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Lou D, Meurer M, Ovchinnikova S, Burk R, Denzler A, Herbst K, Papaioannou IA, Duan Y, Jacobs ML, Witte V, Ürge D, Kirrmaier D, Krogemann M, Gubicza K, Boerner K, Bundschuh C, Weidner NM, Merle U, Knorr B, Welker A, Denkinger CM, Schnitzler P, Kräusslich HG, Dao Thi VL, De Allegri M, Nguyen HT, Deckert A, Anders S, Knop M. Scalable RT-LAMP-based SARS-CoV-2 testing for infection surveillance with applications in pandemic preparedness. EMBO Rep 2023; 24:e57162. [PMID: 36951170 PMCID: PMC10157315 DOI: 10.15252/embr.202357162] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 03/10/2023] [Indexed: 03/24/2023] Open
Abstract
Throughout the SARS-CoV-2 pandemic, limited diagnostic capacities prevented sentinel testing, demonstrating the need for novel testing infrastructures. Here, we describe the setup of a cost-effective platform that can be employed in a high-throughput manner, which allows surveillance testing as an acute pandemic control and preparedness tool, exemplified by SARS-CoV-2 diagnostics in an academic environment. The strategy involves self-sampling based on gargling saline, pseudonymized sample handling, automated RNA extraction, and viral RNA detection using a semiquantitative multiplexed colorimetric reverse transcription loop-mediated isothermal amplification (RT-LAMP) assay with an analytical sensitivity comparable with RT-qPCR. We provide standard operating procedures and an integrated software solution for all workflows, including sample logistics, analysis by colorimetry or sequencing, and communication of results. We evaluated factors affecting the viral load and the stability of gargling samples as well as the diagnostic sensitivity of the RT-LAMP assay. In parallel, we estimated the economic costs of setting up and running the test station. We performed > 35,000 tests, with an average turnover time of < 6 h from sample arrival to result announcement. Altogether, our work provides a blueprint for fast, sensitive, scalable, cost- and labor-efficient RT-LAMP diagnostics, which is independent of potentially limiting clinical diagnostics supply chains.
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Affiliation(s)
- Dan Lou
- Center for Molecular Biology of Heidelberg University (ZMBH), Heidelberg, Germany
| | - Matthias Meurer
- Center for Molecular Biology of Heidelberg University (ZMBH), Heidelberg, Germany
| | - Svetlana Ovchinnikova
- Center for Molecular Biology of Heidelberg University (ZMBH), Heidelberg, Germany
- Bioquant Center, Heidelberg University, Heidelberg, Germany
| | - Robin Burk
- Center for Molecular Biology of Heidelberg University (ZMBH), Heidelberg, Germany
| | - Anna Denzler
- Center for Molecular Biology of Heidelberg University (ZMBH), Heidelberg, Germany
| | - Konrad Herbst
- Center for Molecular Biology of Heidelberg University (ZMBH), Heidelberg, Germany
| | | | - Yuanqiang Duan
- Center for Molecular Biology of Heidelberg University (ZMBH), Heidelberg, Germany
| | - Max L Jacobs
- Center for Molecular Biology of Heidelberg University (ZMBH), Heidelberg, Germany
| | - Victoria Witte
- Center for Molecular Biology of Heidelberg University (ZMBH), Heidelberg, Germany
| | - Daniel Ürge
- Center for Molecular Biology of Heidelberg University (ZMBH), Heidelberg, Germany
| | - Daniel Kirrmaier
- Center for Molecular Biology of Heidelberg University (ZMBH), Heidelberg, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Michelle Krogemann
- Center for Molecular Biology of Heidelberg University (ZMBH), Heidelberg, Germany
| | - Krisztina Gubicza
- Center for Molecular Biology of Heidelberg University (ZMBH), Heidelberg, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Kathleen Boerner
- Department of Infectious Diseases, Virology, Heidelberg University, Heidelberg, Germany
| | - Christian Bundschuh
- Department of Infectious Diseases, Virology, Heidelberg University, Heidelberg, Germany
| | - Niklas M Weidner
- Department of Infectious Diseases, Virology, Heidelberg University, Heidelberg, Germany
| | - Uta Merle
- Department of Gastroenterology, Heidelberg University Hospital, Heidelberg, Germany
| | - Britta Knorr
- Landratsamt Rhein-Neckar-Kreis, Gesundheitsamt, Heidelberg, Germany
| | - Andreas Welker
- Landratsamt Rhein-Neckar-Kreis, Gesundheitsamt, Heidelberg, Germany
| | - Claudia M Denkinger
- Division of Infectious Disease and Tropical Medicine, Heidelberg University Hospital, Heidelberg, Germany
- German Center for Infection Research (DZIF), Heidelberg, Germany
| | - Paul Schnitzler
- Department of Infectious Diseases, Virology, Heidelberg University, Heidelberg, Germany
| | - Hans-Georg Kräusslich
- Department of Infectious Diseases, Virology, Heidelberg University, Heidelberg, Germany
- German Center for Infection Research (DZIF), Heidelberg, Germany
| | - Viet Loan Dao Thi
- German Center for Infection Research (DZIF), Heidelberg, Germany
- Schaller Research Groups, Department of Infectious Diseases, Virology, Heidelberg University, Heidelberg, Germany
| | - Manuela De Allegri
- Heidelberg Institute of Global Health, University Hospital and Medical Faculty, Heidelberg University, Heidelberg, Germany
| | - Hoa Thi Nguyen
- Heidelberg Institute of Global Health, University Hospital and Medical Faculty, Heidelberg University, Heidelberg, Germany
| | - Andreas Deckert
- Heidelberg Institute of Global Health, University Hospital and Medical Faculty, Heidelberg University, Heidelberg, Germany
| | - Simon Anders
- Center for Molecular Biology of Heidelberg University (ZMBH), Heidelberg, Germany
- Bioquant Center, Heidelberg University, Heidelberg, Germany
| | - Michael Knop
- Center for Molecular Biology of Heidelberg University (ZMBH), Heidelberg, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
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Ludwig KU, Schmithausen RM, Li D, Jacobs ML, Hollstein R, Blumenstock K, Liebing J, Słabicki M, Ben-Shmuel A, Israeli O, Weiss S, Ebert TS, Paran N, Rüdiger W, Wilbring G, Feldman D, Lippke B, Ishorst N, Hochfeld LM, Beins EC, Kaltheuner IH, Schmitz M, Wöhler A, Döhla M, Sib E, Jentzsch M, Borrajo JD, Strecker J, Reinhardt J, Cleary B, Geyer M, Hölzel M, Macrae R, Nöthen MM, Hoffmann P, Exner M, Regev A, Zhang F, Schmid-Burgk JL. LAMP-Seq enables sensitive, multiplexed COVID-19 diagnostics using molecular barcoding. Nat Biotechnol 2021; 39:1556-1562. [PMID: 34188222 PMCID: PMC8678193 DOI: 10.1038/s41587-021-00966-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 05/26/2021] [Indexed: 02/06/2023]
Abstract
Frequent testing of large population groups combined with contact tracing and isolation measures will be crucial for containing Coronavirus Disease 2019 outbreaks. Here we present LAMP-Seq, a modified, highly scalable reverse transcription loop-mediated isothermal amplification (RT-LAMP) method. Unpurified biosamples are barcoded and amplified in a single heat step, and pooled products are analyzed en masse by sequencing. Using commercial reagents, LAMP-Seq has a limit of detection of ~2.2 molecules per µl at 95% confidence and near-perfect specificity for severe acute respiratory syndrome coronavirus 2 given its sequence readout. Clinical validation of an open-source protocol with 676 swab samples, 98 of which were deemed positive by standard RT-qPCR, demonstrated 100% sensitivity in individuals with cycle threshold values of up to 33 and a specificity of 99.7%, at a very low material cost. With a time-to-result of fewer than 24 h, low cost and little new infrastructure requirement, LAMP-Seq can be readily deployed for frequent testing as part of an integrated public health surveillance program.
