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Sznycer-Taub NR, Lowery R, Yu S, Owens G, Charpie JR. Reducing Hyperoxia Exposure in Infants Requiring Veno-Arterial Extracorporeal Membrane Oxygenation after Cardiac Surgery. Pediatr Cardiol 2024; 45:143-149. [PMID: 37698698 DOI: 10.1007/s00246-023-03277-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 08/12/2023] [Indexed: 09/13/2023]
Abstract
Recent studies have suggested worse outcomes in patients exposed to hyperoxia while supported on veno-arterial extracorporeal membrane oxygenation (VA-ECMO). However, there are no data regarding the effect of reducing hyperoxia exposure in this population by adjusting the fraction of inspired oxygen (FiO2) of the sweep gas of the ECMO circuit. A retrospective review of 143 patients less than 1 year of age requiring VA-ECMO following cardiac surgery from 2007 to 2018 was completed. 64 patients had a FiO2 of the sweep gas < 100% with an average PaO2 of 210 mm Hg in the first 48 h of support [vs 405 mm Hg in the group with a FiO2 = 100% (p < 0.0001)]. There was no difference in mortality at 30 days after surgery or other markers of end-organ injury with respect to whether the FiO2 was adjusted. At least one PaO2 value < 200 mm Hg in the first 24 h on ECMO in patients with a FiO2 < 100% trended toward a significant association (OR = 0.45, 95% CI = 0.21-1.01) with decreased risk of 30-day mortality when compared to those patients with a FiO2 = 100% and all PaO2 values > 200 mm Hg. Only 47% of patients with a FiO2 < 100% had an average PaO2 less than 200 mm Hg which indicates that the intervention of reducing the FiO2 of the sweep gas was not entirely effective at reducing hyperoxia exposure. Future research is needed for developing clinical protocols to avoid hyperoxia and to identify mechanisms for hyperoxia-induced injury on VA-ECMO.
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Affiliation(s)
- Nathaniel R Sznycer-Taub
- Division of Pediatric Cardiology, C.S. Mott Children's Hospital, University of Michigan, 1540 East Hospital Drive, Ann Arbor, MI, 48109-4204, USA.
| | - Ray Lowery
- Division of Pediatric Cardiology, C.S. Mott Children's Hospital, University of Michigan, 1540 East Hospital Drive, Ann Arbor, MI, 48109-4204, USA
| | - Sunkyung Yu
- Division of Pediatric Cardiology, C.S. Mott Children's Hospital, University of Michigan, 1540 East Hospital Drive, Ann Arbor, MI, 48109-4204, USA
| | - Gabe Owens
- Division of Pediatric Cardiology, C.S. Mott Children's Hospital, University of Michigan, 1540 East Hospital Drive, Ann Arbor, MI, 48109-4204, USA
| | - John R Charpie
- Division of Pediatric Cardiology, C.S. Mott Children's Hospital, University of Michigan, 1540 East Hospital Drive, Ann Arbor, MI, 48109-4204, USA
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Zampi JD, Heinrich KP, Bergersen L, Goldstein BH, Batlivala SP, Fuller S, Glatz AC, O'Byrne ML, Marino B, Afton K, Lowery R, Yu S, Goldberg CS. Neurocognitive function and health-related quality of life in adolescents and young adults with CHD with pulmonary valve dysfunction. Cardiol Young 2023:1-8. [PMID: 38031461 DOI: 10.1017/s1047951123003979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2023]
Abstract
BACKGROUND Neurocognitive impairment and quality of life are two important long-term challenges for patients with complex CHD. The impact of re-interventions during adolescence and young adulthood on neurocognition and quality of life is not well understood. METHODS In this prospective longitudinal multi-institutional study, patients 13-30 years old with severe CHD referred for surgical or transcatheter pulmonary valve replacement were enrolled. Clinical characteristics were collected, and executive function and quality of life were assessed prior to the planned pulmonary re-intervention. These results were compared to normative data and were compared between treatment strategies. RESULTS Among 68 patients enrolled from 2016 to 2020, a nearly equal proportion were referred for surgical and transcatheter pulmonary valve replacement (53% versus 47%). Tetralogy of Fallot was the most common diagnosis (59%) and pulmonary re-intervention indications included stenosis (25%), insufficiency (40%), and mixed disease (35%). There were no substantial differences between patients referred for surgical and transcatheter therapy. Executive functioning deficits were evident in 19-31% of patients and quality of life was universally lower compared to normative sample data. However, measures of executive function and quality of life did not differ between the surgical and transcatheter patients. CONCLUSION In this patient group, impairments in neurocognitive function and quality of life are common and can be significant. Given similar baseline characteristics, comparing changes in neurocognitive outcomes and quality of life after surgical versus transcatheter pulmonary valve replacement will offer unique insights into how treatment approaches impact these important long-term patient outcomes.
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Affiliation(s)
- Jeffrey D Zampi
- Department of Pediatrics, University of Michigan Congenital Heart Center, Ann Arbor, MI, USA
| | | | - Lisa Bergersen
- Division of Pediatric Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - Bryan H Goldstein
- UPMC Children's Hospital of Pittsburgh and Department of Pediatrics, Heart Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | | | - Stephanie Fuller
- Division of Cardiac Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Andrew C Glatz
- Division of Pediatric Cardiology, St. Louis Children's and Washington University Heart Center, St. Louis, MO, USA
| | - Michael L O'Byrne
- Division of Pediatric Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Bradley Marino
- Department of Pediatrics, Division of Pediatric Cardiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Katherine Afton
- Department of Pediatrics, University of Michigan Congenital Heart Center, Ann Arbor, MI, USA
| | - Ray Lowery
- Department of Pediatrics, University of Michigan Congenital Heart Center, Ann Arbor, MI, USA
| | - Sunkyung Yu
- Department of Pediatrics, University of Michigan Congenital Heart Center, Ann Arbor, MI, USA
| | - Caren S Goldberg
- Department of Pediatrics, University of Michigan Congenital Heart Center, Ann Arbor, MI, USA
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Konduri A, West C, Lowery R, Hunter T, Jarosz A, Yu S, Lim HM, McCormick AD, Schumacher KR, Peng DM. Experience with SGLT2 Inhibitors in Patients with Single Ventricle Congenital Heart Disease and Fontan Circulatory Failure. Pediatr Cardiol 2023:10.1007/s00246-023-03332-5. [PMID: 37919530 DOI: 10.1007/s00246-023-03332-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 10/17/2023] [Indexed: 11/04/2023]
Abstract
Heart failure is the leading cause of morbidity and mortality in patients with Fontan circulation. Sodium-glucose-cotransporter 2 inhibitors (SGLT2i) have become a mainstay of heart failure therapy in adult patients, however, there remains a paucity of literature to describe its use in pediatric heart failure patients, especially those with single ventricle physiology. We describe our early experience using SGLT2i in patients with single ventricle congenital heart disease surgically palliated to the Fontan circulation. We conducted a single-center retrospective chart review of all patients with Fontan circulation who were initiated on an SGLT2i from January 1, 2022 to March 1, 2023. Patient demographics, diagnoses, clinical status, and other therapies were collected from the electronic medical record. During the study period, 14 patients (median age 14.5 years, range 2.0-26.4 years) with Fontan circulation were started on a SGLT2i. Mean weight was 54 kg (range 11.6-80.4 kg). Median follow-up since SGLT2i initiation was 4.1 months (range 13 days-7.7 months). Four patients had a systemic left ventricle and 10 had a systemic right ventricle. Half the patients had Fontan Circulatory Failure with reduced Ejection Fraction (FCFrEF) of the systemic ventricle and the other half had Fontan Circulatory Failure with preserved Ejection Fraction (FCFpEF) of the systemic ventricle. In addition, 3 patients experienced Protein Losing Enteropathy (PLE) and 2 patients had plastic bronchitis, one of whom also was diagnosed with chylothorax. There were no genitourinary infections, hypoglycemia, ketoacidosis, hypotension or other significant adverse effects noted in our patient population. One patient experienced significant diuresis and transient acute kidney injury. Patients with FCFrEF showed a decrease in natriuretic peptide levels. Given the lack of proven therapies, demonstrated benefits of SGLT2i in other populations, and some suggestion of efficacy in Fontan circulation, further study of SGTLT2i in patients with Fontan circulation is warranted.
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Affiliation(s)
- Anusha Konduri
- University of Michigan Congenital Heart Center, Ann Arbor, MI, USA.
| | - Caroline West
- University of Michigan Congenital Heart Center, Ann Arbor, MI, USA
| | - Ray Lowery
- University of Michigan Congenital Heart Center, Ann Arbor, MI, USA
| | - Tiffany Hunter
- University of Michigan Congenital Heart Center, Ann Arbor, MI, USA
| | - Audrey Jarosz
- University of Michigan Congenital Heart Center, Ann Arbor, MI, USA
| | - Sunkyung Yu
- University of Michigan Congenital Heart Center, Ann Arbor, MI, USA
| | - Heang M Lim
- University of Michigan Congenital Heart Center, Ann Arbor, MI, USA
| | | | | | - David M Peng
- University of Michigan Congenital Heart Center, Ann Arbor, MI, USA
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McCormick AD, Lim HM, Strohacker CM, Yu S, Lowery R, Vitale C, Ligsay A, Aiyagari R, Schumacher KR, Fifer CG, Owens ST, Cousino MK. Paediatric cardiology training: burnout, fulfilment, and fears. Cardiol Young 2023; 33:2274-2281. [PMID: 36691819 DOI: 10.1017/s1047951123000148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Burnout is well characterised in physicians and residents but not in paediatric cardiology fellows, and few studies follow burnout longitudinally. Training-specific fears have been described in paediatric cardiology fellows but also have not been studied at multiple time points. This study aimed to measure burnout, training-specific fears, and professional fulfilment in paediatric cardiology fellows with the attention to time of year and year-of-training. METHODS This survey-based study included the Professional Fulfillment Index and the Impact of Events Scale as well as an investigator-designed Fellow Fears Questionnaire. Surveys were distributed at three-time points during the academic year to paediatric cardiology fellows at a large Midwestern training programme. Fellow self-reported gender and year-of-training were collected. Descriptive analyses were performed. RESULTS 10/17 (59%) of fellows completed all surveys; 60% were female, 40% in the first-year class, 40% in the second-year class, and 20% in the third-year class. At least half of the fellows reported burnout at each survey time point, with lower mean professional fulfilment scores. The second-year class, who rotate primarily in the cardiac ICU, had higher proportions of burnout than the other two classes. At least half of fellows reported that they "often" or "always" worried about not having enough clinical knowledge or skills and about work-life balance. CONCLUSIONS Paediatric cardiology fellows exhibit high proportions of burnout and training-specific fears. Interventions to mitigate burnout should be targeted specifically to training needs, including during high-acuity rotations.
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Affiliation(s)
| | - Heang M Lim
- Department of Pediatrics, Michigan Medicine, Ann Arbor, MI, USA
| | | | - Sunkyung Yu
- Department of Pediatrics, Michigan Medicine, Ann Arbor, MI, USA
| | - Ray Lowery
- Department of Pediatrics, Michigan Medicine, Ann Arbor, MI, USA
| | - Carolyn Vitale
- Department of Pediatrics, Michigan Medicine, Ann Arbor, MI, USA
| | - Andrew Ligsay
- Department of Pediatrics, Michigan Medicine, Ann Arbor, MI, USA
| | - Ranjit Aiyagari
- Department of Pediatrics, Michigan Medicine, Ann Arbor, MI, USA
| | | | - Carlen G Fifer
- Department of Pediatrics, Michigan Medicine, Ann Arbor, MI, USA
| | - Sonal T Owens
- Department of Pediatrics, Michigan Medicine, Ann Arbor, MI, USA
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Salavitabar A, Zampi JD, Thomas C, Zanaboni D, Les A, Lowery R, Yu S, Whiteside W. Augmented Reality Visualization of 3D Rotational Angiography in Congenital Heart Disease: A Comparative Study to Standard Computer Visualization. Pediatr Cardiol 2023:10.1007/s00246-023-03278-8. [PMID: 37725124 DOI: 10.1007/s00246-023-03278-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 08/12/2023] [Indexed: 09/21/2023]
Abstract
Augmented reality (AR) visualization of 3D rotational angiography (3DRA) provides 3D representations of cardiac structures with full visualization of the procedural environment. The purpose of this study was to evaluate the feasibility of converting 3DRAs of congenital heart disease patients to AR models, highlight the workflow for 3DRA optimization for AR visualization, and assess physicians' perceptions of their use. This single-center study prospectively evaluated 30 retrospectively-acquired 3DRAs that were converted to AR, compared to Computer Models (CM). Median patient age 6.5 years (0.24-38.8) and weight 20.6 kg (3.4-107.0). AR and CM quality were graded highly. RV pacing was associated with higher quality of both model types (p = 0.02). Visualization and identification of structures were graded as "very easy" in 81.1% (n = 73) and 67.8% (n = 61) of AR and CM, respectively. Fifty-nine (66%) grades 'Agreed' or 'Strongly Agreed' that AR models provided superior appreciation of 3D relationships; AR was found to be least beneficial in visualization of aortic arch obstruction. AR models were thought to be helpful in identifying pathology and assisting in interventional planning in 85 assessments (94.4%). There was significant potential seen in the opportunity for patient/family counseling and trainee/staff education with AR models. It is feasible to convert 3D models of 3DRAs into AR models, which are of similar image quality as compared to CM. AR models provided additional benefits to visualization of 3D relationships in most anatomies. Future directions include integration of interventional simulation, peri-procedural counseling of patients and families, and education of trainees and staff with AR models.
