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Opotowsky AR, Khairy P, Diller G, Kasparian NA, Brophy J, Jenkins K, Lopez KN, McCoy A, Moons P, Ollberding NJ, Rathod RH, Rychik J, Thanassoulis G, Vasan RS, Marelli A. Clinical Risk Assessment and Prediction in Congenital Heart Disease Across the Lifespan: JACC Scientific Statement. J Am Coll Cardiol 2024; 83:2092-2111. [PMID: 38777512 DOI: 10.1016/j.jacc.2024.02.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 01/12/2024] [Accepted: 02/22/2024] [Indexed: 05/25/2024]
Abstract
Congenital heart disease (CHD) comprises a range of structural anomalies, each with a unique natural history, evolving treatment strategies, and distinct long-term consequences. Current prediction models are challenged by generalizability, limited validation, and questionable application to extended follow-up periods. In this JACC Scientific Statement, we tackle the difficulty of risk measurement across the lifespan. We appraise current and future risk measurement frameworks and describe domains of risk specific to CHD. Risk of adverse outcomes varies with age, sex, genetics, era, socioeconomic status, behavior, and comorbidities as they evolve through the lifespan and across care settings. Emerging technologies and approaches promise to improve risk assessment, but there is also need for large, longitudinal, representative, prospective CHD cohorts with multidimensional data and consensus-driven methodologies to provide insight into time-varying risk. Communication of risk, particularly with patients and their families, poses a separate and equally important challenge, and best practices are reviewed.
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Affiliation(s)
- Alexander R Opotowsky
- Adult Congenital Heart Disease Program, Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.
| | - Paul Khairy
- Adult Congenital Heart Centre, Montreal Heart Institute, Montréal, Quebec, Canada
| | - Gerhard Diller
- Department of Cardiology III, University Hospital Münster, Münster, Germany
| | - Nadine A Kasparian
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA; Heart and Mind Wellbeing Center, Cincinnati, Ohio, USA; Heart Institute and Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - James Brophy
- Department of Medicine, Faculty of Medicine and Health Sciences, McGill University, Montréal, Quebec, Canada
| | - Kathy Jenkins
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Keila N Lopez
- Department of Pediatrics, Section of Cardiology, Texas Children's Hospital & Baylor College of Medicine, Houston, Texas, USA
| | - Alison McCoy
- Vanderbilt Clinical Informatics Core, Department of Biomedical Informatics, Vanderbilt University Medical Center and Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Philip Moons
- KU Leuven Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium; Institute of Health and Care Sciences, University of Gothenburg, Gothenburg, Sweden; Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Nicholas J Ollberding
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA; Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Rahul H Rathod
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Jack Rychik
- Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - George Thanassoulis
- Department of Medicine, Faculty of Medicine and Health Sciences, McGill University, Montréal, Quebec, Canada
| | - Ramachandran S Vasan
- School of Public Health, University of Texas, San Antonio, Texas, USA; Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Ariane Marelli
- McGill Adult Unit for Congenital Heart Disease Excellence, McGill University, Montreal, Quebec, Canada.
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Kawai C, Kondo H, Miyao M, Sunada M, Ozawa S, Kotani H, Minami H, Nagai H, Abiru H, Yamamoto A, Tamaki K, Nishitani Y. Fatal cardiac dysfunction in a child with Williams syndrome. Leg Med (Tokyo) 2024; 67:102387. [PMID: 38154310 DOI: 10.1016/j.legalmed.2023.102387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 11/24/2023] [Accepted: 12/25/2023] [Indexed: 12/30/2023]
Abstract
Williams syndrome (WS) is a rare genetic disorder caused by a microdeletion of chromosome 7q11.23. Although the mortality rate of patients with WS is not very high, sudden cardiac death can occur, particularly in cases complicated by coronary artery stenosis. A 3-month-old female infant with supravalvular aortic stenosis and peripheral pulmonary stenosis was discovered unconscious in bed by her mother. She was immediately transferred to an emergency hospital but succumbed despite multiple attempts as resuscitation. DNA microarray analysis revealed microdeletions of 7q11.23 and 16p11.2, confirming WS and unexpectedly identifying 16p11.2 deletion syndrome which is known to be associated with neurodevelopmental disorders. Postmortem computed tomography revealed a severely enlarged heart, indicative of cardiac dysfunction. External examination revealed moderate-to-severe developmental delays in height and body weight. The heart, on internal examination, revealed whitish-discolored lesions; histologically severe fibrotic changes and thickening of the intima in the coronary arteries and aorta. In the brain, the dentate gyrus of the hippocampus appeared malformed. Taken together, these findings suggest that the cause of death was cardiac dysfunction due to WS. In addition, it could be possible that 16p11.2 deletion syndrome and dentate gyrus malformation contributed to her death. Future autopsy studies are warranted to clarify the precise role of microdeletion disorders in sudden death to reduce future preventable deaths in children.