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Affiliation(s)
- Kerstin U. Ludwig
- Institute of Human Genetics, University of Bonn and University Hospital Bonn, 53127 Bonn, Germany
| | - Ricarda M. Schmithausen
- Institute of Hygiene and Public Health, University of Bonn and University Hospital Bonn, 53127 Bonn, Germany
| | - David Li
- Broad Institute of MIT and Harvard, Massachusetts Institute of Technology, Cambridge, MA 02139, USA.,McGovern Institute for Brain Research, Massachusetts Institute of Technology, Cambridge, MA 02139, USA.,Department of Brain and Cognitive Sciences, Massachusetts Institute of Technology, Cambridge, MA 02139, USA.,Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Max L. Jacobs
- Institute of Clinical Chemistry and Clinical Pharmacology, University of Bonn and University Hospital Bonn, 53127 Bonn, Germany,Center for Molecular Biology of Heidelberg University (ZMBH), Heidelberg, Germany
| | - Ronja Hollstein
- Institute of Human Genetics, University of Bonn and University Hospital Bonn, 53127 Bonn, Germany
| | - Katja Blumenstock
- Institute of Clinical Chemistry and Clinical Pharmacology, University of Bonn and University Hospital Bonn, 53127 Bonn, Germany
| | - Jana Liebing
- Institute of Experimental Oncology, University of Bonn and University Hospital Bonn, 53127 Bonn, Germany
| | - Mikołaj Słabicki
- Broad Institute of MIT and Harvard, Massachusetts Institute of Technology, Cambridge, MA 02139, USA.,Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA 02215, USA.,Division of Translational Medical Oncology, German Cancer Research Center (DKFZ) and National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
| | - Amir Ben-Shmuel
- Department of Infectious Diseases, Israel Institute for Biological Research, Ness Ziona, Israel
| | - Ofir Israeli
- Department of Biochemistry and Molecular Genetics, Israel Institute for Biological Research, Ness Ziona, Israel
| | - Shay Weiss
- Department of Infectious Diseases, Israel Institute for Biological Research, Ness Ziona, Israel
| | - Thomas S. Ebert
- Institute of Clinical Chemistry and Clinical Pharmacology, University of Bonn and University Hospital Bonn, 53127 Bonn, Germany
| | - Nir Paran
- Department of Infectious Diseases, Israel Institute for Biological Research, Ness Ziona, Israel
| | - Wibke Rüdiger
- Institute of Clinical Chemistry and Clinical Pharmacology, University of Bonn and University Hospital Bonn, 53127 Bonn, Germany
| | - Gero Wilbring
- Institute of Hygiene and Public Health, University of Bonn and University Hospital Bonn, 53127 Bonn, Germany
| | - David Feldman
- Department of Biochemistry and Institute for Protein Design, University of Washington, Seattle, WA 98195, USA
| | - Bärbel Lippke
- Institute of Human Genetics, University of Bonn and University Hospital Bonn, 53127 Bonn, Germany
| | - Nina Ishorst
- Institute of Human Genetics, University of Bonn and University Hospital Bonn, 53127 Bonn, Germany.,Institute of Anatomy, Division of Neuroanatomy, University of Bonn and University Hospital Bonn, 53127 Bonn, Germany
| | - Lara M. Hochfeld
- Institute of Human Genetics, University of Bonn and University Hospital Bonn, 53127 Bonn, Germany
| | - Eva C. Beins
- Institute of Human Genetics, University of Bonn and University Hospital Bonn, 53127 Bonn, Germany
| | - Ines H. Kaltheuner
- Institute of Structural Biology, University of Bonn and University Hospital Bonn, 53127 Bonn, Germany
| | - Maximilian Schmitz
- Institute of Structural Biology, University of Bonn and University Hospital Bonn, 53127 Bonn, Germany
| | - Aliona Wöhler
- Department of General, Visceral and Thoracic Surgery, Bundeswehr Central Hospital Koblenz, Koblenz, Germany
| | - Manuel Döhla
- Institute of Hygiene and Public Health, University of Bonn and University Hospital Bonn, 53127 Bonn, Germany.,Department of Microbiology and Hospital Hygiene, Bundeswehr Central Hospital Koblenz, Koblenz, Germany
| | - Esther Sib
- Institute of Hygiene and Public Health, University of Bonn and University Hospital Bonn, 53127 Bonn, Germany
| | - Marius Jentzsch
- Institute of Clinical Chemistry and Clinical Pharmacology, University of Bonn and University Hospital Bonn, 53127 Bonn, Germany
| | - Jacob D. Borrajo
- Broad Institute of MIT and Harvard, Massachusetts Institute of Technology, Cambridge, MA 02139, USA.,Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Jonathan Strecker
- Broad Institute of MIT and Harvard, Massachusetts Institute of Technology, Cambridge, MA 02139, USA.,McGovern Institute for Brain Research, Massachusetts Institute of Technology, Cambridge, MA 02139, USA.,Department of Brain and Cognitive Sciences, Massachusetts Institute of Technology, Cambridge, MA 02139, USA.,Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Julia Reinhardt
- Institute of Experimental Oncology, University of Bonn and University Hospital Bonn, 53127 Bonn, Germany
| | - Brian Cleary
- Broad Institute of MIT and Harvard, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Matthias Geyer
- Institute of Structural Biology, University of Bonn and University Hospital Bonn, 53127 Bonn, Germany
| | - Michael Hölzel
- Institute of Experimental Oncology, University of Bonn and University Hospital Bonn, 53127 Bonn, Germany
| | - Rhiannon Macrae
- Broad Institute of MIT and Harvard, Massachusetts Institute of Technology, Cambridge, MA 02139, USA.,McGovern Institute for Brain Research, Massachusetts Institute of Technology, Cambridge, MA 02139, USA.,Department of Brain and Cognitive Sciences, Massachusetts Institute of Technology, Cambridge, MA 02139, USA.,Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Markus M. Nöthen
- Institute of Human Genetics, University of Bonn and University Hospital Bonn, 53127 Bonn, Germany
| | - Per Hoffmann
- Institute of Human Genetics, University of Bonn and University Hospital Bonn, 53127 Bonn, Germany.,Genomics Research Group, Department of Biomedicine, University of Basel, Switzerland
| | - Martin Exner
- Institute of Hygiene and Public Health, University of Bonn and University Hospital Bonn, 53127 Bonn, Germany
| | - Aviv Regev
- Broad Institute of MIT and Harvard, Massachusetts Institute of Technology, Cambridge, MA 02139, USA.,Department of Biology, Massachusetts Institute of Technology, Cambridge, MA 02139, USA.,Klarman Cell Observatory, Massachusetts Institute of Technology, Cambridge, MA 02139, USA.,Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA 02139, USA.,Howard Hughes Medical Institute, Cambridge, MA 02139, USA.,Current address: Genentech, 1 DNA Way, South San Francisco, CA, USA
| | - Feng Zhang
- Broad Institute of MIT and Harvard, Massachusetts Institute of Technology, Cambridge, MA 02139, USA.,McGovern Institute for Brain Research, Massachusetts Institute of Technology, Cambridge, MA 02139, USA.,Department of Brain and Cognitive Sciences, Massachusetts Institute of Technology, Cambridge, MA 02139, USA.,Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA.,Howard Hughes Medical Institute, Cambridge, MA 02139, USA
| | - Jonathan L. Schmid-Burgk
- Broad Institute of MIT and Harvard, Massachusetts Institute of Technology, Cambridge, MA 02139, USA.,McGovern Institute for Brain Research, Massachusetts Institute of Technology, Cambridge, MA 02139, USA.,Department of Brain and Cognitive Sciences, Massachusetts Institute of Technology, Cambridge, MA 02139, USA.,Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA.,Institute of Clinical Chemistry and Clinical Pharmacology, University of Bonn and University Hospital Bonn, 53127 Bonn, Germany,Correspondence to:
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Abstract
SummaryThe clinical features and symptoms of postpartum psychoses are presented in relation to the classification according to the Research Diagnostic Criteria (RDC) and the concept of “puerperal psychosis”. A number of symptoms, ie confusional symptoms, depersonalization, misrecognitions and the “kaleidoscopic” picture are shown to be prominent features. In schizoaffective disorder and unspecified functional psychosis a higher frequency of confusional symptoms, misrecognitions, thematic delusions and a “kaleidoscopic” course of illness was found compared to schizophrenia, mania or depression. The findings of this study support a special status for postpartum psychosis and suggest a link with the concept of cycloid psychosis. In the management of postpartum mental disorder the risk of child-directed aggression, suicide and sudden relapses into psychosis requires special attention.
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Abstract
Cancer journeys, encompassing patients' cancer experiences through survivorship, are complex and diverse. Individuals must cope with numerous physical and emotional challenges, balancing clinical tasks alongside responsibilities of daily life. Understanding the breadth of factors that contribute to a patient's cancer experience presents a critical challenge in developing holistic patient-centered technology. To further our understanding of the cancer journey, we conducted focus groups and interviews with 31 breast cancer patients. We present a cancer journey framework depicting the responsibilities, challenges, and personal impacts patients face while transitioning from diagnosis through post-treatment survivorship. Through this work, we aim to aid the development of health tools that consider a patient's cancer journey and health needs more broadly, supporting patient's health management alongside the complexities and priorities of daily life.
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Affiliation(s)
- M L Jacobs
- College of Computing, Georgia Institute of Technology, Atlanta, GA 30308 USA
| | - J Clawson
- College of Computing, Georgia Institute of Technology, Atlanta, GA 30308 USA
| | - E D Mynatt
- College of Computing, Georgia Institute of Technology, Atlanta, GA 30308 USA
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Abstract
Among factors contributing to morbidity and failure of the Fontan circulation is the group of events referred to as thromboembolic complications. These events have been variously attributed to low flow states, stasis in the venous pathways, right-to-left shunts, blind cul-de-sacs, prosthetic material, atrial arrhythmias, and hypercoagulable states. Numerous investigations, most retrospective, have been undertaken to characterize thromboembolic events; describe the frequency and circumstances of these occurrences; and relate the risk of these events to patient, surgical, hemodynamic, and hematologic factors. Practices vary widely with respect to strategies of prophylactic anticoagulation in the hopes of minimizing the occurrence and morbidity of thromboembolism after Fontan operations. Review of the literature suggests that the factors associated with thromboembolic events after Fontan operations likely represent a complex field of biologic factors with multiple interactions. It is unlikely that a single agent will represent the solution to this complex problem.
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Affiliation(s)
- M L Jacobs
- Section of Cardiothoracic Surgery, St. Christopher's Hospital for Children, Erie Avenue at Front Street, Philadelphia, PA 19134, USA.
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6
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Pourmoghadam KK, Moore JW, Khan M, Geary EM, Madan N, Wolfson BJ, de Chadarevian JP, Holsclaw DS, Jacobs ML. Congenital unilateral pulmonary venous atresia: definitive diagnosis and treatment. Pediatr Cardiol 2003; 24:73-9. [PMID: 12360396 DOI: 10.1007/s00246-002-0220-6] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.2] [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] [Received: 10/26/2001] [Accepted: 03/12/2002] [Indexed: 11/25/2022]
Abstract
Three cases of unilateral right-sided pulmonary venous atresia were evaluated over an 18-year period. These bring the total number of cases to 25 in the literature. The clinical presentation of all these patients was similar and consisted of recurrent pulmonary infections, asthma-like symptoms, and exercise intolerance. The patients presented in 1982 (patient 1, a 12-year-old boy), 1994 (patient 2, a 9-year-old girl), and 1999 (patient 3, a 13-year-old boy). All patients were evaluated with a chest roentgenogram, and patients 1 and 2 had a ventilation and perfusion scan. Patients 1 and 3 also had cardiac catheterization and pulmonary angiography. Patient 2 had a magnetic resonance imaging study of the chest. Only patient 3 had wedge pulmonary angiography. Although a rare congenital defect, this diagnosis should be strongly suspected based on the typical clinical presentation and the preliminary studies, such as the chest roentgenogram and ventilation and perfusion scan. However, for definitive diagnosis, cardiac catheterization with wedge pulmonary angiography is necessary. Anastomosis of the atretic pulmonary veins to the left atrium is a theoretical consideration. However, this may not be feasible due to pulmonary venous anatomy or significant pulmonary dysfunction with pulmonary vascular changes. In these circumstances, we recommend performing pneumonectomy to remove the nidus for repeated bouts of pulmonary infections, to eliminate the left-to-right shunt, and to eliminate the dead space contributing to exercise intolerance.
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Affiliation(s)
- K K Pourmoghadam
- Department of Surgery, St Christopher's Hospital for Children, Erie Avenue at Front Street, Philadelphia, PA 19134, USA
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8
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Clancy RR, McGaurn SA, Goin JE, Hirtz DG, Norwood WI, Gaynor JW, Jacobs ML, Wernovsky G, Mahle WT, Murphy JD, Nicolson SC, Steven JM, Spray TL. Allopurinol neurocardiac protection trial in infants undergoing heart surgery using deep hypothermic circulatory arrest. Pediatrics 2001; 108:61-70. [PMID: 11433055 DOI: 10.1542/peds.108.1.61] [Citation(s) in RCA: 101] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE This pharmacologic protection trial was conducted to test the hypothesis that allopurinol, a scavenger and inhibitor of oxygen free radical production, could reduce death, seizures, coma, and cardiac events in infants who underwent heart surgery using deep hypothermic circulatory arrest (DHCA). DESIGN This was a single center, randomized, placebo-controlled, blinded trial of allopurinol in infant heart surgery using DHCA. Enrolled infants were stratified as having hypoplastic left heart syndrome (HLHS) and all other forms of congenital heart disease (non-HLHS). Drug was administered before, during, and after surgery. Adverse events and the clinical efficacy endpoints death, seizures, coma, and cardiac events were monitored until infants were discharged from the intensive care unit or 6 weeks, whichever came first. RESULTS Between July 1992 and September 1997, 350 infants were enrolled and 348 subsequently randomized. A total of 318 infants (131 HLHS and 187 non-HLHS) underwent heart surgery using DHCA. There was a nonsignificant treatment effect for the primary efficacy endpoint analysis (death, seizures, and coma), which was consistent over the 2 strata. The addition of cardiac events to the primary endpoint resulted in a lack of consistency of treatment effect over strata, with the allopurinol treatment group experiencing fewer events (38% vs 60%) in the entire HLHS stratum, compared with the non-HLHS stratum (30% vs 27%). In HLHS surgical survivors, 40 of 47 (85%) allopurinol-treated infants did not experience any endpoint event, compared with 27 of 49 (55%) controls. There were fewer seizures-only and cardiac-only events in the allopurinol versus placebo groups. Allopurinol did not reduce efficacy endpoint events in non-HLHS infants. Treated and control infants did not differ in adverse events. CONCLUSIONS Allopurinol provided significant neurocardiac protection in higher-risk HLHS infants who underwent cardiac surgery using DHCA. No benefits were demonstrated in lower risk, non-HLHS infants, and no significant adverse events were associated with allopurinol treatment.congenital heart defects, hypoplastic left heart syndrome, induced hypothermia, ischemia-reperfusion injury, neuroprotective agents, allopurinol, xanthine oxidase, free radicals, seizures, coma.