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Affiliation(s)
- Arash Salavitabar
- Cardiac Catheterization & Interventional Therapies, The Heart Center, Nationwide Children's Hospital, The Ohio State University College of Medicine, 700 Children's Drive, Columbus, OH, 43205, USA.
| | - Jeffrey D Zampi
- University of Michigan Congenital Heart Center, Ann Arbor, MI, USA
| | - Courtney Thomas
- University of Michigan Congenital Heart Center, Ann Arbor, MI, USA
| | - Dominic Zanaboni
- University of Michigan Congenital Heart Center, Ann Arbor, MI, USA
| | - Andrea Les
- University of Michigan Congenital Heart Center, Ann Arbor, MI, USA
| | - Ray Lowery
- University of Michigan Congenital Heart Center, Ann Arbor, MI, USA
| | - Sunkyung Yu
- University of Michigan Congenital Heart Center, Ann Arbor, MI, USA
| | - Wendy Whiteside
- University of Michigan Congenital Heart Center, Ann Arbor, MI, USA
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6
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Cousino MK, Miller VA, Smith C, Lim HM, Yu S, Lowery R, Uzark K, Fredericks EM, Wolfe J, Blume ED, Schumacher KR. Medical and End-of-Life Decision-Making Preferences in Adolescents and Young Adults with Advanced Heart Disease and Their Parents. JAMA Netw Open 2023; 6:e2311957. [PMID: 37145598 PMCID: PMC10163392 DOI: 10.1001/jamanetworkopen.2023.11957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/06/2023] Open
Abstract
Importance Despite high disease morbidity and mortality and complex treatment decisions, little is known about the medical and end-of-life decision-making preferences of adolescents and young adults (AYA) with advanced heart disease. AYA decision-making involvement is associated with important outcomes in other chronic illness groups. Objective To characterize decision-making preferences of AYAs with advanced heart disease and their parents and determine factors associated with these preferences. Design, Setting, and Participants Cross-sectional survey between July 2018 and April 2021 at a single-center heart failure/transplant service at a Midwestern US children's hospital. Participants were AYAs aged 12 to 24 years with heart failure, listed for heart transplantation, or posttransplant with life-limiting complications and a parent/caregiver. Data were analyzed from May 2021 to June 2022. Main Outcomes and Measures Single-item measure of medical decision-making preferences, MyCHATT, and Lyon Family-Centered Advance Care Planning Survey. Results Fifty-six of 63 eligible patients enrolled in the study (88.9%) with 53 AYA-parent dyads. Median (IQR) patient age was 17.8 (15.8-19.0) years; 34 (64.2%) patients were male, and 40 patients (75.5%) identified as White and 13 patients (24.5%) identified as members of a racial or ethnic minority group or multiracial. The greatest proportion of AYA participants (24 of 53 participants [45.3%]) indicated a preference for active, patient-led decision-making specific to heart disease management, while the greatest proportion of parents (18 of 51 participants [35.3%]) preferred they and physician(s) make shared medical decisions on behalf of their AYA, representing AYA-parent decision-making discordance (χ2 = 11.7; P = .01). Most AYA participants stated a preference to discuss adverse effects or risks of treatment (46 of 53 participants [86.8%]), procedural and/or surgical details (45 of 53 participants [84.9%]), impact of condition on daily activities (48 of 53 participants [90.6%]), and their prognosis (42 of 53 participants [79.2%]). More than half of AYAs preferred to be involved in end-of-life decisions if very ill (30 of 53 participants [56.6%]). Longer time since cardiac diagnosis (r = 0.32; P = .02) and worse functional status (mean [SD] 4.3 [1.4] in New York Heart Association class III or IV vs 2.8 [1.8] in New York Heart Association class I or II; t-value = 2.7; P = .01) were associated with a preference for more active, patient-led decision-making. Conclusions and Relevance In this survey study, most AYAs with advanced heart disease favored active roles in medical decision-making. Interventions and educational efforts targeting clinicians, AYAs with heart disease, and their caregivers are needed to ensure they are meeting the decision-making and communication preferences of this patient population with complex disease and treatment courses.
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Affiliation(s)
- Melissa K Cousino
- Department of Pediatrics, Michigan Medicine, Ann Arbor
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor
| | - Victoria A Miller
- Division of Adolescent Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Cynthia Smith
- Department of Pediatrics, Michigan Medicine, Ann Arbor
| | - Heang M Lim
- Department of Pediatrics, Michigan Medicine, Ann Arbor
| | - Sunkyung Yu
- Department of Pediatrics, Michigan Medicine, Ann Arbor
| | - Ray Lowery
- Department of Pediatrics, Michigan Medicine, Ann Arbor
| | - Karen Uzark
- Department of Pediatrics, Michigan Medicine, Ann Arbor
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor
| | | | - Joanne Wolfe
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts
| | - Elizabeth D Blume
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts
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Zanaboni D, Yu S, Lowery R, Vitale C, Sood V, Schumacher KR. Contemporary Outcomes of Tracheostomy in Patients With Single Ventricle Heart Lesions. World J Pediatr Congenit Heart Surg 2023; 14:142-147. [PMID: 36823957 DOI: 10.1177/21501351221133775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
Abstract
OBJECTIVES Approximately 0.2% to 2.7% of children with congenital heart disease require a tracheostomy after cardiac surgery with the majority having single ventricle (SV) type heart lesions. Tracheostomy in SV patients is reported to be associated with high mortality. We hypothesized that short- and long-term survival of patients with SV heart disease would vary according to tracheostomy indication. METHODS This is a single center, 20-year, retrospective review of all patients with SV heart disease who underwent tracheostomy. Demographic, cardiac anatomy, surgical, intensive care unit, and hospital course data were collected. The primary outcome was survival following tracheostomy. Secondary outcome was the completion of staged palliation to Fontan. RESULTS In total, 25 patients with SV heart disease who underwent tracheostomy were included. Indications for tracheostomy included one or more of the following: tracheobronchomalacia (n = 8), vocal cord paralysis (n = 7), tracheal/subglottic stenosis (n = 6), primary respiratory insufficiency (n = 4), diaphragm paralysis (n = 3), suboptimal hemodynamics (n = 2), and other upper airway issues (n = 1). Survival at six months, one year, five years, and ten years was 76%, 68%, 63%, and 49%, respectively. Most patients completed Fontan palliation (64%). Patients who underwent tracheostomy for suboptimal hemodynamics and/or respiratory insufficiency had a higher mortality risk compared to those with indications of upper airway obstruction or diaphragm paralysis (hazard ratio 4.1, 95% confidence interval 1.2-13.7; P = .02). CONCLUSIONS Mortality risk varies according to tracheostomy indication in patients with SV heart disease. Tracheostomy may allow staged surgical palliation to proceed with acceptable risk if it was indicated for anatomic or functional airway dysfunction.
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Affiliation(s)
- Dominic Zanaboni
- Division of Pediatric Cardiology, 1259University of Michigan C.S. Mott Children's Hospital, Ann Arbor, MI, USA
| | - Sunkyung Yu
- Division of Pediatric Cardiology, 1259University of Michigan C.S. Mott Children's Hospital, Ann Arbor, MI, USA
| | - Ray Lowery
- Division of Pediatric Cardiology, 1259University of Michigan C.S. Mott Children's Hospital, Ann Arbor, MI, USA
| | - Carolyn Vitale
- Division of Pediatric Cardiology, 1259University of Michigan C.S. Mott Children's Hospital, Ann Arbor, MI, USA
| | - Vikram Sood
- Department of Cardiac Surgery, 1259University of Michigan C.S. Mott Children's Hospital, Ann Arbor, MI, USA
| | - Kurt R Schumacher
- Division of Pediatric Cardiology, 1259University of Michigan C.S. Mott Children's Hospital, Ann Arbor, MI, USA
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Thomas C, Yu S, Lowery R, Zampi JD. Timing of Balloon Atrial Septostomy in Patients with d-TGA and Association with Birth Location and Patient Outcomes. Pediatr Cardiol 2022:10.1007/s00246-022-03079-5. [PMID: 36565310 DOI: 10.1007/s00246-022-03079-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 12/14/2022] [Indexed: 12/25/2022]
Abstract
Patients with d-looped transposition of the great arteries (d-TGA), especially those without an adequate atrial septal defect, can experience severe hypoxemia and hemodynamic compromise in the neonatal period. This can be mitigated by urgent balloon atrial septostomy (BAS). However, some patients with d-TGA are born at centers without this capability. The aim of this retrospective study of d-TGA patients who had urgent or emergent BAS at our institution between 2010 and 2021 was to evaluate time from birth to BAS for infants born at a tertiary care center as compared to those requiring transport from other institutions and to examine correlation between time to BAS and patient outcomes. Our primary outcome was time from birth to BAS. Secondary outcomes included hospital and ICU length of stay, mortality, and evidence of pulmonary or neurologic abnormalities including pulmonary hypertension, abnormal neuroimaging, or seizures. Of 96 patients, 67 (70%) were born at our institution. The median time to BAS was 4 h for patients born at our institution vs. 14.1 h for those born elsewhere (p < .0001). A longer time from birth to BAS was associated with longer ICU (r = 0.21, p = 0.046) and hospital length of stay (r = 0.24, p = 0.02) and increased likelihood of elevated right ventricular pressure on post-operative discharge echocardiogram (p = 0.01). There were no differences in mortality between the groups. Therefore, prenatal planning for patients with known d-TGA should include a delivery plan with access to urgent BAS.
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Affiliation(s)
- Courtney Thomas
- CS Mott Children's Hospital, University of Michigan Congenital Heart Center, Ann Arbor, MI, USA.
| | - Sunkyung Yu
- CS Mott Children's Hospital, University of Michigan Congenital Heart Center, Ann Arbor, MI, USA
| | - Ray Lowery
- CS Mott Children's Hospital, University of Michigan Congenital Heart Center, Ann Arbor, MI, USA
| | - Jeffrey D Zampi
- CS Mott Children's Hospital, University of Michigan Congenital Heart Center, Ann Arbor, MI, USA
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Goldstein SA, Yu S, Lowery R, Halligan NLN, Dahmer MK, Rocchini A. Analysis of inflammatory cytokines in the chest tube drainage of post-operative superior cavopulmonary connection patients. Cardiol Young 2022; 33:1-8. [PMID: 35766168 DOI: 10.1017/s1047951122001913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Prolonged pleural effusions are common post Fontan operation and are associated with morbidity. Fontan pleural effusions have elevated proinflammatory cytokines. Little is known about the chest tube drainage after a superior cavopulmonary connection. We examined the chest tube drainage and the inflammatory profiles in post-operative superior cavopulmonary connection patients. METHODS This prospective cohort study enrolled 25 patients undergoing superior cavopulmonary connection and 10 age-similar controls. Data are also compared to 25 previously published Fontan patients and their 15 age-similar controls. Chest tube samples were analysed with a 17-cytokine BioPlex Assay. Descriptive statistics and univariate comparisons were made between groups. RESULTS Duration of chest tube drainage was significantly shorter in superior cavopulmonary connection patients (median 4 days, [interquartile range 3-5 days]) versus Fontan patients (10 days, [7-11 days], p < 0.0001). Cytokine concentrations were higher on post-operative day 1 in superior cavopulmonary connection patients versus Fontan patients (all p ≤ 0.01), however levels were comparable to age-similar controls. While proinflammatory IL 8, MIP-1β, and TNF-α concentrations increased in chest tube drainage of Fontan patients from post-operative day 1 to last chest tube day (all p < 0.0001), there was no change in these biomarkers in superior cavopulmonary connection patients, their controls, or Fontan controls. CONCLUSIONS Our study demonstrates that after superior cavopulmonary connection, proinflammatory cytokines in the chest tube drainage remain similar to biventricular controls of both age groups, unlike the significant rise over time observed in Fontan patients. Inflammation within the chest tube drainage is likely not innate to single ventricle patients.
