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Nathan M, Gauvreau K, White O, Anderson BR, Bacha EA, Barron DJ, Cleveland J, Del Nido PJ, Eghtesady P, Galantowicz M, Kennedy A, Kohlsaat K, Ma M, Mattila C, Van Arsdell G, Gaynor JW. Comparing apples to apples: Exploring public reporting of congenital cardiac surgery outcomes based on common congenital heart operations. J Thorac Cardiovasc Surg 2024; 167:1570-1580.e3. [PMID: 37689234 DOI: 10.1016/j.jtcvs.2023.08.052] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 08/04/2023] [Accepted: 08/17/2023] [Indexed: 09/11/2023]
Abstract
OBJECTIVE We sought to simplify reporting of outcomes in congenital heart surgery that compares well-defined patient groups and accommodates multiple stakeholder needs while being easily understandable. METHODS We selected 19 commonly performed congenital heart surgeries ranging in complexity from repair of atrial septal defects to the Norwood procedure. Strict inclusion/exclusion criteria ensured the creation of 19 well-defined diagnosis/procedure cohorts. Preoperative, procedural, and postoperative data were collected for consecutive eligible patients from 9 centers between January 1, 2016, and December 31, 2021. Unadjusted operative mortality rates and hospital length of stay for each of the 19 diagnosis/procedure cohorts were summarized in aggregate and stratified by each center. RESULTS Of 8572 eligible cases included, numbers in the 19 diagnosis/procedure cohorts ranged from 73 for tetralogy of Fallot repair after previous palliation to 1224 for ventricular septal defect (VSD) repair for isolated VSD. In aggregate, the unadjusted mortality ranged from 0% for atrial septal defect repair to 28.4% for hybrid stage I. There was significant heterogeneity in case mix and mortality for different diagnosis/procedure cohorts across centers (eg, arterial switch operation/VSD, n = 7-42, mortality 0%-7.4%; Norwood procedure, n = 16-122, mortality 5.3%-25%). CONCLUSIONS Reporting of institutional case volumes and outcomes within well-defined diagnosis/procedure cohorts can enable centers to benchmark outcomes, understand trends in mortality, and direct quality improvement. When made public, this type of report could provide parents with information on institutional volumes and outcomes and allow them to better understand the experience of each program with operations for specific congenital heart defects.
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Affiliation(s)
- Meena Nathan
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass; Department of Surgery, Harvard Medical School, Boston, Mass.
| | - Kimberlee Gauvreau
- Department of Cardiology, Boston Children's Hospital, Boston, Mass; Department of Biostatistics, Harvard School of Public Health, Boston, Mass
| | | | - Brett R Anderson
- Division of Pediatric Cardiology, Children's Hospital of New York-Presbyterian (Columbia), New York, NY; Columbia University Irving Medical Center, New York, NY
| | - Emile A Bacha
- Columbia University Irving Medical Center, New York, NY; Division of Cardiothoracic Surgery, Children's Hospital of New York-Presbyterian (Columbia), New York, NY
| | - David J Barron
- Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - John Cleveland
- Divison of Cardiothoracic Surgery, Children's Hospital of Los Angeles, Los Angeles, Calif; Department of Surgery, Keck School of Medicine, Los Angeles, Calif
| | - Pedro J Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass; Department of Surgery, Harvard Medical School, Boston, Mass
| | - Pirooz Eghtesady
- Division of Cardiothoracic Surgery, St Louis Children's Hospital, St Louis, Mo; Department of Surgery, Washington University School of Medicine, St Louis, Mo
| | - Mark Galantowicz
- Department of Cardiothoracic Surgery, Nationwide Children's Hospital, Columbus, Ohio; Department of Surgery, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Andrea Kennedy
- Divsion of Cardiac Surgery, Children's Hospital of Philadelphia, Philadelphia, Pa
| | | | - Michael Ma
- Divsion of Pediatric Cardiac Surgery, Lucile Packard Children's Hospital, Palo Alto, Calif; Division of Pediatric Cardiac Surgery, Stanford University, Palo Alto, Calif
| | - Charlene Mattila
- Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Glen Van Arsdell
- Division of Congenital Cardiovascular Surgery, University of California Los Angeles Mattel Children's Hospital, Los Angeles, Calif; Department of Surgery, University of California Los Angeles, Los Angeles, Calif
| | - J William Gaynor
- Divsion of Cardiac Surgery, Children's Hospital of Philadelphia, Philadelphia, Pa; Department of Surgery, University of Pennsylvania, Philadelphia, Pa
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2
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Gikandi A, Baird CW, Del Nido PJ, Emani SM. Right ventricular papillary muscle approximation to the septum as an adjunct technique during tricuspid valve repair in congenital heart surgery. J Thorac Cardiovasc Surg 2024; 167:1547-1555.e1. [PMID: 37722623 DOI: 10.1016/j.jtcvs.2023.09.026] [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: 06/08/2023] [Revised: 08/22/2023] [Accepted: 09/11/2023] [Indexed: 09/20/2023]
Abstract
OBJECTIVE Tricuspid regurgitation is often caused by leaflet splaying from displaced papillary muscles or ventricular dilatation. Traditional annuloplasty may not address this mechanism. The present study describes a single institution's experience using right ventricular papillary muscle approximation for tricuspid valve repair. METHODS Right ventricular papillary muscle approximation consists of suturing the anterior papillary muscle to a point of the septum (septum or septal papillary muscle) that optimizes leaflet coaptation. We describe our technique and analyze clinical data of patients undergoing tricuspid valve repair with right ventricular papillary muscle approximation during congenital heart surgery between 2012 and 2021. RESULTS Right ventricular papillary muscle approximation was performed as an adjunct procedure in 207 of 825 tricuspid valve repairs (25.1%). Discharge tricuspid regurgitation grade was mild tricuspid regurgitation or less in 153 patients (73.9%), and 140 patients (67.6%) had mild tricuspid regurgitation or less at a median latest follow-up of 3.2 years (interquartile range, 0.7-6.8). Thirty patients (14.5%) underwent 11 early tricuspid valve reinterventions (3 due to right ventricular papillary muscle approximation dehiscence) and 21 late tricuspid valve reinterventions. Estimated 5-year freedom from tricuspid valve reintervention was 84% (95% CI, 77.0-89.2). Systemic right ventricle physiology (odds ratio, 2.88, P = .048) and multiple mechanisms of tricuspid regurgitation (odds ratio, 7.35, P = .038) were significant predictors of tricuspid valve reintervention on multivariable analysis. CONCLUSIONS Tricuspid valve repair with right ventricular papillary muscle approximation demonstrates acceptable short-term durability, but similar to other tricuspid valve repair strategies is less durable in patients with systemic right ventricle pressure and multiple mechanisms of tricuspid regurgitation. Right ventricular papillary muscle approximation is a safe and effective adjunct technique that should be considered in patients with tricuspid regurgitation caused by leaflet splaying from displaced papillary muscles or right ventricle dilatation.
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Affiliation(s)
| | | | - Pedro J Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass
| | - Sitaram M Emani
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass.
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3
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Govindarajan V, Marshall L, Sahni A, Cetatoiu MA, Eickhoff EE, Davee J, St Clair N, Schulz NE, Hoganson DM, Hammer PE, Ghelani SJ, Prakash A, Del Nido PJ, Rathod RH. Impact of Age-Related Change in Caval Flow Ratio on Hepatic Flow Distribution in the Fontan Circulation. Circ Cardiovasc Imaging 2024; 17:e016104. [PMID: 38567518 PMCID: PMC11073583 DOI: 10.1161/circimaging.123.016104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 03/15/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND The Fontan operation is a palliative technique for patients born with single ventricle heart disease. The superior vena cava (SVC), inferior vena cava (IVC), and hepatic veins are connected to the pulmonary arteries in a total cavopulmonary connection by an extracardiac conduit or a lateral tunnel connection. A balanced hepatic flow distribution (HFD) to both lungs is essential to prevent pulmonary arteriovenous malformations and cyanosis. HFD is highly dependent on the local hemodynamics. The effect of age-related changes in caval inflows on HFD was evaluated using cardiac magnetic resonance data and patient-specific computational fluid dynamics modeling. METHODS SVC and IVC flow from 414 patients with Fontan were collected to establish a relationship between SVC:IVC flow ratio and age. Computational fluid dynamics modeling was performed in 60 (30 extracardiac and 30 lateral tunnel) patient models to quantify the HFD that corresponded to patient ages of 3, 8, and 15 years, respectively. RESULTS SVC:IVC flow ratio inverted at ≈8 years of age, indicating a clear shift to lower body flow predominance. Our data showed that variation of HFD in response to age-related changes in caval inflows (SVC:IVC, 2, 1, and 0.5 corresponded to ages, 3, 8, and 15+, respectively) was not significant for extracardiac but statistically significant for lateral tunnel cohorts. For all 3 caval inflow ratios, a positive correlation existed between the IVC flow distribution to both the lungs and the HFD. However, as the SVC:IVC ratio changed from 2 to 0.5 (age, 3-15+) years, the correlation's strength decreased from 0.87 to 0.64, due to potential flow perturbation as IVC flow momentum increased. CONCLUSIONS Our analysis provided quantitative insights into the impact of the changing caval inflows on Fontan's long-term HFD, highlighting the importance of SVC:IVC variations over time on Fontan's long-term hemodynamics. These findings broaden our understanding of Fontan hemodynamics and patient outcomes.
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Affiliation(s)
- Vijay Govindarajan
- Departments of Cardiovascular Surgery (V.G., L.M., A.S., M.A.C., E.E.E., J.D., N.S.C., N.E.S., D.M.H., P.E.H., S.J.G., A.P., P.J.d.N.), Boston Children's Hospital, MA
- Surgery (V.G., D.M.H., P.E.H.), Harvard Medical School, Boston, MA
- Department of Internal Medicine, University of Texas Health Science Center at Houston (V.G.)
| | - Lauren Marshall
- Departments of Cardiovascular Surgery (V.G., L.M., A.S., M.A.C., E.E.E., J.D., N.S.C., N.E.S., D.M.H., P.E.H., S.J.G., A.P., P.J.d.N.), Boston Children's Hospital, MA
| | - Akshita Sahni
- Departments of Cardiovascular Surgery (V.G., L.M., A.S., M.A.C., E.E.E., J.D., N.S.C., N.E.S., D.M.H., P.E.H., S.J.G., A.P., P.J.d.N.), Boston Children's Hospital, MA
| | - Maria A Cetatoiu
- Departments of Cardiovascular Surgery (V.G., L.M., A.S., M.A.C., E.E.E., J.D., N.S.C., N.E.S., D.M.H., P.E.H., S.J.G., A.P., P.J.d.N.), Boston Children's Hospital, MA
| | - Emily E Eickhoff
- Departments of Cardiovascular Surgery (V.G., L.M., A.S., M.A.C., E.E.E., J.D., N.S.C., N.E.S., D.M.H., P.E.H., S.J.G., A.P., P.J.d.N.), Boston Children's Hospital, MA
| | - Jocelyn Davee
- Departments of Cardiovascular Surgery (V.G., L.M., A.S., M.A.C., E.E.E., J.D., N.S.C., N.E.S., D.M.H., P.E.H., S.J.G., A.P., P.J.d.N.), Boston Children's Hospital, MA
| | - Nicole St Clair
- Departments of Cardiovascular Surgery (V.G., L.M., A.S., M.A.C., E.E.E., J.D., N.S.C., N.E.S., D.M.H., P.E.H., S.J.G., A.P., P.J.d.N.), Boston Children's Hospital, MA
| | - Noah E Schulz
- Departments of Cardiovascular Surgery (V.G., L.M., A.S., M.A.C., E.E.E., J.D., N.S.C., N.E.S., D.M.H., P.E.H., S.J.G., A.P., P.J.d.N.), Boston Children's Hospital, MA
| | - David M Hoganson
- Departments of Cardiovascular Surgery (V.G., L.M., A.S., M.A.C., E.E.E., J.D., N.S.C., N.E.S., D.M.H., P.E.H., S.J.G., A.P., P.J.d.N.), Boston Children's Hospital, MA
- Surgery (V.G., D.M.H., P.E.H.), Harvard Medical School, Boston, MA
| | - Peter E Hammer
- Departments of Cardiovascular Surgery (V.G., L.M., A.S., M.A.C., E.E.E., J.D., N.S.C., N.E.S., D.M.H., P.E.H., S.J.G., A.P., P.J.d.N.), Boston Children's Hospital, MA
- Surgery (V.G., D.M.H., P.E.H.), Harvard Medical School, Boston, MA
| | - Sunil J Ghelani
- Departments of Cardiovascular Surgery (V.G., L.M., A.S., M.A.C., E.E.E., J.D., N.S.C., N.E.S., D.M.H., P.E.H., S.J.G., A.P., P.J.d.N.), Boston Children's Hospital, MA
- Cardiology (S.J.G., A.P., P.J.d.N., R.H.R.), Boston Children's Hospital, MA
| | - Ashwin Prakash
- Departments of Cardiovascular Surgery (V.G., L.M., A.S., M.A.C., E.E.E., J.D., N.S.C., N.E.S., D.M.H., P.E.H., S.J.G., A.P., P.J.d.N.), Boston Children's Hospital, MA
- Cardiology (S.J.G., A.P., P.J.d.N., R.H.R.), Boston Children's Hospital, MA
| | - Pedro J Del Nido
- Departments of Cardiovascular Surgery (V.G., L.M., A.S., M.A.C., E.E.E., J.D., N.S.C., N.E.S., D.M.H., P.E.H., S.J.G., A.P., P.J.d.N.), Boston Children's Hospital, MA
- Cardiology (S.J.G., A.P., P.J.d.N., R.H.R.), Boston Children's Hospital, MA
| | - Rahul H Rathod
- Cardiology (S.J.G., A.P., P.J.d.N., R.H.R.), Boston Children's Hospital, MA
- Departments of Pediatrics (R.H.R.), Harvard Medical School, Boston, MA
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4
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Roy N, Parra MF, Brown ML, Sleeper LA, Kossowsky J, Baumer AM, Blitz SE, Booth JM, Higgins CE, Nasr VG, Del Nido PJ, Brusseau R. Erector spinae plane blocks for opioid-sparing multimodal pain management after pediatric cardiac surgery. J Thorac Cardiovasc Surg 2024:S0022-5223(24)00211-3. [PMID: 38493959 DOI: 10.1016/j.jtcvs.2024.03.010] [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: 05/06/2023] [Revised: 02/25/2024] [Accepted: 03/08/2024] [Indexed: 03/19/2024]
Abstract
OBJECTIVE Peripheral regional anesthesia is proposed to enhance recovery. We sought to evaluate the efficacy of bilateral continuous erector spinae plane blocks (B-ESpB) for postoperative analgesia and the impact on recovery in children undergoing cardiac surgery. METHODS Patients aged 2 through 17 years undergoing cardiac surgery in the enhanced recovery after cardiac surgery program were prospectively enrolled to receive B-ESpB at the end of the procedure, with continuous infusions via catheters postoperatively. Participants wore an activity monitor until discharge. B-ESpB patients were retrospectively matched with control patients in the enhanced recovery after cardiac surgery program. Outcomes of the matched clusters were compared using exact conditional logistic regression and generalized linear modeling. RESULTS Forty patients receiving B-ESpB were matched to 78 controls. There were no major complications from the B-ESpB or infusions, and operating room time was longer by a median of 31 minutes. While blocks were infusing, patients with B-ESpB received fewer opioids in oral morphine equivalents than controls at 24 hours (0.60 ± 0.06 vs 0.78 ± 0.04 mg/kg; P = .02) and 48 hours (1.13 ± 0.08 vs 1.35 ± 0.06 mg/kg; P = .04), respectively. Both groups had low median pain scores per 12-hour period. There was no difference in early mobilization, length of stay, or complications. CONCLUSIONS B-ESpBs are safe in children undergoing cardiac surgery. When performed as part of a multimodal pain strategy in an enhanced recovery after cardiac surgery program, pediatric patients with B-ESpB experience good pain control and require fewer opioids in the first 48 hours.
