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Kalfa D, Rajab TK, Cordoves E, Emani S, Bacha E, Jaggers J, Goldstone A, Eghtesady P, Turek J. Living allogenic heart valve transplantation: Relative advantages and unanswered questions. J Thorac Cardiovasc Surg 2024; 167:1543-1546. [PMID: 37743011 DOI: 10.1016/j.jtcvs.2023.09.036] [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: 09/04/2023] [Accepted: 09/11/2023] [Indexed: 09/26/2023]
Affiliation(s)
- David Kalfa
- Section of Pediatric and Congenital Cardiac Surgery, Division of Cardiac, Thoracic, and Vascular Surgery, Columbia University Medical Center, New York-Presbyterian Morgan Stanley Children's Hospital, New York, NY.
| | - Taufiek K Rajab
- Section of Pediatric Cardiothoracic Surgery, Medical University of South Carolina Shawn Jenkin's Children's Hospital, Charleston, SC
| | - Elizabeth Cordoves
- Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Sitaram Emani
- Department of Cardiovascular Surgery, Boston Children's Hospital, Boston, Mass
| | - Emile Bacha
- Section of Pediatric and Congenital Cardiac Surgery, Division of Cardiac, Thoracic, and Vascular Surgery, Columbia University Medical Center, New York-Presbyterian Morgan Stanley Children's Hospital, New York, NY
| | - James Jaggers
- Section of Congenital Heart Surgery, Children's Hospital Colorado, University of Colorado, Aurora, Colo
| | - Andrew Goldstone
- Section of Pediatric and Congenital Cardiac Surgery, Division of Cardiac, Thoracic, and Vascular Surgery, Columbia University Medical Center, New York-Presbyterian Morgan Stanley Children's Hospital, New York, NY
| | - Pirooz Eghtesady
- Section of Pediatric Cardiothoracic Surgery, Washington University School of Medicine, St Louis, Mo
| | - Joseph Turek
- Division of Thoracic and Cardiovascular Surgery, Duke Children's Pediatric and Congenital Heart Center, Duke University, Duke Children's Hospital, Durham, NC
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Liddle D, Gearhart A, Sleeper LA, Lu M, Feins E, Schidlow DN, Ghelani S, Powell AJ, Emani S, Beroukhim RS. Mitral valve orifice area predicts outcome after biventricular repair in patients with hypoplastic left ventricles. J Cardiovasc Magn Reson 2024; 26:101029. [PMID: 38403073 DOI: 10.1016/j.jocmr.2024.101029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 02/20/2024] [Indexed: 02/27/2024] Open
Abstract
BACKGROUND Identification of risk factors for biventricular (BiV) repair in children with hypoplastic left ventricles (HLV) has been challenging. We sought to identify preoperative cardiovascular magnetic resonance (CMR) predictors of outcome in patients with HLVs who underwent BiV repair, with a focus on the mitral valve (MV). METHODS Single-center retrospective analysis of preoperative CMRs on patients with HLV (≤50 mL/m2) and no endocardial fibroelastosis who underwent BiV repair from 2005-2022. CMR measurements included MV orifice area in diastole. The primary composite outcome included time to death, transplant, BiV takedown, heart failure admission, left atrial decompression, or unexpected reoperation; and the secondary outcome included more than or equal to moderate mitral stenosis and/or regurgitation. RESULTS Median follow-up was 0.7 (interquartile range 0.1, 2.2) years. Of 122 patients [59 atrioventricular canal (AVC) and 63 non-AVC] age 3 ± 2.8 years at the time of BiV repair, freedom from the primary outcome at 2 years was 53% for AVC and 69% for non-AVC (log rank p = 0.12), and freedom from the secondary outcome at 2 years was 49% for AVC and 79% for non-AVC (log rank p < 0.01). Independent predictors of primary outcome for AVC patients included MV orifice area z-score <-2 and transitional AVC; for non-AVC patients, predictors included MV orifice area z-score <-2, abnormal MV anatomy, and conal-septal ventricular septal defect. Independent predictors of secondary outcome for AVC patients included older age at surgery, transitional AVC, and transposition of the great arteries. CONCLUSION In children with HLV, low MV orifice area and pre-existing MV pathology are risk factors for adverse outcome after BiV repair.
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Affiliation(s)
- David Liddle
- The Heart Institute, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Addison Gearhart
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA; Department of Pediatrics, Harvard Medical School, Boston, MA, USA.
| | - Lynn A Sleeper
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA; Department of Pediatrics, Harvard Medical School, Boston, MA, USA.
| | - Minmin Lu
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA.
| | - Eric Feins
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA, USA; Department of Surgery, Harvard Medical School, Boston, MA, USA.
| | - David N Schidlow
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA; Department of Pediatrics, Harvard Medical School, Boston, MA, USA.
| | - Sunil Ghelani
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA; Department of Pediatrics, Harvard Medical School, Boston, MA, USA.
| | - Andrew J Powell
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA; Department of Pediatrics, Harvard Medical School, Boston, MA, USA.
| | - Sitaram Emani
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA, USA; Department of Surgery, Harvard Medical School, Boston, MA, USA.
| | - Rebecca S Beroukhim
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA; Department of Pediatrics, Harvard Medical School, Boston, MA, USA.
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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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Gellis L, McGeoghegan P, Lu M, Feins E, Sleeper L, Emani S, Friedman K, Baird C. Left atrioventricular valve repair after primary atrioventricular canal surgery: Predictors of durability. J Thorac Cardiovasc Surg 2023; 166:1168-1177. [PMID: 37160215 DOI: 10.1016/j.jtcvs.2023.04.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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: 11/15/2022] [Revised: 04/03/2023] [Accepted: 04/07/2023] [Indexed: 05/11/2023]
Abstract
OBJECTIVE Acute outcomes after atrioventricular canal defects (AVCD) surgery in the current era are excellent; yet despite surgical advances, ∼15% of patients require future left atrioventricular valve (LAVV) repair. Among patients with AVC who undergo LAVV repair after primary AVC surgery, we sought to characterize the durability of these repairs. Specifically, we aimed to determine predictors for reintervention following an LAVV repair in patients with repaired AVCD, with a focus on postoperative transesophageal echocardiography (TEE). METHODS We reviewed all patients undergoing LAVV repair (after a primary AVCD surgery) at Boston Children's Hospital between 2010 and 2020. Competing risk analysis was performed to evaluate cumulative incidence of LAVV reinterventions. Predictors of LAVV reintervention were evaluated using multivariable Cox regression. RESULTS A total of 137 LAVV repairs following primary AVCD surgery were performed in 113 patients. Median age and weight at LAVV repair were 25 months (interquartile range, 12-76 months) and 11.1 kg (interquartile range, 7.8-19.4 kg). Original anatomy was complete AVCD in 87 (63%), transitional AVCD in 27 (20%), and partial AVCD in 23 (17%) cases. Over a median follow-up of 12 months (interquartile range, 1.3 months-4 years), 47 (34%) of the LAVV repairs required LAVV reintervention. Reinterventions included a total of 27 LAVV re-repairs and 20 LAVV replacements. In multivariable analysis, age at LAVV repair younger than 72 months, partial AVCD anatomy, left ventricle dysfunction, mean LAVV stenosis gradient ≥5 mm Hg, and multiple jets of regurgitation on postoperative LAVV repair TEE were associated with LAVV reintervention. Grade of LAVV regurgitation on postoperative TEE was not an independent risk factor, but reintervention rates were high when residual LAVV stenosis gradient was ≥5 mm Hg and residual mild LAVV regurgitation was present on postoperative TEE (47%) and even higher when residual LAVV stenosis gradient was ≥5 mm Hg and LAVV regurgitation was greater than mild (73%). CONCLUSIONS Reintervention rates remain high for LAVV repairs that occur after primary AVCD surgery, particularly for patients with LAVV stenosis gradient ≥5 mm Hg and mild or greater LAVV regurgitation on postoperative TEE.
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Affiliation(s)
- Laura Gellis
- Department of Cardiology, Children's Hospital Boston, Boston, Mass.