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Affiliation(s)
- Stephanie A Goldstein
- University of Utah, Primary Children's Hospital, Division of Pediatric Critical Care, Salt Lake City, UT, USA
| | - Sunkyung Yu
- University of Michigan, C.S. Mott Children's Hospital, Division of Pediatric Cardiology, Ann Arbor, MI, USA
| | - Ray Lowery
- University of Michigan, C.S. Mott Children's Hospital, Division of Pediatric Cardiology, Ann Arbor, MI, USA
| | - Nadine L N Halligan
- University of Michigan, C.S. Mott Children's Hospital, Division of Pediatric Critical Care, Ann Arbor, MI, USA
| | - Mary K Dahmer
- University of Michigan, C.S. Mott Children's Hospital, Division of Pediatric Critical Care, Ann Arbor, MI, USA
| | - Albert Rocchini
- University of Michigan, C.S. Mott Children's Hospital, Division of Pediatric Cardiology, Ann Arbor, MI, USA
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Peng DM, Yu S, Lowery R, Ventresco C, Cousino MK, St Louis JD, Blume ED, Uzark K. Self-reported quality of life in children with ventricular assist devices. Pediatr Transplant 2022; 26:e14237. [PMID: 35102660 DOI: 10.1111/petr.14237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 12/15/2021] [Accepted: 01/10/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND We sought to describe QOL in children with VAD and to identify factors associated with impaired QOL. METHODS There were 82 children (6-19 years) in the Pediatric Interagency Registry for Mechanical Circulatory Support who completed the PedsQL +/- a VAD-specific QOL assessment pre-VAD implant (n = 18), 3 months post-VAD (n = 63), and/or 6 months post-VAD (n = 38). Significantly impaired QOL is a score >1 SD below norms. RESULTS Study patients were 59% male, 67% Caucasian, with cardiomyopathy diagnosis in 82%, and median age at implant of 14 y (IQR 11-17). PedsQL scores were lower than norms for physical (p < .0001) and psychosocial (p < .01) QOL in pre- and post-VAD groups. Compared to chronic health condition and complex or severe heart disease groups, PedsQL scores were lower for physical and psychosocial QOL in the pre-VAD group (p < .0001); however, psychosocial QOL was not significantly different in post-VAD groups. Psychosocial QOL was impaired in 67%, 40%, and 24% in pre-VAD, 3-month, and 6-month post-VAD groups, respectively. Total and psychosocial QOL scores were significantly higher in the 3-month and 6-month post-VAD group than pre-VAD (all p ≤ .02). VAD patients were most bothered by their inability to participate in usual play activities. Impaired QOL 3 months post-VAD was associated with inotropic support >2 weeks/ongoing post-VAD (p = .04). CONCLUSION Physical QOL is significantly impaired in most children pre- and post-VAD. However, psychosocial QOL is not significantly impaired in most children post-VAD suggesting VAD implantation may improve psychosocial QOL in children.
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Affiliation(s)
- David M Peng
- Department of Pediatrics (Cardiology), CS Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan, USA
| | - Sunkyung Yu
- Department of Pediatrics (Cardiology), CS Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan, USA
| | - Ray Lowery
- Department of Pediatrics (Cardiology), CS Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan, USA
| | - Courtney Ventresco
- Department of Cardiology, Boston Children's Hospital, Harvard University, Boston, Massachusetts, USA
| | - Melissa K Cousino
- Department of Pediatrics (Cardiology), CS Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan, USA
| | - James D St Louis
- Department of Surgery, Medical College of Georgia, Children's Hospital of Georgia, Augusta, Georgia, USA
| | - Elizabeth D Blume
- Department of Cardiology, Boston Children's Hospital, Harvard University, Boston, Massachusetts, USA
| | - Karen Uzark
- Department of Pediatrics (Cardiology), CS Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan, USA
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Abstract
Under-diagnosis of pediatric hypertension remains pervasive due to difficulty recognizing elevated systolic blood pressures (SBPs). We performed a retrospective review comparing recognition of and response to elevated SBPs ≥95th percentile before and after development of a clinical decision support tool (CDST) in an academic pediatric system. Of 44,351 encounters, 477 had elevated SBPs with documented recognition of an elevated SBP in 17.9% of encounters pre-CDST that increased to 33.7% post-CDST (P = .001). Post-CDST, 75.5% of elevated SBPs had repeat measurement, with 90.8% of initially elevated SBPs normalizing to <95th percentile. If repeat measurement was obtained and SBP remained elevated, documented recognition increased from 14.0 to 83.3% (P < .0001). These data support using the CDST is associated with increased identification of elevated SBPs in children with greatest improvements associated with repeat SBP measurement. This suggests targeted training and support systems at medical intake would be high yield for increasing recognition of elevated SBP.
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Affiliation(s)
- Joshua K Meisner
- Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Sunkyung Yu
- Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Ray Lowery
- Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Wen Liang
- Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Kurt R Schumacher
- Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Heather L Burrows
- Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
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12
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McCormick A, Lim H, Yu S, Lowery R, Viers S, Uzark K, Schumacher K, Cousino M. Health-Related Quality of Life in Adolescents and Young Adults with Heart Failure. J Heart Lung Transplant 2022. [DOI: 10.1016/j.healun.2022.01.1273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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13
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Harrison DJ, Uzark K, Gauvreau K, Yu S, Lowery R, Yetman AT, Cramer J, Rudd N, Cohen S, Gurvitz M. Transition readiness in congenital heart disease: Are teens and young adults getting the recommended information? International Journal of Cardiology Congenital Heart Disease 2022. [DOI: 10.1016/j.ijcchd.2021.100311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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14
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Wilson HC, Lu JC, Yu S, Lowery R, Mahani MG, Agarwal PP, Dorfman AL. Ventricular Function in Physiologically Repaired and Unrepaired Congenitally Corrected Transposition of the Great Arteries. Am J Cardiol 2022; 165:95-100. [PMID: 34895701 DOI: 10.1016/j.amjcard.2021.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 10/29/2021] [Accepted: 11/01/2021] [Indexed: 11/24/2022]
Abstract
In patients with congenitally corrected transposition of the great arteries (ccTGA) and hemodynamically significant concomitant lesions, physiologic repair may be undertaken, in which the circulation is septated but the morphologic right ventricle (RV) remains the systemic ventricle. Patients without significant concomitant lesions may be observed without surgery, with a similar physiologic result. We compared cardiovascular magnetic resonance measures of ventricular size and function in patients with physiologically repaired and unrepaired ccTGA. Patients with ccTGA who underwent cardiovascular magnetic resonance at our center between September 2007 and July 2019 were analyzed. In 38 patients identified (12, physiologically repaired; 26, unrepaired; mean age 34.5 [18.7 to 52.0] years), there was a higher proportion of RV ejection fraction ≤45% in physiologically repaired (75% vs unrepaired 35%, p = 0.02). Physiologically repaired patients had worse left ventricle global longitudinal strain (-14.9% ± 5.0% vs unrepaired patients -18.4% ± 2.7%, p = 0.04). The difference in tricuspid regurgitant fraction between groups did not achieve statistical significance (physiologically repaired 27.4 ± 11.1% vs unrepaired patients 19.2 ± 13.0%, p = 0.08). Evaluation for late gadolinium enhancement was more commonly undertaken in physiologically repaired patients (8 of 12 vs unrepaired 7 of 26, p = 0.03) and present more frequently in the left ventricle in physiologically repaired patients in patients evaluated (6 of 8 vs unrepaired 0 of 7, p = 0.01). In conclusion, ventricular function is decreased in patients with ccTGA undergoing physiologic repair compared with those without previous surgery. These cohorts should be considered separately when using ventricular function as an outcome. RV dysfunction is concerning for long-term outcomes following physiologic repair.
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15
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McAree D, Yu S, Schumacher KR, Lowery R, McCormick AD, Thorsson T, Peng DM. Predictors and clinical significance of pericardial effusions after pediatric heart transplantation. Pediatr Transplant 2022; 26:e14153. [PMID: 34585497 DOI: 10.1111/petr.14153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 08/15/2021] [Accepted: 09/01/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND We aimed to describe the incidence, risk factors, and clinical outcomes of pericardial effusions within 6 months after pediatric heart transplantation (HT). METHODS A single-center retrospective cohort study was performed on all pediatric HT recipients from 2004 to 2018. Logistic regression was used to identify factors associated with pericardial effusions post-HT, and survival was compared using log-rank test. RESULTS During the study period, 97 HTs were performed in 93 patients. Fifty patients (52%) had a ≥small pericardial effusion within 6 months, 16 of which were, or became, ≥moderate in size. Pericardial drain was placed in 8 patients. In univariate analysis, larger recipient body surface area (p = .01) and non-congenital heart disease (p = .002) were associated with pericardial effusion development. Donor/recipient size ratios, post-HT hemodynamics, and rejection did not correlate with pericardial effusion development. In multivariable analysis, non-congenital heart disease (adjusted odds ratio 3.3, p = .01) remained independently associated with development of pericardial effusion. There were no significant differences in post-HT survival between patients with and without ≥small (p = .68) or ≥moderate pericardial effusions (p = .40). CONCLUSIONS Pericardial effusions are common after pediatric HT. Patients with cardiomyopathy, or non-congenital heart disease, were at higher risk for post-HT pericardial effusions. Pericardial effusions increased morbidity but had no effect on mortality in our cohort. The risk factors identified may be used for anticipatory guidance in pediatric HT.
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Affiliation(s)
- Daniel McAree
- Department of Pediatrics, Division of Pediatric Cardiology, University of Michigan Congenital Heart Center, C.S. Mott Children's Hospital, Ann Arbor, Michigan, USA
| | - Sunkyung Yu
- Department of Pediatrics, Division of Pediatric Cardiology, University of Michigan Congenital Heart Center, C.S. Mott Children's Hospital, Ann Arbor, Michigan, USA
| | - Kurt R Schumacher
- Department of Pediatrics, Division of Pediatric Cardiology, University of Michigan Congenital Heart Center, C.S. Mott Children's Hospital, Ann Arbor, Michigan, USA
| | - Ray Lowery
- Department of Pediatrics, Division of Pediatric Cardiology, University of Michigan Congenital Heart Center, C.S. Mott Children's Hospital, Ann Arbor, Michigan, USA
| | - Amanda D McCormick
- Department of Pediatrics, Division of Pediatric Cardiology, University of Michigan Congenital Heart Center, C.S. Mott Children's Hospital, Ann Arbor, Michigan, USA
| | - Thor Thorsson
- Department of Pediatrics, Division of Pediatric Cardiology, University of Michigan Congenital Heart Center, C.S. Mott Children's Hospital, Ann Arbor, Michigan, USA
| | - David M Peng
- Department of Pediatrics, Division of Pediatric Cardiology, University of Michigan Congenital Heart Center, C.S. Mott Children's Hospital, Ann Arbor, Michigan, USA
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DeWeert KJ, Gelehrter S, Yu S, Hood MC, Lowery R, Smith C. Perception of parental understanding and parental knowledge acquisition following prenatal counseling for congenital heart disease. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.11.136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
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17
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Manning LN, Schumacher KR, Friedland-Little JM, Yu S, Lowery R, Goldstein BH, Charpie JR. Impact of Protein-Losing Enteropathy on Inflammatory Biomarkers and Vascular Dysfunction in Fontan Circulation. Am J Cardiol 2021; 155:128-134. [PMID: 34315570 DOI: 10.1016/j.amjcard.2021.06.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 06/10/2021] [Accepted: 06/14/2021] [Indexed: 10/20/2022]
Abstract
Fontan palliation has improved survival for single ventricle patients, but long-term complications persist including cardiovascular dysfunction, neurohormonal abnormalities, and protein-losing enteropathy (PLE). Although chronic inflammation contributes to morbidity, an association between inflammation and vascular dysfunction has not been studied. We assessed inflammation and vascular function in 31 Fontan-palliated patients (52% male, median age 14.3 years), including 10 PLE+. Fontan circulation was associated with altered inflammatory cytokines (TNF-α: mean 2.5 ± 1.4 vs. 0.7 ± 0.2 pg/ml, p < 0.0001; sTNFR2: 371 ± 108 vs. 2694 ± 884 pg/ml, p < 0.0001) and vascular dysfunction [log-transformed reactive hyperemia index (lnRHI) 0.28 ± 0.19 vs. 0.47 ± 0.26, p < 0.01; augmentation index (AI) -2.9 ± 13.8 vs. -16.3 ± 12.0, p = 0.001; circulating endothelial progenitor cells (cEPCs) 5.0 ± 8.1 vs. 22.8 ± 15.9, p = 0.0002)]. Furthermore, PLE+ patients showed greater inflammation (IFN-γ 6.3 ± 2.2 vs. 11.5 ± 7.9 pg/ml, p = 0.01; sTNFR1: 1181 ± 420 vs. 771 ± 350 pg/ml, p = 0.01) and decreased arterial compliance (AI: 5.4 ± 17.1 vs. -6.8 ± 10.2, p = 0.02) than PLE- patients. Circulating EPCs, but not inflammatory cytokines, were inversely associated with arterial stiffness in Fontan patients. In conclusion, chronic inflammation and vascular dysfunction are observed after Fontan operation, with greater inflammation and arterial stiffness in Fontan patients with active PLE. However, there is no clear association between inflammatory cytokines and vascular dysfunction, suggesting these pathophysiologic processes are not mechanistically linked.