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Affiliation(s)
- Nathalie Roy
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass; Department of Surgery, Harvard Medical School, Boston, Mass.
| | - M Fernanda Parra
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass; Department of Surgery, Harvard Medical School, Boston, Mass
| | - Morgan L Brown
- Department of Anaesthesia, Harvard Medical School, Boston, Mass; Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, Mass
| | - Lynn A Sleeper
- Departrment of Pediatrics, Harvard Medical School, Boston, Mass; Department of Cardiology, Boston Children's Hospital, Boston, Mass
| | - Joe Kossowsky
- Department of Anaesthesia, Harvard Medical School, Boston, Mass; Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, Mass
| | - Andreas M Baumer
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, Mass
| | | | - Jocelyn M Booth
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, Mass
| | - Connor E Higgins
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass
| | - Viviane G Nasr
- Department of Anaesthesia, Harvard Medical School, Boston, Mass; Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, Mass
| | - Pedro J Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass; Department of Surgery, Harvard Medical School, Boston, Mass
| | - Roland Brusseau
- Department of Anaesthesia, Harvard Medical School, Boston, Mass; Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, Mass
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Konstantinov IE, Bacha E, Barron D, David T, Dearani J, d'Udekem Y, El-Hamamsy I, Najm HK, Del Nido PJ, Pizarro C, Skillington P, Starnes VA, Winlaw D. Optimal timing of Ross operation in children: A moving target? J Thorac Cardiovasc Surg 2024:S0022-5223(24)00175-2. [PMID: 38350595 DOI: 10.1016/j.jtcvs.2024.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 12/30/2023] [Accepted: 02/05/2024] [Indexed: 02/15/2024]
Affiliation(s)
- Igor E Konstantinov
- Royal Children's Hospital, University of Melbourne, Murdoch Children's Research Institute, Melbourne Centre for Cardiovascular Genomics and Regenerative Medicine, Melbourne, Australia.
| | - Emile Bacha
- Columbia University Medical Center, Morgan Stanley Children's Hospital, New York, NY
| | - David Barron
- Department of Cardiovascular Surgery, Hospital for Sick Children, Toronto, Canada
| | - Tirone David
- Department of Cardiovascular Surgery, Toronto General Hospital, Toronto, Canada
| | - Joseph Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Yves d'Udekem
- Division of Cardiac Surgery, Children's National Heart Institute, The George Washington University School of Medicine and Health Sciences, Children's National Hospital, Washington, DC
| | | | - Hani K Najm
- Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | | | - Christian Pizarro
- Cardiothoracic Surgery, Thomas Jefferson University, Nemours Cardiac Center, Wilmington, Del
| | - Peter Skillington
- Department of Cardiothoracic Surgery, Royal Melbourne Hospital, Melbourne, Australia
| | - Vaughn A Starnes
- Department of Surgery, Keck School of Medicine, University of South California, Los Angeles, Calif
| | - David Winlaw
- Department of Cardiothoracic Surgery, Heart Center, Ann and Robert H. Lurie Children's Hospital, Northwestern University, Chicago, Ill
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Fernandez-Cisneros A, Staffa SJ, Emani SM, Chávez M, Friedman KG, Hoganson DM, Kaza AK, Del Nido PJ, Baird CW. Association of tetralogy of Fallot and complete atrioventricular canal: a single-centre 40-year experience. Eur J Cardiothorac Surg 2024; 65:ezae037. [PMID: 38310341 DOI: 10.1093/ejcts/ezae037] [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: 07/21/2023] [Revised: 12/21/2023] [Accepted: 01/31/2024] [Indexed: 02/05/2024] Open
Abstract
OBJECTIVES Outcome data in tetralogy of Fallot (ToF) and complete atrioventricular canal (CAVC) are limited. We report our experience for over 40 years in this patient population. METHODS Single-centre, retrospective analysis of patients who underwent surgical repair with the diagnosis of ToF-CAVC from 1979 to 2022, divided into 2 different periods and compared. RESULTS A total of 116 patients were included: 1979-2007 (n = 61) and 2008-2021 (n = 55). Balanced CAVC (80%) and Rastelli type C CAVC (81%) were most common. Patients in the later era were younger (4 vs 14 months, P < 0.001), fewer had trisomy 21 (60% vs 80%, P = 0.019) and fewer had prior palliative prior procedures (31% vs 43%, P < 0.001). In the earlier era, single-patch technique was more common (62% vs 16%, P < 0.001), and in recent era, double-patch technique was more common (84% vs 33%, P < 0.001). In the earlier era, right ventricular outflow tract was most commonly reconstructed with transannular patch (51%), while in more recent era, valve-sparing repairs were more common (69%) (P < 0.001). In-hospital mortality was 4.3%. The median follow-up was 217 and 74 months for the first and second eras. Survival for earlier and later eras at 2-, 5- and 10-year follow-up was (85.1%, 81.5%, 79.6% vs 94.2%, 94.2%, 94.2% respectively, log-rank test P = 0.03). CONCLUSIONS The surgical approach to ToF-CAVC has evolved over time. More recently, patients tended to receive primary repair at younger ages and had fewer palliative procedures. Improved surgical techniques allowing for earlier and complete repair have shown a decrease in mortality, more valve-sparing procedures without an increase in total reoperations. Presented at the 37th EACTS Annual Meeting, Vienna, Austria.
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Affiliation(s)
| | - Steven J Staffa
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Sitaram M Emani
- Cardiovascular Surgery Department, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Mariana Chávez
- Cardiovascular Surgery Department, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kevin G Friedman
- Cardiology Department, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - David M Hoganson
- Cardiovascular Surgery Department, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Pedro J Del Nido
- Cardiovascular Surgery Department, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Christopher W Baird
- Cardiovascular Surgery Department, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
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7
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Sengupta A, Gauvreau K, Kohlsaat K, Lee JM, Mayer JE, Del Nido PJ, Nathan M. Prognostic utility of a novel risk prediction model of 1-year mortality in patients surviving to discharge after surgery for congenital or acquired heart disease. J Thorac Cardiovasc Surg 2024; 167:454-463.e6. [PMID: 37160220 DOI: 10.1016/j.jtcvs.2023.04.032] [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: 02/22/2023] [Revised: 04/09/2023] [Accepted: 04/22/2023] [Indexed: 05/11/2023]
Abstract
OBJECTIVE We sought to develop a novel risk prediction model of 1-year mortality after congenital heart surgery that accounts for clinical, anatomic, echocardiographic, and socioeconomic factors. METHODS This was a single-center, retrospective review of consecutive index operations for congenital or acquired heart disease, from January 2011 to January 2021, among patients with known survival status at 1 year after discharge from the index hospitalization. The primary outcome was postdischarge mortality at 1 year. Variables of interest included age, prematurity, noncardiac anomalies or syndromes, the Childhood Opportunity Index, primary procedure, major adverse postoperative complications, and the Residual Lesion Score. Logistic regression was used to develop a weighted risk score for the primary outcome. Internal validation using a bootstrap-resampling approach was performed. RESULTS Of 10,412 consecutive operations for congenital or acquired heart disease, 8808 (84.6%) cases met entry criteria, including survival to discharge. There were 190 (2.2%) deaths at 1 year postdischarge. A weighted risk score was formulated on the basis of the variables in the final risk prediction model, which included all aforementioned risk factors of interest. This model had a C-statistic of 0.82 (95% confidence interval, 0.80-0.85). The median risk score was 6 (interquartile range, 4-8) points. Patients were categorized as low (score 0-5), medium (score 6-10), high (score 11-15), or very high (score 16-20) risk. The expected probability of mortality was 0.4% ± 0.2%, 2.0% ± 1.1%, 10.1% ± 5.0%, and 36.6% ± 9.6% for low-risk, medium-risk, high-risk, and very high-risk patients, respectively. CONCLUSIONS A risk prediction model of 1-year mortality may guide prognostication and follow-up of patients after discharge after surgery for congenital or acquired heart disease.
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Affiliation(s)
- Aditya Sengupta
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass
| | - Kimberlee Gauvreau
- Department of Cardiology, Boston Children's Hospital, Boston, Mass; Department of Biostatistics, Harvard School of Public Health, Boston, Mass
| | | | - Ji M Lee
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass
| | - John E Mayer
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass; Department of Surgery, Harvard Medical School, Boston, Mass
| | - Pedro J Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass; Department of Surgery, Harvard Medical School, Boston, Mass
| | - Meena Nathan
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass; Department of Surgery, Harvard Medical School, Boston, Mass.
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8
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Sengupta A, Carreon CK, Gauvreau K, Lee JM, Sanders SP, Colan SD, Del Nido PJ, Mayer JE, Nathan M. Growth of the Neo-Aortic Root and Prognosis of Transposition of the Great Arteries. J Am Coll Cardiol 2024; 83:516-527. [PMID: 37939977 DOI: 10.1016/j.jacc.2023.10.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 10/23/2023] [Accepted: 10/24/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND Neo-aortic root dilatation can lead to significant late morbidity after the arterial switch operation (ASO) for dextro-transposition of the great arteries (d-TGA). OBJECTIVES We sought to examine the growth of the neo-aortic root in d-TGA. METHODS A single-center, retrospective cohort study of patients who underwent the ASO between July 1, 1981 and September 30, 2022 was performed. Morphology was categorized as dextro-transposition of the great arteries with intact ventricular septum (d-TGA-IVS), dextro-transposition of the great arteries with ventricular septal defect (d-TGA-VSD), and double-outlet right ventricle-transposition of the great arteries type (DORV-TGA). Echocardiographically determined diameters and derived z scores were measured at the annulus, sinus of Valsalva, and sinotubular junction immediately before the ASO and throughout follow-up. Trends in root dimensions over time were assessed using linear mixed-effects models. The association between intrinsic morphology and the composite of moderate-severe aortic regurgitation (AR) and neo-aortic valve or root intervention was evaluated with univariable and multivariable Cox proportional hazards models. RESULTS Of 1,359 patients who underwent the ASO, 593 (44%), 666 (49%), and 100 (7%) patients had d-TGA-IVS, d-TGA-VSD, and DORV-TGA, respectively. Each patient underwent a median of 5 echocardiograms (Q1-Q3: 3-10 echocardiograms) over a median follow-up of 8.6 years (range: 0.1-39.3 years). At 30 years, patients with DORV-TGA demonstrated greater annular (P < 0.001), sinus of Valsalva (P = 0.039), and sinotubular junction (P = 0.041) dilatation relative to patients with d-TGA-IVS. On multivariable analysis, intrinsic anatomy, older age at ASO, at least mild AR at baseline, and high-risk root dilatation were associated with moderate-severe AR and neo-aortic valve or root intervention at late follow-up (all P < 0.05). CONCLUSIONS Longitudinal surveillance of the neo-aortic root is warranted long after the ASO.
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Affiliation(s)
- Aditya Sengupta
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts, USA.
| | - Chrystalle Katte Carreon
- The Cardiac Registry, Departments of Cardiology, Pathology, and Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts, USA; Department of Pathology, Harvard Medical School, Boston, Massachusetts, USA
| | - Kimberlee Gauvreau
- Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts, USA; Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Ji M Lee
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Stephen P Sanders
- The Cardiac Registry, Departments of Cardiology, Pathology, and Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts, USA; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Steven D Colan
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Pedro J Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts, USA; Department of Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - John E Mayer
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts, USA; Department of Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Meena Nathan
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts, USA; Department of Surgery, Harvard Medical School, Boston, Massachusetts, USA
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Alemany VS, Nomoto R, Saeed MY, Celik A, Regan WL, Matte GS, Recco DP, Emani SM, Del Nido PJ, McCully JD. Mitochondrial transplantation preserves myocardial function and viability in pediatric and neonatal pig hearts donated after circulatory death. J Thorac Cardiovasc Surg 2024; 167:e6-e21. [PMID: 37211245 DOI: 10.1016/j.jtcvs.2023.05.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [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: 01/06/2023] [Revised: 04/06/2023] [Accepted: 05/03/2023] [Indexed: 05/23/2023]
Abstract
OBJECTIVE Mitochondrial transplantation has been shown to preserve myocardial function and viability in adult porcine hearts donated after circulatory death (DCD) . Herein, we investigate the efficacy of mitochondrial transplantation for the preservation of myocardial function and viability in neonatal and pediatric porcine DCD heart donation. METHODS Circulatory death was induced in neonatal and pediatric Yorkshire pigs by cessation of mechanical ventilation. Hearts underwent 20 or 36 minutes of warm ischemia time (WIT), 10 minutes of cold cardioplegic arrest, and then were harvested for ex situ heart perfusion (ESHP). Following 15 minutes of ESHP, hearts received either vehicle (VEH) or vehicle containing isolated autologous mitochondria (MITO). A sham nonischemic group (SHAM) did not undergo WIT, mimicking donation after brain death heart procurement. Hearts underwent 2 hours each of unloaded and loaded ESHP perfusion. RESULTS Following 4 hours of ESHP perfusion, left ventricle developed pressure, dP/dt max, and fractional shortening were significantly decreased (P < .001) in DCD hearts receiving VEH compared with SHAM hearts. In contrast, DCD hearts receiving MITO exhibited significantly preserved left ventricle developed pressure, dP/dt max, and fractional shortening (P < .001 each vs VEH, not significant vs SHAM). Infarct size was significantly decreased in DCD hearts receiving MITO as compared with VEH (P < .001). Pediatric DCD hearts subjected to extended WIT demonstrated significantly preserved fractional shortening and significantly decreased infarct size with MITO (P < .01 each vs VEH). CONCLUSIONS Mitochondrial transplantation in neonatal and pediatric pig DCD heart donation significantly enhances the preservation of myocardial function and viability and mitigates against damage secondary to extended WIT.
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Affiliation(s)
- Victor S Alemany
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass
| | - Rio Nomoto
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass
| | - Mossab Y Saeed
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass
| | - Aybuke Celik
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass
| | - William L Regan
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass
| | - Gregory S Matte
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass
| | - Dominic P Recco
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass
| | - Sitaram M Emani
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
| | - Pedro J Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
| | - James D McCully
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass.