| | | | - Minmin Lu
- Department of Cardiology, Children's Hospital Boston, Boston, Mass
| | - Eric Feins
- Department of Cardiovascular Surgery, Children's Hospital Boston, Boston, Mass
| | - Lynn Sleeper
- Department of Cardiology, Children's Hospital Boston, Boston, Mass
| | - Sitaram Emani
- Department of Cardiovascular Surgery, Children's Hospital Boston, Boston, Mass
| | - Kevin Friedman
- Department of Cardiology, Children's Hospital Boston, Boston, Mass
| | - Christopher Baird
- Department of Cardiovascular Surgery, Children's Hospital Boston, Boston, Mass
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Prasad D, Romanowicz J, Banka P, Beroukhim R, Ghelani SJ, Emani S, Powell AJ. Cardiac magnetic resonance parameters associated with successful conversion from a single ventricular to a one-and-a-half or biventricular circulation in patients with a hypoplastic right ventricle. J Cardiovasc Magn Reson 2023; 25:51. [PMID: 37759303 PMCID: PMC10537142 DOI: 10.1186/s12968-023-00965-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 09/13/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND Some patients with pulmonary atresia with an intact ventricular septum (PA/IVS) or a left ventricle dominant atrioventricular canal defect (LDAVC) with a hypoplastic right ventricle (RV) and univentricular (1 V) circulation may be candidates for conversion to either a complete biventricular (2 V) repair or a one-and-a-half ventricle repair (1.5 V). We sought to identify pre-operative cardiovascular magnetic resonance (CMR) findings associated with successful conversion from 1V to 1.5V or 2V circulation. METHODS In this single center retrospective study, subjects with PA/IVS or LDAVC and no conotruncal abnormalities were included if they had a 1 V circulation at the time of CMR followed by a surgical intervention intended to convert them to a 1.5 V or 2 V circulation. Conversion failure was defined as any of the following: (1) oxygen saturation < 90% at the most recent follow-up, (2) conversion back to a 1.5 V or 1 V circulation, or (3) death. RESULTS In the PA/IVS cohort (n = 15, median age 1.32 years), 10 patients underwent surgical conversion to a 1.5 V circulation and 5 to a 2 V circulation. In the attempted 1.5 V group, there were 2 failures, and these cases had a lower RV mass (p = 0.04). In the attempted 2 V group, there was 1 failure, and no CMR parameters were significantly different compared to the successes. Among the successful 2 V group patients, the minimum RV end-diastolic volume (EDV) was 27 ml/m2. In the LDAVC cohort (n = 15, median age 1.0 years), 1 patient underwent surgical conversion to a 1.5 V circulation and 14 patients to a 2 V circulation. In the attempted 1.5 V group, the 1 conversion was a failure and had an RV EDV of 15 ml/m2. In the attempted 2 V group, there were 2 failures, and these cases had a smaller RV:LV stroke volume ratio (p = 0.05) and a lower RV ejection fraction (p = 0.05) compared to the successes. Among the successful 2 V group patients, the minimum RV EDV was 22 ml/m2. CONCLUSIONS We identified multiple CMR parameters associated with successful conversion from 1 V circulation to 1.5 V or 2 V circulation in patients with PA/IVS and LDAVC. This information may improve patient selection for conversion procedures and encourage larger studies to better define the role of CMR.
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Affiliation(s)
- Deepa Prasad
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
- Department of Pediatrics, Harvard Medical School, Boston, USA
- Banner Children's at Desert Medical Center, University of Arizona College of Medicine-Phoenix, Phoenix, USA
| | - Jennifer Romanowicz
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
- Department of Pediatrics, Harvard Medical School, Boston, USA
| | - Puja Banka
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
- Department of Pediatrics, Harvard Medical School, Boston, USA
- Merck & Co., Inc, Rahway, NJ, USA
| | - Rebecca Beroukhim
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
- Department of Pediatrics, Harvard Medical School, Boston, USA
| | - Sunil J Ghelani
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
- Department of Pediatrics, Harvard Medical School, Boston, USA
| | - Sitaram Emani
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, USA
- Department of Surgery, Harvard Medical School, Boston, USA
| | - Andrew J Powell
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA.
- Department of Pediatrics, Harvard Medical School, Boston, USA.
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Gavin J, Lampert B, Hasan A, Haas G, Mokadam N, Whitson B, Henn M, Franco V, Vallakati A, Emani S, Foreman B, Patel V, Bole I, Ganapathi A. Comparison of Heart Transplantation Outcomes in Recipients of Insulin-Dependent Diabetic Donor Hearts Based Upon Duration of Insulin Use. J Heart Lung Transplant 2023. [DOI: 10.1016/j.healun.2023.02.758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
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Ganapathi A, Sarwar S, Hasan A, Lampert B, Henn M, Mokadam N, Emani S, Marschalk N, Whitson B. Use of Hepatitis C Positive Donor in HIV Positive Heart Transplant Recipient. J Heart Lung Transplant 2023. [DOI: 10.1016/j.healun.2023.02.663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
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Gavin J, Ganapathi A, Mokadam N, Whitson B, Henn M, Haas G, Hasan A, Franco V, Vallakati A, Emani S, Foreman B, Patel V, Bole I, Lampert B. Heart Transplantation Characteristics and Outcomes in Recipients of Diabetic Donor Hearts. J Heart Lung Transplant 2023. [DOI: 10.1016/j.healun.2023.02.757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
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Emani S, Kan A, Storms T, Bonanno S, Law J, Ray S, Joshi N. Periplasmic stress contributes to a tradeoff between protein secretion and cell growth in E. Coli Nissile. bioRxiv 2023:2023.01.09.523330. [PMID: 36711660 PMCID: PMC9882030 DOI: 10.1101/2023.01.09.523330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Maximizing protein secretion is an important target in the design of engineered living systems. In this paper, we characterize a tradeoff between cell growth and per cell protein secretion in the curli biofilm secretion system of E Coli Nissile 1917. Initial characterization using 24-hour continuous growth and protein production monitoring confirms decreased growth rates at high induction leading to a local maximum in total protein production at intermediate induction. Propidium iodide staining at the endpoint indicates that cellular death is a dominant cause of growth reduction. Assaying variants with combinatorial constructs of inner and outer membrane secretion tags, we find that diminished growth at high production is specific to secretory variants associated with accumulation of protein containing the outer membrane transport tag in the periplasmic space. RNA sequencing experiments indicate upregulation of known periplasmic stress response genes in the highly secreting variant, further implicating periplasmic stress in the growth-secretion tradeoff. Overall, these results motivate additional strategies for optimizing total protein production and longevity of secretory engineered living systems.
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Zaver S, Zaver H, Copeland L, Raines T, Wan J, Dong L, Whitson B, Balasubramaniyan J, Emani S, Ravi Y, Sai-Sudhakar C. Improving Heart Transplant Outcomes in the African American Population? Are We There Yet? J Heart Lung Transplant 2022. [DOI: 10.1016/j.healun.2022.01.128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Zaver S, Ravi Y, Copeland L, Zaver H, Raines T, Emani S, Dong L, Whitson B, Wan J, Sai-Sudhakar C. Education and Its Impact on Post-Heart Transplant Survival? J Heart Lung Transplant 2022. [DOI: 10.1016/j.healun.2022.01.1757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Ravi Y, Zaver S, Raines T, Zaver H, Copeland L, Chinta V, Balasubramaniyan J, Emani S, Dong L, Wan J, Sai-Sudhakar C. Does Post-Heart Transplantation Placement of Permanent Pacemakers Affect Survival? J Heart Lung Transplant 2022. [DOI: 10.1016/j.healun.2022.01.1749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Lang N, Staffa S, Zurakowski D, Baird C, Emani S, Shea M, Del Nido PJ, Marx GR. Anatomic and Quantitative 3D Echocardiographic Predictors for Risk Stratification and Improved Management of Congenital Mitral Valve Disease. Thorac Cardiovasc Surg 2022. [DOI: 10.1055/s-0042-1743026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- N. Lang
- Department of Pediatric Cardiology, Pediatric Cardiology, Children's Heart Clinic, UHZ Hamburg, Hamburg, Deutschland
| | - S. Staffa
- Anesthesiology, Boston Children's Hospital, Boston, United States
| | - D. Zurakowski
- Anesthesiology, Boston Children's Hospital, Boston, United States
| | - C. Baird
- Pediatric Cardiac Surgery, Boston Children's Hospital, Boston, United States
| | - S. Emani
- Pediatric Cardiac Surgery, Boston Children's Hospital, Boston, United States
| | - M. Shea
- Pediatric Cardiology, Boston Children's Hospital, Boston, United States
| | - P. J. Del Nido
- Pediatric Cardiac Surgery, Boston Children's Hospital, Boston, United States
| | - G. R. Marx
- Pediatric Cardiology, Boston Children's Hospital, Boston, United States
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Diaz-Gil D, Piekarski BL, Marx GR, Del Nido PJ, Emani S, Friehs I. Endocardial Fibroelastosis Recurrence: Comparing Single Ventricle Palliation versus Biventricular Repair. Thorac Cardiovasc Surg 2022. [DOI: 10.1055/s-0042-1742956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- D. Diaz-Gil
- Pediatric Cardiac Surgery, Boston Children's Hospital, Boston, United States
| | - B. L. Piekarski
- Pediatric Cardiac Surgery, Boston Children's Hospital, Boston, United States
| | - G. R. Marx
- Pediatric Cardiology, Boston Children's Hospital, Boston, United States
| | - P. J. Del Nido
- Pediatric Cardiac Surgery, Boston Children's Hospital, Boston, United States
| | - S. Emani
- Pediatric Cardiac Surgery, Boston Children's Hospital, Boston, United States
| | - I. Friehs
- Pediatric Cardiac Surgery, Boston Children's Hospital, Boston, United States
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Feins EN, O’Leary ET, Hoganson DM, Schulz N, Eickoff E, Davee J, Triedman JK, Baird CW, del Nido PJ, Emani S, DeWitt ES. Intraoperative Conduction Mapping in Complex Congenital Heart Surgery. JTCVS Tech 2022; 12:159-163. [PMID: 35403044 PMCID: PMC8987603 DOI: 10.1016/j.xjtc.2021.11.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 11/02/2021] [Indexed: 11/22/2022] Open
Abstract
Objective Postoperative heart block is a significant problem in congenital heart surgery because of the unpredictability and variability of conduction tissue location in complex congenital heart defects. A novel technique for intraoperative conduction system mapping during complex congenital heart surgery is described. Methods Intraoperative conduction system mapping was performed utilizing a high-density multielectrode grid catheter to collect intracardiac electrograms on open, beating hearts during repair of complex congenital heart defects. Electrograms were interpreted by electrophysiologists, and conduction tissue location was communicated in real time to the surgeon. After localizing conduction tissue, the heart was arrested and the repair was completed taking care to avoid injury to the mapped conduction system. Results Two patients with complex heterotaxy syndrome underwent intraoperative conduction mapping during biventricular repair. Mapping accurately identified the location of conduction tissue thereby enabling avoidance of conduction system injury during surgery. Notably, conduction was unexpectedly found to be located inferiorly in a patient with L-looped ventricles. Successful biventricular repair was accomplished in both patients without injury to the conduction system. Conclusions Intraoperative conduction mapping can effectively localize the conduction system during surgery and enable the surgeon to avoid its injury. This can lower the risk of heart block requiring pacemaker in children undergoing complex congenital heart surgery.