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18
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Hale BW, Lu JC, Romano JC, Lowery R, Yu S, Norris MD. Kommerell diverticulum: distinctions between arch side, and evaluation of morphology, size, and risk. Ann Thorac Surg 2021; 114:848-856. [PMID: 34283954 DOI: 10.1016/j.athoracsur.2021.06.035] [Citation(s) in RCA: 2] [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] [Received: 12/13/2020] [Revised: 05/05/2021] [Accepted: 06/01/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND Kommerell diverticulum (KD) is a dilated proximal aberrant subclavian artery associated with either right or left aortic arches (RAA-ARSA or LAA-ALSA). Although case series suggest KD may be a liability for vascular complications, the risk, pattern of dilation throughout the lifespan, and differences between arch sides, are not known. METHODS A single-center retrospective review of patients of all ages with KD on cross-sectional imaging. Maximal short axis diameter of KD (KDmax), absolute and indexed to descending aortic (DAo) diameter, was correlated with age. Comparisons were made between arch sides. Patients with vascular complications are described. RESULTS One hundred and four patients with KD were included [68 (65%) RAA-ALSA, 36 (35%) LAA-ARSA; 43 (41%) asymptomatic]. Although KDmax was correlated with age (RAA-ALSA r=0.84 [p<.0001]; LAA-ARSA r=0.51 [p=0.001]), KDmax/DAo was not (RAA-ALSA r=0.14 [p=0.27]; LAA-ARSA r=-0.22 [p=0.21]). RAA-ALSA had larger KDmax/DAo (1.02±0.20 vs 0.89±0.18 mm/mm, p=0.002), more symptoms (75% vs 28%, p <.0001), and younger age (median 9.5 vs 61.7 years, p<.0001). Six patients had vascular complications, age 58-80 years, all with LAA-ARSA and risk factors for acquired aneurysms. CONCLUSIONS In older patients, KDmax/DAo was not larger, arguing against isolated KD dilation with age. Diverticula from RAA-ALSA and LAA-ARSA demonstrate different phenotypes, suggesting different disease processes and likely different risk. The incidence of vascular complication was lower than previous reports, and occurred exclusively in patients with LAA-ARSA and aneurysm risk factors. This suggests conservative management of asymptomatic KD is often reasonable, especially with RAA-ALSA.
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Affiliation(s)
- Benjamin W Hale
- University of Michigan Congenital Heart Center, C.S. Mott Children's Hospital, Ann Arbor, Michigan; University of Michigan Adult Congenital Heart Disease Program, Ann Arbor, Michigan.
| | - Jimmy C Lu
- University of Michigan Congenital Heart Center, C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Jennifer C Romano
- University of Michigan Congenital Heart Center, C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Ray Lowery
- University of Michigan Congenital Heart Center, C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Sunkyung Yu
- University of Michigan Congenital Heart Center, C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Mark D Norris
- University of Michigan Congenital Heart Center, C.S. Mott Children's Hospital, Ann Arbor, Michigan; University of Michigan Adult Congenital Heart Disease Program, Ann Arbor, Michigan
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19
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Goldstein S, Yu S, Lowery R, Halligan N, Dahmer M, Rocchini A. ANALYSIS OF INFLAMMATORY CYTOKINES IN THE CHEST TUBE DRAINAGE OF POSTOPERATIVE SUPERIOR CAVO-PULMONARY CONNECTION PATIENTS. J Am Coll Cardiol 2021. [DOI: 10.1016/s0735-1097(21)01839-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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20
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Peng D, Yu S, Lowery R, Ventresco C, Blume E, Uzark K. Self-Reported Quality of Life in Children on Ventricular Assist Devices: A Pedimacs Analysis. J Heart Lung Transplant 2021. [DOI: 10.1016/j.healun.2021.01.509] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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21
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Cousino M, Blume E, Smith C, Lim H, Yu S, Lowery R, Viers S, Uzark K, Fredericks E, Miller V, Schumacher K. Palliative and End of Life Care Preferences in Adolescents and Young Adults with Heart Failure. J Heart Lung Transplant 2021. [DOI: 10.1016/j.healun.2021.01.385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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22
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Srnka CM, Strohacker CM, Balasubramanian S, Yu S, Lowery R, Lu JC. Improving adherence to echocardiogram reporting guidelines in patients with repaired tetralogy of fallot: A quality improvement initiative. Echocardiography 2021; 38:596-603. [PMID: 33729621 DOI: 10.1111/echo.15030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 01/30/2021] [Accepted: 03/01/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND In patients with repaired tetralogy of Fallot (TOF), key echocardiogram report elements have been identified, but poor adherence has been demonstrated, particularly for quantitative assessment. We report a quality improvement effort to improve adherence at our institution, with a focus on increasing quantitative assessment of right ventricular (RV) function. METHODS Baseline compliance was established by a 3-month retrospective review of outpatient echocardiogram reports. Intervention 1 included presenting baseline data and reviewing the guidelines with echocardiogram laboratory staff (physicians and sonographers). Intervention 2, chosen to focus on quantitative assessment of RV function, involved recommending measurement of tricuspid annular plane systolic excursion (TAPSE) for all echocardiograms. Reporting rates were prospectively analyzed for 1 month after each intervention. To evaluate sonographer versus physician compliance, both study images (acquisition of TAPSE images) and reports were reviewed. RESULTS At baseline, adherence was poor (median 65% of elements reported), with lower rates for measurements versus descriptive elements (median 40% vs 78%, p<.0001). Following intervention 1, total reported elements improved (median 71% vs 65%, p=0.02) due to increase in measurements (median 50% vs 40%, p=0.02). Reports of quantitative RV function did not significantly change after either intervention, but sonographer compliance improved after intervention 1 (33% vs 14%, p=0.03), with further improvement after intervention 2 (53% vs 14%, p=0.001). CONCLUSION While education on lesion-specific guidelines may modestly improve adherence, standardization has a greater effect. However, interventions may have differential impact on sonographers versus attendings, and iterative interventions may be required to change practice patterns.
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Affiliation(s)
- Charlotte M Srnka
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Courtney M Strohacker
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Sowmya Balasubramanian
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Sunkyung Yu
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Ray Lowery
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Jimmy C Lu
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
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Porter A, Yu S, Lowery R, Fifer CG, Lu JC. Echocardiographic Findings Associated with Transplantation-Free Survival and Left Ventricular Systolic Function at Midterm Follow-Up after Ross Procedure in Infants with Critical Aortic Stenosis. J Am Soc Echocardiogr 2020; 34:522-528.e1. [PMID: 33385500 DOI: 10.1016/j.echo.2020.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 12/21/2020] [Accepted: 12/21/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND The Ross operation is an important option for children with critical aortic stenosis with residual disease, but operation in infancy is associated with significant morbidity and mortality. The aim of this study was to evaluate echocardiographic correlates of transplantation-free survival, reintervention, and left ventricular (LV) function in midterm follow-up. METHODS This retrospective, single-center study included all infants with critical aortic stenosis who underwent Ross by 1 year of age from January 2000 to September 2018. Serial echocardiograms were analyzed for LV ejection fraction (LVEF) and systolic and diastolic longitudinal strain. The primary outcome was mortality or transplantation; secondary outcomes were reintervention and abnormal LVEF (≤55%). RESULTS Among 40 infants (30 male [75%]; median age at Ross, 51 days) with median follow-up duration of 3.3 years (interquartile range, 1.0-9.4 years), the primary outcome was met in 11 (28%). Rates of transplantation-free survival was 79%, 77%, and 69% at 1, 5, and 10 years after Ross. Predictors of transplantation or death included neonatal surgery, cross-clamp time, and preoperative left atrial dilatation and lower LVEF. Median freedom from reintervention was 7.1 years after Ross, with no identified associations. LV longitudinal strain improved 1 year after Ross (-21.1 ± 3.8% vs -17.4 ± 5.1%, P = .02), although LVEF did not reach significance. Lower LVEF at 1 year was related to pre-Ross left atrial dilatation (P = .02), abnormal LVEF (P = .04), and lower early diastolic longitudinal strain rate (P = .03). LVEF remained stable 3 years after Ross. CONCLUSIONS Both transplantation-free survival and normalization of LV function after Ross in infancy are associated with preoperative LV systolic and diastolic measures, highlighting the prognostic value of echocardiography in this population. Further data are necessary in a larger, multicenter cohort to allow more precise risk stratification.
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Affiliation(s)
- Andrew Porter
- Department of Pediatrics, Division of Pediatric Cardiology, Emory University, Atlanta, Georgia
| | - Sunkyung Yu
- Department of Pediatrics, Division of Pediatric Cardiology, University of Michigan Congenital Heart Center, Ann Arbor, Michigan
| | - Ray Lowery
- Department of Pediatrics, Division of Pediatric Cardiology, University of Michigan Congenital Heart Center, Ann Arbor, Michigan
| | - Carlen G Fifer
- Department of Pediatrics, Division of Pediatric Cardiology, University of Michigan Congenital Heart Center, Ann Arbor, Michigan
| | - Jimmy C Lu
- Department of Pediatrics, Division of Pediatric Cardiology, University of Michigan Congenital Heart Center, Ann Arbor, Michigan.
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24
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Patel MD, Dorfman AL, Yu S, Lowery R, Mahani MG, Agarwal PP, Christensen JT, Lu JC. Neo-aortic Root Dilatation, Aortic Stiffness, and Ventricular interactions in Long-Term Follow-Up After the Ross Procedure in Childhood. Pediatr Cardiol 2020; 41:1107-1114. [PMID: 32367305 DOI: 10.1007/s00246-020-02360-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Accepted: 04/23/2020] [Indexed: 11/30/2022]
Abstract
Patients after the Ross procedure are at risk for right (RV) and left ventricular (LV) dysfunction due to neo-aortic and pulmonary dysfunction. While neo-aortic root dilatation has been related to LV dysfunction, the potential contributions of aortic stiffness and ventricular interactions have not been evaluated. Patients status post Ross procedure up to age 18 years with cardiac magnetic resonance (CMR) exam from 2007 to 2018 were retrospectively reviewed. Aortic pulse wave velocity (PWV) was calculated from phase contrast and angiogram images. RV and LV peak global longitudinal (GLS) and circumferential strain (GCS) were measured using tissue tracking software. Multivariable regression was performed for variables associated with parameters of LV function. In 58 patients (median age 20.5 years at CMR exam), male gender, longer time since Ross procedure, aortic root dilatation, and lower RV ejection fraction (EF) were associated with decreased LV EF. There was no association with LV late gadolinium enhancement or neo-aortic or conduit regurgitation. LV GCS and GLS also correlated with RV GCS, RV GLS and PWV. In multivariable analysis, the relation of RV and LV systolic function, but not aortic measurements, remained significant. In conclusion, in long-term follow-up after pediatric Ross procedure, RV function rather than aortic root size or aortic stiffness most closely relates to LV function. Ventricular interactions may impact decision-making on timing of conduit intervention, which could differ from established criteria in populations with only aortic or pulmonary valve disease. Further study is warranted to evaluate possible association with clinical outcome.