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10
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Gikandi A, Gauvreau K, Kohlsaat K, Newburger JW, Del Nido PJ, Quinonez L, Nathan M. Postoperative Troponin Levels in Children Undergoing Open Heart Surgery With and Without Coronary Intervention. Pediatr Cardiol 2024; 45:184-195. [PMID: 37773463 DOI: 10.1007/s00246-023-03304-9] [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: 07/22/2023] [Accepted: 09/12/2023] [Indexed: 10/01/2023]
Abstract
We aimed to characterize the ranges, temporal trends, influencing factors, and prognostic significance of postoperative troponin levels after congenital heart surgery. This single-center retrospective study included patients from 2006 to 2021 who had ≥ 1 postoperative troponin-T measurement collected within 96 h of congenital heart surgery (CHS). Patients were grouped as Anomalous Aortic Origin of the Coronary Artery-"AAOCA repair," or congenital heart surgery with "Other Coronary Interventions" other than AAOCA repair, or "No Coronary Intervention." In each group, information on concomitant surgery requiring one or more of the following-atriotomy, ventriculotomy, right ventricular muscle bundle resection, and/or septal myectomy-was collected. Clinical correlates of troponin values were analyzed in three postoperative windows: < 8, 8-24, and 24-48 h. The highest median [range] troponin levels (ng/mL) for the samples were 0.34 [0.06, 1.32] at < 8 h for "AAOCA repair," 1.35 [0.14, 12.0] at < 8 h for those undergoing CHS with "Other Coronary Interventions," and 0.87 [0.06, 25.1] at 8-24 h for those undergoing CHS with "No Coronary Interventions." Atriotomy was associated with higher median troponin levels in the AAOCA group at < 8 h (0.40 [0.31, 0.77] vs. 0.29 [0.17, 0.54], P = 0.043) and in the Other Coronary Intervention group at 8-24 h (1.67 [1.04, 2.63] vs. 0.40 [0.19, 1.32], P = 0.002). Patients experiencing major postoperative complications (vs. those who did not) had higher troponin levels in the AAOCA group as early as 8-24 h (0.36 [0.24, 0.57] vs. 0.21 [0.14, 0.33], P = 0.03). Similar findings were noted in the Coronary Intervention (2.20 [1.34, 3.90] vs. 1.11 [0.51, 2.90], P = 0.028) and No Coronary Intervention (2.2 [1.49, 15.1] vs. 0.74 [0.40, 2.34], P = 0.027) groups but earlier at < 8 h. In the AAOCA group, 2/18 (11%) troponin outliers experienced cardiac arrest in comparison to 0/80 (0%) non-outliers (P = 0.032). In the Other Coronary Intervention group, troponin outliers had longer median times to ICU discharge (10 vs. 4 days) and hospital discharge (21 vs. 10 days) (both P < 0.001). Postoperative troponin levels depend on a multitude of factors and may have prognostic value in patients undergoing congenital heart surgery with coronary interventions.
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Affiliation(s)
- Ajami Gikandi
- Department of Cardiac Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02215, USA
- Harvard Medical School, Boston, MA, USA
| | - Kimberlee Gauvreau
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
- Department of Biostatistics, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Katherine Kohlsaat
- Department of Cardiac Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02215, USA
| | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Pedro J Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02215, USA
- Department of Surgery, Harvard Medical School, Boston, MA, USA
| | - Luis Quinonez
- Department of Cardiac Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02215, USA
- Department of Surgery, Harvard Medical School, Boston, MA, USA
| | - Meena Nathan
- Department of Cardiac Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02215, USA.
- Department of Surgery, Harvard Medical School, Boston, MA, USA.
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11
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Emani SM, Del Nido PJ. Systemic Atrioventricular Valve Regurgitation in Corrected Transposition of the Great Arteries: Where Are We? J Am Coll Cardiol 2023; 82:2209-2211. [PMID: 38030350 DOI: 10.1016/j.jacc.2023.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 10/23/2023] [Accepted: 10/24/2023] [Indexed: 12/01/2023]
Affiliation(s)
- Sitaram M Emani
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts, USA.
| | - Pedro J Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
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12
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Sperotto F, Lang N, Nathan M, Kaza A, Hoganson DM, Valencia E, Odegard K, Allan CK, da Cruz EM, Del Nido PJ, Emani SM, Baird C, Maschietto N. Transcatheter Palliation With Pulmonary Artery Flow Restrictors in Neonates With Congenital Heart Disease: Feasibility, Outcomes, and Comparison With a Historical Hybrid Stage 1 Cohort. Circ Cardiovasc Interv 2023; 16:e013383. [PMID: 38113289 DOI: 10.1161/circinterventions.123.013383] [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: 06/24/2023] [Accepted: 08/31/2023] [Indexed: 12/21/2023]
Abstract
BACKGROUND Neonates with complex congenital heart disease and pulmonary overcirculation have been historically treated surgically. However, subcohorts may benefit from less invasive procedures. Data on transcatheter palliation are limited. METHODS We present our experience with pulmonary flow restrictors (PFRs) for palliation of neonates with congenital heart disease, including procedural feasibility, technical details, and outcomes. We then compared our subcohort of high-risk single ventricle neonates palliated with PFRs with a similar historical cohort who underwent a hybrid Stage 1. Cox regression was used to evaluate the association between palliation strategy and 6-month mortality. RESULTS From 2021 to 2023, 17 patients (median age, 4 days; interquartile range [IQR], 2-8; median weight, 2.5 kilograms [IQR, 2.1-3.3]) underwent a PFR procedure; 15 (88%) had single ventricle physiology; 15 (88%) were high-risk surgical candidates. All procedures were technically successful. At a median follow-up of 6.2 months (IQR, 4.0-10.8), 13 patients (76%) were successfully bridged to surgery (median time since PFR procedure, 2.6 months [IQR, 1.1-4.4]; median weight, 4.9 kilograms [IQR, 3.4-5.8]). Pulmonary arteries grew adequately for age, and devices were easily removed without complications. The all-cause mortality rate before target surgery was 24% (n=4). Compared with the historical hybrid stage 1 cohort (n=23), after adjustment for main confounding (age, weight, intact/severely restrictive atrial septum or left ventricle to coronary fistulae), the PFR procedure was associated with a significantly lower all-cause 6-month mortality risk (adjusted hazard ratio, 0.26 [95% CI, 0.08-0.82]). CONCLUSIONS Transcatheter palliation with PFR is feasible, safe, and represents an effective strategy for bridging high-risk neonates with congenital heart disease to surgical palliation, complete repair, or transplant while allowing for clinical stabilization and somatic growth.
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Affiliation(s)
- Francesca Sperotto
- Department of Cardiology (F.S., N.L., E.V., C.K.A., E.M.d.C., N.M.), Boston Children's Hospital, Harvard Medical School, MA
| | - Nora Lang
- Department of Cardiology (F.S., N.L., E.V., C.K.A., E.M.d.C., N.M.), Boston Children's Hospital, Harvard Medical School, MA
- Department of Pediatric Cardiology, University Heart & Vascular Center Hamburg, Germany (N.L.)
| | - Meena Nathan
- Department of Cardiac Surgery (M.N., A.K., D.M.H., P.J.D.N., S.M.E., C.B.), Boston Children's Hospital, Harvard Medical School, MA
| | - Aditya Kaza
- Department of Cardiac Surgery (M.N., A.K., D.M.H., P.J.D.N., S.M.E., C.B.), Boston Children's Hospital, Harvard Medical School, MA
| | - David M Hoganson
- Department of Cardiac Surgery (M.N., A.K., D.M.H., P.J.D.N., S.M.E., C.B.), Boston Children's Hospital, Harvard Medical School, MA
| | - Eleonore Valencia
- Department of Cardiology (F.S., N.L., E.V., C.K.A., E.M.d.C., N.M.), Boston Children's Hospital, Harvard Medical School, MA
| | - Kirsten Odegard
- Department of Cardiac Anesthesia (K.O.), Boston Children's Hospital, Harvard Medical School, MA
| | - Catherine K Allan
- Department of Cardiology (F.S., N.L., E.V., C.K.A., E.M.d.C., N.M.), Boston Children's Hospital, Harvard Medical School, MA
| | - Eduardo M da Cruz
- Department of Cardiology (F.S., N.L., E.V., C.K.A., E.M.d.C., N.M.), Boston Children's Hospital, Harvard Medical School, MA
| | - Pedro J Del Nido
- Department of Cardiac Surgery (M.N., A.K., D.M.H., P.J.D.N., S.M.E., C.B.), Boston Children's Hospital, Harvard Medical School, MA
| | - Sitaram M Emani
- Department of Cardiac Surgery (M.N., A.K., D.M.H., P.J.D.N., S.M.E., C.B.), Boston Children's Hospital, Harvard Medical School, MA
| | - Christopher Baird
- Department of Cardiac Surgery (M.N., A.K., D.M.H., P.J.D.N., S.M.E., C.B.), Boston Children's Hospital, Harvard Medical School, MA
| | - Nicola Maschietto
- Department of Cardiology (F.S., N.L., E.V., C.K.A., E.M.d.C., N.M.), Boston Children's Hospital, Harvard Medical School, MA
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13
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Sengupta A, Lee JM, Gauvreau K, Colan SD, Del Nido PJ, Mayer JE, Nathan M. Natural history of aortic root dilatation and pathologic aortic regurgitation in tetralogy of Fallot and its morphological variants. J Thorac Cardiovasc Surg 2023; 166:1718-1728.e4. [PMID: 37164053 DOI: 10.1016/j.jtcvs.2023.04.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 03/28/2023] [Accepted: 04/12/2023] [Indexed: 05/12/2023]
Abstract
OBJECTIVE We sought to characterize the natural history of aortic root dilatation and aortic regurgitation in tetralogy of Fallot (TOF). METHODS A single-center review of patients who underwent TOF repair from January 1960 to December 2022 was performed. Morphology was categorized as TOF-pulmonary stenosis or TOF-variant (including TOF-pulmonary atresia and TOF-pulmonary atresia-major aortopulmonary collateral arteries). Echocardiographically determined diameters and derived z scores were measured at the annulus, sinus of Valsalva, and sinotubular junction immediately before TOF repair and throughout follow-up. Linear mixed-effects models assessed trends in dimensions over time. RESULTS Of 2205 patients who underwent primary repair of TOF at a median age of 4.9 months (interquartile range, 2.3-20.5 months) and survived to discharge, 1608 (72.9%) patients had TOF-pulmonary stenosis and 597 (27.1%) patients had TOF-variant. At a median postoperative follow-up of 14.4 years (interquartile range, 3.3-27.6 years; range, 0.1-62.6 years), 313 (14.2%) patients had mild or greater aortic regurgitation and 34 (1.5%) patients required an aortic valve or root intervention. The overall mean rates of annular, sinus of Valsalva, and sinotubular junction growth were 0.5 ± 0.2, 0.6 ± 0.3, and 0.7 ± 0.5 mm/year, respectively. Root z scores remained stable with time. At baseline, patients with TOF-variant had larger diameters and z scores at the annulus, sinus of Valsalva, and sinotubular junction, compared with patients with TOF-pulmonary stenosis (all P values < .05). Over time, patients with TOF-variant demonstrated relatively greater annular (P = .020), sinus of Valsalva (P < .001), and sinotubular junction (P < .001) dilatation. Patients with ≥75th percentile root growth rates had a higher incidence of mild or greater aortic regurgitation (P < .001), moderate or greater aortic regurgitation (P < .001), and aortic valve repair or replacement (P = .045). CONCLUSIONS Patients with TOF-variant are at comparatively greater risk of pathologic root dilatation over time, warranting closer longitudinal follow-up.
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Affiliation(s)
- Aditya Sengupta
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass
| | - Ji M Lee
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass
| | - Kimberlee Gauvreau
- Department of Cardiology, Boston Children's Hospital, Boston, Mass; Department of Biostatistics, Harvard School of Public Health, Boston, Mass
| | - Steven D Colan
- Department of Cardiology, Boston Children's Hospital, Boston, Mass; Department of Pediatrics, Harvard Medical School, Boston, Mass
| | - Pedro J Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass; Department of Surgery, Harvard Medical School, Boston, Mass
| | - John E Mayer
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass; Department of Surgery, Harvard Medical School, Boston, Mass
| | - Meena Nathan
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass; Department of Surgery, Harvard Medical School, Boston, Mass.
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14
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Del Nido PJ. Center Volume: The Easy to Measure Imperfect Surrogate. Ann Thorac Surg 2023; 116:1240. [PMID: 37734643 DOI: 10.1016/j.athoracsur.2023.09.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Accepted: 09/11/2023] [Indexed: 09/23/2023]
Affiliation(s)
- Pedro J Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, 300 Longwood Ave, Boston, MA 02115.
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15
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Sengupta A, Gauvreau K, Lee JM, Colan SD, Emani S, Baird CW, Del Nido PJ, Nathan M. Prognostic Utility of a Risk Prediction Model for Pre-Discharge Major Residual Lesions or Unplanned Reinterventions Following Congenital Mitral Valve Repair. J Thorac Cardiovasc Surg 2023:S0022-5223(23)01100-5. [PMID: 37995862 DOI: 10.1016/j.jtcvs.2023.11.024] [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: 06/28/2023] [Revised: 10/18/2023] [Accepted: 11/15/2023] [Indexed: 11/25/2023]
Abstract
OBJECTIVE We sought to develop a risk prediction model for pre-discharge major mitral valve (MV) residual lesions or unplanned MV reinterventions following congenital MV repair. METHODS Patients that underwent congenital MV repair (excluding primary repair, but including secondary repair, of canal-type defects) at a single institution from 01/2000-12/2020 and survived to discharge were retrospectively reviewed. The primary outcome was major MV residua (mean gradient >6 mmHg or ≥moderate regurgitation on the discharge echocardiogram) or pre-discharge unplanned MV reintervention. Risk factors of interest included age, single ventricle physiology, preoperative and intraoperative post-repair MV stenosis and regurgitation severity, MV annular diameter z-score, systemic ventricle ejection fraction, unfavorable anatomy, concomitant left-heart procedure, and various technique-related categories. Logistic regression was used to develop a weighted risk score for the primary outcome. Internal validation using bootstrap-resampling was performed. RESULTS Of 866 patients that underwent congenital MV repair at a median age of 2.7 (IQR 0.7-9.1) years, 202 (23.3%) patients developed the primary outcome. The final risk prediction model had a C-statistic of 0.82 (95% CI 0.78-0.85). A weighted risk score was formulated per the variables in this model. The median risk score was 8 (IQR 6-11) points. Patients were categorized as low (score 0-5), medium (score 6-10), high (score 11-15), or very high (score ≥16) risk. The probability of the primary outcome was 5.0±1.7%, 15.2±6.7%, 45.9±12.6%, and 76.7±8.8% for low, medium, high, and very high risk patients, respectively. CONCLUSIONS Our risk prediction model may guide prognostication of patients following congenital MV repair.
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Affiliation(s)
- Aditya Sengupta
- Department of Cardiovascular Surgery, Boston Children's Hospital, Boston, MA
| | - Kimberlee Gauvreau
- Department of Cardiology, Boston Children's Hospital, Boston, MA;; Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, MA
| | - Ji M Lee
- Department of Cardiovascular Surgery, Boston Children's Hospital, Boston, MA
| | - Steven D Colan
- Department of Cardiology, Boston Children's Hospital, Boston, MA;; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Sitaram Emani
- Department of Cardiovascular Surgery, Boston Children's Hospital, Boston, MA;; Department of Surgery, Harvard Medical School, Boston, MA
| | - Christopher W Baird
- Department of Cardiovascular Surgery, Boston Children's Hospital, Boston, MA;; Department of Surgery, Harvard Medical School, Boston, MA
| | - Pedro J Del Nido
- Department of Cardiovascular Surgery, Boston Children's Hospital, Boston, MA;; Department of Surgery, Harvard Medical School, Boston, MA
| | - Meena Nathan
- Department of Cardiovascular Surgery, Boston Children's Hospital, Boston, MA;; Department of Surgery, Harvard Medical School, Boston, MA.