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Nellis ME, Karam O, Valentine SL, Bateman ST, Remy KE, Lacroix J, Cholette JM, Bembea MM, Russell RT, Steiner ME, Goobie SM, Tucci M, Stricker PA, Stanworth SJ, Delaney M, Lieberman L, Muszynski JA, Bauer DF, Steffen K, Nishijima D, Ibla J, Emani S, Vogel AM, Haas T, Goel R, Crighton G, Delgado D, Demetres M, Parker RI. Executive Summary of Recommendations and Expert Consensus for Plasma and Platelet Transfusion Practice in Critically Ill Children: From the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding (TAXI-CAB). Pediatr Crit Care Med 2022; 23:34-51. [PMID: 34989711 PMCID: PMC8820267 DOI: 10.1097/pcc.0000000000002851] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [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] [Indexed: 01/03/2023]
Abstract
OBJECTIVES Critically ill children frequently receive plasma and platelet transfusions. We sought to determine evidence-based recommendations, and when evidence was insufficient, we developed expert-based consensus statements about decision-making for plasma and platelet transfusions in critically ill pediatric patients. DESIGN Systematic review and consensus conference series involving multidisciplinary international experts in hemostasis, and plasma/platelet transfusion in critically ill infants and children (Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding [TAXI-CAB]). SETTING Not applicable. PATIENTS Children admitted to a PICU at risk of bleeding and receipt of plasma and/or platelet transfusions. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A panel of 29 experts in methodology, transfusion, and implementation science from five countries and nine pediatric subspecialties completed a systematic review and participated in a virtual consensus conference series to develop recommendations. The search included MEDLINE, EMBASE, and Cochrane Library databases, from inception to December 2020, using a combination of subject heading terms and text words for concepts of plasma and platelet transfusion in critically ill children. Four graded recommendations and 49 consensus expert statements were developed using modified Research and Development/UCLA and Grading of Recommendations, Assessment, Development, and Evaluation methodology. We focused on eight subpopulations of critical illness (1, severe trauma, intracranial hemorrhage, or traumatic brain injury; 2, cardiopulmonary bypass surgery; 3, extracorporeal membrane oxygenation; 4, oncologic diagnosis or hematopoietic stem cell transplantation; 5, acute liver failure or liver transplantation; 6, noncardiac surgery; 7, invasive procedures outside the operating room; 8, sepsis and/or disseminated intravascular coagulation) as well as laboratory assays and selection/processing of plasma and platelet components. In total, we came to consensus on four recommendations, five good practice statements, and 44 consensus-based statements. These results were further developed into consensus-based clinical decision trees for plasma and platelet transfusion in critically ill pediatric patients. CONCLUSIONS The TAXI-CAB program provides expert-based consensus for pediatric intensivists for the administration of plasma and/or platelet transfusions in critically ill pediatric patients. There is a pressing need for primary research to provide more evidence to guide practitioners.
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Affiliation(s)
- Marianne E Nellis
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, NY Presbyterian Hospital-Weill Cornell Medicine, New York, NY
| | - Oliver Karam
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Children's Hospital of Richmond at VCU, Richmond, VA
| | - Stacey L Valentine
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Massachusetts Medical School, Worcester, MA
| | - Scot T Bateman
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Massachusetts Medical School, Worcester, MA
| | - Kenneth E Remy
- Division of Pediatric Critical Care Medicine and Pulmonary/Critical Care Medicine, Departments of Pediatrics and Internal Medicine, Washington University of St. Louis, St. Louis, MO
| | - Jacques Lacroix
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montreal, QC, Canada
| | - Jill M Cholette
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Rochester Golisano Children's Hospital, Rochester, NY
| | - Melania M Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Robert T Russell
- Department of Surgery, University of Alabama Birmingham, Birmingham, AL
| | - Marie E Steiner
- Department of Pediatrics, University of Minnesota, Minneapolis, MN
| | - Susan M Goobie
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Marisa Tucci
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montreal, QC, Canada
| | - Paul A Stricker
- Department of Anesthesiology and Critical Care, The Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, PA
| | - Simon J Stanworth
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, NY Presbyterian Hospital-Weill Cornell Medicine, New York, NY
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Children's Hospital of Richmond at VCU, Richmond, VA
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Massachusetts Medical School, Worcester, MA
- Division of Pediatric Critical Care Medicine and Pulmonary/Critical Care Medicine, Departments of Pediatrics and Internal Medicine, Washington University of St. Louis, St. Louis, MO
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montreal, QC, Canada
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Rochester Golisano Children's Hospital, Rochester, NY
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Surgery, University of Alabama Birmingham, Birmingham, AL
- Department of Pediatrics, University of Minnesota, Minneapolis, MN
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
- Department of Anesthesiology and Critical Care, The Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, PA
- NHS Blood and Transplant, Oxford, United Kingdom
- Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
- Radcliffe Department of Medicine and Oxford BRC Haematology Theme, University of Oxford, Oxford, United Kingdom
- Division of Pathology & Laboratory Medicine, Children's National Hospital, Washington, DC
- Department of Pathology & Pediatrics, The George Washington University Health Sciences, Washington, DC
- Department of Clinical Pathology, University Health Network Hospitals, Toronto, ON, Canada
- Department of Laboratory Medicine & Pathobiology, University of Toronto, Toronto, ON, Canada
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH
- Division of Pediatric Neurosurgery Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, TX
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Stanford University, Palo Alto, CA
- Department of Emergency Medicine, University of California, Davis School of Medicine, Davis, CA
- Department of Cardiovascular Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
- Division of Pediatric Surgery Texas Children's Hospital, Department of Surgery, Baylor College of Medicine, Houston, TX
- Department of Pediatric Anesthesia, University Children's Hospital Zurich, Zurich, Switzerland
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University, Baltimore, MD
- Department of Haematology, Royal Children's Hospital, Melbourne, VIC, Australia
- Samuel J. Wood Library & C.V. Starr Biomedical Information Center, Weill Cornell Medicine, New York, NY
- Department of Pediatric Hematology/Oncology, Renaissance School of Medicine, State University of New York at Stony Brook, Stony Brook, NY
| | - Meghan Delaney
- Division of Pathology & Laboratory Medicine, Children's National Hospital, Washington, DC
- Department of Pathology & Pediatrics, The George Washington University Health Sciences, Washington, DC
| | - Lani Lieberman
- Department of Clinical Pathology, University Health Network Hospitals, Toronto, ON, Canada
- Department of Laboratory Medicine & Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Jennifer A Muszynski
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH
| | - David F Bauer
- Division of Pediatric Neurosurgery Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, TX
| | - Katherine Steffen
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Stanford University, Palo Alto, CA
| | - Daniel Nishijima
- Department of Emergency Medicine, University of California, Davis School of Medicine, Davis, CA
| | - Juan Ibla
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Sitaram Emani
- Department of Cardiovascular Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Adam M Vogel
- Division of Pediatric Surgery Texas Children's Hospital, Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Thorsten Haas
- Department of Pediatric Anesthesia, University Children's Hospital Zurich, Zurich, Switzerland
| | - Ruchika Goel
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University, Baltimore, MD
| | - Gemma Crighton
- Department of Haematology, Royal Children's Hospital, Melbourne, VIC, Australia
| | - Diana Delgado
- Samuel J. Wood Library & C.V. Starr Biomedical Information Center, Weill Cornell Medicine, New York, NY
| | - Michelle Demetres
- Samuel J. Wood Library & C.V. Starr Biomedical Information Center, Weill Cornell Medicine, New York, NY
| | - Robert I Parker
- Department of Pediatric Hematology/Oncology, Renaissance School of Medicine, State University of New York at Stony Brook, Stony Brook, NY
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17
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Cholette JM, Muszynski JA, Ibla JC, Emani S, Steiner ME, Vogel AM, Parker RI, Nellis ME, Bembea MM. Plasma and Platelet Transfusions Strategies in Neonates and Children Undergoing Cardiac Surgery With Cardiopulmonary Bypass or Neonates and Children Supported by Extracorporeal Membrane Oxygenation: From the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding. Pediatr Crit Care Med 2022; 23:e25-e36. [PMID: 34989703 PMCID: PMC8769357 DOI: 10.1097/pcc.0000000000002856] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVES To present the recommendations and consensus statements with supporting literature for plasma and platelet transfusions in critically ill neonates and children undergoing cardiac surgery with cardiopulmonary bypass or supported by extracorporeal membrane oxygenation from the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding. DESIGN Systematic review and consensus conference of international, multidisciplinary experts in platelet and plasma transfusion management of critically ill children. SETTING Not applicable. PATIENTS Critically ill neonates and children following cardiopulmonary bypass or supported by extracorporeal membrane oxygenation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A panel of nine experts developed evidence-based and, when evidence was insufficient, expert-based statements for plasma and platelet transfusions in critically ill neonates and children following cardiopulmonary bypass or supported by extracorporeal membrane oxygenation. These statements were reviewed and ratified by the 29 Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding experts. A systematic review was conducted using MEDLINE, EMBASE, and Cochrane Library databases, from inception to December 2020. Consensus was obtained using the Research and Development/University of California, Los Angeles Appropriateness Method. Results were summarized using the Grading of Recommendations Assessment, Development, and Evaluation method. We developed one good practice statement, two recommendations, and three expert consensus statements. CONCLUSIONS Whereas viscoelastic testing and transfusion algorithms may be considered, in general, evidence informing indications for plasma and platelet transfusions in neonatal and pediatric patients undergoing cardiac surgery with cardiopulmonary bypass or those requiring extracorporeal membrane oxygenation support is lacking.