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Affiliation(s)
- Mehul D Patel
- Division of Pediatric Cardiology, Department of Pediatrics, University of Texas Health Science Center at Houston, Houston, TX, USA. .,UT Physicians Pediatric Cardiology, 6410 Fannin St, UT Professional Building Suite 425, Houston, TX, 77030, USA.
| | - Adam L Dorfman
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA.,Section of Pediatric Radiology, Department of Radiology, University of Michigan, Ann Arbor, MI, USA
| | - Sunkyung Yu
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Ray Lowery
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Maryam Ghadimi Mahani
- Section of Pediatric Radiology, Department of Radiology, University of Michigan, Ann Arbor, MI, USA.,Division of Cardiothoracic Radiology, Department of Radiology, University of Michigan, Ann Arbor, MI, USA
| | - Prachi P Agarwal
- Division of Cardiothoracic Radiology, Department of Radiology, University of Michigan, Ann Arbor, MI, USA
| | - Jason T Christensen
- Division of Pediatric Cardiology, Department of Pediatrics, University of Nebraska Medical Center, Omaha, NE, USA
| | - Jimmy C Lu
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA.,Section of Pediatric Radiology, Department of Radiology, University of Michigan, Ann Arbor, MI, USA
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Hart MR, Whiteside W, Yu S, Lowery R, Dorfman AL, Ghadimi Mahani M, Agarwal PP, Lu JC. Differences in Pulmonary and Systemic Flow Measurements by Cardiac Magnetic Resonance vs Cardiac Catheterization and Relation to Collateral Flow in Single Ventricle Patients. Pediatr Cardiol 2020; 41:885-891. [PMID: 32100056 DOI: 10.1007/s00246-020-02327-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 02/17/2020] [Indexed: 11/29/2022]
Abstract
Both cardiac magnetic resonance (CMR) and cardiac catheterization (cath) may assess patients with single ventricle physiology prior to stage II or Fontan palliation. However, development of significant aortopulmonary collaterals may invalidate assumptions of the Fick method. We compared CMR and cath flow measurements and evaluated the relation to collateral flow. This single-center study included all pre-stage II and pre-Fontan patients between 2010 and 2017 with CMR and cath within 1 month. Pulmonary (Qp) and systemic flow (Qs) by cath were calculated by Fick method. CMR Qp was calculated by total pulmonary venous flow, and Qs by total vena caval flow. Collateral flow by CMR was the difference of pulmonary vein and pulmonary artery flow. In 26 studies (16 pre-stage II and 10 pre-Fontan) in 21 patients, collateral flow was higher in pre-Fontan patients (1.8 ± 0.6 vs 0.9 ± 0.8 L/min/m2, p = 0.01). Overall, CMR and cath had good agreement for Qs and Qp:Qs, with moderate correlation (r = 0.44, p = 0.02 for Qs, r = 0.48, p = 0.02 for Qp:Qs). In pre-Fontan but not in pre-stage II patients, CMR had higher Qp (mean difference - 1.71 L/min/m2) and Qp:Qs (mean difference - 0.36). The underestimation of cath Qp correlated with amount of collateral flow (r = - 0.47, p = 0.02). Neither cath nor CMR flow measurements correlated with outcomes in this small cohort. In conclusion, collaterals lead to systematically higher Qp and Qp:Qs measurements by CMR vs cath in single ventricle patients. Measurements may not be used interchangeably, with potential clinical significance in estimating pulmonary vascular resistance. Further study is necessary to evaluate possible relation to clinical outcomes.
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Affiliation(s)
- Michael R Hart
- Division of Pediatric Cardiology, Department of Pediatrics, Maine Medical Center, Portland, ME, USA
| | - Wendy Whiteside
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Sunkyung Yu
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Ray Lowery
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Adam L Dorfman
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA.,Section of Pediatric Radiology, Department of Radiology, University of Michigan, Ann Arbor, MI, USA
| | - Maryam Ghadimi Mahani
- Section of Pediatric Radiology, Department of Radiology, University of Michigan, Ann Arbor, MI, USA.,Division of Cardiothoracic Radiology, Department of Radiology, University of Michigan, Ann Arbor, MI, USA
| | - Prachi P Agarwal
- Division of Cardiothoracic Radiology, Department of Radiology, University of Michigan, Ann Arbor, MI, USA
| | - Jimmy C Lu
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA. .,Section of Pediatric Radiology, Department of Radiology, University of Michigan, Ann Arbor, MI, USA. .,C.S. Mott Children's Hospital, University of Michigan Congenital Heart Center, 11th floor, 1540 E. Hospital Dr., Ann Arbor, MI, 48109, USA.
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Uzark K, Yu S, Lowery R, Afton K, Yetman AT, Cramer J, Rudd N, Cohen S, Gongwer R, Gurvitz M. Transition Readiness in Teens and Young Adults with Congenital Heart Disease: Can We Make a Difference? J Pediatr 2020; 221:201-206.e1. [PMID: 32446482 DOI: 10.1016/j.jpeds.2020.02.040] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 02/18/2020] [Accepted: 02/19/2020] [Indexed: 01/05/2023]
Abstract
OBJECTIVES To examine changes in transition readiness (knowledge, self-efficacy, self-management) over time and explore factors associated with transition readiness, including psychosocial quality of life (QOL) and health service utilization in teens/young adults with congenital heart disease. STUDY DESIGN In a multicenter prospective cohort study, 356 patients, age 14-27 years, completed transition readiness and QOL assessments at routine cardiology visits at baseline and 1-year follow-up. RESULTS Median patient age was 19.8 years at 1.03 years (IQR 0.98-1.24) following baseline transition readiness assessment. Average knowledge deficit scores decreased at follow-up (P < .0001) and self-efficacy scores increased (P < .0001). Self-management scores increased (P < .0001), but remained low (mean 57.7, 100-point scale). Information was requested by 73% of patients at baseline and was associated with greater increase in knowledge at follow-up (P = .005). Increased knowledge (P = .003) and perceived self-efficacy (P = .01) were associated with improved psychosocial QOL, but not health service utilization at follow-up. Patients who preferred face-to-face information from healthcare providers (47%) vs other information sources were more likely to request information (P < .0001). In patients <18 years old, greater agreement between teen and parental perception of teen's knowledge was associated with greater increase in patient knowledge (P = .02) and self-efficacy (P = .003). CONCLUSION Transition readiness assessment demonstrated improved knowledge, self-efficacy, and self-management at 1-year follow-up in teens/young adults with congenital heart disease. Improved knowledge and self-efficacy were associated with improved psychosocial QOL. Self-management remained low. Supplemental media for conveying information and greater involvement of parents may be needed to optimize transition readiness.
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Affiliation(s)
- Karen Uzark
- Department of Pediatrics, University of Michigan Mott Children's Hospital, Ann Arbor, MI; Department of Cardiac Surgery, University of Michigan Mott Children's Hospital, Ann Arbor, MI.
| | - Sunkyung Yu
- Department of Pediatrics, University of Michigan Mott Children's Hospital, Ann Arbor, MI
| | - Ray Lowery
- Department of Pediatrics, University of Michigan Mott Children's Hospital, Ann Arbor, MI
| | - Katherine Afton
- Department of Pediatrics, University of Michigan Mott Children's Hospital, Ann Arbor, MI
| | - Anji T Yetman
- Department of Pediatrics, Children's Hospital and Medical Center, Omaha, NE
| | - Jonathan Cramer
- Department of Pediatrics, Children's Hospital and Medical Center, Omaha, NE
| | - Nancy Rudd
- Department of Pediatrics, Children's Hospital of Wisconsin, Milwaukee, WI
| | - Scott Cohen
- Department of Pediatrics, Children's Hospital of Wisconsin, Milwaukee, WI; Department of Internal Medicine, Children's Hospital of Wisconsin, Milwaukee, WI
| | - Russell Gongwer
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Michelle Gurvitz
- Department of Cardiology, Boston Children's Hospital, Boston, MA
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27
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Rodenbarger A, Thorsson T, Stiver C, Jantzen D, Chevenon M, Yu S, Lowery R, Gelehrter S. Third trimester predictors of interventional timing and accuracy of fetal anticipatory guidance in tetralogy of Fallot: A multi-center study. Prenat Diagn 2020; 40:870-877. [PMID: 32274817 DOI: 10.1002/pd.5697] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 03/30/2020] [Accepted: 04/02/2020] [Indexed: 11/09/2022]
Abstract
OBJECTIVE The objective was to evaluate and improve accuracy of anticipatory counseling regarding neonatal intervention for prenatally diagnosed tetralogy of Fallot (TOF) by assessing new and previously published predictors of neonatal intervention. METHODS This is a multi-center, retrospective study from three centers of 112 fetal TOF patients undergoing third trimester fetal echocardiograms from 2004 to 2017. Additional cardiac defects requiring neonatal intervention were excluded. Fetal echocardiographic, clinical, and consultation data were compared between neonatal and late intervention. Optimal echocardiographic values were determined. RESULTS Twenty-six infants (23%) required neonatal intervention. Those infants had significantly different pulmonary valve (PV) z-scores, PV:aortic valve (AoV) ratios, PV:AoV z-score differences (absolute difference between z-scores), and increased likelihood of abnormal ductal flow. Counseling during fetal echocardiogram regarding interventional timing was accurate for 50% needing neonatal intervention and 86% undergoing late intervention (P = .002). The best neonatal intervention predictors were PV:AoV ratio of <0.6 and counseling for neonatal intervention. PV:AoV z-score difference ≥5 provided 89% negative predictive value for excluding patients from neonatal repair. CONCLUSIONS Third trimester fetal echocardiograms can predict interventional timing. The best predictors of neonatal intervention are PV:AoV ratio <0.6, PV:AoV z-score difference ≥5, and cardiologist counseling that neonatal intervention was likely.
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Affiliation(s)
- Andrew Rodenbarger
- Michigan Congenital Heart Center, Mott Children's Hospital, Ann Arbor, Michigan, USA
| | - Thor Thorsson
- Michigan Congenital Heart Center, Mott Children's Hospital, Ann Arbor, Michigan, USA
| | - Corey Stiver
- The Heart Center, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - David Jantzen
- Congenital Heart Center, Children's Hospital of Illinois, Peoria, Illinois, USA
| | - Marie Chevenon
- Congenital Heart Center, Children's Hospital of Illinois, Peoria, Illinois, USA
| | - Sunkyung Yu
- Michigan Congenital Heart Center, Mott Children's Hospital, Ann Arbor, Michigan, USA
| | - Ray Lowery
- Michigan Congenital Heart Center, Mott Children's Hospital, Ann Arbor, Michigan, USA
| | - Sarah Gelehrter
- Michigan Congenital Heart Center, Mott Children's Hospital, Ann Arbor, Michigan, USA
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28
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Cochran CD, Yu S, Gakenheimer-Smith L, Lowery R, Lu JC, Mahani MG, Agarwal PP, Dorfman AL. Identifying Risk Factors for Massive Right Ventricular Dilation in Patients With Repaired Tetralogy of Fallot. Am J Cardiol 2020; 125:970-976. [PMID: 31964501 DOI: 10.1016/j.amjcard.2019.12.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 12/03/2019] [Accepted: 12/09/2019] [Indexed: 12/28/2022]
Abstract
In repaired tetralogy of Fallot (rTOF), pulmonary insufficiency results in varying degrees of right ventricle (RV) dilation. A subset of patients is diagnosed at initial cardiac magnetic resonance imaging (CMR) with a massively dilated RV, far beyond pulmonary valve replacement (PVR) criteria, which is unlikely to return to normal size after PVR. This study aimed to identify risk factors for massive RV dilation at initial CMR. This nested case-control study included all patients at our institution with rTOF and massive RV dilation (indexed RV end-diastolic volume [RVEDVi] ≥200 ml/m2) on initial CMR. Patients were matched by age at first CMR, gender, and type of repair with rTOF controls with RVEDVi<200 ml/m2. In 39 cases (median RVEDVi 227 ml/m2, interquartile range [IQR] 213 to 250) and 73 controls (median RVEDVi 155 ml/m2, IQR 130 to 169), repair at >6 months of age, longer QRS duration, and non-Caucasian race were significantly associated with massive RV dilation on univariate analysis. In multivariate analysis, repair at >6 months of age (adjusted odds ratio [AOR] 2.90, 95% confidence interval [CI] 1.12 to 7.55, p = 0.03), longer QRS duration (AOR = 1.03, 95% CI 1.01 to 1.05, p = 0.005), and non-Caucasian race (AOR = 7.84, 95% CI 1.76 to 34.8, p = 0.01) remained independently associated with massive RV dilation. Era of repair, history of systemic to pulmonary shunt palliation, genetic anomaly, and additional cardiac lesions did not differ between groups. In conclusion, these risk factors identify a subset of patients who may benefit from earlier CMR evaluation to avoid massive irreversible RV dilation.