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16
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Alemany VS, Recco DP, Emani SM, Del Nido PJ, McCully JD. Model of Ischemia and Reperfusion Injury in Rabbits. J Vis Exp 2023. [PMID: 37982519 DOI: 10.3791/64752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2023] Open
Abstract
The protocol here provides a simple, highly replicable methodology to induce in situ acute regional myocardial ischemia in the rabbit for non-survival and survival experiments. New Zealand White adult rabbit is sedated with atropine, acepromazine, butorphanol, and isoflurane. The animal is intubated and placed on mechanical ventilation. An intravenous catheter is inserted into the marginal ear vein for the infusion of medications. The animal is pre-medicated with heparin, lidocaine, and lactated Ringer's solution. A carotid cut-down is performed to obtain arterial line access for blood pressure monitoring. Select physiologic and mechanical parameters are monitored and recorded by continuous real-time analysis. With the animal sedated and fully anesthetized, either a fourth intercostal space small left thoracotomy (survival) or midline sternotomy (non-survival) is performed. The pericardium is opened, and the left anterior descending (LAD) artery is located. A polypropylene suture is passed around the second or third diagonal branch of the LAD artery, and the polypropylene filament is threaded through a small vinyl tube, forming a snare. The animal is subjected to 30 min of regional ischemia, achieved by occluding the LAD by tightening the snare. Myocardial ischemia is confirmed visually by regional cyanosis of the epicardium. Following regional ischemia, the ligature is loosened, and the heart is allowed to re-perfuse. For both survival and non-survival experiments, the myocardial function can be assessed via an echocardiography (ECHO) measurement of the fractional shortening. For non-survival studies, data from sonomicrometry collected using three digital piezoelectric ultrasonic probes implanted within the ischemic area and the left ventricle developed pressure (LVDP) using an apically inserted left ventricle (LV) catheter can be continuously acquired for evaluating the regional and global myocardial function, respectively. For survival studies, the incision is closed, a left needle thoracentesis is performed for pleural air evacuation, and postoperative pain control is achieved.
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Affiliation(s)
- Victor S Alemany
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School;
| | - Dominic P Recco
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School
| | - Sitaram M Emani
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School
| | - Pedro J Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School
| | - James D McCully
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School
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Hoganson DM, Eickhoff ER, Prakash A, Del Nido PJ. Management of severe calcific aortic stenosis in children with progeria syndrome. J Thorac Cardiovasc Surg 2023; 166:1292-1297. [PMID: 37236599 DOI: 10.1016/j.jtcvs.2023.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 04/26/2023] [Accepted: 05/10/2023] [Indexed: 05/28/2023]
Affiliation(s)
- David M Hoganson
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass.
| | - Emily R Eickhoff
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass
| | - Ashwin Prakash
- Department of Cardiology, Boston Children's Hospital, Boston, Mass
| | - Pedro J Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass
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18
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Sengupta A, Gauvreau K, Kaza A, Baird CW, Schidlow DN, Del Nido PJ, Nathan M. A Risk Prediction Model for Reintervention After Total Anomalous Pulmonary Venous Connection Repair. Ann Thorac Surg 2023; 116:796-802. [PMID: 35779604 DOI: 10.1016/j.athoracsur.2022.05.058] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 05/10/2022] [Accepted: 05/25/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Outcomes after total anomalous pulmonary venous connection (TAPVC) repair remain suboptimal due to recurrent pulmonary vein (PV) obstruction requiring reinterventions. We sought to develop a clinical prediction rule for PV reintervention after TAPVC repair. METHODS Data from consecutive patients who underwent TAPVC repair at a single institution from January 1980 to January 2020 were retrospectively reviewed after Institutional Review Board approval. The primary outcome was postdischarge (late) unplanned PV surgical or transcatheter reintervention. Echocardiographic criteria were used to assess PV residual lesion severity at discharge (class 1: no residua; class 2: minor residua; class 3: major residua). Competing risk models were used to develop a weighted risk score for late reintervention. RESULTS Of 437 patients who met entry criteria, there were 81 (18.5%) reinterventions at a median follow-up of 15.6 (interquartile range, 5.5-22.2) years. On univariable analysis, minor and major PV residua, age, single-ventricle physiology, infracardiac and mixed TAPVC, and preoperative obstruction were associated with late reintervention (all P < .05). The final risk prediction model included PV residua (class 2: subdistribution hazard ratio [SHR], 4.8; 95% CI, 2.8-8.1; P < .001; class 3: SHR, 6.4; 95% CI, 3.5-11.7; P < .001), age <1 year (SHR, 3.3; 95% CI, 1.3-8.5; P = .014), and preoperative obstruction (SHR, 1.8; 95% CI, 1.1-2.8; P = .015). A risk score comprising PV residua (class 2 or 3: 3 points), age (neonate or infant: 2 points), and obstruction (1 point) was formulated. Higher risk scores were significantly associated with worse freedom from reintervention (P < .001). CONCLUSIONS A risk prediction model of late reintervention may guide prognostication of high-risk patients after TAPVC repair.
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Affiliation(s)
- Aditya Sengupta
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts.
| | - Kimberlee Gauvreau
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts
| | - Aditya Kaza
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts; Department of Surgery, Harvard Medical School, Boston, Massachusetts
| | - Christopher W Baird
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts; Department of Surgery, Harvard Medical School, Boston, Massachusetts
| | - David N Schidlow
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Pedro J Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts; Department of Surgery, Harvard Medical School, Boston, Massachusetts
| | - Meena Nathan
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts; Department of Surgery, Harvard Medical School, Boston, Massachusetts
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19
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Feins EN, Del Nido PJ. Conduction in congenital heart surgery. J Thorac Cardiovasc Surg 2023; 166:1182-1188. [PMID: 36933789 DOI: 10.1016/j.jtcvs.2023.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Accepted: 03/12/2023] [Indexed: 03/20/2023]
Affiliation(s)
- Eric N Feins
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass.
| | - Pedro J Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass
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20
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Sengupta A, Gauvreau K, Sadhwani A, Butler SC, Newburger JW, Del Nido PJ, Nathan M. Impact of Residual Lesion Severity on Neurodevelopmental Outcomes Following Congenital Heart Surgery in Infancy and Childhood. Pediatr Cardiol 2023:10.1007/s00246-023-03248-0. [PMID: 37543999 DOI: 10.1007/s00246-023-03248-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 07/20/2023] [Indexed: 08/08/2023]
Abstract
Children with congenital heart disease are at increased risk of neurodevelopmental delay throughout their lifespan. This risk is exacerbated following congenital heart surgery (CHS) in infancy. However, there are few modifiable risk factors for postoperative neurodevelopmental delay. In this study, we assessed the Residual Lesion Score (RLS), a quality assessment metric that evaluates residual lesion severity following CHS, as a predictor of neurodevelopmental delay. This was a single-center, retrospective review of patients who underwent CHS from 01/2011 to 03/2021 and post-discharge neurodevelopmental evaluation from 12 to 42 months of age using the Bayley Scales of Infant Development, 3rd Edition (BSID-III). RLS was assigned per published criteria: RLS 1, no residua; RLS 2, minor residua; and RLS 3, major residua or pre-discharge reintervention. Associations between RLS and BSID-III scores, as well as trends in neurodevelopmental outcomes over time, were evaluated. Of 517 patients with median age at neurodevelopmental testing of 20.0 (IQR 18.0-22.7) months, 304 (58.8%), 146 (28.2%), and 67 (13.0%) were RLS 1, 2, and 3, respectively. RLS 3 patients had significantly lower scaled scores in the cognitive, receptive, and expressive communication, and fine and gross motor domains, compared with RLS 1 patients. Multivariable models accounted for 21.5%-31.5% of the variation in the scaled scores, with RLS explaining 1.4-7.3% of the variation. In a subgroup analysis, RLS 3 patients demonstrated relatively fewer gains in cognitive, expressive communication, and gross motor scores over time (all p < 0.05). In conclusion, RLS 3 patients are at increased risk for neurodevelopmental delay, warranting closer follow-up and greater developmental support for cognitive, language, and motor skills soon after surgery.
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Affiliation(s)
- Aditya Sengupta
- Department of Cardiac Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA.
| | - Kimberlee Gauvreau
- Department of Biostatistics, Harvard School of Public Health, Boston, MA, USA
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - Anjali Sadhwani
- Department of Psychiatry and Behavioral Sciences, Harvard Medical School, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Samantha C Butler
- Department of Psychiatry and Behavioral Sciences, Harvard Medical School, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Pedro J Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
- Department of Surgery, Harvard Medical School, Boston, MA, USA
| | - Meena Nathan
- Department of Cardiac Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
- Department of Surgery, Harvard Medical School, Boston, MA, USA
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21
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Gierlinger G, Rech L, Emani SM, Del Nido PJ, Friehs I. A Neonatal Heterotopic Rat Heart Transplantation Model for the Study of Endothelial-to-Mesenchymal Transition. J Vis Exp 2023. [PMID: 37677007 DOI: 10.3791/65426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023] Open
Abstract
Endocardial fibroelastosis (EFE), defined by subendocardial tissue accumulation, has major impacts on the development of the left ventricle (LV) and precludes patients with congenital critical aortic stenosis and hypoplastic left heart syndrome (HLHS) from curative anatomical biventricular surgical repair. Surgical resection is currently the only available therapeutic option, but EFE often recurs, sometimes with an even more infiltrative growth pattern into the adjacent myocardium. To better understand the underlying mechanisms of EFE and to explore therapeutic strategies, an animal model suitable for preclinical testing was developed. The animal model takes into consideration that EFE is a disease of the immature heart and is associated with flow disturbances, as supported by clinical observations. Thus, the heterotopic heart transplantation of neonatal rat donor hearts is the basis for this model. A neonatal rat heart is transplanted into an adolescent rat's abdomen and connected to the recipient's infrarenal aorta and inferior vena cava. While perfusion of the coronary arteries preserves the viability of the donor heart, flow stagnation within the LV induces EFE growth in the very immature heart. The underlying mechanism of EFE formation is the transition of endocardial endothelial cells to mesenchymal cells (EndMT), which is a well-described mechanism of early embryonic development of the valves and septa but also the leading cause of fibrosis in heart failure. EFE formation can be macroscopically observed within days after transplantation. Transabdominal echocardiography is used to monitor the graft viability, contractility, and the patency of the anastomoses. Following euthanasia, the EFE tissue is harvested, and it shows the same histopathological characteristics as human EFE tissue from HLHS patients. This in vivo model allows for studying the mechanisms of EFE development in the heart and testing treatment options to prevent this pathological tissue formation and provides the opportunity for a more generalized examination of EndMT-induced fibrosis.
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Affiliation(s)
- Gregor Gierlinger
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School
| | - Lavinia Rech
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School
| | - Sitaram M Emani
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School
| | - Pedro J Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School
| | - Ingeborg Friehs
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School;
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22
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Sengupta A, Gauvreau K, Shukla A, Kohlsaat K, Colan SD, Del Nido PJ, Mayer JE, Nathan M. Natural History of Truncal Root Dilatation and Truncal Valve Regurgitation in Truncus Arteriosus. Ann Thorac Surg 2023; 116:78-84. [PMID: 37030430 DOI: 10.1016/j.athoracsur.2023.03.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [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: 01/19/2023] [Revised: 03/06/2023] [Accepted: 03/20/2023] [Indexed: 04/10/2023]
Abstract
BACKGROUND The natural history of the dilated truncal root in repaired truncus arteriosus (TA) is incompletely understood. METHODS A single-center review of patients who underwent TA repair between January 1984 and December 2018 was performed. Echocardiographically determined root diameters and derived z scores were measured at the annulus, sinus of Valsalva (SoV), and sinutubular junction (STJ) immediately before TA repair and throughout follow-up. Linear mixed-effects models assessed trends in root dimensions over time. RESULTS Of 193 patients who underwent TA repair at a median age of 12 days (interquartile range, 6-48 days) and survived to discharge, 34 (17.6%), 110 (57.0%), and 49 (25.4%) patients had bicuspid, tricuspid, and quadricuspid truncal valves, respectively. Median postoperative follow-up was 11.6 years (interquartile range, 4.4-22.0 years; range, 0.1-34.8 years). Truncal valve or root intervention was required in 38 patients (19.7%). The mean rates of annular, SoV, and STJ growth were 0.7 ± 0.3 mm/y, 0.8 ± 0.5 mm/y, and 0.9 ± 0.4 mm/y, respectively. Root z scores remained stable with time. At baseline, compared with patients with tricuspid leaflet anatomy, bicuspid patients had larger diameters at the SoV (P = .003) and STJ (P = .029), whereas quadricuspid patients had larger STJ diameters (P = .004). Over time, the bicuspid and quadricuspid cohorts demonstrated comparatively greater annular dilatation (both P < .05). Patients with ≥75th percentile root growth rates had a higher incidence of moderate-severe truncal regurgitation (P = .019) and truncal valve intervention (P = .002). CONCLUSIONS Root dilatation in TA persisted for up to 30 years after primary repair. Patients with bicuspid and quadricuspid truncal valves demonstrated greater root dilatation over time and required more valve interventions. Continued longitudinal follow-up is warranted in this higher-risk cohort.
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Affiliation(s)
- Aditya Sengupta
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts
| | - Kimberlee Gauvreau
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts
| | - Akalpit Shukla
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts
| | - Katherine Kohlsaat
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts
| | - Steven D Colan
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Pedro J Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts; Department of Surgery, Harvard Medical School, Boston, Massachusetts
| | - John E Mayer
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts; Department of Surgery, Harvard Medical School, Boston, Massachusetts
| | - Meena Nathan
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts; Department of Surgery, Harvard Medical School, Boston, Massachusetts.
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23
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Sengupta A, Bucholz EM, Gauvreau K, Newburger JW, Schroeder M, Kaza AK, Del Nido PJ, Nathan M. Impact of Neighborhood Socioeconomic Status on Outcomes Following First-Stage Palliation of Single Ventricle Heart Disease. J Am Heart Assoc 2023; 12:e026764. [PMID: 36892043 PMCID: PMC10111557 DOI: 10.1161/jaha.122.026764] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/10/2023]
Abstract
Background The impact of neighborhood socioeconomic status (SES) on outcomes following first-stage palliation of single ventricle heart disease remains incompletely characterized. Methods and Results This was a single-center, retrospective review of consecutive patients who underwent the Norwood procedure from January 1, 1997 to November 11, 2017. Outcomes of interest included in-hospital (early) mortality or transplant, postoperative hospital length-of-stay, inpatient cost, and postdischarge (late) mortality or transplant. The primary exposure was neighborhood SES, assessed using a composite score derived from 6 US census-block group measures related to wealth, income, education, and occupation. Associations between SES and outcomes were assessed using logistic regression, generalized linear, or Cox proportional hazards models, adjusting for baseline patient-related risk factors. Of 478 patients, there were 62 (13.0%) early deaths or transplants. Among 416 transplant-free survivors at hospital discharge, median postoperative hospital length-of-stay and cost were 24 (interquartile range, 15-43) days and $295 000 (interquartile range, $193 000-$563 000), respectively. There were 97 (23.3%) late deaths or transplants. On multivariable analysis, patients in the lowest SES tertile had greater risk of early mortality or transplant (odds ratio [OR], 4.3 [95% CI, 2.0-9.4; P<0.001]), had longer hospitalizations (coefficient 0.4 [95% CI, 0.2-0.5; P<0.001]), incurred higher costs (coefficient 0.5 [95% CI, 0.3-0.7; P<0.001]), and had greater risk of late mortality or transplant (hazard ratio, 2.2 [95% CI, 1.3-3.7; P=0.004]), compared with those in the highest tertile. The risk of late mortality was partially attenuated with successful completion of home monitoring programs. Conclusions Lower neighborhood SES is associated with worse transplant-free survival following the Norwood operation. This risk persists throughout the first decade of life and may be mitigated with successful completion of interstage surveillance programs.