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Affiliation(s)
- Jill M Cholette
- Department of Pediatrics, University of Rochester Golisano Children's Hospital, Rochester, NY
| | - Jennifer A Muszynski
- Department of Pediatrics, Division of Critical Care Medicine, Nationwide Children's Hospital, Columbus, OH
| | - Juan C Ibla
- Division of Cardiac Anesthesia, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Sitaram Emani
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA
| | - Marie E Steiner
- Divisions of Critical Care and Hematology, Department of Pediatrics, University of Minnesota Masonic Children's Hospital, Minneapolis, MN
| | - Adam M Vogel
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | - Robert I Parker
- Professor Emeritus, Department of Pediatrics, Hematology/Oncology, Renaissance School of Medicine, SUNY at Stony Brook, Stony Brook, NY
| | - Marianne E Nellis
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, NY Presbyterian Hospital - Weill Cornell Medicine, New York, NY
| | - Melania M Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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18
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Uppal S, Emani S, Mazzaferri E, Mast D, Satyapriya S, Whitson B, Boudoulas K. Out-of-hospital cardiac arrest due to refractory pulseless ventricular tachycardia and/or ventricular fibrillation. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.0657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Survival rates for out-of-hospital cardiac arrest (OOHCA) are extremely low and neurologic recovery is poor. Extracorporeal cardiopulmonary resuscitation (ECPR), which combines extracorporeal membrane oxygenation (ECMO) with cardiopulmonary resuscitation (CPR), has emerged as a viable strategy to improve outcomes in OOHCA. A collaborative ECPR program for out-of-hospital refractory pulseless ventricular tachycardia (VT) and/or ventricular fibrillation (VF) has been developed between The Ohio State University Wexner Medical Center and Columbus Division of Fire Emergency Medical Services (EMS).
Purpose
Outcomes for patients who present as an ECPR alert from the field, but did not meet predefined criteria for placement of extracorporeal membrane oxygenation (ECMO) in the cardiac catheterization laboratory (CCL) is described.
Methods
Between September 15, 2017 and October 12, 2019, 50 subjects presented as an ECPR alert for OOHCA secondary to pulseless VT/VF refractory to defibrillation. All subjects were placed on an automated CPR device prior to transfer to the CCL. From these 50 individuals, 28 (56%) did not meet prespecified laboratory criteria (lactate ≤15 mg/dL, partial pressure of oxygen (PaO2) ≥50 mm Hg, end-tidal carbon dioxide (ETCO2) of ≥10) and did not have a shockable rhythm in the CCL, thus ECMO was not placed and usual care for cardiac arrest was administered.
Results
Nine (32%) of the 28 patients achieved return of spontaneous circulation (ROSC), while the remaining 19 (68%) where pronounced deceased in the CCL. All 9 patients who achieved ROSC underwent a coronary angiography with 4 (44%) requiring percutaneous coronary intervention and 4 (44%) requiring an acute mechanical circulatory support device (Impella with 1 change out to ECMO). Of the patients that achieved ROSC, 4 (44%) were discharged from the hospital with good neurologic recovery; the remaining 5 (56%) ultimately expired during the hospitalization. From the initial 28 patient cohort, there were 4 (14%) patients discharged alive. Patients who achieved ROSC as compared to no ROSC were found on presentation in the CCL to have a significantly lower lactate (12.3±4.3 vs 16.2±3.6, respectively; p=0.03) and greater PaO2 (145±125 vs 47±9, respectively; p=0.01); there was no significant differences between groups in ETCO2, age or emergency services dispatch to CCL arrival time.
Conclusion
This study demonstrates that an ECPR program for OOHCA due to refractory VT/VF may provide benefit to patients that do not meet the predefined criteria for ECMO. This may be due to minimizing no flow/low flow time by early recognition and ongoing CPR en route to the CCL by a skilled EMS team, high efficiency citywide expedited transport/triage, the provision of high quality uninterrupted chest compressions using the mechanical CPR device during transport, and the care provided by highly trained multidisciplinary team members in the CCL.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- S Uppal
- Ohio State University Wexner Medical Center, Columbus, United States of America
| | - S Emani
- Ohio State University Wexner Medical Center, Columbus, United States of America
| | - E Mazzaferri
- Ohio State University Wexner Medical Center, Columbus, United States of America
| | - D Mast
- Ohio State University Wexner Medical Center, Columbus, United States of America
| | - S Satyapriya
- Ohio State University Wexner Medical Center, Columbus, United States of America
| | - B Whitson
- Ohio State University Wexner Medical Center, Columbus, United States of America
| | - K.D Boudoulas
- Ohio State University Wexner Medical Center, Columbus, United States of America
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19
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Irwin M, Binney G, Gauvreau K, Emani S, Blume ED, Brown DW. Native Bicuspid Pulmonary Valve in D-Loop Transposition of the Great Arteries: Outcomes of the Neo-Aortic Valve Function and Root Dilation After Arterial Switch Operation. J Am Heart Assoc 2021; 10:e021599. [PMID: 34482704 PMCID: PMC8649553 DOI: 10.1161/jaha.121.021599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Neo-aortic root dilation and neo-aortic regurgitation (AR) are common after arterial switch operation for D-loop transposition of the great arteries. We sought to evaluate these outcomes in patients with bicuspid native pulmonary valve (BNPV). Methods and Results A retrospective analysis of patients with transposition of the great arteries undergoing arterial switch operation at Boston Children's Hospital from 1989 to 2018 matched BNPV patients 1:3 with patients with tricuspid native pulmonary valve by year of arterial switch operation. Kaplan-Meier analyses with log-rank test compared groups for time to first neo-aortic valve reoperation, occurrence of ≥moderate AR, and neo-aortic root dilation (root z score ≥4). A total of 83 patients with BNPV were matched with 217 patients with tricuspid native pulmonary valve. Patients with BNPV more often had ventricular septal defects (73% versus 43%; P<0.001). Hospital length of stay (11 versus 10 days) and 30-day surgical mortality (3.6% versus 2.8%) were similar. During median 11 years follow-up, neo-aortic valve reoperation occurred in 4 patients with BNPV (6.0%) versus 6 patients with tricuspid native pulmonary valve (2.8%), with no significant difference in time to reoperation. More BNPV had AR at discharge (4.9% versus 0%; P=0.014) and during follow-up (13.4% versus 4.3%; hazard ratio [HR], 3.9; P=0.004), with shorter time to first occurrence of AR; this remained significant after adjusting for ventricular septal defects. Similarly, neo-aortic root dilation was more common in BNPV (45% versus 38%; HR, 1.64; P=0.026) with shorter time to first occurrence. Conclusions While patients with BNPV have similar short-term arterial switch operation outcomes, AR and neo-aortic root dilation occur more frequently and earlier compared with patients with tricuspid native pulmonary valve. Further long-term studies are needed to determine whether this results in greater need for neo-aortic valve reoperation.