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Affiliation(s)
- Clinton D Cochran
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan.
| | - Sunkyung Yu
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | | | - Ray Lowery
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - Jimmy C Lu
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - Maryam Ghadimi Mahani
- Section of Cardiothoracic Radiology, Section of Pediatric Radiology, Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | - Prachi P Agarwal
- Section of Cardiothoracic Radiology, Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | - Adam L Dorfman
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
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29
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Cousino MK, Miller VA, Smith C, Uzark K, Lowery R, Rottach N, Blume ED, Schumacher KR. Medical and end-of-life decision making in adolescents' pre-heart transplant: A descriptive pilot study. Palliat Med 2020; 34:272-280. [PMID: 31647374 PMCID: PMC8063635 DOI: 10.1177/0269216319874689] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Adolescents and young adults undergoing heart transplantation experience risks of morbidity and mortality both pre- and post-transplant. To improve end-of-life care for this population, it is necessary to understand their medical and end-of-life decision-making preferences. AIM (1) To examine adolescent/young adult decision-making involvement specific to heart transplant listing, and (2) to characterize their preferences specific to medical and end-of-life decision making. DESIGN This cross-sectional research study utilized survey methods. Data were collected from October 2016 to March 2018. SETTING/PARTICIPANTS Twelve adolescent and young adult patients listed for heart transplant (ages = 12-19 years) and one parent for each were enrolled at a single-center, US children's hospital. RESULTS Consistent with their preferences, the majority of adolescent/young adult participants (82%) perceived a high level of involvement in the decision to be listed for transplant. Patient involvement in this decision was primarily by way of seeking advice or information from their parents and being asked to express their opinion from parents. Despite a preference among patients to discuss their prognosis and be involved in end-of-life decision making if seriously ill, only 42% of patients had discussed their end-of-life wishes with anyone. Few parents recounted having such discussions. Preferences regarding the timing and nature of end-of-life decision-making discussions varied. CONCLUSIONS Although young people are involved in the decision to pursue heart transplantation, little attention is paid to involving them in discussions regarding end-of-life decision making in a manner that is consistent with individual preferences.
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Affiliation(s)
- Melissa K Cousino
- Department of Pediatrics, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA.,University of Michigan Transplant Center, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA.,Congenital Heart Center, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA
| | - Victoria A Miller
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Cynthia Smith
- Congenital Heart Center, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA
| | - Karen Uzark
- Department of Pediatrics, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA.,Congenital Heart Center, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA
| | - Ray Lowery
- Congenital Heart Center, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA
| | - Nichole Rottach
- Congenital Heart Center, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA
| | - Elizabeth D Blume
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - Kurt R Schumacher
- Department of Pediatrics, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA.,University of Michigan Transplant Center, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA.,Congenital Heart Center, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA
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30
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McCormick AD, Schumacher KR, Zamberlan M, Uzark K, Yu S, Lowery R, Rottach N, Cousino MK. Generalized and specific anxiety in adolescents following heart transplant. Pediatr Transplant 2020; 24:e13647. [PMID: 31885147 DOI: 10.1111/petr.13647] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 11/26/2019] [Accepted: 12/09/2019] [Indexed: 12/18/2022]
Abstract
Mental health concerns are associated with worse outcomes after adult heart transplant. Illness-specific anxiety is associated with worsened psychological well-being after other solid organ transplants but has never been characterized after pediatric heart transplant. This single-center cross-sectional study aimed to evaluate illness-specific and generalized anxiety after heart transplantation in adolescents. A novel 12-item PHTF, GAD-7, and the PedsQL were administered. Univariate associations of demographics, clinical features, and medication adherence as measured by immunosuppression standard deviation with the PHTF and GAD-7 scores were evaluated. Internal consistency and validity of the PHTF were examined. In total, 30 patients participated. The most common illness-specific fears were retransplantation, rejection, and more generally post-transplant complications. The PHTF had good internal consistency (Cronbach α = .88). Construct validity was demonstrated between PHTF and GAD-7 (r = .62) and PedsQL (r = -.54 to -.62). 23% endorsed moderate to severe generalized anxiety symptoms. More severe symptoms were associated with older age at survey (P = .03), older age at listing (P = .01) and having post-transplant complications (P = .004). Patients with moderate or severe symptoms were more likely to report late immunosuppression doses (P = .004). Illness-specific and generalized anxiety may be prevalent after pediatric heart transplant. Screening for anxiety in adolescents post-transplant may identify those at risk for adverse outcomes including non-adherence. The PHTF is a brief, valid, and reliable instrument identifying illness-specific anxiety in this population.
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Affiliation(s)
| | - Kurt R Schumacher
- Department of Pediatrics, Michigan Medicine, Ann Arbor, Michigan.,University of Michigan Transplant Center, Ann Arbor, Michigan
| | - Mary Zamberlan
- Department of Pediatrics, Michigan Medicine, Ann Arbor, Michigan
| | - Karen Uzark
- Department of Pediatrics, Michigan Medicine, Ann Arbor, Michigan
| | - Sunkyung Yu
- Department of Pediatrics, Michigan Medicine, Ann Arbor, Michigan
| | - Ray Lowery
- Department of Pediatrics, Michigan Medicine, Ann Arbor, Michigan
| | - Nichole Rottach
- Department of Pediatrics, Michigan Medicine, Ann Arbor, Michigan
| | - Melissa K Cousino
- Department of Pediatrics, Michigan Medicine, Ann Arbor, Michigan.,University of Michigan Transplant Center, Ann Arbor, Michigan
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31
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Wu K, Yu S, Dorfman AL, Lowery R, Agarwal PP, Ghadimi Mahani M, Lu JC. Differential Myocardial Mechanics in Volume and Pressure Loaded Right Ventricles Demonstrated by Cardiac Magnetic Resonance. Pediatr Cardiol 2019; 40:1503-1508. [PMID: 31346663 DOI: 10.1007/s00246-019-02175-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Accepted: 07/19/2019] [Indexed: 11/30/2022]
Abstract
In patients with D-looped transposition of the great arteries (D-TGA) status post atrial switch operation, the systemic right ventricle (RV) shifts to predominantly circumferential (CS) rather than longitudinal strain (LS), which may represent adaptation or dysfunction. We aimed to evaluate myocardial mechanics in pressure loaded, volume-loaded, and normal RVs by cardiac magnetic resonance (CMR). Patients with D-TGA post atrial switch operation with CMR from 2008 to 2015 were matched 1:1 for age and RV ejection fraction (EF) with repaired tetralogy of Fallot (TOF) patients (volume-loaded RVs), and 1:1 for age with control patients. RV free wall LS and CS were measured using feature tracking software (TomTec, Unterscleissheim, Germany). A total of 32 D-TGA (median age 32 years, 56% male), 32 TOF, and 32 control patients were included. D-TGA patients had less dilatation than TOF patients (125 ± 35 ml/m2 vs. 149 ± 44 ml/m2, p = 0.02) and lower RVEF than controls (42.9 ± 7.7% vs. 56.3 ± 5.6%, p < 0.0001). RV LS was similar in D-TGA and TOF ( - 13.2 ± 4.5% vs. - 14.5 ± 5.9%, p = 0.32), both decreased compared to controls. However, CS in D-TGA was higher than controls ( - 14.1 ± 4.1% vs. - 11.4 ± 4.4%, p = 0.01), with a higher CS:LS ratio (1.2 ± 0.7 vs. 0.6 ± 0.3, p < 0.0001), while CS in TOF and controls did not differ. RVEF in D-TGA correlated closely with CS (r = - 0.85, p < 0.0001) but not LS (r = 0.10, p = 0.58). I n conclusion, CMR can differentiate strain patterns in pressure- and volume-loaded RVs, with decreased LS in both conditions, while systemic RVs compensate with supra-normal CS. CS may be a more clinically relevant measure of RV function in this population.
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Affiliation(s)
- Karena Wu
- Division of Pediatric Cardiology, Department of Pediatrics, University of Texas Medical School at Houston, Houston, TX, USA
| | - Sunkyung Yu
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Adam L Dorfman
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA.,Section of Pediatric Radiology, Department of Radiology, University of Michigan, Ann Arbor, MI, USA
| | - Ray Lowery
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Prachi P Agarwal
- Division of Cardiothoracic Radiology, Department of Radiology, University of Michigan, Ann Arbor, MI, USA
| | - Maryam Ghadimi Mahani
- Section of Pediatric Radiology, Department of Radiology, University of Michigan, Ann Arbor, MI, USA.,Division of Cardiothoracic Radiology, Department of Radiology, University of Michigan, Ann Arbor, MI, USA
| | - Jimmy C Lu
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA. .,Section of Pediatric Radiology, Department of Radiology, University of Michigan, Ann Arbor, MI, USA. .,C.S. Mott Children's Hospital, University of Michigan Congenital Heart Center, 1540 E. Hospital Dr., Ann Arbor, MI, 48109-4204, USA.
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32
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Uzark K, Afton K, Yu S, Lowery R, Smith C, Norris MD. Transition Readiness in Adolescents and Young Adults with Heart Disease: Can We Improve Quality of Life? J Pediatr 2019; 212:73-78. [PMID: 31182220 DOI: 10.1016/j.jpeds.2019.04.060] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 04/24/2019] [Accepted: 04/29/2019] [Indexed: 01/26/2023]
Abstract
OBJECTIVES We previously reported common knowledge deficits and lack of transition readiness in 13- 25-year-olds with congenital or acquired heart disease. The aims of this study were to re-evaluate transition readiness in this cohort at follow-up and to examine the relationship between changes in transition readiness and quality of life (QOL). STUDY DESIGN In this prospective cohort study, patients completed the Transition Readiness Assessment and the Pediatric Quality of Life Inventory using an e-tablet, web-based format at a routine follow-up visit. Changes from initial to follow-up scores were evaluated. RESULTS Sixty-five percent of patients (106 of 164) completed follow-up assessments at a median age of 18.7 years (IQR, 16.5-21.2 years) at a median follow-up of 1 year. The average perceived knowledge deficit score (percent of items with no knowledge) at follow-up was 18.0 ± 15.2%, which decreased from 24.7 ± 16.5% (P < .0001). On a 100-point scale, the mean score for self-efficacy increased from 71.4 ± 17.0 to 76.7 ± 18.2 (P = .0004) and for self-management increased from 47.9 ± 18.4 to 52.0 ± 20.7 (P = .004). Although physical QOL did not change, the mean psychosocial QOL score increased significantly (P = .02). A decrease in the knowledge deficit score at follow-up was significantly associated with an increased psychosocial QOL score (P = .03). An increase in the self-efficacy score was associated with an increase in psychosocial QOL score (P = .04), especially social QOL (P = .02). CONCLUSIONS Although deficits in knowledge and self-management skills persist, transition readiness assessment and recognition of deficits can improve transition readiness with improved psychosocial QOL.
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Affiliation(s)
- Karen Uzark
- Department of Pediatrics, University of Michigan Mott Children's Hospital, Ann Arbor, MI; Department of Cardiac Surgery, University of Michigan Mott Children's Hospital, Ann Arbor, MI.
| | - Katherine Afton
- Department of Pediatrics, University of Michigan Mott Children's Hospital, Ann Arbor, MI
| | - Sunkyung Yu
- Department of Pediatrics, University of Michigan Mott Children's Hospital, Ann Arbor, MI
| | - Ray Lowery
- Department of Pediatrics, University of Michigan Mott Children's Hospital, Ann Arbor, MI
| | - Cynthia Smith
- Department of Pediatrics, University of Michigan Mott Children's Hospital, Ann Arbor, MI
| | - Mark D Norris
- Department of Pediatrics, University of Michigan Mott Children's Hospital, Ann Arbor, MI
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33
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McCormick A, Schumacher K, Zamberlan M, Uzark K, Yu S, Lowery R, Rottach N, Cousino M. Illness Specific Anxiety Following Pediatric Heart Transplant. J Heart Lung Transplant 2019. [DOI: 10.1016/j.healun.2019.01.218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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34
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Mazurek AA, Yu S, Lowery R, Ohye RG. Routine Septal Myectomy During Subaortic Stenosis Membrane Resection: Effect on Recurrence Rates. Pediatr Cardiol 2018; 39:1627-1634. [PMID: 30310939 DOI: 10.1007/s00246-018-1941-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 07/23/2018] [Indexed: 11/30/2022]
Abstract
Recurrence of subaortic stenosis (SubAS) is up to ~ 19% following resection. Historically, treatment has consisted of membrane resection alone. This study investigated the effect of routine septal myectomy in addition to membrane resection. A single-center retrospective review was performed in all patients < 18 years of age undergoing membrane resection with septal myectomy for SubAS from 2003 to 2013. Demographic, perioperative, and follow-up data were collected. Freedom from reoperation and risk factors for reoperation were determined. 107 patients (median age 4.8 years) were included. There was one in-hospital death, five patients (5%) requiring pacemaker, and no iatrogenic ventricular septal defects. Follow-up was 80% complete and median follow-up was 4.9 years (range 0.5-12 years). Fourteen (16%) subjects required reoperation. Freedom from reoperation was 98% at 1 year, 86% at 5 years, and 69% at 10 years (Fig. 1). There was no difference in decrease of peak gradient between subjects who did and did not require reoperation (- 47 vs. - 40 mmHg; p = 0.59). In univariate analysis, chromosomal anomaly (hazard ratio [HR] 5.0, p = 0.02), smaller body surface area (HR 0.1, p = 0.03), and younger age at surgery (HR 0.7, p = 0.01) were significantly associated with reoperation. The routine use of myectomy with membrane excision did not result in a lower rate of reoperation or higher rates of complications compared to historical controls. Younger age, smaller size, and chromosomal anomaly were associated with increased risk for reoperation. Patients with these risk factors may benefit from more intensive long-term follow-up.
