01.1055] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2012] [Revised: 01/30/2013] [Accepted: 01/30/2013] [Indexed: 10/27/2022] Open
Abstract
BACKGROUND Pediatric patients with severe pulmonary arterial hypertension (PAH) are treated with intravenous epoprostenol or intravenous or subcutaneous treprostinil. Little is known about longitudinal hemodynamics and outcomes of epoprostenol, treprostinil, and transitions from epoprostenol to treprostinil. METHODS This was retrospective study of 77 pediatric patients (47 idiopathic PAH, 24 congenital heart disease-PAH) receiving epoprostenol or treprostinil from 1992 to 2010 at 2 centers. Outcomes were defined as living vs dead/transplant. RESULTS Mean age at baseline was 7.7 ± 5.2 years, with follow-up of 4.3 ± 3.4 years. Thirty-seven patients were treated with epoprostenol, 20 with treprostinil, and 20 were transitioned from epoprostenol to treprostinil. Mean pulmonary-to-systemic vascular resistance ratio (Rp/Rs) for epoprostenol was 1.0 ± 0.4, 0.8 ± 0.4, 0.8 ± 0.4, 1.0 ± 0.4, and 1.2 ± 0.4, respectively, at baseline, 1, 2, 3, and 4 years. For treprostinil, Rp/Rs was 0.9 ± 0.3, 0.7 ± 0.3, 0.5 ± 0.2, (p < 0.01 vs baseline), and 1.1 ± 0.2, respectively, at baseline, 1, 2, and 3 to 4 years, respectively. There were similar changes in mean pulmonary artery pressure and pulmonary vascular resistance index. The Rp/Rs 1 year after epoprostenol to treprostinil transition increased from 0.6 to 0.8 (n = 7). Changes not statistically significant unless noted. Eight patients died or received a transplant within 2 years of baseline; compared with the rest of the cohort, mean baseline Rp/Rs, right atrial pressure, and pulmonary vascular resistance index were significantly worse in this group. Thirty-nine patients remain on prostanoids, 17 are off, 16 died, and 5 received heart-lung transplant. Kaplan-Meier 5-year transplant-free survival was 70% (95% confidence interval, 56%-80%). CONCLUSION There was improvement in Rp/Rs on both therapies at 1 to 2 years that was not sustained. The 5-year transplant-free survival was better than in similar adult studies.
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Affiliation(s)
- Stephanie L Siehr
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University, Palo Alto, California 94304, USA
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