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Affiliation(s)
- Margaret Irwin
- Harvard Medical School Boston MA.,Department of Cardiology Boston Children's Hospital Boston MA
| | - Geoffrey Binney
- Department of Cardiology Boston Children's Hospital Boston MA
| | - Kimberlee Gauvreau
- Harvard Medical School Boston MA.,Department of Cardiology Boston Children's Hospital Boston MA
| | - Sitaram Emani
- Harvard Medical School Boston MA.,Department of Cardiovascular Surgery Boston Children's Hospital Boston MA
| | - Elizabeth D Blume
- Harvard Medical School Boston MA.,Department of Cardiology Boston Children's Hospital Boston MA
| | - David W Brown
- Harvard Medical School Boston MA.,Department of Cardiology Boston Children's Hospital Boston MA
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20
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Kaka Y, Ganapathi A, Emani S, Kahwash R, Hasan A, Franco V, Haas G, Vallakati A, Henn M, Benza R, Mokadam N, Whitson B, Lampert B. The Waiting Game: Waitlist Times and Outcomes for Highly Sensitized Patients in the New Heart Transplant Allocation System. J Heart Lung Transplant 2021. [DOI: 10.1016/j.healun.2021.01.1775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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21
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Hong X, Oh N, Wang K, Neumeyer J, Lee CN, Lin RZ, Piekarski B, Emani S, Greene AK, Friehs I, Del Nido PJ, Melero-Martin JM. Human endothelial colony-forming cells provide trophic support for pluripotent stem cell-derived cardiomyocytes via distinctively high expression of neuregulin-1. Angiogenesis 2021; 24:327-344. [PMID: 33454888 DOI: 10.1007/s10456-020-09765-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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: 09/18/2020] [Accepted: 12/20/2020] [Indexed: 01/19/2023]
Abstract
The search for a source of endothelial cells (ECs) with translational therapeutic potential remains crucial in regenerative medicine. Human blood-derived endothelial colony-forming cells (ECFCs) represent a promising source of autologous ECs due to their robust capacity to form vascular networks in vivo and their easy accessibility from peripheral blood. However, whether ECFCs have distinct characteristics with translational value compared to other ECs remains unclear. Here, we show that vascular networks generated with human ECFCs exhibited robust paracrine support for human pluripotent stem cell-derived cardiomyocytes (iCMs), significantly improving protection against drug-induced cardiac injury and enhancing engraftment at ectopic (subcutaneous) and orthotopic (cardiac) sites. In contrast, iCM support was notably absent in grafts with vessels lined by mature-ECs. This differential trophic ability was due to a unique high constitutive expression of the cardioprotective growth factor neuregulin-1 (NRG1). ECFCs, but not mature-ECs, were capable of actively releasing NRG1, which, in turn, reduced apoptosis and increased the proliferation of iCMs via the PI3K/Akt signaling pathway. Transcriptional silencing of NRG1 abrogated these cardioprotective effects. Our study suggests that ECFCs are uniquely suited to support human iCMs, making these progenitor cells ideal for cardiovascular regenerative medicine.
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Affiliation(s)
- Xuechong Hong
- Department of Cardiac Surgery, Boston Children's Hospital, 300 Longwood Ave., Enders 349, Boston, MA, 02115, USA.,Department of Surgery, Harvard Medical School, Boston, MA, 02115, USA
| | - Nicholas Oh
- Department of Cardiac Surgery, Boston Children's Hospital, 300 Longwood Ave., Enders 349, Boston, MA, 02115, USA.,Department of Surgery, Harvard Medical School, Boston, MA, 02115, USA
| | - Kai Wang
- Department of Cardiac Surgery, Boston Children's Hospital, 300 Longwood Ave., Enders 349, Boston, MA, 02115, USA.,Department of Surgery, Harvard Medical School, Boston, MA, 02115, USA
| | - Joseph Neumeyer
- Department of Cardiac Surgery, Boston Children's Hospital, 300 Longwood Ave., Enders 349, Boston, MA, 02115, USA
| | - Chin Nien Lee
- Department of Cardiac Surgery, Boston Children's Hospital, 300 Longwood Ave., Enders 349, Boston, MA, 02115, USA.,Department of Surgery, Harvard Medical School, Boston, MA, 02115, USA
| | - Ruei-Zeng Lin
- Department of Cardiac Surgery, Boston Children's Hospital, 300 Longwood Ave., Enders 349, Boston, MA, 02115, USA.,Department of Surgery, Harvard Medical School, Boston, MA, 02115, USA
| | - Breanna Piekarski
- Department of Cardiac Surgery, Boston Children's Hospital, 300 Longwood Ave., Enders 349, Boston, MA, 02115, USA
| | - Sitaram Emani
- Department of Cardiac Surgery, Boston Children's Hospital, 300 Longwood Ave., Enders 349, Boston, MA, 02115, USA.,Department of Surgery, Harvard Medical School, Boston, MA, 02115, USA
| | - Arin K Greene
- Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, MA, 02115, USA
| | - Ingeborg Friehs
- Department of Cardiac Surgery, Boston Children's Hospital, 300 Longwood Ave., Enders 349, Boston, MA, 02115, USA.,Department of Surgery, Harvard Medical School, Boston, MA, 02115, USA
| | - Pedro J Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, 300 Longwood Ave., Enders 349, Boston, MA, 02115, USA.,Department of Surgery, Harvard Medical School, Boston, MA, 02115, USA
| | - Juan M Melero-Martin
- Department of Cardiac Surgery, Boston Children's Hospital, 300 Longwood Ave., Enders 349, Boston, MA, 02115, USA. .,Department of Surgery, Harvard Medical School, Boston, MA, 02115, USA. .,Harvard Stem Cell Institute, Cambridge, MA, 02138, USA.
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22
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Chiu P, Emani S. Left Ventricular Recruitment in Patients With Hypoplastic Left Heart Syndrome. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2021; 24:30-36. [PMID: 34116780 DOI: 10.1053/j.pcsu.2021.03.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 02/22/2021] [Accepted: 03/05/2021] [Indexed: 11/11/2022]
Abstract
Hypoplastic left heart complex with "borderline left ventricle" and intact ventricular septum is a clinical conundrum for the congenital heart surgeon. The choice between neonatal biventricular repair and single ventricle palliation can be challenging, and the current tools to aid in the decision-making process fail to account for the morbidity associated with intermediate and late diastolic dysfunction. Staged ventricular recruitment, consisting of valvular repair techniques, resection of endocardial fibroelastosis, atrial septal restriction, and augmentation of pulmonary blood flow, has been shown to improve left ventricular size and function culminating in eventual biventricular circulation. Despite staged ventricular recruitment, some patients cannot undergo biventricular conversion. Strategies to address these complex patients, including the "reverse" double switch, are the next frontier in biventricular repair.
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Affiliation(s)
- Peter Chiu
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sitaram Emani
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.
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23
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Gonzalez Corcia MC, Walsh EP, Emani S. Long-term results of atrial maze surgery in patients with congenital heart disease. Europace 2020; 21:1345-1352. [PMID: 31004150 DOI: 10.1093/europace/euz056] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [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: 08/20/2018] [Accepted: 03/25/2019] [Indexed: 01/31/2023] Open
Abstract
AIMS Recurrent atrial tachycardia is common after repair of many types of congenital heart disease, and surgical ablation with a maze procedure represents a potential treatment strategy. The objective of this study is to report a single-centre 19 years' experience with maze surgery in congenital heart patients. METHODS AND RESULTS Patients undergoing maze procedure concomitantly with cardiac surgical procedures were retrospectively analysed. The maze procedure was classified as therapeutic if the patient demonstrated preoperative atrial arrhythmias, or as prophylactic if done because the patient was considered high risk for post-operative arrhythmias. Acute outcomes and longer-term freedom from atrial arrhythmias were analysed. Maze surgery was performed in 166 patients: 137 in the therapeutic group, and 29 in the prophylactic group. The most common congenital heart lesion was single ventricle for the therapeutic group (27%) and Ebstein's anomaly for the prophylactic group (76%). Surgery consisted of a right atrial maze in 63%, left atrial maze in 4%, and bilateral maze in 33%. There were no direct complications or mortality related to the maze procedure itself. For the therapeutic group, freedom from arrhythmias was 82% and 67% at 1 and 5 years post-maze. Younger age at the time of surgery correlated with a lower long-term recurrence risk. CONCLUSION Maze procedure at the time of an elective anatomic surgery is reasonably effective to prevent and treat atrial arrhythmias in patients with congenital heart disease at short- and mid-term, with low morbidity and mortality.
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Affiliation(s)
- M Cecilia Gonzalez Corcia
- Department of Pediatric Cardiology, Cliniques Universitaires St Luc, Catholic UNiversity of Louvai, Brussels, Belgium
| | - Edward P Walsh
- Electrophysiology Division, Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sitaram Emani
- Department of Cardiovascular Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
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24
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Abstract
BACKGROUND Long-term outcomes in heterotaxy syndrome (HS) are poorly described. Some reports suggest improved survival in the recent era, whereas others do not. We sought to describe long-term outcomes and assess whether outcomes have changed over time. METHODS Patients with HS born between 1985 and 2014 who had cardiac care (except initial palliation) at our institution were divided into 4 birth eras and survival over time was compared. Independent risk factors for mortality were identified by using Cox proportional hazards regression. In patients who underwent surgery, association between surgical pathway (univentricular versus biventricular repair) and mortality after adjusting for baseline confounders was evaluated. A risk stratification model was created by using classification and regression analysis. RESULTS Among 264 patients, 118 (44.7%) had asplenia and 146 (55.3%) had polysplenia syndrome. Overall mortality was 40.2% (n = 106), with median follow-up of 10.2 years (longest 31.5 years). In multivariable analysis, pulmonary vein stenosis, coarctation, univentricular circulation, asplenia phenotype, and at least mild atrioventricular valve regurgitation at presentation were associated with mortality, whereas birth era was not. Among patients who underwent surgery, univentricular repair remained associated with mortality after adjustment. In classification and regression analysis, patients with biventricular circulation (especially those with polysplenia) had lower mortality than those with univentricular circulation. CONCLUSIONS In this large retrospective study of HS, outcomes remain poor and have not improved since the early 1990s. We identified risks factors associated with earlier mortality and found that those with univentricular circulation and totally anomalous pulmonary venous connection had the worst prognosis. Survival was higher in those with biventricular circulation.