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Affiliation(s)
- Aditya Sengupta
- Department of Cardiac Surgery Boston Children's Hospital Boston MA
| | - Emily M Bucholz
- Department of Cardiology Boston Children's Hospital Boston MA
| | - Kimberlee Gauvreau
- Department of Cardiology Boston Children's Hospital Boston MA
- Department of Biostatistics Harvard School of Public Health Boston MA
| | - Jane W Newburger
- Department of Cardiology Boston Children's Hospital Boston MA
- Department of Pediatrics Harvard Medical School Boston MA
| | | | - Aditya K Kaza
- Department of Cardiac Surgery Boston Children's Hospital Boston MA
- Department of Surgery Harvard Medical School Boston MA
| | - Pedro J Del Nido
- Department of Cardiac Surgery Boston Children's Hospital Boston MA
- Department of Surgery Harvard Medical School Boston MA
| | - Meena Nathan
- Department of Cardiac Surgery Boston Children's Hospital Boston MA
- Department of Surgery Harvard Medical School Boston MA
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24
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Celik A, Orfany A, Dearling J, Del Nido PJ, McCully JD, Bakar-Ates F. Mitochondrial transplantation: Effects on chemotherapy in prostate and ovarian cancer cells in vitro and in vivo. Biomed Pharmacother 2023; 161:114524. [PMID: 36948134 DOI: 10.1016/j.biopha.2023.114524] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 03/10/2023] [Accepted: 03/10/2023] [Indexed: 03/24/2023] Open
Abstract
Prostate and ovarian cancers affect the male and female reproductive organs and are among the most common cancers in developing countries. Previous studies have demonstrated that cancer cells have a high rate of aerobic glycolysis that is present in nearly all invasive human cancers and persists even under normoxic conditions. Aerobic glycolysis has been correlated with chemotherapeutic resistance and tumor aggressiveness. These data suggest that mitochondrial dysfunction may confer a significant proliferative advantage during the somatic evolution of cancer. In this study we investigated the effect of direct mitochondria transplantation on cancer cell proliferation and chemotherapeutic sensitivity in prostate and ovarian cancer models, both in vitro and in vivo. Our results show that the transplantation of viable, respiration competent mitochondria has no effect on cancer cell proliferation but significantly decreases migration and alters cell cycle checkpoints. Our results further demonstrate that mitochondrial transplantation significantly increases chemotherapeutic sensitivity, providing similar apoptotic levels with low-dose chemotherapy as that achieved with high-dose chemotherapy. These results suggest that mitochondria transplantation provides a novel approach for early prostate and ovarian cancer therapy, significantly increasing chemotherapeutic sensitivity in in vitro and in vivo murine models.
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Affiliation(s)
- Aybuke Celik
- Department of Biochemistry, Faculty of Pharmacy, Ankara University, Ankara, Turkey; Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Arzoo Orfany
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Jason Dearling
- Department of Radiology, Boston Children's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Pedro J Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - James D McCully
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Filiz Bakar-Ates
- Department of Biochemistry, Faculty of Pharmacy, Ankara University, Ankara, Turkey.
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26
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Sengupta A, Gauvreau K, Kaza A, Hoganson D, Del Nido PJ, Nathan M. Timing of reintervention influences survival and resource utilization following first-stage palliation of single ventricle heart disease. J Thorac Cardiovasc Surg 2023; 165:436-446. [PMID: 35961880 DOI: 10.1016/j.jtcvs.2022.04.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 04/11/2022] [Accepted: 04/27/2022] [Indexed: 01/18/2023]
Abstract
OBJECTIVE Outcomes after first-stage palliation of single-ventricle heart disease are influenced by many factors, including the presence of residual lesions requiring reintervention. However, there is a dearth of information regarding the optimal timing of reintervention. We assessed if earlier reintervention would be favorably associated with in-hospital outcomes among patients requiring unplanned reinterventions after the Norwood operation. METHODS This was a single-center, retrospective review of all patients who underwent the Norwood procedure from January 1997 to November 2017 and required a predischarge unplanned surgical or transcatheter reintervention on 1 or more subcomponent areas repaired at the index operation. Outcomes of interest included in-hospital mortality or transplant, postoperative hospital length of stay, and inpatient cost. Associations between timing of reintervention and outcomes were assessed using logistic regression (mortality or transplant) or generalized linear models (postoperative hospital length of stay and cost), adjusting for baseline patient-related and procedural factors. RESULTS Of 500 patients who underwent the Norwood operation, 92 (18.4%) required an unplanned reintervention. Median time to reintervention was 12 days (interquartile range, 5-35 days). There were 31 (33.7%) deaths or transplants, median postoperative hospital length of stay was 49 days (interquartile range, 32-87 days), and median cost was $328,000 (interquartile range, $204,000-$464,000). On multivariable analysis, each 5-day increase in time to reintervention increased the odds of mortality or transplant by 20% (odds ratio, 1.2; 95% confidence interval, 1.1-1.3; P = .004). Longer time to reintervention was also significantly associated with greater postoperative hospital length of stay (P < .001) and higher cost (P < .001). CONCLUSIONS For patients requiring predischarge unplanned reinterventions after the Norwood operation, earlier reintervention is associated with improved in-hospital transplant-free survival and resource use.
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Affiliation(s)
- Aditya Sengupta
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass
| | - Kimberlee Gauvreau
- Department of Cardiology, Boston Children's Hospital, Boston, Mass; Department of Biostatistics, Harvard School of Public Health, Boston, Mass
| | - Aditya Kaza
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass; Department of Surgery, Harvard Medical School, Boston, Mass
| | - David Hoganson
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass; Department of Surgery, Harvard Medical School, Boston, Mass
| | - Pedro J Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass; Department of Surgery, Harvard Medical School, Boston, Mass
| | - Meena Nathan
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass; Department of Surgery, Harvard Medical School, Boston, Mass.
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27
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Sengupta A, Gauvreau K, Marx GR, Colan SD, Newburger JW, Baird CW, Del Nido PJ, Nathan M. Residual Lesion Severity Predicts Midterm Outcomes After Congenital Aortic Valve Repair. Ann Thorac Surg 2023; 115:159-165. [PMID: 36075398 DOI: 10.1016/j.athoracsur.2022.08.032] [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: 03/01/2022] [Revised: 07/27/2022] [Accepted: 08/08/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND We sought to validate the technical performance score (TPS) as a predictor of midterm outcomes after congenital aortic valve repair. METHODS This was a single-center, retrospective review of consecutive patients who underwent aortic valve repair between January 1, 2011, and December 31, 2019. Predischarge echocardiograms were used to assign a TPS for each index operation as class 1, no aortic valve residua; class 2, minor aortic valve residua; or class 3, major aortic valve residua or predischarge reintervention for major residua. The primary outcome was postdischarge (late) unplanned aortic valve reintervention. Secondary outcomes included late mortality and at least moderate aortic regurgitation or stenosis at the latest follow-up or before the earliest reintervention. Associations between TPS and outcomes were assessed using competing risk, Cox proportional hazards, or logistic regression models, adjusting for preoperative patient- and procedure-related covariates. RESULTS Of 507 patients, there were 110 (21.7%) reinterventions, 22 (4.3%) deaths, and 67 (13.2%) cases of at least moderate aortic regurgitation or stenosis at the latest follow-up or earliest reintervention. On multivariable analysis, class 3 patients had a greater risk of reintervention (subdistribution hazard ratio, 2.6; 95% CI, 1.3-5.1; P = .005) and mortality (hazard ratio, 5.3; 95% CI. 1.1-25.2; P = .038) compared with class 1 patients. Adjusting for duration of follow-up, class 3 patients also had a greater risk of at least moderate aortic regurgitation or stenosis at the latest follow-up or earliest reintervention (odds ratio, 7.7; 95% CI, 2.5-24.2; P < .001) vs class 1 patients. CONCLUSIONS Patients with major residua after congenital aortic valve repair have significantly worse midterm outcomes compared with those with no residua, warranting closer follow-up.
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Affiliation(s)
- Aditya Sengupta
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts
| | - Kimberlee Gauvreau
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts
| | - Gerald R Marx
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Steven D Colan
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Christopher W Baird
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts; Department of Surgery, Harvard Medical School, Boston, Massachusetts
| | - Pedro J Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts; Department of Surgery, Harvard Medical School, Boston, Massachusetts
| | - Meena Nathan
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts; Department of Surgery, Harvard Medical School, Boston, Massachusetts.
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28
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Sengupta A, Gauvreau K, Bucholz EM, Newburger JW, Del Nido PJ, Nathan M. Contemporary Socioeconomic and Childhood Opportunity Disparities in Congenital Heart Surgery. Circulation 2022; 146:1284-1296. [PMID: 36164982 DOI: 10.1161/circulationaha.122.060030] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [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] [Indexed: 01/24/2023]
Abstract
BACKGROUND While singular measures of socioeconomic status have been associated with outcomes after surgery for congenital heart disease, the multifaceted pathways through which a child's environment impacts similar outcomes remain incompletely characterized. We sought to evaluate the association between childhood opportunity level and adverse outcomes after congenital heart surgery. METHODS Data from patients undergoing congenital cardiac surgery from January 2011 to January 2020 at a quaternary referral center were retrospectively reviewed. Outcomes of interest included predischarge (early) mortality or transplant, postoperative hospital length-of-stay, inpatient cost of hospitalization, postdischarge (late) mortality or transplant, and late unplanned reintervention. The primary predictor was a US census tract-based, nationally-normed composite metric of contemporary child neighborhood opportunity comprising 29 indicators across 3 domains (education, health and environment, and socioeconomic), categorized as very low, low, moderate, high, and very high. Associations between childhood opportunity level and outcomes were evaluated using logistic regression (early mortality), generalized linear (length-of-stay and cost), Cox proportional hazards (late mortality), or competing risk (late reintervention) models, adjusting for baseline patient-related factors, case complexity, and residual lesion severity. RESULTS Of 6133 patients meeting entry criteria, the median age was 2.0 years (interquartile range, 3.6 months-8.3 years). There were 124 (2.0%) early deaths or transplants, the median postoperative length-of-stay was 7 days (interquartile range, 5-13 days), and the median inpatient cost was $76 000 (interquartile range, $50 000-130 000). No significant association between childhood opportunity level and early mortality or transplant was observed (P=0.21). On multivariable analysis, children with very low and low opportunity had significantly longer length-of-stay and incurred higher costs compared with those with very high opportunity (all P<0.05). Of 6009 transplant-free survivors of hospital discharge, there were 175 (2.9%) late deaths or transplants, and 1008 (16.8%) reinterventions at up to 10.5 years of follow-up. Patients with very low opportunity had a significantly greater adjusted risk of late death or transplant (hazard ratio, 1.7 [95% CI, 1.1-2.6]; P=0.030) and reintervention (subdistribution hazard ratio, 1.9 [95% CI, 1.5-2.3]; P<0.001), versus those with very high opportunity. CONCLUSIONS Childhood opportunity level is independently associated with adverse outcomes after congenital heart surgery. Children from resource-limited settings thus constitute an especially high-risk cohort that warrants closer surveillance and tailored interventions.
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Affiliation(s)
- Aditya Sengupta
- Departments of Cardiac Surgery (A.S., P.J.dN., M.N.), Boston Children's Hospital, MA
| | - Kimberlee Gauvreau
- Departments of Cardiac Surgery (A.S., P.J.dN., M.N.), Boston Children's Hospital, MA.,Department of Biostatistics, Harvard School of Public Health, Boston, MA (K.G.)
| | - Emily M Bucholz
- Cardiology (K.G., E.M.B., J.W.N.), Boston Children's Hospital, MA
| | - Jane W Newburger
- Cardiology (K.G., E.M.B., J.W.N.), Boston Children's Hospital, MA.,Departments of Pediatrics (J.W.N.), Harvard Medical School, Boston, MA
| | - Pedro J Del Nido
- Departments of Cardiac Surgery (A.S., P.J.dN., M.N.), Boston Children's Hospital, MA.,Surgery (P.J.dN., M.N.), Harvard Medical School, Boston, MA
| | - Meena Nathan
- Departments of Cardiac Surgery (A.S., P.J.dN., M.N.), Boston Children's Hospital, MA.,Surgery (P.J.dN., M.N.), Harvard Medical School, Boston, MA
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Scully BB, Feins EN, Tworetzky W, Ghelani S, Beroukhim R, Del Nido PJ, Emani SM. Early Experience With Reverse Double Switch Operation for the Borderline Left Heart. Semin Thorac Cardiovasc Surg 2022; 36:67-79. [PMID: 36180012 DOI: 10.1053/j.semtcvs.2022.09.009] [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] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 09/02/2022] [Indexed: 11/11/2022]
Abstract
This study reviews our early experience with the "reverse" double switch operation (R-DSO) for borderline left hearts. A retrospective review of children with borderline left hearts who underwent R-DSO between 2017 and 2021 was conducted. Patient characteristics and early hemodynamic and clinical outcomes were collected. R-DSO was performed in 8 patients with no operative or postoperative deaths; 5 underwent decompressing bidirectional Glenn. Left ventricular (LV) poor-compliance was the dominant pathophysiology. Four patients had undergone staged LV recruitment but were not candidates for anatomical biventricular circulation due to LV hypoplasia and/or diastolic dysfunction. 7/8 patients had risk factors for Fontan circulation including pulmonary vein stenosis, pulmonary hypertension, and pulmonary artery stenosis. Median age at R-DSO was 3.7 years (19 months-12 years). All patients were in sinus rhythm at discharge. At median follow-up of 15 months (57 days-4.1 years) no mortalities, reoperations or heart transplants had occurred. All patients had normal morphologic LV systolic function. In one patient, pre-existing pulmonary hypertension (HTN) resolved after R-DSO. Reinterventions included transcatheter mitral valve replacement for residual mitral stenosis and neo-pulmonary balloon valvuloplasty. In 4 patients follow-up catheterization done at a median of 519 days (320 days-4 years) demonstrated median cardiac index of 3.2 L/min/m2 (2.2-4); median sub-pulmonary left ventricular end diastolic pressure was 9 mm Hg (7-15); median inferior vena cava/baffle pressure was 8 mm Hg (7-13). R-DSO is an alternative to anatomical biventricular repair or single ventricle palliation in patients with borderline left hearts and can result in low inferior vena cava pressures and favorable early results. This approach can also relieve pulmonary HTN and allow future transplant candidacy.