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Affiliation(s)
- R R Clancy
- Division of Neurology, Pennsylvania, USA.
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9
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Dandolu BR, Jacobs ML. Recent advances in reconstructive surgical management of hypoplastic left heart syndrome. Adv Card Surg 2001; 13:21-60. [PMID: 11209656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/16/2023]
Affiliation(s)
- B R Dandolu
- MCP Hahnemann University School of Medicine, Philadelphia, PA, USA
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Abstract
AIM To investigate the late sequellae of necrotizing pancreatitis on the endocrine function of the pancreas. PATIENTS AND METHODS Twenty patients, 15 men (mean +/- SEM age 52.2+/-2.6 years and BMI 26.8+/-0.8 kg/m2) and 5 women (age 51.0+/-7.6 years and BMI 26.7+/-0.8 kg/m2) were submitted to a glucagon stimulation test 63 (range 8-136) months after an attack of pancreatitis. All nondiabetic patients (n = 15) were also submitted to an oral glucose tolerance test. For comparison, 16 healthy volunteers, 8 men (age 56.0+/-0.9 years and BMI 26.3+/-0.4 kg/m2) and 8 women (age 50.5+/-1.0 years and BMI 28.2+/-0.6 kg/m2), were also studied. RESULTS Five patients (25%) had diabetes mellitus and needed insulin treatment, 6 patients (30%) had an impaired glucose tolerance (IGT). Nondiabetic patients (IGT included) had a significantly higher basal insulin level (15.8+/-1.9 vs. 10.9 +/-2.2 mU/l, p < 0.05) and a lower glucose/insulin ratio (p < 0.05) compared with controls. The serum concentrations of insulin and C peptide, after stimulation with glucagon, calculated as peak value, maximal increment and as area under the curve were not significantly different in the nondiabetic patients compared to controls. The subgroup of IGT patients had a significantly higher basal C peptide (p < 0.05) and a reduced maximal increment (p < 0.05). CONCLUSIONS After nonresectional therapy for necrotizing pancreatitis, there is a high prevalence of disturbances in glucose metabolism. Patients with IGT have signs of both loss of beta-cell function and insulin resistance.
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Affiliation(s)
- H C Buscher
- Department of Surgery, University Hospital St. Radboud, Nijmegen, The Netherlands
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12
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Abstract
Hypoplastic left heart syndrome (HLHS) encompasses a spectrum of structural cardiac malformations that are characterized by severe underdevelopment of the structures in the left heart-aorta complex, including the left ventricular cavity and mass. The severe end of the spectrum consists of aortic atresia and mitral atresia with a nonexistent left ventricle, whereas at the mild end patients have aortic valve and mitral valve hypoplasia without intrinsic valve stenosis, and milder degrees of left ventricular hypoplasia, recently described as hypoplastic left heart complex (HLHC). Although the overwhelming majority of the patients can only have a univentricular repair, a small minority of patients with HLHS, particularly those that are described as having HLHC, may be candidates for biventricular repair. In this paper, the extant nomenclature for HLHS is reviewed for the purpose of establishing a unified reporting system. The subject was debated and reviewed by members of the STS-Congenital Heart Surgery Nomenclature and Database Committee and representatives from the European Association for Cardiothoracic Surgery. Efforts were made to include all relevant nomenclature categories using synonyms where appropriate. A comprehensive database set is presented, which is based on a hierarchical scheme. Data are entered at various levels of complexity and detail that can be determined by the clinician. These data can lay the foundation for comprehensive risk stratification analyses. A minimum database set is also presented which will allow for data sharing, and would lend itself to basic interpretation of trends. Outcome tables relating diagnoses, procedures, and various risk factors are presented.
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Affiliation(s)
- C I Tchervenkov
- Division of Cardiovascular Surgery, The Montreal Children's Hospital, McGill University, Québec, Canada.
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13
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Abstract
The extant nomenclature for truncus arteriosus (TA) is reviewed for the purpose of establishing a unified reporting system. The subject was debated and reviewed by members of the STS-Congenital Heart Surgery Database Committee and representatives from the European Association for Cardiothoracic Surgery. All efforts were made to include all relevant nomenclature categories using synonyms where appropriate. A modified Van Praagh (VP) classification is proposed involving three main categories of TA: TA with confluent or near confluent pulmonary arteries (large aorta type, VP A1, A2), TA with absence of one pulmonary artery (VP A3), and TA with interrupted aortic arch or coarctation (large pulmonary artery type, VP A4). A comprehensive database set is presented that is based on a hierarchical scheme. Data are entered at various levels of complexity and detail that can be determined by the clinician. These data can lay the foundation for comprehensive risk stratification analyses. A minimum database set is also presented that will allow for data sharing and would lend itself to basic interpretation of trends. Outcome tables relating diagnoses, procedures, and various risk factors are presented.
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Affiliation(s)
- M L Jacobs
- Section of Cardiothoracic Surgery, St. Christopher's Hospital for Children, Philadelphia, Pennsylvania 19134-1095, USA
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Walters HL, Mavroudis C, Tchervenkov CI, Jacobs JP, Lacour-Gayet F, Jacobs ML. Congenital Heart Surgery Nomenclature and Database Project: double outlet right ventricle. Ann Thorac Surg 2000; 69:S249-63. [PMID: 10798433 DOI: 10.1016/s0003-4975(99)01247-3] [Citation(s) in RCA: 97] [Impact Index Per Article: 4.0] [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: 02/06/2023]
Abstract
Double outlet right ventricle (DORV) is a type of ventriculoarterial connection in which both great vessels arise entirely or predominantly from the right ventricle. Although the presence of aortic-mitral discontinuity and bilateral coni are important descriptors, they should not serve as absolute prerequisites for the diagnosis of DORV. The morphology of DORV is encompassed by a careful description of the ventricular septal defect (VSD) with its relationship to the semilunar valves, the great artery relationships to each other, the coronary artery anatomy, the presence or absence of pulmonary outflow tract obstruction (POTO) and aortic outflow tract obstruction (AOTO), the tricuspid-pulmonary annular distance, and the presence or absence of associated cardiac lesions. The preferred surgical treatment involves the connection of the left ventricle to the systemic circulation by an intraventricular tunnel repair connecting the VSD to the systemic semilunar valve. This ideal surgical therapy is not always possible due to the presence of confounding anatomical barriers. A multitude of alternative surgical procedures has been devised to accommodate these more complex situations. A framework for the development of the DORV module for a pediatric cardiac surgical database is proposed.
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Affiliation(s)
- H L Walters
- Department of Surgery, Wayne State University School of Medicine, Children's Hospital of Michigan, Detroit 48201, USA.
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15
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Abstract
The extant nomenclature for tetralogy of Fallot (TOF) is reviewed for the purpose of establishing a unified reporting system. The subject was debated and reviewed by members of the STS-Congenital Heart Surgery Database Committee and representatives from the European Association for Cardiothoracic Surgery. All efforts were made to include all relevant nomenclature categories using synonyms where appropriate. The general categories of TOF are: classic TOF with varying degrees of pulmonary stenosis, TOF with common atrioventricular canal defect, and TOF with absent pulmonary valve. Although centers may choose to code a fourth general category, TOF with pulmonary atresia, this lesion will be grouped with pulmonary atresia-ventricular septal defect for multi-institutional analysis. A comprehensive database set is presented that is based on a hierarchical scheme. Data are entered at various levels of complexity and detail that can be determined by the clinician. These data can lay the foundation for comprehensive risk stratification analyses. A minimum database set is also presented that will allow for data sharing and would lend itself to basic interpretation of trends. Outcome tables relating diagnoses, procedures, and various risk factors are presented.
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Affiliation(s)
- M L Jacobs
- Section of Cardiothoracic Surgery, St. Christopher's Hospital for Children, Philadelphia, Pennsylvania 19134-1095, USA
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16
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Abstract
The extant nomenclature for single ventricle (SV) hearts is reviewed for the purpose of establishing a unified reporting system. The subject was debated and reviewed by members of the STS-Congenital Heart Surgery Database Committee and representatives from the European Association for Cardiothoracic Surgery. Efforts were made to include all relevant nomenclature categories using synonyms where appropriate. Although many issues regarding single ventricle or univentricular hearts remain unresolved among anatomists and pathologists, a classification is proposed that is relevant to surgical therapy. A comprehensive database set is presented, which is based on a hierarchical scheme. Data are entered at various levels of complexity and detail, which can be determined by the clinician. These data can lay the foundation for comprehensive risk stratification analyses. A minimum data set is also presented that will allow for data sharing and would lend itself to basic interpretation of trends. Outcome tables relating diagnoses, procedures, and various risk factors are presented.
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Affiliation(s)
- M L Jacobs
- Section of Cardiothoracic Surgery, St. Christopher's Hospital for Children, Philadelphia, Pennsylvania 19134-1095, USA
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17
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Clancy RR, McGaurn SA, Wernovsky G, Spray TL, Norwood WI, Jacobs ML, Murphy JD, Gaynor JW, Goin JE. Preoperative risk-of-death prediction model in heart surgery with deep hypothermic circulatory arrest in the neonate. J Thorac Cardiovasc Surg 2000; 119:347-57. [PMID: 10649211 DOI: 10.1016/s0022-5223(00)70191-7] [Citation(s) in RCA: 111] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Our goal was to generate a preoperative risk-of-death prediction model in selected neonates with congenital heart disease undergoing surgery with deep hypothermic circulatory arrest. METHODS We completed a single-center, prospective, randomized, double-blind, placebo- controlled neuroprotection trial in selected neonates with congenital heart disease requiring operations for which deep hypothermic circulatory arrest was used. An extensive database was generated that included preoperative, intraoperative, and postoperative variables. Variables (delivery, maternal, and infant related) were evaluated to produce a preoperative risk-of-death prediction model by means of logistic regression. An operative risk-of-death prediction model including duration of deep hypothermic circulatory arrest was also generated. RESULTS Between July 1992 and September 1997, 350 (74%) of 473 eligible infants were enrolled with 318 undergoing deep hypothermic circulatory arrest. The mortality was 52 of 318 (16.4%), unaffected by investigational drug. The resulting preoperative risk model contained 4 variables: (1) cardiac anatomy (two-ventricle vs single ventricle surgery, with/without arch obstruction), (2) 1-minute Apgar score (</=5 vs >5), (3) presence of genetic syndrome, and (4) age at hospital admission for surgery (</=5 or >5 days). Mortality for two-ventricle repair was 3.2% (4/130). Mortality for single ventricle palliation was 25.5% (48/188) and was significantly influenced by Apgar score, genetic diagnosis, and admission age. The preoperative model had a prediction accuracy of 80%. The operative risk model included duration of deep hypothermic circulatory arrest, which significantly (P =.03) increased risk of death, with a prediction accuracy of 82%. CONCLUSIONS In this selected population, postoperative mortality risk is significantly affected by preoperative conditions. Identification of infants with varying mortality risks may affect family counseling, therapeutic intervention, and risk stratification for future study designs.