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Affiliation(s)
- Puja Banka
- Departments of Cardiology and.,Departments of Pediatrics and
| | | | | | - Lynn A Sleeper
- Departments of Cardiology and.,Departments of Pediatrics and
| | - Sitaram Emani
- Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts; and.,Surgery, Medical School, Harvard University, Boston, Massachusetts
| | - Tal Geva
- Departments of Cardiology and .,Departments of Pediatrics and
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25
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Shaw R, Tighe N, Odegard KC, Alexander P, Emani S, Yuki K. Intubation precautions in a pediatric patient with severe COVID-19. J Pediatr Surg Case Rep 2020; 58:101495. [PMID: 32455111 PMCID: PMC7233244 DOI: 10.1016/j.epsc.2020.101495] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 05/11/2020] [Accepted: 05/12/2020] [Indexed: 01/08/2023] Open
Abstract
We present the case of a child diagnosed with COVID-19 soon after open-heart surgery who required an urgent second surgery. The patient suffered from severe COVID-19 disease. The utility of preoperative COVID-19 testing, determination of recovery by an array of inflammatory markers and perioperative management are described.
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Affiliation(s)
- Robert Shaw
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, USA
| | - Nathaniel Tighe
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, USA
| | - Kirsten C. Odegard
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, USA
| | - Peta Alexander
- Department of Cardiology Boston Children's Hospital, USA
- Department of Pediatrics Harvard Medical School, USA
| | - Sitaram Emani
- Department of Surgery, Cardiac Surgery, Boston Children's Hospital, USA
| | - Koichi Yuki
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, USA
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26
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Zaver S, Chinta V, Wan J, Lei D, Emani S, Sai-Sudhakar C, Ravi Y. Can Pre-Transplant Renal Function Predict Short-Term and Long-Term Post-Transplant Survival? J Heart Lung Transplant 2020. [DOI: 10.1016/j.healun.2020.01.563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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27
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Ganapathi A, Whitson B, LaFrancesca S, McLaughlin B, Hassan A, Emani S, Lampert B, Mokadam N. The Effect of Donor Heart Risk Factors on Cardiac Transplantation. J Heart Lung Transplant 2020. [DOI: 10.1016/j.healun.2020.01.1234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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28
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Ravi Y, Zaver S, Emani S, Lei D, Whitson B, Wan J, Sai-Sudhakar C. Education and Its Impact on Post-Heart Transplant Survival. J Heart Lung Transplant 2020. [DOI: 10.1016/j.healun.2020.01.646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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29
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Ganapathi A, Whitson B, Lampert B, McLaughlin B, Hassan A, Lee P, Emani S, Mokadam N. Impact of Preoperative Mechanical Support Following Heart Transplant. J Heart Lung Transplant 2020. [DOI: 10.1016/j.healun.2020.01.1133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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30
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Choi PS, Nam HH, Lasso A, Herz C, Drouin S, Harrild DM, Quartermain M, Fichtinger G, Mascio CE, Emani S, Jolley MA. Three-Dimensional Modeling of Surgically Implanted Stent-Based Valves in the Mitral Position in Children. Ann Thorac Surg 2020; 110:670-675. [PMID: 32199821 DOI: 10.1016/j.athoracsur.2020.02.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [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: 01/10/2020] [Revised: 01/24/2020] [Accepted: 02/04/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE In children with a mitral annulus too small to accommodate traditional prostheses, surgical implantation of stent-based valves is a promising option. However no reliable preoperative methods exist to guide patient selection, device sizing, and positioning. We describe a novel methodology to visualize and quantify device fit in 3-dimensional echocardiogram (3DE)-derived heart models. DESCRIPTION Heart models were created from existing preoperative 3DEs using custom software. Valve models were virtually implanted into the models, and both device fit and left ventricular outflow tract (LVOT) area were quantified. EVALUATION The 3DEs of 3 patients who underwent Melody valve placement in the mitral position were retrospectively modeled: 1 with LVOT obstruction, 1 with perivalvar leak, and 1 without complications. In all cases 2-dimensional measurements underestimated 3D annular dimensions, and the patient with clinical LVOT obstruction had the lowest predicted LVOT area-to-aortic area ratio (0.5). CONCLUSIONS 3DE-based preoperative modeling of surgical implantation of stent-based valves in the mitral position may improve quantification of mitral valve dimensions and inform risk stratification for potential LVOT obstruction.
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Affiliation(s)
- Perry S Choi
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Hannah H Nam
- Department of Anesthesia and Critical Care, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Christian Herz
- Department of Anesthesia and Critical Care, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Simon Drouin
- Brigham and Women's Hospital, Boston, Massachusetts
| | - David M Harrild
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Michael Quartermain
- Division of Pediatric Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Christopher E Mascio
- Division of Pediatric Cardiac Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Sitaram Emani
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Matthew A Jolley
- Department of Anesthesia and Critical Care, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Division of Pediatric Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
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31
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Weixler VHM, Zurakowski D, Baird CW, Guariento A, Piekarski B, del Nido PJ, Emani S. Do patients with anomalous origin of the left coronary artery benefit from an early repair of the mitral valve? Eur J Cardiothorac Surg 2019; 57:72-77. [DOI: 10.1093/ejcts/ezz158] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [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: 12/30/2018] [Revised: 04/15/2019] [Accepted: 04/24/2019] [Indexed: 11/13/2022] Open
Abstract
Abstract
OBJECTIVES
The aim of this study was to determine mid-term outcomes of patients with anomalous origin of the left coronary artery from the pulmonary artery undergoing coronary repair only (group A) or simultaneous mitral valve repair (group B).
METHODS
Patients with anomalous origin of the left coronary artery from the pulmonary artery who underwent surgery from 2000 to 2017 were reviewed. Mitral regurgitation (MR) grade (none, mild, moderate, severe), left ventricular (LV) function [ejection fraction (EF): <40%, 40–50%, >50%] and LV Z-scores (long axis) were assessed preoperatively and at last visit. Outcomes were compared within/between the groups using the Wilcoxon signed-rank test.
RESULTS
Of 58 patients (67% women; median age 4.4 months), 39 patients were in group A (67%) and 19 patients in group B (33%). The median hospital stay (11 days, interquartile range 5–18) and average follow-up time (2.6 ± 0.5 years) did not differ significantly between the groups (P > 0.05). Four patients in group A (10.3%) underwent mitral valve reintervention. The median MR grade differed significantly between the groups preoperatively (2 vs 3, P < 0.001) but not at the last visit (2 vs 2, P = 0.88); both groups improved significantly (P = 0.021, P < 0.001). EF grade (<40%, 40–50%, >50%) did not differ significantly between the groups at baseline (group A: 38%/23%/38% vs group B: 58%/10%/32%, P = 0.32) or at last visit (group A: 18%/15%/67% vs group B: 26%/16%/58%, P = 0.75); both groups improved significantly (P = 0.004, P = 0.014). The mean LV Z-scores for groups A and B were 3.1 ± 0.5 and 4.5 ± 0.6 before surgery (P < 0.05) and 1.5 ± 0.3 and 2.7 ± 0.6 at last visit (P = 0.77).
CONCLUSIONS
The repair of anomalous origin of the left coronary artery from the pulmonary artery is associated with improvement in MR, EF and LV dimensions. However, in cases of ≥moderate MR, the risk of mitral valve reintervention may be higher in patients undergoing coronary transfer only.
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Affiliation(s)
- Viktoria H M Weixler
- 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
- Department of Anesthesiology, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Christopher W Baird
- 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
| | - Breanna Piekarski
- 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
| | - Sitaram Emani
- Department of Cardiac Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
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32
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Ravi Y, Srikanth N, Paul I, Whitson B, Emani S, Sai-Sudhakar C. Heart Transplant Recipient and Donor Age: Should the Younger Recipient Be Matched with the Younger Donor? J Heart Lung Transplant 2019. [DOI: 10.1016/j.healun.2019.01.386] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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33
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Schmidt ACS, Maschietto N, Emani S, Pearson D, Kerr W, Maguire JH, Landzberg M. THE ELEPHANT IN THE CONDUIT: BACTEREMIA IN A PATIENT WITH TETRALOGY OF FALLOT AND A TRANSCATHETER PULMONARY VALVE REPLACEMENT. J Am Coll Cardiol 2019. [DOI: 10.1016/s0735-1097(19)32772-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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34
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Weixler V, Zurakowski D, Guariento A, Rhodes J, del Nido P, Emani S. Ventricular Dominance and Cardiac Morphology as Independent Predictors of the Outcome of Fontan Procedures—A Single-Center Experience. Thorac Cardiovasc Surg 2019. [DOI: 10.1055/s-0039-1678787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- V. Weixler
- Boston Children’s Hospital, Boston, United States
| | | | - A. Guariento
- Boston Children’s Hospital, Boston, United States
| | - J. Rhodes
- Boston Children’s Hospital, Boston, United States
| | - P. del Nido
- Boston Children’s Hospital, Boston, United States
| | - S. Emani
- Boston Children’s Hospital, Boston, United States
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35
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Carreon CK, Benini A, Baird C, Hoganson D, Borisuk M, Emani S, Hofferberth S, Padera RF, Sanders SP. Pathology of valved venous homografts used as right ventricle-to-pulmonary artery conduits in congenital heart disease surgery. J Thorac Cardiovasc Surg 2019; 157:342-350.e3. [DOI: 10.1016/j.jtcvs.2018.08.102] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 08/22/2018] [Accepted: 08/26/2018] [Indexed: 10/28/2022]
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36
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Barry OM, Friedman KG, Bergersen L, Emani S, Moeyersoms A, Tworetzky W, Marshall AC, Lock JE. Clinical and Hemodynamic Results After Conversion from Single to Biventricular Circulation After Fetal Aortic Stenosis Intervention. Am J Cardiol 2018; 122:511-516. [PMID: 30201114 DOI: 10.1016/j.amjcard.2018.04.035] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Revised: 04/03/2018] [Accepted: 04/05/2018] [Indexed: 12/13/2022]
Abstract
At our institution a multidisciplinary team has performed fetal aortic valvuloplasty (FAV) for severe aortic stenosis with evolving hypoplastic left heart syndrome with high technical success rates. Measurement of postnatal success has been biventricular circulation (BC). Postnatal survival for patients after FAV who achieved a BC appears encouraging. However, there are limited late clinical and hemodynamic outcomes in this cohort and there is concern for diastolic dysfunction. We reviewed all patients with FAV at our institution who initially underwent single ventricle palliation and subsequently BC, as this is likely the subset at high-risk for poor outcomes. Clinical, imaging, and surgical data were collected. Two of 7 patients (29%) died within 16 months of BC, and 1 patient has been listed for transplant. Diastolic dysfunction was common and progressive with median left ventricular end diastolic pressure of 12 mm Hg before BC, and increasing to 22 mm Hg for survivors at last follow-up. Left ventricular size was adequate with all patients reaching a left ventricular end diastolic volume (LVEDV) z score in the normal or elevated range. Presence and severity of residual valve lesions decreased over time secondary to a median of 6 interventions (range 3 to 10), either surgical or cath-based, performed for these 7 patients during the study period. In conclusion, clinical outcomes are concerning for this high-risk group. Diastolic dysfunction is persistent and progressive despite anatomic interventions and adequate left ventricular growth. The main contributing factor to poor outcomes may be intrinsic myocardial dysfunction and primordial pathology. Achievement of a BC after FAV may not be an appropriate measure of success.