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Affiliation(s)
- Brandi Braud Scully
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.
| | - Eric N Feins
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Wayne Tworetzky
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sunil Ghelani
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Rebecca Beroukhim
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Pedro J Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sitaram M Emani
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
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Sengupta A, Beroukhim R, Baird CW, Del Nido PJ, Geva T, Gauvreau K, Marcus E, Sanders SP, Nathan M. Outcomes of Repair of Congenital Aortic Valve Lesions Using Autologous Pericardium vs Porcine Intestinal Submucosa. J Am Coll Cardiol 2022; 80:1060-1068. [PMID: 36075675 DOI: 10.1016/j.jacc.2022.06.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 05/11/2022] [Accepted: 06/21/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND Outcomes following congenital aortic valve (AoV) repair are plagued by progressive dysfunction of currently available leaflet substitute materials. OBJECTIVES We compared the long-term outcomes of congenital AoV repair using porcine intestinal submucosa vs autologous pericardium (AP). METHODS This was a single-center retrospective review of all patients who underwent congenital AoV repair with either porcine intestinal submucosa or AP from October 2009 to March 2013. The primary outcome was postdischarge (late) unplanned AoV reintervention. Secondary outcomes included number of late AoV reinterventions and a composite of at least moderate aortic regurgitation or stenosis at latest follow-up or before the first reintervention. Associations between leaflet repair material and outcomes were assessed using multivariable regression models, adjusting for prespecified patient-related and operative variables. RESULTS Of 26 porcine intestinal submucosa and 49 AP patients who met entry criteria, the median age was 11.0 years (IQR: 4.7-16.6 years). At a median follow-up of 8.5 years (IQR: 4.4-9.6 years), 17 (65.4%) porcine intestinal submucosa and 22 (44.9%) AP patients underwent at least 1 AoV reintervention. On multivariable analysis, porcine intestinal submucosa use was significantly associated with unplanned AoV reintervention (HR: 4.6; 95% CI: 2.2-9.8; P < 0.001), number of postdischarge AoV reinterventions (incidence rate ratio: 1.7; 95% CI: 1.0-2.9; P = 0.037), and at least moderate aortic regurgitation or stenosis at latest follow-up or before the first reintervention (OR: 5.0; 95% CI: 1.2-21.0; P = 0.027). CONCLUSIONS Aortic valvuloplasty with porcine intestinal submucosa is associated with earlier time to reintervention compared with autologous pericardium. The search for the ideal AoV leaflet repair material continues.
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Affiliation(s)
- Aditya Sengupta
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts, USA.
| | - Rebecca Beroukhim
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher W Baird
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts, USA; Department of Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Pedro J Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts, USA; Department of Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Tal Geva
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Kimberlee Gauvreau
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA; Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts, USA
| | - Edward Marcus
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Stephen P Sanders
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA; Cardiac Registry, Departments of Cardiology, Pathology and Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Meena Nathan
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts, USA; Department of Surgery, Harvard Medical School, Boston, Massachusetts, USA
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Saba TG, Geddes GC, Ware SM, Schidlow DN, Del Nido PJ, Rubalcava NS, Gadepalli SK, Stillwell T, Griffiths A, Bennett Murphy LM, Barber AT, Leigh MW, Sabin N, Shapiro AJ. A multi-disciplinary, comprehensive approach to management of children with heterotaxy. Orphanet J Rare Dis 2022; 17:351. [PMID: 36085154 PMCID: PMC9463860 DOI: 10.1186/s13023-022-02515-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 09/04/2022] [Indexed: 11/10/2022] Open
Abstract
Heterotaxy (HTX) is a rare condition of abnormal thoraco-abdominal organ arrangement across the left-right axis of the body. The pathogenesis of HTX includes a derangement of the complex signaling at the left-right organizer early in embryogenesis involving motile and non-motile cilia. It can be inherited as a single-gene disorder, a phenotypic feature of a known genetic syndrome or without any clear genetic etiology. Most patients with HTX have complex cardiovascular malformations requiring surgical intervention. Surgical risks are relatively high due to several serious comorbidities often seen in patients with HTX. Asplenia or functional hyposplenism significantly increase the risk for sepsis and therefore require antimicrobial prophylaxis and immediate medical attention with fever. Intestinal rotation abnormalities are common among patients with HTX, although volvulus is rare and surgical correction carries substantial risk. While routine screening for intestinal malrotation is not recommended, providers and families should promptly address symptoms concerning for volvulus and biliary atresia, another serious morbidity more common among patients with HTX. Many patients with HTX have chronic lung disease and should be screened for primary ciliary dyskinesia, a condition of respiratory cilia impairment leading to bronchiectasis. Mental health and neurodevelopmental conditions need to be carefully considered among this population of patients living with a substantial medical burden. Optimal care of children with HTX requires a cohesive team of primary care providers and experienced subspecialists collaborating to provide compassionate, standardized and evidence-based care. In this statement, subspecialty experts experienced in HTX care and research collaborated to provide expert- and evidence-based suggestions addressing the numerous medical issues affecting children living with HTX.
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Affiliation(s)
- Thomas G Saba
- Department of Pediatrics, Pulmonary Division, University of Michigan Medical School, 1500 E. Medical Center Drive, Ann Arbor, MI, USA.
| | - Gabrielle C Geddes
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Stephanie M Ware
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - David N Schidlow
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Pedro J Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Nathan S Rubalcava
- Department of Surgery, Section of Pediatric Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Samir K Gadepalli
- Department of Surgery, Section of Pediatric Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Terri Stillwell
- Department of Pediatrics, Infectious Disease Division, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Anne Griffiths
- Department of Pediatrics, Pulmonary/Critical Care Division, Children's Minnesota and Children's Respiratory and Critical Care Specialists, Minneapolis, MN, USA
| | - Laura M Bennett Murphy
- Department of Pediatrics, Division of Pediatric Psychiatry and Behavioral Health, University of Utah, Primary Children's Hospital, Salt Lake City, UT, USA
| | - Andrew T Barber
- Department of Pediatrics, Division of Pulmonology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Margaret W Leigh
- Department of Pediatrics, Division of Pulmonology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Necia Sabin
- Heterotaxy Connection, Eagle Mountain, UT, USA
| | - Adam J Shapiro
- Department of Pediatrics, McGill University Health Centre Research Institute, Montreal, QC, Canada
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Prasanna A, Beroukhim RS, Ghelani S, Feins EN, Del Nido PJ, Emani SM. Staged Ventricular Septation in Double-Inlet Ventricle - A Strategy to Avoid Fontan? Semin Thorac Cardiovasc Surg 2022; 36:91-101. [PMID: 36089119 DOI: 10.1053/j.semtcvs.2022.08.014] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Accepted: 08/16/2022] [Indexed: 11/11/2022]
Abstract
Single-stage ventricular septation for double-inlet left or right ventricle (DILV or DIRV) has historically been associated with poor outcomes. We hypothesize that staged ventricular septation may demonstrate favorable clinical outcomes to be an alternative to Fontan palliation. This single-center retrospective study reviewed patients with DILV or DIRV who underwent staged ventricular septation between 2015-2021. The strategy involves pulmonary artery banding or Norwood procedure during infancy (stage 1), followed by partial ventricular septation to anchor the septum, while maintaining systemic RV pressure to avoid septal shift (stage 2). Residual septal defects are closed with pulmonary artery band removal at stage 3. Results are reported as median (interquartile range). Twelve patients underwent partial ventricular septation. At a median follow-up time of 17 months (8-30) after stage 2, there were no interstage deaths or cardiac transplants; LV dysfunction was observed in one patient. Hemodynamic evaluation after stage 2 demonstrated median left atrial pressure of 9.5 mm Hg (8.9-11.5), cardiac index of 3.4 L/min/m2 (3.2-3.6), and RV and LV indexed end-diastolic volumes of 52 ml/m2 (41-67) and 105 ml/m2 (81-115), respectively. Five patients have progressed to stage 3; one required pacemaker for complete heart block. Unplanned reintervention was required in 4 patients after stage 1, 2 patients after stage 2, and 3 patients after stage 3. Staged ventricular septation is an alternative to single-ventricle palliation in a subset of double-inlet ventricle patients and is associated with acceptable early outcomes. Further studies are necessary to determine long-term outcomes.
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Affiliation(s)
- Anagha Prasanna
- Harvard Medical School, 25 Shattuck Street, Boston, MA, 02115
| | - Rebecca S Beroukhim
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115
| | - Sunil Ghelani
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115
| | - Eric N Feins
- Department of Cardiovascular Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115
| | - Pedro J Del Nido
- Department of Cardiovascular Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115
| | - Sitaram M Emani
- Department of Cardiovascular Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115.
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Vorisek C, Weixler V, Dominguez M, Axt-Fliedner R, Hammer PE, Lin RZ, Melero-Martin JM, Del Nido PJ, Friehs I. Mechanical strain triggers endothelial-to-mesenchymal transition of the endocardium in the immature heart. Pediatr Res 2022; 92:721-728. [PMID: 34837068 PMCID: PMC9133271 DOI: 10.1038/s41390-021-01843-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 09/27/2021] [Accepted: 10/28/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND Endothelial-to-mesenchymal-transition (EndMT) plays a major role in cardiac fibrosis, including endocardial fibroelastosis but the stimuli are still unknown. We developed an endothelial cell (EC) culture and a whole heart model to test whether mechanical strain triggers TGF-β-mediated EndMT. METHODS Isolated ECs were exposed to 10% uniaxial static stretch for 8 h (stretch) and TGF-β-mediated EndMT was determined using the TGF-β-inhibitor SB431542 (stretch + TGF-β-inhibitor), BMP-7 (stretch + BMP-7) or losartan (stretch + losartan), and isolated mature and immature rats were exposed to stretch through a weight on the apex of the left ventricle. Immunohistochemical staining for double-staining with endothelial markers (VE-cadherin, PECAM1) and mesenchymal markers (αSMA) or transcription factors (SLUG/SNAIL) positive nuclei was indicative of EndMT. RESULTS Stretch-induced EndMT in ECs expressed as double-stained ECs/total ECs (cells: 46 ± 13%; heart: 15.9 ± 2%) compared to controls (cells: 7 ± 2%; heart: 3.1 ± 0.1; p < 0.05), but only immature hearts showed endocardial EndMT. Inhibition of TGF-β decreased the number of double-stained cells significantly, comparable to controls (cells/heart: control: 7 ± 2%/3.1 ± 0.1%, stretch: 46 ± 13%/15 ± 2%, stretch + BMP-7: 7 ± 2%/2.9 ± 0.1%, stretch + TGF-β-inhibitor (heart only): 5.2 ± 1.3%, stretch + losartan (heart only): 0.89 ± 0.1%; p < 0.001 versus stretch). CONCLUSIONS Endocardial EndMT is an age-dependent consequence of increased strain triggered by TGF- β activation. Local inhibition through either rebalancing TGF-β/BMP or with losartan was effective to block EndMT. IMPACT Mechanical strain imposed on the immature LV induces endocardial fibroelastosis (EFE) formation through TGF-β-mediated activation of endothelial-to-mesenchymal transition (EndMT) in endocardial endothelial cells but has no effect in mature hearts. Local inhibition through either rebalancing the TGF-β/BMP pathway or with losartan blocks EndMT. Inhibition of endocardial EndMT with clinically applicable treatments may lead to a better outcome for congenital heart defects associated with EFE.
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Affiliation(s)
- Carina Vorisek
- Department of Cardiac Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Viktoria Weixler
- Department of Cardiac Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Massiel Dominguez
- Department of Cardiac Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Roland Axt-Fliedner
- Center for Prenatal Medicine and Fetal Therapy, Justus-Liebig-University of Giessen, Giessen, Germany
| | - Peter E Hammer
- Department of Cardiac Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Ruei-Zeng Lin
- Department of Cardiac Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Juan M Melero-Martin
- Department of Cardiac Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Pedro J Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Ingeborg Friehs
- Department of Cardiac Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA.
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Herrmann HC, Pibarot P, Wu C, Hahn RT, Tang GHL, Abbas AE, Playford D, Ruel M, Jilaihawi H, Sathananthan J, Wood DA, De Paulis R, Bax JJ, Rodes-Cabau J, Cameron DE, Chen T, Del Nido PJ, Dweck MR, Kaneko T, Latib A, Moat N, Modine T, Popma JJ, Raben J, Smith RL, Tchetche D, Thomas MR, Vincent F, Yoganathan A, Zuckerman B, Mack MJ, Leon MB. Bioprosthetic Aortic Valve Hemodynamics: Definitions, Outcomes, and Evidence Gaps: JACC State-of-the-Art Review. J Am Coll Cardiol 2022; 80:527-544. [PMID: 35902177 DOI: 10.1016/j.jacc.2022.06.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [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: 02/10/2022] [Revised: 05/19/2022] [Accepted: 06/01/2022] [Indexed: 12/23/2022]
Abstract
A virtual workshop was organized by the Heart Valve Collaboratory to identify areas of expert consensus, areas of disagreement, and evidence gaps related to bioprosthetic aortic valve hemodynamics. Impaired functional performance of bioprosthetic aortic valve replacement is associated with adverse patient outcomes; however, this assessment is complicated by the lack of standardization for labelling, definitions, and measurement techniques, both after surgical and transcatheter valve replacement. Echocardiography remains the standard assessment methodology because of its ease of performance, widespread availability, ability to do serial measurements over time, and correlation with outcomes. Management of a high gradient after replacement requires integration of the patient's clinical status, physical examination, and multimodality imaging in addition to shared patient decisions regarding treatment options. Future priorities that are underway include efforts to standardize prosthesis sizing and labelling for both surgical and transcatheter valves as well as trials to characterize the consequences of adverse hemodynamics.