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Affiliation(s)
- R R Clancy
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA.
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18
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Abstract
We report the case of a child with hypoplastic left heart syndrome who developed pulmonary arteriovenous (AV) malformations after superior cavopulmonary anastomoses. Resolution of the pulmonary AV malformations occurred following a completion Fontan procedure. This phenomenon has been reported previously, but only in patients with heterotaxy and polysplenia.
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Affiliation(s)
- M L Jacobs
- Section of Cardiothoracic Surgery, St. Christopher's Hospital for Children, Philadelphia, Pennsylvania 19134-1095, USA
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19
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Donofrio MT, Clark BJ, Ramaciotti C, Jacobs ML, Fellows KE, Weinberg PM, Fogel MA. Regional wall motion and strain of transplanted hearts in pediatric patients using magnetic resonance tagging. Am J Physiol 1999; 277:R1481-7. [PMID: 10564222 DOI: 10.1152/ajpregu.1999.277.5.r1481] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Abnormal ventricular systolic torsion is present during histological rejection in adult cardiac transplant patients. Because biomechanical properties of transplanted hearts in the baseline state have not been studied in children, pediatric patients were evaluated to quantify ventricular wall motion and strain. Eight transplant studies and eight normal controls were evaluated. Magnetic resonance tagging was performed to determine radial shortening, twist, and strain in four ventricular anatomic areas at two short-axis levels. Controls had counterclockwise twist. Six transplant studies had clockwise twist, six had akinetic regions, and all had regions of no twist. One demonstrated paradoxical motion of the septum. A comparison between transplant patients and controls revealed strain to be similar in all regions except one (superior wall at the atrioventricular valve level) and strain distribution to be different only in two of eight regions. Pediatric transplant patients demonstrate regional wall motion abnormalities in the absence of rejection. Compared with normal controls, the transplanted left ventricle maintains normal strain in the presence of abnormal twist. This may be a compensatory mechanism and have clinical implications.
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Affiliation(s)
- M T Donofrio
- Division of Cardiology, Department of Pediatrics, The University of Pennsylvania Hospital, Philadelphia, Pennsylvania 19104, USA.
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20
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Abstract
We performed a combined atrial (Mustard) and ventricular (Rastelli) repair on a previously palliated patient with situs inversus, atrioventricular discordance, ventricular septal defect, and pulmonary atresia. The suitability and durability of this operative strategy is supported by the satisfactory hemodynamic and functional status of the patient 10 years later.
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Affiliation(s)
- M L Jacobs
- Department of Surgery, Deborah Heart and Lung Center, Browns Mills, New Jersey, USA
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21
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Orwin RG, Garrison-Mogren R, Jacobs ML, Sonnefeld LJ. Retention of homeless clients in substance abuse treatment. Findings from the National Institute on Alcohol Abuse and Alcoholism Cooperative Agreement Program. J Subst Abuse Treat 1999; 17:45-66. [PMID: 10435252 DOI: 10.1016/s0740-5472(98)00046-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.3] [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: 11/21/2022]
Abstract
Retaining clients in treatment who are homeless presents a particular challenge for substance abuse treatment providers. A National Institute on Alcohol Abuse and Alcoholism Cooperative Agreement Program offered the first opportunity to systematically study program retention in a multisite study of interventions for homeless persons with alcohol and other drug problems. This article presents results from analyses conducted across 15 interventions implemented at 8 Cooperative Agreement sites. Both qualitative and quantitative data were collected and analyzed. Key findings were that (a) retention problems with homeless clients are as or more pervasive than in the general addicted population; (b) the provision of housing increases retention, but the increases tend to be nullified when the housing is bundled with high-intensity services; (c) homeless clients leave treatment programs for a multitude of reasons; and (d) midcourse corrections to increase retention are frequently successful. The discussion focuses on service components related to retention, the importance of attending to phase transitions, and the importance of being programmatically responsive when serving this population.
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Affiliation(s)
- R G Orwin
- R.O.W. Sciences, Inc., Rockville, MD, USA.
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22
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Abstract
A new technique to repair tetralogy of Fallot with an anomalous coronary artery crossing the right ventricular outflow tract is described, together with intermediate term follow-up. Using a pedicled flap of the anterior pulmonary artery wall as the floor, and a vascular or prosthetic patch as the roof, a composite conduit with the potential for growth is constructed. Together with the native outflow tract, this provides unobstructed egress from the right ventricle to the branch pulmonary arteries. Since 1990, 4 infants aged 2-weeks to 6-months have undergone primary repair using this technique. Intermediate term follow-up shows adequate durability of the repair.
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Affiliation(s)
- B R Dandolu
- Division of Cardiothoracic Surgery, Deborah Heart and Lung Center, Browns Mills, New Jersey, USA
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23
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Cohen MI, Wernovsky G, Vetter VL, Wieand TS, Gaynor JW, Jacobs ML, Spray TL, Rhodes LA. Sinus node function after a systematically staged Fontan procedure. Circulation 1998; 98:II352-8; discussion II358-9. [PMID: 9852926] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
BACKGROUND Sinus node dysfunction has been previously reported to occur in 13% to 16% of patients after the Fontan operation. Although there is concern that an intermediate cavopulmonary connection may increase the risk of sinus node dysfunction, previous studies have not reported on patients routinely staged to a Fontan operation. This study sought to determine the early and late incidences of sinus node dysfunction in patients systematically and uniformly staged to a Fontan operation after a prior hemi-Fontan. METHODS AND RESULTS To determine the early incidence of sinus node dysfunction, hospital records and perioperative ECGs were reviewed in all 287 patients having had a staged Fontan operation between January 1990 and December 1995. A cross-sectional analysis was performed on 220 of 239 surviving patients (92%) to determine the late incidence of sinus node dysfunction. Sinus node dysfunction was present in 7% of the patients before and in 15% after the hemi-Fontan. Although most patients (81%) regained normal sinus node function between the 2 stages, 23% had sinus node dysfunction in the early postoperative period after the Fontan. Of the 95 patients followed for > 4 years after the Fontan operation, 44% had sinus node dysfunction. However, at a mean follow-up of 3.5 +/- 1.7 years, only 16 patients (6.7%) had received a pacemaker and only 10 (4.1%) had documented atrial flutter. CONCLUSIONS Perioperative sinus node dysfunction is common after both the hemi-Fontan and the Fontan procedures. Although many patients regain sinus node function between the 2 stages, late sinus node dysfunction is common and more likely to occur in patients with early sinus node dysfunction and those with longer follow-up.
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Affiliation(s)
- M I Cohen
- Division of Cardiology, Children's Hospital of Philadelphia, PA 19104, USA.
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24
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Jacobs ML, Blackstone EH, Bailey LL. Intermediate survival in neonates with aortic atresia: a multi-institutional study. The Congenital Heart Surgeons Society. J Thorac Cardiovasc Surg 1998; 116:417-31. [PMID: 9731784 DOI: 10.1016/s0022-5223(98)70008-x] [Citation(s) in RCA: 100] [Impact Index Per Article: 3.8] [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: 02/08/2023]
Abstract
OBJECTIVE Controversy persists with regard to the treatment of patients with aortic atresia. Staged reconstructive operations and primary transplantation have been advocated as treatment strategies, but in many instances no treatment is undertaken. A multi-institutional study was undertaken for the purpose of characterizing this challenging patient group, comparing the prevalence and outcomes of the various treatment strategies, and identifying potential predictors of success or failure with each. METHODS AND RESULTS A total of 323 neonates with aortic atresia were entered into a 21-institution prospective, nonrandomized study between January 1, 1994, and January 1, 1997. Three protocols were used, nonexclusively in many institutions: (1) staged reconstructive surgery with initial palliation by a Norwood procedure and eventual Fontan operation, (2) heart transplantation as initial definitive therapy, and (3) nonsurgical management. Analysis was based on initial protocol assignment: staged reconstructive surgery in 253 patients, heart transplantation in 49 patients, and nonsurgical management in 21 patients. For all patients initially entered into the 2 surgical treatment protocols, survival at 1, 3, 12, 24, and 36 months after entry was 67%, 59%, 52%, 51%, and 50%, respectively. A multivariable analysis found incremental risk factors for death at any time after entry to be lower birth weight (P=.04), associated noncardiac anomaly (P=.007), and entry into the nonsurgical protocol (P < .0001) or the staged reconstructive surgery protocol (P=.03). Four institutions had higher survival statistics; 2 used a heart transplantation protocol and 2 used a staged reconstructive surgery protocol. For the 113 patients treated at these 4 institutions, survival at 1, 3, 12, 24, and 36 months after entry was 77%, 70%, 64%, 62%, and 61%, respectively. Survival among the 4 institutions was similar (P=0.1). CONCLUSIONS Among patients with aortic atresia, other features of cardiac structure including aortic size, degree of left ventricular hypoplasia, and degree of mitral hypoplasia or atresia are not predictive of survival from 2 surgical protocols. The highest survival was achieved with either treatment strategy at institutions strongly committed to the use of one or the other surgical management protocol.
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Affiliation(s)
- M L Jacobs
- Department of Surgery, Deborah Heart and Lung Center, Browns Mills, NJ 08015, USA
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25
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Abstract
BACKGROUND Superior cavopulmonary connection reduces the volume work of the single ventricle. METHODS To determine the effects of superior cavopulmonary connection on preload, wall stress (or afterload), and systolic ventricular function, we studied 9 patients before and after operation, and at hospital discharge. Using echocardiography, preload was estimated by the ventricular end-diastolic area, and wall stress was calculated at end-systole and peak-systole. Ventricular function was represented by rate-corrected velocity of circumferential fiber shortening and fractional area change divided by rate-corrected ejection time. RESULTS End-diastolic area and wall stress decreased postoperatively. Ventricular wall thickness increased with a concomitant decrease in cavity area. There was no change in mean blood pressure or heart rate or in rate-corrected velocity of circumferential fiber shortening or fractional area change divided by rate-corrected ejection time. These findings persisted at hospital discharge. CONCLUSIONS In single ventricles, superior cavopulmonary correction results in an immediate decrease in preload and afterload. The decrease in afterload results primarily from alterations in ventricular geometry. Although no improvement in systolic function was noted, diminished work related to the reduction in loading conditions may have beneficial long-term effects on preserving myocardial performance.