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37
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Fang ZA, Bernier R, Emani S, Emani S, Matte G, DiNardo JA, Faraoni D, Ibla JC. Preoperative Thromboelastographic Profile of Patients with Congenital Heart Disease: Association of Hypercoagulability and Decreased Heparin Response. J Cardiothorac Vasc Anesth 2018; 32:1657-1663. [DOI: 10.1053/j.jvca.2017.12.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Indexed: 11/11/2022]
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38
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Nathan M, Emani S, Del Nido PJ. Reply to Buratto et al. Eur J Cardiothorac Surg 2018; 53:1296. [PMID: 29365088 DOI: 10.1093/ejcts/ezx500] [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: 12/15/2017] [Accepted: 12/18/2017] [Indexed: 11/13/2022] Open
Affiliation(s)
- Meena Nathan
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA, USA.,Department of Surgery, Harvard Medical School, Boston, MA, USA
| | - Sitaram Emani
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA, USA.,Department of Surgery, Harvard Medical School, Boston, MA, USA
| | - Pedro J Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA, USA.,Department of Surgery, Harvard Medical School, Boston, MA, USA
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39
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Beroukhim RS, Jing L, Harrild DM, Fornwalt BK, Mejia-Spiegeler A, Rhodes J, Emani S, Powell AJ. Impact of the cone operation on left ventricular size, function, and dyssynchrony in Ebstein anomaly: a cardiovascular magnetic resonance study. J Cardiovasc Magn Reson 2018; 20:32. [PMID: 29783986 PMCID: PMC5963144 DOI: 10.1186/s12968-018-0452-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [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: 01/17/2018] [Accepted: 04/10/2018] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND In addition to tricuspid regurgitation (TR) and right ventricular (RV) enlargement, patients with Ebstein anomaly are at risk for left ventricular (LV) dysfunction and dyssynchrony. We studied the impact of the cone tricuspid valve reconstruction operation on LV size, function, and dyssynchrony. METHODS All Ebstein anomaly patients who had both pre- and postoperative cardiovascular magnetic resonance (CMR) studies were retrospectively identified. From cine images, RV and LV volumes and ejection fractions (EF) were calculated, and LV circumferential and longitudinal strain were measured by feature tracking. To quantify LV dyssynchrony, temporal offsets (TOs) were computed among segmental circumferential strain versus time curves using cross-correlation analysis and patient-specific reference curves. An LV dyssynchrony index was calculated as the standard deviation of the TOs. RESULTS Twenty patients (65% female) were included with a median age at cone operation of 16 years, and a median time between pre- and postoperative CMR of 2.8 years. Postoperatively, there was a decline in the TR fraction (56 ± 19% vs. 5 ± 4%, p < 0.001), RV end-diastolic volume (EDV) (242 ± 110 ml/m2 vs. 137 ± 82 ml/m2, p < 0.001), and RV stroke volume (SV) (101 ± 35 vs. 51 ± 7 ml/m2, p < 0.001). RV EF was unchanged. Conversely, there was an increase in both LV EDV (68 ± 13 vs. 85 ± 13 ml/m2, p < 0.001) and LV stroke volume (37 ± 8 vs. 48 ± 6 ml/m2, p < 0.001). There was no change in LV EF, or global circumferential and longitudinal strain but basal septal circumferential strain improved (16 ± 7% vs. 22 ± 5%, p = 0.04). LV contraction become more synchronous (dyssynchrony index: 32 ± 17 vs. 21 ± 9 msec, p = 0.02), and the extent correlated with the reduction in RV EDV and TR. CONCLUSIONS In patients with the Ebstein anomaly, the cone operation led to reduced TR and RV stroke volume, increased LV stroke volume, improved LV basal septal strain, and improved LV synchrony. Our data demonstrates that the detrimental effect of the RV on LV function can be mitigated by the cone operation.
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Affiliation(s)
- Rebecca S. Beroukhim
- Department of Pediatrics, Massachusetts General Hospital, 175 Cambridge Street, 5th Floor, Boston, MA 02114 USA
- Department of Cardiology, Boston Children’s Hospital, Boston, MA USA
- Department of Pediatrics, Harvard Medical School, Boston, MA USA
| | - Linyuan Jing
- Department of Imaging Science and Innovation, Geisinger, Danville, PA USA
| | - David M. Harrild
- Department of Cardiology, Boston Children’s Hospital, Boston, MA USA
- Department of Pediatrics, Harvard Medical School, Boston, MA USA
| | - Brandon K. Fornwalt
- Department of Imaging Science and Innovation, Geisinger, Danville, PA USA
- Department of Radiology, Geisinger, Danville, PA USA
| | | | - Jonathan Rhodes
- Department of Cardiology, Boston Children’s Hospital, Boston, MA USA
- Department of Pediatrics, Harvard Medical School, Boston, MA USA
| | - Sitaram Emani
- Department of Cardiac Surgery, Boston Children’s Hospital, Boston, MA USA
- Department of Surgery, Harvard Medical School, Boston, MA USA
| | - Andrew J. Powell
- Department of Cardiology, Boston Children’s Hospital, Boston, MA USA
- Department of Pediatrics, Harvard Medical School, Boston, MA USA
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Abstract
Current laboratory methods for comprehensive thrombophilia status require large blood volumes and long turn-around times. We demonstrate the feasibility of performing thrombophilia panel testing of enzymatic functional assays on a microfluidic cartridge using low sample volume.Functional assays for Antithrombin III, Protein C, Factor VIII, and plasminogen were adapted on the digital microfluidic platform by developing novel fluorogenic substrates and establishing on-cartridge fluorescence (360/460 nm) detection. Cartridge vs. microtiter plate results were compared using samples obtained from pediatric patients. Linear regression and Bland-Altman plots were used to establish correlations. Results were not significantly different when performed on-cartridge compared to microtiter plates. Importantly, the sample volume required is significantly lower for all on-cartridge compared to microtiter plate assays (25 μL vs. 2 ml).This study demonstrates the feasibility of thrombophilia panel testing with high-fidelity using small plasma volume. The efficacy of this near-patient technology in clinical settings needs further investigation.
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Affiliation(s)
- Sirisha Emani
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA
| | | | | | | | | | - Sitaram Emani
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA
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41
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Derbala M, Lee B, Alghothani M, McDavid A, Lampert B, Whitson B, Hasson R, Emani S, Hasan A, Kilic A, Donneyong M, Smith S. Administration of Beta-Blockers Early After LVAD Implantation is Not Associated with Early Right Ventricular Failure or Increased Mortality. J Heart Lung Transplant 2018. [DOI: 10.1016/j.healun.2018.01.967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
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42
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Breathett K, Maffett S, Foraker R, Sturdivant R, Moon K, Hasan A, Franco V, Smith S, Lampert B, Emani S, Haas G, Kahwash R, Hershberger R, Binkley P, Helmkamp L, Colborn K, Peterson P, Sweitzer N, Abraham W. Pilot Randomized Controlled Trial to Reduce Readmission for Heart Failure Using Novel Tablet and Nurse Practitioner Education. J Heart Lung Transplant 2018. [DOI: 10.1016/j.healun.2018.01.807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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43
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Gellis L, Baird CW, Emani S, Borisuk M, Gauvreau K, Padera RF, Sanders SP. Morphologic and histologic findings in bioprosthetic valves explanted from the mitral position in children younger than 5 years of age. J Thorac Cardiovasc Surg 2018; 155:746-752. [DOI: 10.1016/j.jtcvs.2017.09.091] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 09/01/2017] [Accepted: 09/17/2017] [Indexed: 11/30/2022]
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44
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Angelidou A, Michael Z, Hotz A, Friedman K, Emani S, LaRovere K, Christou H. Is There More to Zika? Complex Cardiac Disease in a Case of Congenital Zika Syndrome. Neonatology 2018; 113:177-182. [PMID: 29248924 DOI: 10.1159/000484656] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Accepted: 10/27/2017] [Indexed: 11/19/2022]
Abstract
The epidemic of Zika virus (ZIKV) has resulted in a surge of newborns with microcephaly and brain abnormalities. In this report, we describe the first case, to our knowledge, of congenital Zika syndrome with concomitant critical congenital heart disease. The mother had a confirmed ZIKV infection in the first trimester of pregnancy. Fetal ultrasonography at 31 weeks of gestation revealed cerebral cortical calcifications and hypoplastic left heart syndrome. The severity of brain involvement was assessed by postnatal magnetic resonance imaging and echocardiogram, and palliative surgery was performed. The ethical dimensions of this infant's clinical management are discussed. ZIKV is known to affect neural progenitor cells, but whether it could have a tropism for other tissues remains unclear.