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Affiliation(s)
- Howard C Herrmann
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | - Philippe Pibarot
- Department of Medicine, Québec Heart and Lung Institute, Laval University, Québec City, Quebec, Canada
| | - Changfu Wu
- U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Rebecca T Hahn
- Columbia University Medical Center, New York, New York, USA
| | | | - Amr E Abbas
- Beaumont Hospital Royal Oak, Royal Oak, Michigan, USA
| | - David Playford
- The University of Notre Dame, Fremantle, Western Australia, Australia
| | - Marc Ruel
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Hasan Jilaihawi
- Heart Valve Center, NYU Langone Health, New York, New York, USA
| | - Janarthanan Sathananthan
- Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | - David A Wood
- Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Jeroen J Bax
- Leiden University Medical Centre, Leiden, the Netherlands
| | - Josep Rodes-Cabau
- Department of Medicine, Québec Heart and Lung Institute, Laval University, Québec City, Quebec, Canada
| | - Duke E Cameron
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Tiffany Chen
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Pedro J Del Nido
- Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Marc R Dweck
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Tsuyoshi Kaneko
- Division of Thoracic and Cardiac Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Azeem Latib
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Neil Moat
- Abbott Structural Heart, Santa Clara, California, USA
| | - Thomas Modine
- Hopital Cardiologique de Haut Leveque, Bordeaux, France
| | | | - Jamie Raben
- U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Robert L Smith
- Baylor Scott and White, The Heart Hospital, Plano, Texas, USA
| | | | | | | | - Ajit Yoganathan
- Georgia Institute of Technology and Emory University, Atlanta, Georgia, USA
| | - Bram Zuckerman
- U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Michael J Mack
- Baylor Scott and White, The Heart Hospital, Plano, Texas, USA
| | - Martin B Leon
- Columbia University Medical Center, New York, New York, USA
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Sengupta A, Gauvreau K, Kohlsaat K, Colan SD, Newburger JW, Del Nido PJ, Nathan M. Long-Term Outcomes of Patients Requiring Unplanned Repeated Interventions After Surgery for Congenital Heart Disease. J Am Coll Cardiol 2022; 79:2489-2499. [PMID: 35738709 DOI: 10.1016/j.jacc.2022.04.027] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 03/25/2022] [Accepted: 04/04/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND Unplanned catheter-based or surgical reinterventions after congenital heart operations are independently associated with operative mortality and increased postoperative length of stay. OBJECTIVES This study assessed the long-term outcomes of transplant-free survivors of hospital discharge requiring predischarge reinterventions after congenital cardiac surgery. METHODS Data from patients who required predischarge reinterventions in the anatomic area of repair after congenital cardiac surgery and survived to hospital discharge at a quaternary referral center from January 2011 to December 2019 were retrospectively reviewed. Previously published echocardiographic criteria were used to assess the severity of persistent residual lesions at discharge (Grade 1, no residua; Grade 2, minor residua; and Grade 3, major residua). Outcomes included postdischarge (late) mortality or transplant and unplanned reintervention. Associations between predischarge residual lesion severity and outcomes were assessed by using Cox or competing risk models, adjusting for baseline patient characteristics, case complexity, and preoperative risk factors. RESULTS Among the 408 patients who met entry criteria, there were 58 (14.2%) postdischarge deaths or transplants and 208 (51.0%) late reinterventions at a median follow-up of 3.0 years (IQR: 1.1-6.8 years). Greater predischarge residual lesion severity was associated with worse transplant-free survival and freedom from reintervention (both, P < 0.05). On multivariable analyses, Grade 3 patients had an increased risk of postdischarge mortality or transplant (HR: 4.8; 95% CI: 2.0-11; P < 0.001) and late reintervention (subdistribution HR: 2.1; 95% CI: 1.4-3.1; P < 0.001) vs Grade 1 patients. CONCLUSIONS Among transplant-free survivors requiring predischarge reinterventions after congenital cardiac surgery, those with persistent major residua have significantly worse long-term outcomes. These high-risk patients warrant closer surveillance.
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Affiliation(s)
- Aditya Sengupta
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts, USA.
| | - Kimberlee Gauvreau
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA; Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts, USA
| | - Katherine Kohlsaat
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Steven D Colan
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Pedro J Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts, USA; Department of Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Meena Nathan
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts, USA; Department of Surgery, Harvard Medical School, Boston, Massachusetts, USA
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Reed AK, Chiu P, Carreon CK, Sanders SP, Del Nido PJ, Baird CW. Unrepairable Infant Mitral Valve: An Unexpected Case of Decompensated Heart Failure. Circulation 2022; 145:1175-1178. [PMID: 35404678 DOI: 10.1161/circulationaha.121.056881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | - Peter Chiu
- Department of Cardiac Surgery (P.C., P.J.d.N., C.W.B.), Boston Children's Hospital/Harvard Medical School, MA
| | - Chrystalle Katte Carreon
- Department of Pathology (C.K.C., S.P.S.), Boston Children's Hospital/Harvard Medical School, MA.,Cardiac Registry, Departments of Cardiology, Pathology, and Cardiac Surgery, Boston Children's Hospital, MA (C.K.C., S.P.S.)
| | - Stephen P Sanders
- Department of Pathology (C.K.C., S.P.S.), Boston Children's Hospital/Harvard Medical School, MA.,Cardiac Registry, Departments of Cardiology, Pathology, and Cardiac Surgery, Boston Children's Hospital, MA (C.K.C., S.P.S.)
| | - Pedro J Del Nido
- Department of Cardiac Surgery (P.C., P.J.d.N., C.W.B.), Boston Children's Hospital/Harvard Medical School, MA
| | - Christopher W Baird
- Department of Cardiac Surgery (P.C., P.J.d.N., C.W.B.), Boston Children's Hospital/Harvard Medical School, MA
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Abstract
The treatment of end-stage heart failure has evolved substantially with advances in medical treatment, cardiac transplantation, and mechanical circulatory support (MCS) devices such as left ventricular assist devices and total artificial hearts. However, current MCS devices are inherently blood contacting and can lead to potential complications including pump thrombosis, hemorrhage, stroke, and hemolysis. Attempts to address these issues and avoid blood contact led to the concept of compressing the failing heart from the epicardial surface and the design of direct cardiac compression (DCC) devices. We review the fundamental concepts related to DCC, present the foundational devices and recent devices in the research and commercialization stages, and discuss the milestones required for clinical translation and adoption of this technology. Expected final online publication date for the Annual Review of Biomedical Engineering, Volume 24 is June 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.
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Affiliation(s)
- Jean Bonnemain
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA.,Department of Adult Intensive Care Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland;
| | - Pedro J Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts, USA;
| | - Ellen T Roche
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA.,Department of Mechanical Engineering and Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA;
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39
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Marathe SP, Chávez M, Schulz A, Sleeper LA, Marx GR, Emani SM, Del Nido PJ, Baird CW. Contemporary outcomes of the double switch operation for congenitally corrected transposition of the great arteries. J Thorac Cardiovasc Surg 2022; 164:1980-1990.e7. [PMID: 35688715 DOI: 10.1016/j.jtcvs.2022.01.049] [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: 07/15/2020] [Revised: 09/24/2021] [Accepted: 01/10/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To determine the contemporary outcomes of the double switch operation (DSO) (ie, Mustard or Senning + arterial switch). METHODS A single-institution, retrospective review of all patients with congenitally corrected transposition of the great arteries undergoing a DSO. RESULTS Between 1999 and 2019, 103 patients underwent DSO with a Mustard (n = 93) or Senning (n = 10) procedure. Segmental anatomy was (S, L, L) in 93 patients and (I, D, D) in 6 patients. Eight patients had heterotaxy and 71 patients had a ventricular septal defect. Median age was 2.1 years (range, 1.8 months-40 years), including 34 patients younger than age 1 year (33%). Median weight was 10.9 kg (range, 3.4-64 kg). Sixty-one patients had prior pulmonary artery bands for a median of 1.1 years (range, 14 days-12.9 years; interquartile range, 0.7-3.1 years). Median intensive care unit and hospital lengths of stay were 5 and 10 days, respectively. Median follow-up was 3.4 years (interquartile range, 1-9.8 years) and 5.2 years (interquartile range, 2.3-10.7 years) in 79 patients with >1 year follow-up. At latest follow-up, aortic, mitral, tricuspid valve regurgitation, and left ventricle dysfunction was less than moderate in 96%, 98%, 96%, and 93%, respectively. Seventeen patients underwent reoperation: neoaortic valve intervention (n = 10), baffle revision (n = 5), and ventricular septal defect closure (n = 4). At latest follow-up, 17 patients (17%) had a pacemaker and 27 (26%) had cardiac resynchronization therapy devices. There were 2 deaths and 2 transplants. Transplant-free survival was 94.6% at 5 years. Risk factors for death or transplant included longer cardiopulmonary bypass time and older age at DSO. CONCLUSIONS The outcomes of the DSO are promising. Earlier age at operation might favor better outcomes. Progressive neoaortic regurgitation and reinterventions on the neo-aortic valve are anticipated problems.
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Affiliation(s)
- Supreet P Marathe
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
| | - Mariana Chávez
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
| | - Antonia Schulz
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
| | - Lynn A Sleeper
- Harvard Medical School, Boston, Mass; Department of Cardiology, Boston Children's Hospital, Boston, Mass
| | - Gerald R Marx
- Harvard Medical School, Boston, Mass; Department of Cardiology, Boston Children's Hospital, Boston, Mass
| | - Sitaram M Emani
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
| | - Pedro J Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
| | - Christopher W Baird
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass.
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40
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Doulamis IP, Marathe SP, Oh NA, Saeed MY, Muter A, Del Nido PJ, Nathan M. Major Aortopulmonary Collateral Arteries Requiring Percutaneous Intervention Following the Arterial Switch Operation: A Case Series and Systematic Review. World J Pediatr Congenit Heart Surg 2022; 13:146-154. [PMID: 35238700 DOI: 10.1177/21501351211064140] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Dextro transposition of the great arteries (d-TGA) is the most common critical congenital cardiac defect surgically treated in the neonatal period by arterial switch operation (ASO). Major aortopulmonary collaterals (MAPCAs) can be present in this population and may complicate the early postoperative period. Our aim was to review our institutional data and systematically review the available literature to provide further insight on the clinical significance of MAPCAs during the early postoperative course after ASO. Methods: This is a retrospective study of patients with simple d-TGA who underwent ASO between March 1998 and September 2020 at Boston Children's Hospital. The MEDLINE, Embase, and Cochrane databases were searched from inception to June 2020. Results: Of the 671 d-TGA patients who underwent ASO at our center, 13 (1.9%) were diagnosed with MAPCAs. Five were diagnosed before ASO, while eight were diagnosed after ASO. Of these, two patients required catheterization for MAPCAs coiling during the same hospitalization on the 2nd and 11th postoperative days. The systematic review retrieved a total of 34 articles after duplicates were removed. Finally, nine studies reporting on 23 patients were deemed eligible for our analysis. The average time to MAPCAs coiling was 12 days, while the mean hospital stay was 36 days. Conclusions: MAPCAs should be included in the differential diagnosis of ASO complicated by cardiac or respiratory failure, or pulmonary hemorrhage acutely postoperatively. Once managed, recovery of these patients is predictable, and mortality is low. Further studies investigating the diagnostic value of echocardiography and the long-term outcomes of these MAPCAs are necessary.
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Affiliation(s)
- Ilias P Doulamis
- Department of Cardiac Surgery, 1862Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Supreet P Marathe
- Department of Cardiac Surgery, 1862Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Nicholas A Oh
- Department of Cardiac Surgery, 1862Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Mossab Y Saeed
- Department of Cardiac Surgery, 1862Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Angelika Muter
- Department of Cardiac Surgery, 1862Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Pedro J Del Nido
- Department of Cardiac Surgery, 1862Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Meena Nathan
- Department of Cardiac Surgery, 1862Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
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41
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McCully JD, Del Nido PJ, Emani SM. Mitochondrial Transplantation for Organ Rescue. Mitochondrion 2022; 64:27-33. [PMID: 35217248 DOI: 10.1016/j.mito.2022.02.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [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: 01/05/2022] [Revised: 02/11/2022] [Accepted: 02/21/2022] [Indexed: 01/19/2023]
Abstract
Mitochondrial transplantation involves the replacement or augmentation of native mitochondria damaged, by ischemia, with viable, respiration-competent mitochondria isolated from non-ischemic tissue obtained from the patient's own body. The uptake and cellular functional integration of the transplanted mitochondria appears to occur in all cell types. Efficacy and safety have been demonstrated in cell culture, isolated perfused organ, in vivo large animal studies and in a first-human clinical study. Herein, we review our findings and provide insight for use in the treatment of organ ischemia- reperfusion injury.
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Affiliation(s)
- James D McCully
- Department of Cardiac Surgery, Boston Children's Hospita; Harvard Medical School, Boston, MA.
| | - Pedro J Del Nido
- Department of Cardiac Surgery, Boston Children's Hospita; Harvard Medical School, Boston, MA
| | - Sitaram M Emani
- Department of Cardiac Surgery, Boston Children's Hospita; Harvard Medical School, Boston, MA
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42
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Guariento A, Doulamis IP, Staffa SJ, Gellis L, Oh NA, Kido T, Mayer JE, Baird CW, Emani SM, Zurakowski D, Del Nido PJ, Nathan M. Reply from authors: A new shared vision on survival analysis: Good news from Baltimore. JTCVS Open 2021; 8:583-584. [PMID: 36004124 PMCID: PMC9390261 DOI: 10.1016/j.xjon.2021.10.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Alvise Guariento
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Ilias P Doulamis
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Steven J Staffa
- Departments of Anesthesiology and Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Laura Gellis
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Nicholas A Oh
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Takashi Kido
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - John E Mayer
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Christopher W Baird
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Sitaram M Emani
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - David Zurakowski
- Departments of Anesthesiology and Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Pedro J Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Meena Nathan
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass
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43
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Oh NA, Hong X, Doulamis IP, Meibalan E, Peiseler T, Melero-Martin J, García-Cardeña G, Del Nido PJ, Friehs I. Abnormal Flow Conditions Promote Endocardial Fibroelastosis Via Endothelial-to-Mesenchymal Transition, Which Is Responsive to Losartan Treatment. JACC Basic Transl Sci 2021; 6:984-999. [PMID: 35024504 PMCID: PMC8733675 DOI: 10.1016/j.jacbts.2021.10.002] [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] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 10/05/2021] [Accepted: 10/05/2021] [Indexed: 12/14/2022]
Abstract
EFE is a congenital cardiac pathology contributing to increased morbidity and mortality. The pathologic triggers of EFE remain to be characterized. To determine whether abnormal flow promotes EFE development, we used in vivo neonatal rodent surgical models and an in vitro model using human primary endocardial cells We established novel surgical model with flow profiles seen in patients that develop EFE. Static and turbulent flow conditions promoted EFE development in neonatal rodent hearts. Losartan treatment is shown to significantly ameliorate EFE progression and decreases mRNA and protein expression of EndoMT markers in neonatal rodent hearts. RNAseq analysis of human endocardial cells subjected to different flow conditions show that normal flow suppresses gene expression critical for mesenchymal differentiation and Notch signaling.
Endocardial fibroelastosis (EFE) is defined by fibrotic tissue on the endocardium and forms partly through aberrant endothelial-to-mesenchymal transition. However, the pathologic triggers are still unknown. In this study, we showed that abnormal flow induces EFE partly through endothelial-to-mesenchymal transition in a rodent model, and that losartan can abrogate EFE development. Furthermore, we translated our findings to human endocardial endothelial cells, and showed that laminar flow promotes the suppression of genes associated with mesenchymal differentiation. These findings emphasize the role of flow in promoting EFE in endocardial endothelial cells and provide a novel potential therapy to treat this highly morbid condition.