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Affiliation(s)
- M T Donofrio
- Department of Pediatrics, The Children's Hospital of Philadelphia, Pennsylvania, USA.
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26
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Abstract
A rare case of truncus arteriosus associated with mitral valve atresia, hypoplastic left ventricle, and intact ventricular septum is reported. Successful medical management and surgical palliation of this defect is described. The possible embryology, pertinent hemodynamics, and clinical concerns with this unusual case are discussed.
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Affiliation(s)
- E C Michelfelder
- Department of Pediatric Cardiology, Deborah Heart and Lung Center, Browns Mills, New Jersey 08055, USA
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27
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Abstract
BACKGROUND This study examined the results of a Fontan operation for patients with acquired atresia of one main branch pulmonary artery. METHODS The data for 7 patients identified as having a hypoplastic left pulmonary artery discontinuous from the right pulmonary artery were compared with those for 65 patients with continuous pulmonary arteries who consecutively underwent a completion Fontan procedure. RESULTS No significant differences were found preoperatively with respect to right atrial pressure, aortic saturation, ventricular end-diastolic pressure, pulmonary artery pressure, pulmonary blood flow, or pulmonary vascular resistance. In the first 24 postoperative hours, there were no significant differences in heart rate, urine output, systemic venous pressure, or pulmonary venous pressure. Also, data regarding hospitalization length, effusions, and mortality were similar between the two groups. Postoperative systemic arterial saturation was lower in the one-lung group. There were no early postoperative deaths in the one-lung group, and 5 of the 7 patients are long-term survivors. CONCLUSIONS A completion Fontan procedure can be successfully performed in patients with a hypoplastic and discontinuous left pulmonary artery, although postoperative systemic arterial saturation is not as high as in patients with continuous pulmonary arteries.
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Affiliation(s)
- C H Zachary
- Division of Pediatric Cardiology, The Children's Hospital of Philadelphia, Pennsylvania, USA
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28
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Rychik J, Fogel MA, Donofrio MT, Goldmuntz E, Cohen MS, Spray TL, Jacobs ML. Comparison of patterns of pulmonary venous blood flow in the functional single ventricle heart after operative aortopulmonary shunt versus superior cavopulmonary shunt. Am J Cardiol 1997; 80:922-6. [PMID: 9382009 DOI: 10.1016/s0002-9149(97)00546-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.9] [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: 02/05/2023]
Abstract
In this study we investigated the patterns of pulmonary venous flow in children with functional single ventricles to obtain a better understanding of the determinants of transpulmonary blood flow. Sixty-eight patients with functional single ventricles and aortopulmonary shunt (n = 34, group I), or superior cavopulmonary connection (n = 34, group II) underwent transesophageal Doppler echocardiographic assessment of flow in the left upper pulmonary vein before undergoing the next stage of surgery. Twelve patients from group II also underwent simultaneous evaluation of superior vena caval flow. Biphasic forward pulmonary venous flow was noted in 62 patients in sinus rhythm (S wave in systole, D wave in diastole); in 6 patients with junctional rhythm, significant early systolic reversal of flow was present. Both the S- and D-wave velocity-time integrals (VTI) were greater in group I than in group II (S(VTI) 9.9 +/- 4.2 vs 8.0 +/- 2.6, p = 0.02; D(VTI) 8.0 +/- 3.5 vs 4.2 +/- 2.6, p <0.001). In both groups, pulmonary venous flow was predominantly systolic; however, the proportion of flow during ventricular systole was significantly greater in group II than in group I (S(VTI)/D(VTI) group II: 2.4 +/- 1.5; group I 1.4 +/- 0.5, p = 0.001; percent systolic fraction of pulmonary venous flow group II = 67%, group I = 56%, p <0.001). Analysis of superior vena caval flow in group II revealed a single predominant wave with onset at early systole and peak in late systole at a mean of 150 ms after the pulmonary venous S-wave peak. Our data suggest that ventricular systole (i.e., atrial relaxation, atrioventricular valve descent) asserts great influence on transpulmonary blood flow in the functional single ventricle.
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Affiliation(s)
- J Rychik
- Division of Cardiology, The Children's Hospital of Philadelphia,and the University of Pennsylvania School of Medicine, 19104, USA
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29
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Janssen JA, Jacobs ML, Derkx FH, Weber RF, van der Lely AJ, Lamberts SW. Free and total insulin-like growth factor I (IGF-I), IGF-binding protein-1 (IGFBP-1), and IGFBP-3 and their relationships to the presence of diabetic retinopathy and glomerular hyperfiltration in insulin-dependent diabetes mellitus. J Clin Endocrinol Metab 1997; 82:2809-15. [PMID: 9284701 DOI: 10.1210/jcem.82.9.4180] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [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: 02/05/2023]
Abstract
The existing literature on serum insulin-like growth factor I (IGF-I) levels in insulin-dependent diabetes mellitus (IDDM) is conflicting. Free IGF-I may have greater physiological and clinical relevance than total IGF-I. Recently, a validated method has been developed to measure free IGF-I levels in the circulation. Serum free and total IGF-I, IGF-binding protein-1 (IGFBP-1), and IGFBP-3 levels were measured in 56 insulin-treated IDDM patients and 52 healthy sex- and age-matched controls. Diabetic retinopathy was established by direct fundoscopy. In 54 IDDM patients, the glomerular filtration rate (GFR) and effective renal plasma flow were calculated from the clearance rate of [125I]iothalamate and [131I]iodohippurate sodium. Fasting free IGF-I, total IGF-I, and IGFBP-3 levels were significantly lower in IDDM patients than in age- and sex-matched healthy controls (free IGF-I, P < 0.005; total IGF-I, P < 0.001; IGFBP-3, P = 0.001), whereas IGFBP-1 levels were higher (P < 0.001). In IDDM subjects, decreases in free IGF-I, total IGF-I, and IGFBP-3 levels with age were observed (free IGF-I, r = -0.27 and P = 0.05; total IGF-I, r = -0.52 and P < 0.001; IGFBP-3, r = -0.37 and P = 0.005). Free IGF-I was inversely related to fasting glucose in IDDM subjects (r = -0.35; P = 0.01), whereas the relationship between total IGF-I and fasting glucose did not reach significance (r = -0.27; P = 0.06). Age-adjusted free IGF-I levels were significantly higher (P < 0.05) in IDDM subjects with retinopathy than in subjects without retinopathy after adjustment for age. Total IGF-I and IGFBP-3 levels were positively related to GFR (total IGF-I, r = 0.35 and P < 0.05; IGFBP-3, r = 0.28 and P < 0.05). Both of these differences lost significance after adjustment for age. Free IGF-I, total IGF-I, and IGFBP-3 levels were lower and IGFBP-1 levels were higher in insulin-treated IDDM subjects compared to those in age- and sex-matched controls. Free IGF-I, total IGF-I, and IGFBP-3 levels decreased significantly with age in IDDM subjects. Age-adjusted free IGF-I levels in subjects with diabetic retinopathy were higher than those in subjects without diabetic retinopathy. Total IGF-I and IGFBP-3 levels were positively related to GFR in IDDM subjects, but these relations were lost after adjustment for age. Measurement of serum free IGF-I levels in IDDM subjects did not have clear advantages compared to that of total IGF-I, IGFBP-1, and IGFBP-3 levels. Serum IGF-I and IGFBPs reflect their tissue concentrations to a various degree. Consequently, extrapolations concerning the pathogenetic role of the IGF/IGFBP system in the development of diabetic complications at the tissue level remain speculative.
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Affiliation(s)
- J A Janssen
- Department of Internal Medicine, Erasmus University, Rotterdam, The Netherlands
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30
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Abstract
BACKGROUND Significant morbidity after Fontan operation results in either takedown, heart transplantation, or death. Initial creation of a fenestration results in less morbidity and mortality; however, the role of late creation of a fenestration in aiding patients manifesting morbidity after an initial nonfenestrated Fontan operation is unclear. METHODS AND RESULTS We reviewed our experience with late creation of a surgical fenestration in 9 patients (5.2 +/- 3.1 years old) exhibiting chronic effusions (n = 4) or protein-losing enteropathy (PLE) (n = 5) after lateral tunnel-type Fontan operation. Patients with effusions had creation via coronary punch of two or three 3-mm defects; patients with PLE had creation of a large, 5-mm defect. One child with effusions and multisystem organ failure before fenestration died 7 weeks after surgery secondary to low cardiac output; the other 3 had resolution of effusions within 4 to 6 weeks. Of the 5 with PLE, 3 had normalization of serum proteins and resolution of symptoms at 2 to 6 weeks. The 2 failures had arterial saturations > 89% after surgery. Follow-up was from 25 to 30 months. Spontaneous closure of defects occurred in all 3 with effusions. No return of symptoms was noted in 2; however, the third reaccumulated effusions and has undergone refenestration with a large defect. All 3 patients with PLE have remained asymptomatic with patency of the fenestration (4 to 5 mm on echocardiography) and arterial saturation < or = 85% for > 2 years. CONCLUSIONS Late surgical creation of fenestration results in resolution of morbidity after Fontan operation. Improvement is related to the degree of right-to-left shunt created.
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Affiliation(s)
- J Rychik
- Division of Cardiology, Children's Hospital of Philadelphia 19104, USA.
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Jacobs ML, Chandrashekar V, Bartke A, Weber RF. Early effects of streptozotocin-induced diabetes on insulin-like growth factor-I in the kidneys of growth hormone-transgenic and growth hormone-deficient dwarf mice. Exp Nephrol 1997; 5:337-44. [PMID: 9259189] [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] [Grants] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND The renal growth and hyperfiltration observed in humans and animals with early diabetes might be dependent on growth hormone (GH) and insulin-like growth factor (IGF)-I. The aim of this study was to investigate the early changes in kidney IGF-I in experimental diabetes in mice transgenic for bovine GH and in genetically GH-deficient Ames dwarf mice. METHODS At 2, 4 and 8 days after a single intraperitoneal injection with streptozotocin, animals were weighted, bled and killed; plasma was analyzed for glucose and IGF-I. IGF-I levels were determined in tissue from snap-frozen kidney and liver. RESULTS Body weight decreased significantly after the induction of diabetes. Kidney weight increased significantly in GH-transgenic, but not in normal or dwarf mice. Plasma IGF-I was significantly decreased at day 2 in GH-transgenic and normal mice, while liver IGF-I was increased at day 4 in all mice. Kidney IGF-I increased significantly in normal and GH-transgenic mice and was increased more than 3-fold at day 4 in GH-transgenic mice. In dwarf mice, no kidney IGF-I was detectable. CONCLUSION The diabetes-induced increase in renal IGF-I is dependent on the presence of GH. GH deficiency may protect diabetic animals from early changes in the kidney.