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Affiliation(s)
- Asimenia Angelidou
- Division of Newborn Medicine, Boston Children's Hospital, Boston, MA, USA
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45
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Hunt R, Hoffman CM, Emani S, Trenor CC, Emani SM, Faraoni D, Kimchi-Sarfaty C, Ibla JC. Elevated preoperative von Willebrand factor is associated with perioperative thrombosis in infants and neonates with congenital heart disease. J Thromb Haemost 2017; 15:2306-2316. [PMID: 28981194 DOI: 10.1111/jth.13860] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Indexed: 01/19/2023]
Abstract
Essentials Perioperative thrombosis is a major cause of morbidity and mortality in congenital heart disease. Neonates and infants undergoing repair of congenital heart lesions were prospectively followed. Elevated von Willebrand factor (VWF) to ADAMTS-13 activity ratios typified the postoperative period. Thrombosis was associated with preoperative VWF activity and cryoprecipitate transfusion SUMMARY: Background The surgical repair of congenital heart malformations is frequently complicated by perioperative thrombosis of unclear etiology. An imbalance between von Willebrand factor (VWF) and ADAMTS-13 is an emerging variable in thrombosis. Objectives To describe perioperative changes to VWF, ADAMTS-13 and NETosis, and evaluate clinical and biochemical associations with postoperative thrombosis. Methods Neonates and infants undergoing palliation or definitive surgical repair of congenital heart malformations were recruited (n = 133). Preoperative and postoperative plasma levels of VWF, ADAMTS-13 and markers of NETosis were determined. Patients were followed for up to 30 days for the occurrence of thrombosis. Univariate and multivariate logistic regression analyses were conducted to identify variables associated with thrombosis. Results We identified significant postoperative increases in VWF activity, VWF level, DNA-histone complexes and cell-free DNA with an overall decrease in ADAMTS-13 activity. Patients experiencing postoperative thrombotic events (9%) were characterized by surgery performed at a lower intraoperative temperature, higher preoperative lactic acid levels, and higher preoperative VWF activity and level. A multivariate logistic regression model identified preoperative VWF activity (odds ratio (OR) 8.39 per IU mL-1 , 95% confidence interval [CI] 1.73-40.55) and transfusion of cryoprecipitate (OR 1.10 per mL kg-1 , 95% CI 1.03-1.17) as being associated with thrombosis. Conclusions Pediatric patients undergoing surgical repair of congenital heart malformations are exposed to high levels of VWF with diminished or minimal change to ADAMTS-13 in the immediate postoperative period. Elevated preoperative VWF activity is associated with postoperative thrombosis in pediatric congenital heart disease.
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Affiliation(s)
- R Hunt
- Hemostasis Branch, Division of Plasma Protein Therapeutics, Office of Tissues and Advanced Therapeutics, Center for Biologics Evaluation and Research, US FDA, Silver Spring, MD, USA
| | - C M Hoffman
- Hemostasis Branch, Division of Plasma Protein Therapeutics, Office of Tissues and Advanced Therapeutics, Center for Biologics Evaluation and Research, US FDA, Silver Spring, MD, USA
| | - S Emani
- Department of Cardiac Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - C C Trenor
- Division of Hematology/Oncology, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - S M Emani
- Department of Cardiac Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - D Faraoni
- Division of Cardiac Anesthesia, Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - C Kimchi-Sarfaty
- Hemostasis Branch, Division of Plasma Protein Therapeutics, Office of Tissues and Advanced Therapeutics, Center for Biologics Evaluation and Research, US FDA, Silver Spring, MD, USA
| | - J C Ibla
- Department of Anesthesiology Perioperative and Pain Medicine, Division of Cardiac Anesthesia, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
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Lin RZ, Lee CN, Moreno-Luna R, Neumeyer J, Piekarski B, Zhou P, Moses MA, Sachdev M, Pu WT, Emani S, Melero-Martin JM. Host non-inflammatory neutrophils mediate the engraftment of bioengineered vascular networks. Nat Biomed Eng 2017; 1. [PMID: 28868207 PMCID: PMC5578427 DOI: 10.1038/s41551-017-0081] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Notwithstanding remarkable progress in vascular network engineering, implanted bioengineered microvessels largely fail to form anastomoses with the host vasculature. Here, we demonstrate that implants containing assembled human vascular networks (A-Grafts) fail to engraft due to their inability to engage non-inflammatory host neutrophils upon implantation into mice. In contrast, unassembled vascular cells (U-Grafts) readily engage alternatively polarized neutrophils, which in turn serve as indispensable mediators of vascular assembly and anastomosis. The depletion of host neutrophils abrogated vascularization in U-Grafts, whereas an adoptive transfer of neutrophils fully restored vascularization in myeloid-depleted mice. Neutrophil engagement was regulated by secreted factors and was progressively silenced as the vasculature matured. Exogenous addition of factors from U-Grafts reengaged neutrophils and enhanced revascularization in A-Grafts, a process that was recapitulated by blocking Notch signaling. Our data suggest that the pro-vascularization potential of neutrophils can be harnessed to improve the engraftment of bioengineered tissues.
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Affiliation(s)
- Ruei-Zeng Lin
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA 02115, USA.,Department of Surgery, Harvard Medical School, Boston, MA 02115, USA
| | - Chin Nien Lee
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA 02115, USA.,Department of Surgery, Harvard Medical School, Boston, MA 02115, USA
| | - Rafael Moreno-Luna
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA 02115, USA.,Department of Surgery, Harvard Medical School, Boston, MA 02115, USA
| | - Joseph Neumeyer
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA 02115, USA
| | - Breanna Piekarski
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA 02115, USA
| | - Pingzhu Zhou
- Department of Cardiology, Boston Children's Hospital, Boston, MA 02115, USA
| | - Marsha A Moses
- Department of Surgery, Harvard Medical School, Boston, MA 02115, USA.,Vascular Biology Program, Boston Children's Hospital, Boston, MA 02115, USA.,Department of Surgery, Boston Children's Hospital, Boston, MA 02115, USA
| | - Monisha Sachdev
- Vascular Biology Program, Boston Children's Hospital, Boston, MA 02115, USA
| | - William T Pu
- Department of Cardiology, Boston Children's Hospital, Boston, MA 02115, USA.,Harvard Stem Cell Institute, Cambridge, MA 02138, USA
| | - Sitaram Emani
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA 02115, USA.,Department of Surgery, Harvard Medical School, Boston, MA 02115, USA
| | - Juan M Melero-Martin
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA 02115, USA.,Department of Surgery, Harvard Medical School, Boston, MA 02115, USA.,Harvard Stem Cell Institute, Cambridge, MA 02138, USA
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Nathan M, Emani S, IJsselhof R, Liu H, Gauvreau K, del Nido P. Mid-term outcomes in unbalanced complete atrioventricular septal defect: role of biventricular conversion from single-ventricle palliation†. Eur J Cardiothorac Surg 2017; 52:565-572. [DOI: 10.1093/ejcts/ezx129] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 03/04/2017] [Indexed: 12/28/2022] Open
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48
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Ravi Y, Stock E, Lella S, Balasubramaniyan J, Nikloidis L, Copeland L, Emani S, Sai-Sudhakar C. Does a History of Malignancy Affect Long-Term Survival in Heart Transplant Recipients? J Heart Lung Transplant 2017. [DOI: 10.1016/j.healun.2017.01.597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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49
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John R, Keebler M, Stulak J, Emani S, Klodell C, Nathan S, Brieke A, Uriel N, Chin J, Eckman P, Nsair A, Agarwal R, Thenappan T, Adamson R, Chuang J, Farrar D, Sundareswaran K, Katz J. Incidence and Risk Factors of Late Bleeding in Patients Enrolled in the PREVENT Study. J Heart Lung Transplant 2017. [DOI: 10.1016/j.healun.2017.01.318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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50
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Thenappan T, Stulak J, Agarwal R, Maltais S, Shah P, Eckman P, Emani S, Katz J, Gregoric I, Keebler M, Uriel N, Adler E, Chuang J, Farrar D, Sundareswaran K, John R. Trends in Serum Lactate Dehydrogenase During HeartMate II Left Ventricular Assist Device Support and Its Relation to Clinical Outcomes: Insights from the PREVENT Study. J Heart Lung Transplant 2017. [DOI: 10.1016/j.healun.2017.01.285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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