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Key Words
- AR, aortic regurgitation
- EFE, endocardial fibroelastosis
- EndoMT, endothelial-to-mesenchymal transition
- GO, gene ontology
- HLHS, hypoplastic left heart syndrome
- HUEEC, human endocardial endothelial cells
- HUVEC, human umbilical vein endothelial cells
- LSS, laminar shear stress
- LV, left ventricle
- congenital heart disease
- endocardial endothelial cells
- endocardial fibroelastosis
- endothelial-to-mesenchymal transition
- wall shear stress
- α-SMA, alpha-smooth muscle actin
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Affiliation(s)
- Nicholas A Oh
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Cardiothoracic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Xuechong Hong
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Ilias P Doulamis
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Elamaran Meibalan
- Laboratory for Systems Mechanobiology, Center for Excellence in Vascular Biology, Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Teresa Peiseler
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Juan Melero-Martin
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Guillermo García-Cardeña
- Laboratory for Systems Mechanobiology, Center for Excellence in Vascular Biology, Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Pedro J Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Ingeborg Friehs
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
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Marathe SP, Chávez M, Sleeper LA, Marx GR, Friedman K, Feins EN, Del Nido PJ, Baird CW. Single-Leaflet Aortic Valve Reconstruction Utilizing the Ozaki Technique in Patients With Congenital Aortic Valve Disease. Semin Thorac Cardiovasc Surg 2021; 34:1262-1272. [PMID: 34757016 DOI: 10.1053/j.semtcvs.2021.10.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 10/22/2021] [Indexed: 11/11/2022]
Abstract
Evaluate outcomes of single leaflet aortic valve reconstruction using Ozaki sizer and template. Single institute retrospective analysis between August 2015 and August 2019. Thirty-three patients, median age 9.3 years and weight 29.2 kg underwent single leaflet Ozaki repair. Preoperative indications were: AR (n = 17), AS (n = 3) or AS/AR (n = 13). Baseline anatomy was unicuspid (n = 15), bicuspid (n = 9) or tricuspid (n = 9). Two patients had endocarditis. Prior interventions included balloon valvuloplasty (n = 22) and aortic valve repair (n = 9). Pre-op average native annulus diameter was 19.6 mm and peak echo gradient was 36 mm Hg. Autologous pericardium, Photofix and CardioCel bovine pericardium were used in 26, 5, and 2 patients. Non-coronary sinus enlargement was required in 3 and aortic root reduction in 9 patients. Single leaflet reconstruction was done for the right coronary cusp (n = 25), non-coronary cusp in (n = 6) and left coronary cusp (n = 2). Additional procedures were done in 30 patients. Median ICU and hospital LOS were 2.1 and 6.3 days. There were no early re-interventions or conversions to valve replacement and one unrelated mortality.en At discharge, all patients had < moderate AR and/or AS with average peak gradients of 15 mm Hg. The median follow-up was 1.1 year, (IQR 0.7-1.8 years). Freedom from ≥ moderate AR and AS at 2 years was 76% and 86%. One patient required surgical re-intervention for severe AR 1.5 years after surgery for inflammatory infiltrate with calcification and fibrosis. Single-leaflet aortic valve leaflet reconstruction utilizing the Ozaki technique has promising early results and can be considered in patients when there are acceptable native leaflets.
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Affiliation(s)
- Supreet P Marathe
- Dept. of Cardiac Surgery, Harvard Medical School, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Mariana Chávez
- Dept. of Cardiac Surgery, Harvard Medical School, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Lynn A Sleeper
- Harvard Medical School, Boston, Massachusetts; Dept. of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Gerald R Marx
- Harvard Medical School, Boston, Massachusetts; Dept. of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Kevin Friedman
- Harvard Medical School, Boston, Massachusetts; Dept. of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Eric N Feins
- Dept. of Cardiac Surgery, Harvard Medical School, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Pedro J Del Nido
- Dept. of Cardiac Surgery, Harvard Medical School, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Christopher W Baird
- Dept. of Cardiac Surgery, Harvard Medical School, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts.
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45
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Roy N, Parra MF, Brown ML, Sleeper LA, Carlson L, Rhodes B, Nathan M, Mistry KP, Del Nido PJ. Enhancing Recovery in Congenital Cardiac Surgery. Ann Thorac Surg 2021; 114:1754-1761. [PMID: 34710385 DOI: 10.1016/j.athoracsur.2021.09.040] [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: 04/02/2021] [Revised: 09/07/2021] [Accepted: 09/09/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND The benefits of a comprehensive enhanced recovery after surgery (ERAS®) program for the congenital heart disease population are largely unknown. We evaluated adherence and outcomes following a recently implemented enhanced recovery program (ERP) in congenital cardiac surgery. METHODS Patients undergoing elective surgery for simple and moderately complex congenital cardiac surgery followed institutional ERP guidelines since 10/2018. Adherence to guidelines over a 12-month period (P2) was compared to implementation data (P1:5 months). The association of outcomes with continuous time was estimated using linear regression. RESULTS Among 559 patients (representing 40% of the cardiac surgical volume) following the ERP over a period of 17 months, no differences in patient characteristics were observed between periods, except higher incidence of prior operations in P2. Adherence to many aspects of guidelines improved from P1 to P2. Notably, operating room extubation: 27% in P2 vs.16% in P1, p=0.006; decrease in median ventilation time: 6.0-hrs (IQR 0-9.2) in P2 vs. 7.6-hrs (IQR 3.8-12.3) in P1, p=0.002. In addition, there was a reduction in opioids, reported as oral morphine equivalents (OME), most significant for intraoperative OME: 5.00 mg/kg (3.11-7.60) in P2 vs. 6.05 mg/kg (3.77-9.78) in P1, p=0.001. There was no difference in overall intensive care unit (ICU) and postoperative length of stay except in lower risk surgeries. Surgical outcomes were similar in the two periods. CONCLUSIONS An enhanced recovery program reduced the use of opioids, led to more OR extubation and reduced mechanical ventilation duration in patients undergoing congenital cardiac surgery.
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Affiliation(s)
- Nathalie Roy
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States.
| | - M Fernanda Parra
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Morgan L Brown
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Lynn A Sleeper
- Department of Cardiology, Boston Children's Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Laura Carlson
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA, United States
| | - Barbara Rhodes
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA, United States
| | - Meena Nathan
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Kshitij P Mistry
- Department of Cardiology, Boston Children's Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Pedro J Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
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46
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O'Leary ET, Feins EN, Triedman JK, Walsh EP, Schulz N, Eickhoff E, Hoganson DM, Del Nido PJ, Emani SM, DeWitt ES. B-AB20-01 INTRAOPERATIVE HIGH DENSITY CONDUCTION SYSTEM MAPPING IN HETEROTAXY SYNDROME: CHALLENGING THE DOGMA. Heart Rhythm 2021. [DOI: 10.1016/j.hrthm.2021.06.112] [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: 11/28/2022]
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47
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El-Assaad I, Jurow K, Dasgupta S, Beroukhim R, Geva T, Bezzerides VJ, Mah DY, Del Nido PJ, Walsh EP, O'Leary E. B-AB20-02 VENTRICULAR ARRHYTHMIAS FOLLOWING FIBROMA RESECTION: ARE PATIENTS STILL AT RISK? Heart Rhythm 2021. [DOI: 10.1016/j.hrthm.2021.06.113] [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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48
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Wamala I, Payne CJ, Saeed MY, Bautista-Salinas D, Van Story D, Thalhofer T, Staffa SJ, Ghelani SJ, Del Nido PJ, Walsh CJ, Vasilyev NV. Importance of Preserved Tricuspid Valve Function for Effective Soft Robotic Augmentation of the Right Ventricle in Cases of Elevated Pulmonary Artery Pressure. Cardiovasc Eng Technol 2021; 13:120-128. [PMID: 34263419 PMCID: PMC8888489 DOI: 10.1007/s13239-021-00562-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 06/29/2021] [Indexed: 11/30/2022]
Abstract
Purpose In clinical practice, many patients with right heart failure (RHF) have elevated pulmonary artery pressures and increased afterload on the right ventricle (RV). In this study, we evaluated the feasibility of RV augmentation using a soft robotic right ventricular assist device (SRVAD), in cases of increased RV afterload. Methods In nine Yorkshire swine of 65–80 kg, a pulmonary artery band was placed to cause RHF and maintained in place to simulate an ongoing elevated afterload on the RV. The SRVAD was actuated in synchrony with the ventricle to augment native RV output for up to one hour. Hemodynamic parameters during SRVAD actuation were compared to baseline and RHF levels. Results Median RV cardiac index (CI) was 1.43 (IQR, 1.37–1.80) L/min/m2 and 1.26 (IQR 1.05–1.57) L/min/m2 at first and second baseline. Upon PA banding RV CI fell to a median of 0.79 (IQR 0.63–1.04) L/min/m2. Device actuation improved RV CI to a median of 0.87 (IQR 0.78–1.01), 0.85 (IQR 0.64–1.59) and 1.11 (IQR 0.67–1.48) L/min/m2 at 5 min (p = 0.114), 30 min (p = 0.013) and 60 (p = 0.033) minutes respectively. Statistical GEE analysis showed that lower grade of tricuspid regurgitation at time of RHF (p = 0.046), a lower diastolic pressure at RHF (p = 0.019) and lower mean arterial pressure at RHF (p = 0.024) were significantly associated with higher SRVAD effectiveness. Conclusions Short-term augmentation of RV function using SRVAD is feasible even in cases of elevated RV afterload. Moderate or severe tricuspid regurgitation were associated with reduced device effectiveness. Supplementary Information The online version contains supplementary material available at 10.1007/s13239-021-00562-7
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Affiliation(s)
- Isaac Wamala
- Department of Cardiac Surgery, Harvard Medical School, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02115, USA. .,Clinic for Cardiovascular Surgery, Charité Universitätsmedizin, Berlin, Germany.
| | - Christopher J Payne
- Wyss Institute for Biologically Inspired Engineering, Boston, USA.,Harvard School of Engineering and Applied Sciences, Boston, USA
| | - Mossab Y Saeed
- Department of Cardiac Surgery, Harvard Medical School, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02115, USA
| | - Daniel Bautista-Salinas
- Department of Cardiac Surgery, Harvard Medical School, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02115, USA.,Industrial Engineering, Technical University of Cartagena, Murcia, Spain
| | - David Van Story
- Department of Cardiac Surgery, Harvard Medical School, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02115, USA
| | | | - Steven J Staffa
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, USA
| | - Sunil J Ghelani
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - Pedro J Del Nido
- Department of Cardiac Surgery, Harvard Medical School, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02115, USA
| | - Conor J Walsh
- Wyss Institute for Biologically Inspired Engineering, Boston, USA.,Harvard School of Engineering and Applied Sciences, Boston, USA
| | - Nikolay V Vasilyev
- Department of Cardiac Surgery, Harvard Medical School, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02115, USA
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Hofferberth SC, Saeed MY, Tomholt L, Fernandes MC, Payne CJ, Price K, Marx GR, Esch JJ, Brown DW, Brown J, Hammer PE, Bianco RW, Weaver JC, Edelman ER, Del Nido PJ. A geometrically adaptable heart valve replacement. Sci Transl Med 2021; 12:12/531/eaay4006. [PMID: 32075944 DOI: 10.1126/scitranslmed.aay4006] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 01/23/2020] [Indexed: 12/12/2022]
Abstract
Congenital heart valve disease has life-threatening consequences that warrant early valve replacement; however, the development of a growth-accommodating prosthetic valve has remained elusive. Thousands of children continue to face multiple high-risk open-heart operations to replace valves that they have outgrown. Here, we demonstrate a biomimetic prosthetic valve that is geometrically adaptable to accommodate somatic growth and structural asymmetries within the heart. Inspired by the human venous valve, whose geometry is optimized to preserve functionality across a wide range of constantly varying volume loads and diameters, our balloon-expandable synthetic bileaflet valve analog exhibits similar adaptability to dimensional and shape changes. Benchtop and acute in vivo experiments validated design functionality, and in vivo survival studies in growing sheep demonstrated that mechanical valve expansion accommodated growth. As illustrated in this work, dynamic size adaptability with preservation of unidirectional flow in prosthetic valves thus offers a paradigm shift in the treatment of heart valve disease.
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Affiliation(s)
- Sophie C Hofferberth
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA.
| | - Mossab Y Saeed
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Lara Tomholt
- Wyss Institute for Biologically Inspired Engineering, Harvard University, Cambridge, MA 02138, USA.,Harvard Graduate School of Design, Harvard University, Cambridge, MA 02138, USA
| | - Matheus C Fernandes
- Wyss Institute for Biologically Inspired Engineering, Harvard University, Cambridge, MA 02138, USA.,John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA 02138, USA
| | - Christopher J Payne
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Karl Price
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Gerald R Marx
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Jesse J Esch
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - David W Brown
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Jonathan Brown
- Biomedical Engineering Center, Institute for Medical Engineering & Science, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Peter E Hammer
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Richard W Bianco
- Department of Surgery, University of Minnesota, Minneapolis, MN 55455, USA
| | - James C Weaver
- Wyss Institute for Biologically Inspired Engineering, Harvard University, Cambridge, MA 02138, USA
| | - Elazer R Edelman
- Biomedical Engineering Center, Institute for Medical Engineering & Science, Massachusetts Institute of Technology, Cambridge, MA 02139, USA.,Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Pedro J Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA.
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50
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Doulamis IP, Guariento A, Duignan T, Orfany A, Kido T, Zurakowski D, Del Nido PJ, McCully JD. Mitochondrial transplantation for myocardial protection in diabetic hearts. Eur J Cardiothorac Surg 2021; 57:836-845. [PMID: 31782771 DOI: 10.1093/ejcts/ezz326] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 10/30/2019] [Accepted: 11/01/2019] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES Type 2 diabetes causes mitochondrial dysfunction, which increases myocardial susceptibility to ischaemia-reperfusion injury. We investigated the efficacy of transplantation of mitochondria isolated from diabetic or non-diabetic donors in providing cardioprotection from warm global ischaemia and reperfusion in the diabetic rat heart. METHODS Ex vivo perfused hearts from Zucker diabetic fatty (ZDF fa/fa) rats (n = 6 per group) were subjected to 30 min of warm global ischaemia and 120 min reperfusion. Immediately prior to reperfusion, vehicle alone (VEH) or vehicle containing mitochondria isolated from either ZDF (MTZDF) or non-diabetic Zucker lean (ZL +/?) (MTZL) skeletal muscle were delivered to the coronary arteries via the aortic cannula. RESULTS Following 30-min global ischaemia and 120-min reperfusion, left ventricular developed pressure was significantly increased in MTZDF and MTZL groups compared to VEH group (MTZDF: 92.8 ± 5.2 mmHg vs MTZL: 110.7 ± 2.4 mmHg vs VEH: 44.3 ± 5.9 mmHg; P < 0.01 each); and left ventricular end-diastolic pressure was significantly decreased (MTZDF 12.1 ± 1.3 mmHg vs MTZL 8.6 ± 0.8 mmHg vs VEH: 18.6 ± 1.5 mmHg; P = 0.016 for MTZDF vs VEH and P < 0.01 for MTZL vs VEH). Total tissue ATP content was significantly increased in both MT groups compared to VEH group (MTZDF: 18.9 ± 1.5 mmol/mg protein/mg tissue vs MTZL: 28.1 ± 2.3 mmol/mg protein/mg tissue vs VEH: 13.1 ± 0.5 mmol/mg protein/mg tissue; P = 0.018 for MTZDF vs VEH and P < 0.01 for MTZL vs VEH). Infarct size was significantly decreased in the MT groups (MTZDF: 11.8 ± 0.7% vs MTZL: 9.9 ± 0.5% vs VEH: 52.0 ± 1.4%; P < 0.01 each). CONCLUSIONS Mitochondrial transplantation significantly enhances post-ischaemic myocardial functional recovery and significantly decreases myocellular injury in the diabetic heart.
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Affiliation(s)
- Ilias P Doulamis
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Alvise Guariento
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Thomas Duignan
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Arzoo Orfany
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Takashi Kido
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - David Zurakowski
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Pedro J Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - James D McCully
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
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