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Affiliation(s)
- M L Jacobs
- Department of Internal Medicine, University of Dijkzigt, Rotterdam, The Netherlands
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Donofrio MT, Jacobs ML, Rychik J. Tetralogy of Fallot with absent pulmonary valve: echocardiographic morphometric features of the right-sided structures and their relationship to presentation and outcome. J Am Soc Echocardiogr 1997; 10:556-61. [PMID: 9203496 DOI: 10.1016/s0894-7317(97)70010-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [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: 02/04/2023]
Abstract
Respiratory symptoms in tetralogy of Fallot with absent pulmonary valve are believed to be due to bronchial compression secondary to dilated pulmonary arteries; however, not all patients are born compromised. Echocardiographic morphometry of the right-sided structures was investigated to determine the possible relationship between anatomy and clinical presentation. Twenty-five patients were identified, and 15 had preoperative echocardiograms. Patients were divided into two groups: those with respiratory distress (group I, n = 9) and those without (group II, n = 6). No difference was noted in branch pulmonary artery diameters between groups; however, the pulmonary valve/ aortic valve ratio, reflecting the dimension of the narrowest pathway from the right ventricle, was larger in group I (0.74 +/- 0.15 versus 0.60 +/- 0.07, p < 0.05). Pulmonary valve diameter correlated with main and right pulmonary artery diameters. We conclude that patients with tetralogy of Fallot with absent pulmonary valve and respiratory compromise have a greater pulmonary valve/aortic valve ratio but do not have greater dilatation of proximal branch pulmonary arteries. This suggests that the pathophysiology is not due solely to compression of the bronchi but is also related to the blood flow dynamics in the pulmonary vessels.
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Affiliation(s)
- M T Donofrio
- The Children's Hospital of Philadelphia, Department of Pediatrics, University of Pennsylvania School of Medicine, USA
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Fogel MA, Weinberg PM, Hoydu AK, Hubbard AM, Rychik J, Jacobs ML, Fellows KE, Haselgrove J. Effect of surgical reconstruction on flow profiles in the aorta using magnetic resonance blood tagging. Ann Thorac Surg 1997; 63:1691-700. [PMID: 9205169 DOI: 10.1016/s0003-4975(97)00330-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.6] [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: 02/04/2023]
Abstract
BACKGROUND The aorta that has undergone an aorta-pulmonary artery anastomosis may not exhibit the same velocity profile as the nonreconstructed aorta, whose velocity profile is thought to be uniform across the vessel diameter (plug flow). This may have an impact on fluid dynamics and will alter Doppler flow calculations. Our objective was to determine the impact of surgical reconstruction on the velocity and flow profiles of the reconstructed ascending and descending aorta. METHODS Using a magnetic resonance imaging tagging technique that labels flowing blood (bolus tagging), we studied 22 patients (mean age, 8.6 +/- 4.7 years) who had had a Fontan procedure. A cine sequence labeled the blood and acquired the image after 20 ms in the middle of the ascending aorta and behind the left atrium in the descending aorta. The repetition time was 50 ms. RESULTS The reconstructed ascending aorta displayed a velocity profile skewed anteriorly, whereas in the nonreconstructed aorta, the velocity profile was flat. Reconstructed aortas also displayed flows that were higher anteriorly, took a longer time to reach maximum velocity, and were less like "plug" flow than the nonreconstructed aorta. The descending aorta, regardless of whether aortic reconstruction was present, displayed velocity profiles (at various phases of systole) skewed posteriorly. CONCLUSIONS The reconstructed aorta displays disturbed flow, and the velocities across the ascending aortic diameter are more varied than those in aortas without reconstruction and are skewed anteriorly. The descending aortic velocity profile in children is skewed posteriorly, regardless of whether aortic reconstruction is present. This information may help design and build a "better" aortic reconstruction.
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Affiliation(s)
- M A Fogel
- Department of Pediatrics, The Children's Hospital of Philadelphia, The University of Pennsylvania School of Medicine, 19104, USA
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Rychik J, Tian ZY, Fogel MA, Joshi V, Rose NC, Jacobs ML. The single ventricle heart in the fetus: accuracy of prenatal diagnosis and outcome. J Perinatol 1997; 17:183-8. [PMID: 9210071] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES The purpose of this study was to determine the diagnostic accuracy of fetal echocardiography in evaluating anatomic details of the single ventricle heart and the outcome of fetuses diagnosed with this anomaly. STUDY DESIGN This is a retrospective study of 57 fetuses in which the results of fetal echocardiography were compared with the diagnoses at postnatal echocardiography, and postnatal surgical outcome was reviewed. RESULTS Diagnostic accuracy was present in predicting morphology of the predominant ventricle, visceral situs, presence of pulmonary or aortic outflow tract obstruction, and presence of obstructed pulmonary venous outflow (sensitivity 100%). However, the ability to predict for a ductal dependent pulmonary circulation was poor (sensitivity 63%). Errors were made in the fetal assessment of ventricular size and viability such that in three cases, postnatal plans were altered toward a two-ventricular intervention. Of the 57 fetuses, intervention was elected in 37 (75%). Termination or nonintervention was elected in 14, and and 6 died before intervention. Of those operated on, 71% are presently alive after various stages of intervention. CONCLUSIONS Accurate diagnosis of the fetal single ventricle heart is possible, and outcome is improving. Caution must be used in judging ventricular size and in predicting ductal dependent pulmonary circulation.
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Affiliation(s)
- J Rychik
- Divisions of Cardiology and Cardiothoracic Surgery, Children's Hospital of Philadelphia, PA 19104, USA
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Abstract
OBJECTIVE To investigate whether long-acting somatostatin (SMS) can suppress renal hyperfiltration in patients with IDDM. RESEARCH DESIGN AND METHODS A double-blind, randomized treatment of nine patients with IDDM was used. Selection criteria were renal hyperfiltration (glomerular filtration rate [GFR] > or = 129 ml.min-1.1.73 m2) and absence of hypertension and macroalbuminuria. Treatment was either with a long-acting SMS analog (Somatulin, 30 mg) or with placebo, given by intramuscular injections every 10 days for 9 months. GFR, effective renal plasma flow (ERPF), IGF-I, and 24-h growth hormone (GH) profiles were used as evaluation parameters. RESULTS Five patients were randomized to Somatulin, four patients to placebo. One of the patients treated with Somatulin stopped after 3 months because of persistent abdominal discomfort after the injections. Somatulin treatment for 3 months lowered GFR and ERPF compared with placebo (P < 0.05). After 9 months, the differences were no longer significant. After 3 months, IGF-I concentrations were decreased in all Somatulin-treated patients. GH secretion tended to increase in the placebo group. CONCLUSIONS The administration of long-acting Somatulin to patients with IDDM and renal hyperfiltration leads to only a temporary reduction of ERPF/GFR.
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Affiliation(s)
- M L Jacobs
- Department of Internal Medicine III, University Hospital Dijkzigt, Rotterdam, The Netherlands
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Shah MJ, Rychik J, Fogel MA, Murphy JD, Jacobs ML. Pulmonary AV malformations after superior cavopulmonary connection: resolution after inclusion of hepatic veins in the pulmonary circulation. Ann Thorac Surg 1997; 63:960-3. [PMID: 9124971 DOI: 10.1016/s0003-4975(96)00961-7] [Citation(s) in RCA: 129] [Impact Index Per Article: 4.8] [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: 02/04/2023]
Abstract
BACKGROUND A high incidence of pulmonary arteriovenous malformations (PAVMs) has been reported in patients who have polysplenia and congenital heart disease after superior cavopulmonary anastomosis. Interruption of hepatic venous return to the pulmonary circulation is believed to potentiate the development of PAVMs. Surgical inclusion of hepatic flow in the pulmonary circulation may result in their resolution. METHODS We reviewed 3 patients with congenital heart disease and polysplenia in whom PAVMs developed and who had subsequent hepatic vein inclusion in the pulmonary circulation. RESULTS Patients underwent superior cavopulmonary connection at a median age of 8 months. The PAVMs were diagnosed at a median duration of 8 months after operation (arterial saturation <75% in room air). Hepatic venous flow was included in the pulmonary circulation at operation. Resolution of PAVMs occurred at a median duration of 7 months after operation (arterial saturation >90% in room air). CONCLUSIONS Surgical inclusion of hepatic venous blood in the pulmonary circulation results in the resolution of PAVMs. Electively associating the hepatic veins with the pulmonary vasculature may prevent the development of PAVMs in patients who are at risk.
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Affiliation(s)
- M J Shah
- Division of Cardiology, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, 19104, USA
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Jacobs ML, Elte JW, van Ouwerkerk BM, Janssens EN, Schop C, Knoop JA, Hoogma RP, Groenendijk R, Weber RF. Effect of BMI, insulin dose and number of injections on glycaemic control in insulin-using diabetic patients. Studygroup Diabetes Rijnmond (SDR). Neth J Med 1997; 50:153-9. [PMID: 9130838 DOI: 10.1016/s0300-2977(97)00008-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [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: 02/04/2023]
Abstract
BACKGROUND Strict glucose control is essential to the prevention of diabetic complications. The level of glycaemic control in insulin-treated patients with diabetes mellitus (DM) in a routine clinical setting is not known. METHODS In a cross-sectional survey comprising 8 hospitals in the Rijnmond area, The Netherlands, age, body mass index (BMI), insulin dose, number of injections, and HbA1c were scored in 712 patients with insulin-dependent DM (IDDM) and 462 patients with non-insulin-dependent DM (NIDDM). RESULTS In IDDM and NIDDM patients, respectively, age (mean +/- SD) was 40 +/- 17 and 65 +/- 12 years, BMI was 24.1 +/- 3.5 and 27.3 +/- 4.1 kg/m2, daily insulin dose was 49 +/- 18 and 44 +/- 18 U (P < 0.001). Intensive therapy (> or = 4 injections or continuous subcutaneous insulin infusion) was used in 59% of IDDM and 13% of NIDDM patients. HbA1c below the upper normal limit was achieved in 11% of the patients, and within 20% above the upper normal limit in 37%. Obesity was positively associated with HbA1c in NIDDM patients (P < 0.01). A higher insulin dose was associated with higher HbA1c in both IDDM and NIDDM patients (P < 0.01). CONCLUSIONS Good glycaemic control was established in 37% of our patients. Intensive insulin treatment and higher insulin dose did not improve glucose regulation. Obesity is a risk factor for poor glycaemic control.