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Affiliation(s)
- Alyssa A Mazurek
- Massachusetts General Hospital, 2 Leighton Street, Unit 310, Cambridge, MA, 02141, USA.
| | - Sunkyung Yu
- Michigan Medicine Congenital Heart Center, C.S. Mott Children's Hospital, Ann Arbor, MI, USA
| | - Ray Lowery
- Michigan Medicine Congenital Heart Center, C.S. Mott Children's Hospital, Ann Arbor, MI, USA
| | - Richard G Ohye
- Pediatric Cardiovascular Surgery, C.S. Mott Children's Hospital, Ann Arbor, MI, USA
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Hancock HS, Romano JC, Armstrong A, Yu S, Lowery R, Gelehrter S. Single Ventricle and Total Anomalous Pulmonary Venous Connection: Implications of Prenatal Diagnosis. World J Pediatr Congenit Heart Surg 2018; 9:434-439. [PMID: 29945508 DOI: 10.1177/2150135118771344] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Single ventricle (SV) patients with total anomalous pulmonary venous connection (TAPVC) are at high risk. Given the limited published data available, we examined outcomes and the implications of a prenatal diagnosis of SV/TAPVC. METHODS A single-center, retrospective review was performed in neonates with SV/TAPVC from 1998 to 2014, identified through institutional databases. Patient demographic, perioperative, and follow-up data were collected. RESULTS Thirty-four eligible infants with SV/TAPVC were identified (mean birth weight: 3.0 kg). The TAPVC types were supracardiac (59%), infracardiac (21%), mixed (12%), and cardiac (9%). Heterotaxy syndrome was present in 25 (74%) infants. A prenatal diagnosis of SV was made in 26 (76%) infants, with TAPVC identified in 12 (35%). Seventeen (50%) had obstructed TAPVC within the first 48 hours of life; 7 of these patients had obstructed TAPVC identified prenatally. There were two preoperative deaths. Overall survival for the cohort was 65% at 1 year and 50% at 3 years. Survival in the obstructed group was significantly worse compared to the unobstructed group (47% vs 81% at 1 year; 27% vs 73% at 3 years, P = .01). Obstructed TAPVC and a prenatal prediction of obstructed TAPVC were significantly associated with postoperative mortality ( P = .01 and .03, respectively). CONCLUSIONS Patients with SV/TAPVC remain a high-risk group, with obstructed TAPVC a significant risk factor for mortality. Prenatal diagnosis of TAPVC in SV patients is challenging, but given those with obstructed TAPVC are especially at high risk, improved prenatal diagnostic techniques in this group may enhance counseling/delivery planning.
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Affiliation(s)
- Hayley S Hancock
- 1 Division of Pediatric Cardiology, Department of Pediatrics, Ward Family Heart Center, Children's Mercy Kansas City, Kansas City, MO, USA
| | - Jennifer C Romano
- 2 Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA.,3 Section of Pediatric Cardiac Surgery, Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Aimee Armstrong
- 4 Division of Pediatric Cardiology, Department of Pediatrics, The Heart Center, Nationwide Children's Hospital, Columbus, OH, USA
| | - Sunkyung Yu
- 2 Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Ray Lowery
- 2 Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Sarah Gelehrter
- 2 Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
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Pizzuto M, Patel M, Romano J, Retzloff L, Yu S, Lowery R, Gelehrter S. Similar Interstage Outcomes for Single Ventricle Infants Palliated With an Aortopulmonary Shunt Compared to the Norwood Procedure. World J Pediatr Congenit Heart Surg 2018; 9:407-411. [PMID: 29945506 DOI: 10.1177/2150135118768720] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Interstage outcomes for single ventricle infants following Norwood operation have been well studied, showing significant mortality. Other single ventricle infants require only an aortopulmonary shunt. The aim of the study was to describe the interstage outcomes of this group compared to Norwood patients and identify risk factors for mortality. METHODS A single-center retrospective cohort review was performed in patients who underwent a Norwood operation (Norwood) or aortopulmonary shunt (Shunt) during 2000 to 2011 and survived to discharge. Hybrid or pulmonary artery banding patients were excluded. Univariate comparison was made between Norwood and Shunt patients as well as a Shunt subgroup analysis. RESULTS A total of 486 patients (368 Norwood and 118 Shunt) were included. Norwood and Shunt patients were similar in terms of preterm birth, surgery weight, and stage 1 complications. Shunt patients were more likely to be female, have an extracardiac or genetic anomaly, and have a shorter hospital length of stay compared to the Norwood patients (all P < .0001). No significant difference in interstage mortality was seen between the Shunt and Norwood patients (6.8% vs 11.1%, respectively; P = .17). Stage 2 mortality was also similar (Shunt 4.6% vs Norwood 7.8%; P = .25). In the Shunt patients, those who died during interstage weighed less at surgery (2.7 [0.7] kg vs 3.3 [0.7] kg, P = .03) and were more likely to have arrhythmias (50% vs 12%, P = .01), compared to survivors. CONCLUSIONS Shunt patients have an interstage mortality that is not significantly less than Norwood patients. Lower weight at surgery and arrhythmias are risk factors for interstage death in Shunt patients.
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Affiliation(s)
- Matthew Pizzuto
- 1 C.S. Mott Hospital, University of Michigan, Ann Arbor, MI, USA.,2 Duke Children's Hospital, Duke University, Durham, NC, USA
| | - Mehul Patel
- 3 UT Health Science Center San Antonio, San Antonio, TX, USA
| | - Jennifer Romano
- 1 C.S. Mott Hospital, University of Michigan, Ann Arbor, MI, USA
| | - Lauren Retzloff
- 1 C.S. Mott Hospital, University of Michigan, Ann Arbor, MI, USA
| | - Sunkyung Yu
- 1 C.S. Mott Hospital, University of Michigan, Ann Arbor, MI, USA
| | - Ray Lowery
- 1 C.S. Mott Hospital, University of Michigan, Ann Arbor, MI, USA
| | - Sarah Gelehrter
- 1 C.S. Mott Hospital, University of Michigan, Ann Arbor, MI, USA
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Schumacher KR, Yu S, Butts R, Castleberry C, Chen S, Edens E, Godown J, Johnson J, Kemna M, Lin K, Lowery R, Simpson K, West S, Wilmot I, Gossett JG. Fontan-associated protein-losing enteropathy and post‒heart transplant outcomes: A multicenter study. J Heart Lung Transplant 2018; 38:17-25. [PMID: 30391195 DOI: 10.1016/j.healun.2018.09.024] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 08/08/2018] [Accepted: 09/25/2018] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The influence of Fontan-associated protein-losing enteropathy's (PLE) severity, duration, and treatment on heart transplant (HTx) outcomes is unknown. We hypothesized that long-standing PLE and PLE requiring more intensive therapy are associated with increased post-HTx mortality. METHODS This 12-center, retrospective cohort study of post-Fontan patients with PLE referred for HTx from 2003 to 2015 involved collection of demographic, medical, surgical, and catheterization data, as well as PLE-specific data, including duration of disease, intensity/details of treatment, hospitalizations, and complications. Factors associated with waitlist and post-HTx outcomes and PLE resolution were sought. RESULTS Eighty patients (median of 5 per center) were referred for HTx evaluation. Of 68 patients listed for HTx, 8 were removed due to deterioration, 4 died waiting, and 4 remain listed. In 52 patients undergoing HTx, post-HTx 1-month survival was 92% and 1-year survival was 83%. PLE-specific factors, including duration of PLE pre-HTx, pre-HTx hospitalizations, need for/frequency of albumin replacement, PLE therapies, and growth parameters had no association with post-HTx mortality. Immunosuppressant regimen was associated with mortality; standard mycophenolate mofetil immunotherapy was used in 95% of survivors compared with only 44% of non-survivors (p = 0.03). Rejection (53%) and infection (42%) post-HTx were common, but not associated with PLE-specific factors. PLE resolved completely in all but 1 HTx survivor at a median of 1 month (interquartile range 1 to 3 months); resolution was not affected by PLE-specific factors. CONCLUSIONS PLE severity, duration, and treatment do not influence post-HTx outcome, but immunosuppressive regimen may have an impact on survival. PLE resolves in nearly all survivors.
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Affiliation(s)
- Kurt R Schumacher
- University of Michigan Congenital Heart Center, Ann Arbor, Michigan, USA.
| | - Sunkyung Yu
- University of Michigan Congenital Heart Center, Ann Arbor, Michigan, USA
| | - Ryan Butts
- University of Texas-Southwestern Children's Medical Center Dallas, Dallas, Texas, USA
| | - Chesney Castleberry
- Washington University, St. Louis Children's Hospital, St. Louis, Missouri, USA
| | - Sharon Chen
- Stanford University, Lucile Packard Children's Hospital, Palo Alto, California, USA
| | - Erik Edens
- University of Iowa, Iowa City, Iowa, USA
| | - Justin Godown
- Vanderbilt University, Monroe Carell Chidren's Hospital, Nashville, Tennessee, USA
| | | | - Mariska Kemna
- Seattle Children's Hospital, Seattle, Washington, USA
| | - Kimberly Lin
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Ray Lowery
- University of Michigan Congenital Heart Center, Ann Arbor, Michigan, USA
| | - Kathleen Simpson
- Washington University, St. Louis Children's Hospital, St. Louis, Missouri, USA
| | - Shawn West
- Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ivan Wilmot
- Cincinnati Children's Medical Center, Cincinnati, Ohio, USA
| | - Jeffrey G Gossett
- University of California‒San Francisco Benioff Children's Hospital, San Francisco, California, USA
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Cochran C, Gakenheimer-Smith L, Yu S, Lowery R, Lu J, Mahani MG, Agarwal P, Dorfman A. IDENTIFYING RISK FACTORS FOR MASSIVE RIGHT VENTRICULAR DILATION IN PATIENTS WITH REPAIRED TETRALOGY OF FALLOT. J Am Coll Cardiol 2018. [DOI: 10.1016/s0735-1097(18)31160-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Johnson JN, Yu S, Lowery R, Butts R, Castleberry C, Chen S, Edens E, Godown J, Gossett J, Kemna M, Lin K, Simpson K, West S, Wilmot I, Schumacher K. TREATMENT VARIATION AND ITS IMPLICATION FOR SEVERE FONTAN-ASSOCIATED PROTEIN LOSING ENTEROPATHY. J Am Coll Cardiol 2018. [DOI: 10.1016/s0735-1097(18)31165-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Lu JC, Lowery R, Yu S, Ghadimi Mahani M, Agarwal PP, Dorfman AL. Predictors of missed appointments in patients referred for congenital or pediatric cardiac magnetic resonance. Pediatr Radiol 2017; 47:911-916. [PMID: 28432402 DOI: 10.1007/s00247-017-3851-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Revised: 02/19/2017] [Accepted: 03/27/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND Congenital cardiac magnetic resonance is a limited resource because of scanner and physician availability. Missed appointments decrease scheduling efficiency, have financial implications and represent missed care opportunities. OBJECTIVE To characterize the rate of missed appointments and identify modifiable predictors. MATERIALS AND METHODS This single-center retrospective study included all patients with outpatient congenital or pediatric cardiac MR appointments from Jan. 1, 2014, through Dec. 31, 2015. We identified missed appointments (no-shows or same-day cancellations) from the electronic medical record. We obtained demographic and clinical factors from the medical record and assessed socioeconomic factors by U.S. Census block data by patient ZIP code. Statistically significant variables (P<0.05) were included into a multivariable analysis. RESULTS Of 795 outpatients (median age 18.5 years, interquartile range 13.4-27.1 years) referred for congenital cardiac MR, a total of 91 patients (11.4%) missed appointments; 28 (3.5%) missed multiple appointments. Reason for missed appointment could be identified in only 38 patients (42%), but of these, 28 (74%) were preventable or could have been identified prior to the appointment. In multivariable analysis, independent predictors of missed appointments were referral by a non-cardiologist (adjusted odds ratio [AOR] 5.8, P=0.0002), referral for research (AOR 3.6, P=0.01), having public insurance (AOR 2.1, P=0.004), and having scheduled cardiac MR from November to April (AOR 1.8, P=0.01). CONCLUSION Demographic factors can identify patients at higher risk for missing appointments. These data may inform initiatives to limit missed appointments, such as targeted education of referring providers and patients. Further data are needed to evaluate the efficacy of potential interventions.