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Affiliation(s)
- M L Jacobs
- Department of Internal Medicine III, University Hospital Dijkzigt, Rotterdam, Netherlands
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Abstract
OBJECTIVE Previous work has found cerebral oxygen extraction to decrease during hypothermic cardiopulmonary bypass in children. To elucidate cardiopulmonary bypass factors controlling cerebral oxygen extraction, we examined the effect of perfusate temperature, pump flow rate, and hematocrit value on cerebral hemoglobin-oxygen saturation as measured by near infrared spectroscopy. METHODS Forty children less than 7 years of age scheduled for cardiac operations with continuous cardiopulmonary bypass were randomly assigned to warm bypass, hypothermic bypass, hypothermic low-flow bypass, or hypothermic low-hematocrit bypass. For warm bypass, arterial perfusate was 37 degrees C, hematocrit value 23%, and pump flow 150 ml/kg per minute. Hypothermic bypass differed from warm bypass only in initial perfusate temperature (22 degrees C); hypothermic low-flow bypass and low-hematocrit bypass differed from hypothermic bypass only in pump flow (75 ml/kg per minute) and hematocrit value (16%), respectively. Cerebral oxygen saturation was recorded before bypass (baseline), during bypass, and for 15 minutes after bypass had been discontinued. RESULTS In the warm bypass group, cerebral oxygen saturation remained at baseline levels during and after bypass. In the hypothermic bypass group, cerebral oxygen saturation increased 20% +/- 2% during bypass cooling (p < 0.001), returned to baseline during bypass rewarming, and remained at baseline after bypass. In the hypothermic low-flow and hypothermic low-hematocrit bypass groups, cerebral oxygen saturation remained at baseline levels during bypass but increased 6% +/- 2% (p = 0.05) and 10% +/- 2% (p < 0.03), respectively, after bypass was discontinued. CONCLUSIONS In children, cortical oxygen extraction is maintained during warm cardiopulmonary bypass at full flow and moderate hemodilution. Bypass cooling can decrease cortical oxygen extraction but requires a certain pump flow and hematocrit value to do so. Low-hematocrit hypothermic bypass and low-flow hypothermic bypass can also alter cortical oxygen extraction after discontinuation of cardiopulmonary bypass.
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Affiliation(s)
- C D Kurth
- Department of Anesthesia, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, 19104, USA
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Abstract
OBJECTIVE The mechanisms by which diabetes leads to rapidly progressive atherosclerosis are not fully understood. Adherence of monocytes to the arterial wall is an early event in the development of atherosclerotic lesions. RESEARCH DESIGN AND METHODS The binding of freshly isolated monocytes from patients with NIDDM, IDDM, and healthy control subjects to a monolayer of endothelial cells obtained from human umbilical vein was investigated. RESULTS Endothelial adherence of monocytes from normolipidemic patients with IDDM (15.8 +/- 4.5%) or NIDDM (16.9 +/- 4.6%) was comparable to that of monocytes from a control population (15.3 +/- 3.5%). In patients with NIDDM with a serum triglyceride concentration > 2.5 mmol/l, the percentage of cells that adhere to endothelial cells in vitro was significantly increased (23.3 +/- 3.1%). Glycemic control did not correlate with monocyte adherence. The presence of symptomatic atherosclerotic disease, age, or sex was not associated with a change in monocyte binding in vitro. CONCLUSIONS The results suggest that in NIDDM hypertriglyceridemia should be treated to reduce the high risk for atherosclerosis.
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Affiliation(s)
- N Hoogerbrugge
- Department of Internal Medicine III, University Hospital Rotterdam Dijkzigt, The Netherlands.
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Abstract
OBJECTIVES This study was designed to define morphometric echocardiographic variables of unbalanced common atrioventricular canal (CAVC) that could aid in appropriate referral for surgical repair. BACKGROUND Unbalanced CAVC has a high surgical mortality rate. This may be secondary to inappropriate referral of some patients for two-ventricle repair (closure of septal defects) instead of single-ventricle repair (Norwood palliation and Fontan operation). METHODS The echocardiograms of 103 patients with CAVC were retrospectively reviewed. In the subcostal left anterior oblique view, the area of the atrioventricular (AV) valve aportioned over each ventricle was measured, and an AV valve index (AVVI) was calculated as left/right valve area. The ventricular cavity ratio between the two ventricles was estimated as left ventricular length times width divided by right ventricular length times width. These variables were correlated with surgical referral and outcome. RESULTS Patients previously categorized as having balanced CAVC all had AVVI > 0.67 (n = 77). Of the patients with unbalanced CAVC (n = 26), 11 had ductal-dependent circulation and underwent Norwood palliation (AVVI 0.21 +/- 0.13, mean +/- SD), and 15 had two-ventricle repair (AVVI 0.51 +/- 0.12, p < 0.0001). Of these 15 patients, 9 have survived, with no difference in mean AVVI between survivors and nonsurvivors (0.52 +/- 0.11 versus 0.49 +/- 0.13, p = 0.72). For all 103 patients, AVVI correlated with ventricular cavity ratio. However, of the unbalanced CAVC group who underwent two-ventricle repair, three nonsurvivors had a discrepancy between AVVI and ventricular cavity ratio (low AVVI but normal ventricular size). A large ventricular septal defect was present in all six nonsurvivors but in only four of nine survivors (p < 0.05). CONCLUSIONS Echocardiographic morphometry is useful in defining unbalance in CAVC. If AVVI is < 0.67 in the presence of a large ventricular septal defect, a single-ventricle approach to repair should be considered.
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Affiliation(s)
- M S Cohen
- Division of Cardiology, Children's Hospital of Philadelphia, Pennsylvania 19104, USA
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Jacobs ML, Rychik J, Rome JJ, Apostolopoulou S, Pizarro C, Murphy JD, Norwood WI. Early reduction of the volume work of the single ventricle: the hemi-Fontan operation. Ann Thorac Surg 1996; 62:456-61; discussion 461-2. [PMID: 8694605] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND In hearts with a functional single ventricle, cavity volume and myocardial muscle mass increase as a consequence of the excessive volume work associated with parallel pulmonary and systemic circulations. The hemi-Fontan operation was conceived as a means of accomplishing early reduction of the volume work of the single ventricle. METHODS All patients presenting in infancy with single-ventricle physiology were managed by early hemi-Fontan operation in anticipation of a subsequent completion Fontan operation. Between May 1989 and August 1995, 400 patients less than 2 years of age underwent hemi-Fontan operations. Mean age at operation was 8.5 months (range, 2 months to 24 months). The hemi-Fontan operation included association of superior vena(e) cava(e) with the branch pulmonary arteries, augmentation of the central pulmonary arteries, occlusion of the inflow of the superior vena cava into the right atrium, and elimination of other sources of pulmonary blood flow. RESULTS Operative mortality ( < 30 days) was 31 of 400 patients (7.8%). For the last 200 patients, operative mortality was 8 of 200 (4.0%). Younger age at operation was not an independent risk factor for operative mortality. Urgent operation in the presence of a hemodynamic burden requiring concomitant procedures was associated with increased mortality. CONCLUSIONS The hemi-Fontan operation can be accomplished with low operative mortality in young patients, achieving early reduction of the volume work of the single-ventricle heart.
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Affiliation(s)
- M L Jacobs
- Department of Surgery, Deborah Heart and Lung Center, Browns Mills, New Jersey 08015, USA
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Jacobs ML, Nathoe HM, Blankestijn PJ, Stijnen T, Weber RF. Growth hormone responses to growth hormone-releasing hormone and clonidine in patients with type I diabetes and in normal controls: effect of age, body mass index and sex. Clin Endocrinol (Oxf) 1996; 44:547-53. [PMID: 8762731 DOI: 10.1046/j.1365-2265.1996.713534.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [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: 02/02/2023]
Abstract
OBJECTIVE Increased plasma concentrations of GH and increased GH responses to provocative stimuli are reported in patients with poorly controlled type I diabetes and are suggested to be related to complications. Our aim was to investigate GH concentrations in moderately controlled patients. PATIENTS AND MEASUREMENTS We have investigated IGF-I concentrations and fasting GH concentrations and the response to 1 microgram/kg body weight GH-releasing hormone (GHRH) intravenously and/or to 150 micrograms clonidine intravenously in 77 moderately controlled patients with type I diabetes and in 46 healthy controls. RESULTS Median HbA1c in the patients was 8.5% (upper level of normal 6.3%). Fasting GH and GH concentrations after the administration of GHRH were not significantly different in patients with type I diabetes compared with normal controls. Fasting and stimulated GH concentrations after the administration of clonidine were significantly higher in the patients, but this could be explained by their lower age and body mass index compared with controls. In controls but not in patients there was a negative correlation between GH and glucose concentrations. IGF-I was significantly lower in patients with diabetes than in controls, even after correction for age, body mass index and sex. CONCLUSIONS Patients with moderately controlled type I diabetes mellitus have normal baseline and stimulated GH concentrations after the administration of GHRH or clonidine compared with healthy controls, when corrected for age, body mass index and sex. However, these 'normal' GH concentrations must be considered inappropriately high in view of the hyperglycaemia in these patients. The low plasma IGF-I concentrations might be responsible for the GH over-production.
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Affiliation(s)
- M L Jacobs
- Department of Internal Medicine III, Erasmus University Hospital, Rotterdam, Netherlands
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Rychik J, Gullquist SD, Jacobs ML, Norwood WI. Doppler echocardiographic analysis of flow in the ductus arteriosus of infants with hypoplastic left heart syndrome: relationship of flow patterns to systemic oxygenation and size of interatrial communication. J Am Soc Echocardiogr 1996; 9:166-73. [PMID: 8849612 DOI: 10.1016/s0894-7317(96)90024-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [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: 02/02/2023]
Abstract
Excessive pulmonary overcirculation related to imbalance in the pulmonary/systemic vascular resistance ratio contributes to hemodynamic instability in infants with the hypoplastic left heart syndrome. Because the ductus arteriosus bridges the two vascular circuits in this lesion, we studied the Doppler echocardiographic flow patterns in the ductus arteriosus of 50 infants with hypoplastic left heart syndrome to investigate their relationship to the degree of pulmonary blood flow as measured by simultaneously obtained levels of partial pressure of oxygen in arterial blood. The degree of restriction to pulmonary venous egress as determined by size of the interatrial communication was also correlated with ductal flow patterns and partial pressure of oxygen in arterial blood. Biphasic flow was noted in all infants. Mean peak velocity of antegrade flow (pulmonary artery to aorta) was greater than that of retrograde flow (aorta to pulmonary artery) (131 +/- 45 cm/sec versus 54 +/- 15 cm/sec; p < 0.001), mean time of retrograde flow was greater than that of antegrade flow (246 +/- 60 msec versus 174 +/- 28 msec; p < 0.001), and mean velocity-time integral of antegrade flow was greater than that of retrograde flow (13.3 +/- 4.8 cm versus 6.3 +/- 3.4 cm; p < 0.001). The ratio of velocity-time integral of retrograde flow/antegrade flow (a volumetric estimate of diastolic reversal into the pulmonary vascular bed indexed to systemic output) correlated extremely well with partial pressure of oxygen in arterial blood (r = 0.91; p < 0.0001). Categoric size of the interatrial communication (none, n = 2; small [<2 mm], n = 9; moderate [3 to 4 mm], n = 23; and large [>4 mm], n = 16) correlated with partial pressure of oxygen in arterial blood (r = 0.82; p < 0.001); the smaller the interatrial communication the lower the partial pressure of oxygen in arterial blood and velocity-time integral ratio of retrograde/antegrade flow. Doppler flow patterns in the ductus arteriosus of infants with hypoplastic left heart syndrome are reflective of the resistance ratio between the pulmonary and systemic vascular circuits and may be helpful in monitoring the hemodynamics of these infants.
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Affiliation(s)
- J Rychik
- Non-Invasive Cardiovascular Laboratories, Division of Cadiology, The Children's Hospital of Philadelphia, PA 19104, USA
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Abstract
Whether coarctation or interruption (IAA) of the aorta, ostensibly similar in morphology (and management), result from the same or different developmental errors can be inferred by examining the pattern of associated anomalies. Among the most common associated lesions, especially in IAA, is ventricular septal defect (VSD). Although muscular and perimembranous VSDs are the most common in aortic coarctation, the prevalence of various VSD morphologies in IAA has not been examined in as much detail. As part of the recent prospective multiinstitutional study of IAA conducted by the Congenital Heart Surgeons Society, 53 echocardiographic studies were reviewed; 42 of 45 patients with type B IAA had VSDs involving maldevelopment of the outflow region. In type A IAA, a significantly lower percentage (4/8) had this kind of VSD. Therefore the mechanism of development of type B IAA is likely to be different from that of type A IAA.
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Affiliation(s)
- A J Chin
- Cardiology Division, Children's Hospital, Philadelphia, PA 19104, USA
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Abstract
A 4-year-old child with hypoplastic left heart syndrome and a 6-year-old child with tricuspid atresia had both undergone staged reconstructive operations culminating in a Fontan operation. Peripheral edema, ascites, and hypoalbuminemia refractory to dietary manipulation and steroid therapy developed in both patients. After hemodynamic assessment, each child underwent surgical creation of a 4.8-mm fenestration in the previously placed baffle that separated the systemic venous pathway from the pulmonary venous atrium. Peripheral edema and ascites promptly resolved and serum protein levels normalized within 2 weeks after operation. Systemic arterial saturation is 86% in each child, and both children remain clinically well with no evidence of protein-losing enteropathy on normal diets and without specific medical therapy.
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Affiliation(s)
- M L Jacobs
- Division of Cardiothoracic Surgery, Childrens Hospital of Philadelphia, Pennsylvania 19104, USA
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Abstract
BACKGROUND Subaortic obstruction is a frequent accompaniment of single-ventricle anatomy. Most often, the aorta arises from an outflow chamber that is connected to the single ventricle by a bulboventricular foramen or ventricular septal defect. This connection may be restrictive of flow at birth, or may become obstructive after surgical procedures that reduce the volume work of the ventricle. Subaortic obstruction is recognized as a risk factor for reconstructive surgical procedures for single ventricle. METHODS To prevent the consequences of subaortic obstruction, we have routinely amalgamated the proximal main pulmonary artery with the ascending aorta and arch early in the management of these patients. From September 1990 through September 1994, 29 neonates and infants with single ventricle and established or potential subaortic obstruction underwent staged reconstructive surgical procedures. The initial operation in the newborn period was a Norwood procedure (18 patients) or a pulmonary artery band (5 patients). All survivors underwent a hemi-Fontan procedure at approximately 6 months. RESULTS Eighteen patients have undergone a completion Fontan operation with no deaths. Five await completion Fontan. None has subaortic obstruction, and none has pulmonary valve insufficiency that is graded more than mild. CONCLUSIONS Early association of the proximal main pulmonary artery with the ascending aorta appears to obviate the risks and complications associated with subaortic obstruction in patients with single ventricle.
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Affiliation(s)
- M L Jacobs
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Pennsylvania 19104, USA
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Abstract
BACKGROUND After surgical removal of a volume load, regression of myocardial mass proceeds slowly relative to diminution in ventricular cavity size, resulting in increased wall thickness and decreased cavity dimensions, which may affect the filling properties and performance of the heart. We investigated the acute changes in ventricular geometry that occur after the Fontan operation and hemi-Fontan operation for tricuspid atresia, and compared them with closure of a ventricular septal defect in a two-ventricle heart. METHODS We reviewed the results of echocardiography performed before and 8 +/- 7 days after (1) Fontan operation for tricuspid atresia (n = 9), (2) hemi-Fontan operation for tricuspid atresia (n = 10), and (3) closure of a ventricular septal defect (n = 13). Measurements were made from images of the left ventricle at end-diastole: (1) apical, septal, and posterior wall thickness; and (2) long- and short-axis cavity diameters, cross-sectional areas, and ventricular volume. Posterior wall thickness to cavity dimension ratio was calculated. RESULTS Wall thickness increased in all groups, with the greatest degree of increase after the Fontan operation. Cavity measures decreased most dramatically after the Fontan operation, with less dramatic and equivalent changes noted after the hemi-Fontan operation and ventricular septal defect closure. Posterior wall thickness to cavity diameter ratios were equivalent in all before operation, increased after operation, and were greatest after the Fontan operation. CONCLUSIONS Changes in ventricular geometry identified as an increase in wall thickness and a decrease in cavity dimension are most dramatic after the Fontan operation. Changes seen after the hemi-Fontan operation are of a milder degree, which may in part explain the excellent clinical course after this operation.
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Affiliation(s)
- J Rychik
- Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine 19104, USA
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Jacobs ML, Rychik J, Murphy JD, Nicolson SC, Steven JM, Norwood WI. Results of Norwood's operation for lesions other than hypoplastic left heart syndrome. J Thorac Cardiovasc Surg 1995; 110:1555-61; discussion 1561-2. [PMID: 7475208 DOI: 10.1016/s0022-5223(95)70079-x] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.1] [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: 01/25/2023]
Abstract
Norwood's operation provides satisfactory palliation for neonates with hypoplastic left heart syndrome. The dominant physiologic features of hypoplastic left heart syndrome, ductal dependency of the systemic circulation and parallel pulmonary and systemic circulations, are shared by a multitude of other less common congenital heart malformations. Theoretically, these should be equally amenable to palliation by Norwood's operation. Between January 1990 and June 1994, 60 neonates with malformations other than hypoplastic left heart syndrome underwent initial surgical palliation by Norwood's procedure. Diagnoses included single left ventricle with levo-transposition of the great arteries (12); critical aortic stenosis (8); complex double-outlet right ventricle (8); interrupted aortic arch with ventricular septal defect and subaortic stenosis (7); ventricular septal defect, subaortic stenosis, and coarctation of the aorta (7); aortic atresia with large ventricular septal defect (6); tricuspid atresia with transposition of the great arteries (6); heterotaxy syndrome with subaortic obstruction (3); and other (3). There were 10 hospital deaths and 50 survivors (83% survival). After the introduction of inspired carbon dioxide therapy into the postoperative management protocol (1991), 42 of 47 patients survived (89% survival). Mortality was independent of diagnosis and essentially the same as that for hypoplastic left heart syndrome. With minor technical modifications, Norwood's operation provides satisfactory initial palliation for a wide variety of malformations characterized by ductal dependency of the systemic circulation in anticipation of either a Fontan procedure or a biventricular repair.
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Affiliation(s)
- M L Jacobs
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, PA 19104, USA
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Abstract
Interrupted aortic arch (IAA) is often related developmentally to subaortic obstruction (SAO). When severe, SAO must be addressed in surgical management of IAA. From 1990 to 1993, 25 neonates presented for initial surgical management of IAA complexes. Associated lesions were ventricular septal defect (VSD) with or without atrial septal defect (19 patients), truncus arteriosus (3 patients), tricuspid atresia with transposition of the great arteries (1 patient), aortic atresia with VSD (1 patient), and d-transposition of the great arteries with VSD (1 patient). Overall hospital mortality was 20% (five deaths). One death was related to sepsis and two to sudden hemodynamic decompensation (a 2-kg premature infant after arch repair and VSD closure and a neonate with IAA-truncus arteriosus after arch repair and truncus repair with aortic root replacement). Two deaths were related to low cardiac output in patients with severe subaortic narrowing (< 3 mm by two-dimensional echocardiography), which was not addressed surgically. Of 10 additional patients judged preoperatively to have severe SAO, 1 underwent resection of the infundibular septum together with VSD closure and arch reconstruction, and 9 underwent a modification of Norwood's operation with arch reconstruction and proximal pulmonary artery to aortic anastomosis (7 with systemic to pulmonary artery shunts and 2 with right ventricle to pulmonary artery outflow tract reconstruction). One patient died 2 months after surgery of staphylococcal sepsis. All 9 others were discharged well. Subaortic narrowing is a physiologically important element of IAA complexes. When SAO is severe, satisfactory initial palliation can be achieved by a modification of Norwood's operation.
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Affiliation(s)
- M L Jacobs
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, PA 19104, USA
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Donofrio MT, Jacobs ML, Norwood WI, Rychik J. Early changes in ventricular septal defect size and ventricular geometry in the single left ventricle after volume-unloading surgery. J Am Coll Cardiol 1995; 26:1008-15. [PMID: 7560593 DOI: 10.1016/0735-1097(95)00241-5] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.5] [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: 01/25/2023]
Abstract
OBJECTIVES This study investigated the phenomenon of, and the relation between, alterations in ventricular geometry after acute surgical volume unloading of the ventricle and the development of subaortic stenosis in patients with a single ventricle and ventricular septal defect-dependent systemic flow. BACKGROUND Subaortic outflow obstruction has been observed to occur in patients with a single left ventricle after placement of a pulmonary artery band. The timing and etiology of this phenomenon are not well defined. METHODS The preoperative and postoperative echocardiograms of 18 patients 14.9 +/- 22.8 months old (mean +/- SD) with a diagnosis of single left ventricle who underwent pulmonary artery banding or cavopulmonary connection were reviewed. Postoperative studies were performed a mean of 7.0 +/- 6.5 days after operation. The ventricular septal defect diameter was measured in two orthogonal views and the area calculated using the formula for an ellipse. Interventricular septal and posterior wall thickness and left ventricular diameter and length were also measured. RESULTS Mean ventricular septal defect area indexed to body surface area diminished by 36 +/- 23% (3.1 +/- 2.7 to 2.0 +/- 1.8 cm2/m2, p < 0.01). Mean interventricular septal and posterior wall thickness increased significantly, and left ventricular diameter and length decreased significantly. A greater diminution in ventricular septal defect area was noted after cavopulmonary connection (41 +/- 19%, p < 0.01) than after pulmonary artery banding (25 +/- 28%, p = 0.22). CONCLUSIONS In the single left ventricle, diminution in ventricular septal defect size occurs early and is related to an acute alteration in ventricular geometry that accompanies the decrease in ventricular volume. Ventricular septal defect diminution was greater after volume unloading of the ventricle after cavopulmonary connection than after pulmonary artery banding.
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Affiliation(s)
- M T Donofrio
- Division of Cardiology, Children's Hospital of Philadelphia, Pennsylvania 19104, USA
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