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Affiliation(s)
- Jimmy C Lu
- Department of Pediatrics and Communicable Diseases, Division of Pediatric Cardiology, University of Michigan Health System, University of Michigan Congenital Heart Center, C. S. Mott Children's Hospital, 1540 E. Hospital Drive, Ann Arbor, MI, 48109-4204, USA.
- Department of Radiology, University of Michigan Health System, Section of Pediatric Radiology, C. S. Mott Children's Hospital, Ann Arbor, MI, USA.
| | - Ray Lowery
- Department of Pediatrics and Communicable Diseases, Division of Pediatric Cardiology, University of Michigan Health System, University of Michigan Congenital Heart Center, C. S. Mott Children's Hospital, 1540 E. Hospital Drive, Ann Arbor, MI, 48109-4204, USA
| | - Sunkyung Yu
- Department of Pediatrics and Communicable Diseases, Division of Pediatric Cardiology, University of Michigan Health System, University of Michigan Congenital Heart Center, C. S. Mott Children's Hospital, 1540 E. Hospital Drive, Ann Arbor, MI, 48109-4204, USA
| | - Maryam Ghadimi Mahani
- Department of Radiology, University of Michigan Health System, Section of Pediatric Radiology, C. S. Mott Children's Hospital, Ann Arbor, MI, USA
| | - Prachi P Agarwal
- Department of Radiology, Division of Cardiothoracic Radiology, University of Michigan Health System, Ann Arbor, MI, USA
| | - Adam L Dorfman
- Department of Pediatrics and Communicable Diseases, Division of Pediatric Cardiology, University of Michigan Health System, University of Michigan Congenital Heart Center, C. S. Mott Children's Hospital, 1540 E. Hospital Drive, Ann Arbor, MI, 48109-4204, USA
- Department of Radiology, University of Michigan Health System, Section of Pediatric Radiology, C. S. Mott Children's Hospital, Ann Arbor, MI, USA
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Zampi JD, Loccoh E, Armstrong AK, Yu S, Lowery R, Rocchini AP, Hirsch-Romano JC. Twenty years of experience with intraoperative pulmonary artery stenting. Catheter Cardiovasc Interv 2017; 90:398-406. [PMID: 28471080 DOI: 10.1002/ccd.27094] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 01/25/2017] [Accepted: 03/25/2017] [Indexed: 11/09/2022]
Abstract
OBJECTIVES To describe our 20-year experience with intraoperative pulmonary artery (PA) stent placement and evaluate long-term patient outcomes, specifically the need and risk factors for reintervention. BACKGROUND Intraoperative PA stent placement is an alternative to surgical patch arterioplasty and percutaneous angioplasty or stent placement to treat branch PA stenosis. METHODS We performed a retrospective review of all intraoperative PA stents placed at our institution from 1994-2013. Patient and stent characteristics and outcome data were collected. Risk factors associated with reintervention were identified using univariate cox regression analysis. RESULTS Eighty-one PA stents were placed in 68 patients. The procedural complication rate was 4.4%. During a median follow-up period of 6 years (interquartile range [IQR] 0.9-12.7), 30 patients (44%) underwent reintervention on the stented PA with a median time to first reintervention of 2.6 years (IQR 0.7-4.4 years). The first reintervention was surgical in 30% and catheter-based in 70%. Risk factors for reintervention included age < 18 months (Hazard ratio [HR] 2.97, P = 0.005) and body surface area < 0.47 m2 (HR 3.20, P = 0.003) at the time of stent implantation, and the presence of multiple aortopulmonary collaterals in patients with tetralogy of Fallot (HR 4.61, P = 0.003). CONCLUSIONS Intraoperative PA stent implantation is a safe and effective alternative to percutaneous stent implantation and offers several advantages, including the ability to implant adult-size stents in small patients while avoiding injury to peripheral vessels, to position stents to facilitate future percutaneous stent redilation, and to access the PAs directly, which eliminates radiation exposure. © 2017 Wiley Periodicals, Inc.
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Affiliation(s)
- Jeffrey D Zampi
- Division of Pediatric Cardiology, University of Michigan Congenital Heart Center, C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Emefah Loccoh
- Ohio State University, College of Medicine, Columbus, Ohio
| | - Aimee K Armstrong
- Division of Pediatric Cardiology, Nationwide Children's Hospital, Columbus, Ohio, 43205
| | - Sunkyung Yu
- Division of Pediatric Cardiology, University of Michigan Congenital Heart Center, C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Ray Lowery
- Division of Pediatric Cardiology, University of Michigan Congenital Heart Center, C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Albert P Rocchini
- Division of Pediatric Cardiology, University of Michigan Congenital Heart Center, C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Jennifer C Hirsch-Romano
- Department of Cardiac Surgery, University of Michigan Congenital Heart Center, C.S. Mott Children's Hospital, Ann Arbor, Michigan
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Hale BW, Lu J, Romano J, Richer EJ, Lowery R, Norris M. KOMMERELL DIVERTICULUM ACROSS THE AGES: DESTINED FOR DILATION? J Am Coll Cardiol 2017. [DOI: 10.1016/s0735-1097(17)35457-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Friedland-Little JM, Uzark K, Yu S, Lowery R, Aiyagari R, Hirsch-Romano JC. Functional Status and Quality of Life in Survivors of Extracorporeal Membrane Oxygenation After the Norwood Operation. Ann Thorac Surg 2017; 103:1950-1955. [PMID: 28223051 DOI: 10.1016/j.athoracsur.2016.11.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Revised: 10/27/2016] [Accepted: 11/01/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND Infants who require extracorporeal membrane oxygenation (ECMO) support after a Norwood operation are at increased risk for early and late death compared with patients who do not require ECMO post-Norwood. Little is known about the effect that ECMO post-Norwood has on functional status and quality of life among long-term survivors. METHODS We prospectively evaluated functional status and health-related quality of life in 12 surviving patients (cases) and 19 corresponding patients (controls) from a previous retrospective case-control assessment of long-term survival in patients requiring ECMO post-Norwood. Functional status was assessed with the Vineland Adaptive Behavior Scale-II, and health-related quality of life was assessed with the Pediatric Quality of Life Inventory (PedsQL) core and cardiac modules. RESULTS There were no differences in demographics, extracardiac or genetic anomalies, or age at follow-up assessment between ECMO cases and non-ECMO controls. The Vineland Adaptive Behavior Scale-II scores were comparable between groups, with both groups demonstrating function in the normal range in all four domains tested. The only difference in PedsQL scores between cases and controls was perceived physical appearance, which was lower among ECMO survivors by both patient and proxy report. PedsQL scores of both groups were comparable to published scores for patients with single-ventricle congenital heart disease but generally lower than scores for the healthy population. CONCLUSIONS The requirement for ECMO support after a Norwood operation does not appear to significantly affect functional status or quality of life among the subset of patients who achieve long-term survival.
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Affiliation(s)
- Joshua M Friedland-Little
- Division of Pediatric Cardiology, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington.
| | - Karen Uzark
- Division of Pediatric Cardiology, Department of Pediatrics and Communicable Disease, University of Michigan, Ann Arbor, Michigan
| | - Sunkyung Yu
- Division of Pediatric Cardiology, Department of Pediatrics and Communicable Disease, University of Michigan, Ann Arbor, Michigan
| | - Ray Lowery
- Division of Pediatric Cardiology, Department of Pediatrics and Communicable Disease, University of Michigan, Ann Arbor, Michigan
| | - Ranjit Aiyagari
- Division of Pediatric Cardiology, Department of Pediatrics and Communicable Disease, University of Michigan, Ann Arbor, Michigan
| | - Jennifer C Hirsch-Romano
- Division of Pediatric Cardiology, Department of Pediatrics and Communicable Disease, University of Michigan, Ann Arbor, Michigan; Section of Pediatric Cardiac Surgery, Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
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Lu JC, Yu S, Lowery R, Sagi J, DeLong A, Agarwal PP, Mahani MG, Dorfman AL. Predictors of change in functional health status in adults with repaired tetralogy of Fallot. J Cardiovasc Magn Reson 2016. [PMCID: PMC5032716 DOI: 10.1186/1532-429x-18-s1-p166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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DeLong AC, Yu S, Lowery R, Lu JC. Estimation of pulmonary arterial pressure in shunted single ventricle patients by cardiac magnetic resonance. Progress in Pediatric Cardiology 2016. [DOI: 10.1016/j.ppedcard.2016.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Lu JC, Magdo HS, Yu S, Lowery R, Aiyagari R, Zamberlan M, Gajarski RJ. Usefulness of Diastolic Strain Measurements in Predicting Elevated Left Ventricular Filling Pressure and Risk of Rejection or Coronary Artery Vasculopathy in Pediatric Heart Transplant Recipients. Am J Cardiol 2016; 117:1533-8. [PMID: 26976792 DOI: 10.1016/j.amjcard.2016.02.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Revised: 02/08/2016] [Accepted: 02/08/2016] [Indexed: 10/22/2022]
Abstract
In pediatric heart transplant recipients, elevated pulmonary capillary wedge pressure (PCWP) is associated with rejection and coronary artery vasculopathy. This study aimed to evaluate which echocardiographic parameters track changes in PCWP and predict adverse outcomes (rejection or coronary artery vasculopathy). This prospective single-center study enrolled 49 patients (median 11.4 years old, interquartile range 7.4 to 16.5) at time of cardiac catheterization and echocardiography. Median follow-up was 2.4 years (range 1.2 to 3.1 years), with serial testing per clinical protocol. Ratio of early mitral inflow to annular velocity (E/E'), left atrial (LA) distensibility, peak LA systolic strain, E/left ventricular (LV) diastolic strain, and E/LV diastolic strain rate were measured from echocardiograms. Increase in PCWP ≥3 mm Hg was associated with changes in LA distensibility, E/E', and E/LV diastolic strain, with highest area under the receiver operating characteristic curve for E/LV diastolic strain (0.76). In 9 patients who subsequently developed rejection or coronary artery vasculopathy, E/LV diastolic strain rate at baseline differed from patients without events (median 57.0 vs 43.6, p = 0.02). On serial studies, only change in LV ejection fraction differed in patients with events (median -10% vs -1%, p = 0.01); decrease in LV ejection fraction of -19% had a specificity of 100% and sensitivity of 44%. In conclusion, LV diastolic strain and strain rate measurements can track changes in PCWP and identify patients at risk for subsequent rejection or coronary artery vasculopathy. Further studies are necessary to confirm these data in a larger cohort.
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Hancock H, Pituch K, Uzark K, Bhat P, Fifer C, Silveira M, Yu S, Donohue J, Lowery R, Aiyagari R. IMPACT OF EARLY PALLIATIVE CARE INTERVENTION ON MATERNAL STRESS IN MOTHERS OF INFANTS PRENATALLY DIAGNOSED WITH SINGLE VENTRICLE HEART DISEASE: A RANDOMIZED CLINICAL TRIAL. J Am Coll Cardiol 2016. [DOI: 10.1016/s0735-1097(16)30921-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Wu K, Yu S, Dorfman A, Lowery R, Agarwal P, Mahani MG, Lu J. DIFFERENTIAL MYOCARDIAL MECHANICS IN VOLUME AND PRESSURE LOADED RIGHT VENTRICLES DEMONSTRATED BY CARDIAC MAGNETIC RESONANCE. J Am Coll Cardiol 2016. [DOI: 10.1016/s0735-1097(16)30958-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Goldstein S, LaPage M, Dechert B, Serwer G, Yu S, Lowery R, Bradley D. DECREASED INAPPROPRIATE SHOCKS WITH NEWER ICDS IN PEDIATRIC AND CONGENITAL PATIENTS. J Am Coll Cardiol 2016. [DOI: 10.1016/s0735-1097(16)30822-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Lowery R, Gibson MI, Thompson RL, Fullam E. Deuterated carbohydrate probes as 'label-free' substrates for probing nutrient uptake in mycobacteria by nuclear reaction analysis. Chem Commun (Camb) 2015; 51:4838-41. [PMID: 25695462 PMCID: PMC4774366 DOI: 10.1039/c4cc09588j] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Deuterated sugars that are transported into mycobacteria can be detected using ion beam (nuclear reaction) analysis.
Understanding and probing small molecule uptake in cells is challenging, requiring sterically large chemical labels, or radioactive isotopes. Here, the uptake of deuterated sugars by Mycobacterium smegmatis, a non-pathogenic model of Mycobacterium tuberculosis, has been investigated using ion-beam (nuclear reaction) analysis demonstrating a new technique for label-free nutrient acquisition measurement.
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Affiliation(s)
- R Lowery
- School of Life Sciences, University of Warwick, CV4 7AL, UK.
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