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Affiliation(s)
- Chihiro Kawai
- Department of Forensic Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Hidehito Kondo
- Department of Pediatrics, Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
| | - Masashi Miyao
- Department of Forensic Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan.
| | - Mariko Sunada
- Department of Pediatrics, Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
| | - Seiichiro Ozawa
- Department of Pediatrics, Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
| | - Hirokazu Kotani
- Forensic Medicine and Sciences, Mie University Graduate School of Medicine, Mie, Japan
| | - Hirozo Minami
- Department of Forensic Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Hideki Nagai
- Department of Forensic Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Hitoshi Abiru
- Department of Forensic Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Akira Yamamoto
- Center for Medical Education, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Keiji Tamaki
- Department of Forensic Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yoko Nishitani
- Department of Forensic Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
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3
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Markush D, Sanchez-Lara PA, Grand K, Wong R, Garg R. Sudden Cardiac Arrest During a Sedated Cardiac Magnetic Resonance Study in a Nonsyndromic Child with Evolving Supravalvar Aortic Stenosis Due to Familial ELN Mutation. Pediatr Cardiol 2023; 44:946-950. [PMID: 36790509 PMCID: PMC10063468 DOI: 10.1007/s00246-022-03089-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 12/22/2022] [Indexed: 02/16/2023]
Abstract
Supravalvar aortic stenosis (SVAS) is a less common but clinically important form of left ventricular outflow tract obstruction, and commonly associated with Williams syndrome (WS). SVAS outside of WS may also occur sporadically or in a familial form, often with identifiable mutations in the elastin (ELN) gene. While risk of sudden cardiac death in patients with SVAS has been extensively described in the context of WS, less is known about risk in patients with isolated SVAS. We report a case of a nonsyndromic two-year-old boy with evolving manifestations of SVAS who developed sudden cardiac arrest and death during a sedated cardiac magnetic resonance imaging study. A strong family history of SVAS was present and targeted genetic testing identified an ELN gene mutation in the boy's affected father and other paternal relatives. We review risk factors found in the literature for SCA in SVAS patients and utilize this case to raise awareness of the risk of cardiac events in these individuals even in the absence of WS or severe disease. This case also underscores the importance of genetic testing, including targeted panels specifically looking for ELN gene mutations, in all patients with SVAS even in the absence of phenotypic concerns for WS or other genetic syndromes.
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Affiliation(s)
- Dor Markush
- Guerin Family Congenital Heart Program, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
- Department of Pediatrics, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Pedro A Sanchez-Lara
- Department of Pediatrics, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Department of Medical Genetics, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Katheryn Grand
- Department of Pediatrics, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Department of Medical Genetics, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Robert Wong
- Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Ruchira Garg
- Guerin Family Congenital Heart Program, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Department of Pediatrics, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Yuan Y, Zhou R. An infant with suspected missed diagnosis of Williams syndrome failed weaning off CPB after surgical correction of pulmonary stenosis: a case report and literature review. Perfusion 2023; 38:203-207. [PMID: 34538195 DOI: 10.1177/02676591211046876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Williams syndrome (WS) is a rare congenital developmental disorder caused by the deletion of between 26 and 28 genes on chromosome 7q11.23. For patients with WS, in view of the particularity of the supravalvular aortic stenosis, choosing appropriate arterial cannula, maintaining higher perfusion pressure as well as strengthening myocardial protection during cardiopulmonary bypass (CPB) is essential to the clinical outcome. Here, we report a child with pulmonary artery valvular stenosis who failed to wean off CPB because of malignant arrhythmias and cardiac insufficiency after surgical correction of pulmonary valvular stenosis. With the assistance of extracorporeal membrane oxygenation (ECMO), emergency cardiac catheterization revealed supravalvular aortic stenosis (SVAS), which suggests a suspected missed diagnosis of WS. Finally, under the support of ECMO, the cardiac function gradually returned to normal, and the child was discharged 23 days after surgery.
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Affiliation(s)
- Yuan Yuan
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, Sichuan, P.R. China
| | - Ronghua Zhou
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, Sichuan, P.R. China
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Nasr VG, Markham LW, Clay M, DiNardo JA, Faraoni D, Gottlieb-Sen D, Miller-Hance WC, Pike NA, Rotman C. Perioperative Considerations for Pediatric Patients With Congenital Heart Disease Presenting for Noncardiac Procedures: A Scientific Statement From the American Heart Association. Circ Cardiovasc Qual Outcomes 2023; 16:e000113. [PMID: 36519439 DOI: 10.1161/hcq.0000000000000113] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Continuous advances in pediatric cardiology, surgery, and critical care have significantly improved survival rates for children and adults with congenital heart disease. Paradoxically, the resulting increase in longevity has expanded the prevalence of both repaired and unrepaired congenital heart disease and has escalated the need for diagnostic and interventional procedures. Because of this expansion in prevalence, anesthesiologists, pediatricians, and other health care professionals increasingly encounter patients with congenital heart disease or other pediatric cardiac diseases who are presenting for surgical treatment of unrelated, noncardiac disease. Patients with congenital heart disease are at high risk for mortality, complications, and reoperation after noncardiac procedures. Rigorous study of risk factors and outcomes has identified subsets of patients with minor, major, and severe congenital heart disease who may have higher-than-baseline risk when undergoing noncardiac procedures, and this has led to the development of risk prediction scores specific to this population. This scientific statement reviews contemporary data on risk from noncardiac procedures, focusing on pediatric patients with congenital heart disease and describing current knowledge on the subject. This scientific statement also addresses preoperative evaluation and testing, perioperative considerations, and postoperative care in this unique patient population and highlights relevant aspects of the pathophysiology of selected conditions that can influence perioperative care and patient management.
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Calleja-García C, Muñoz-Gallego A, Dorado-López-Rosado A, López-López C, Tejada-Palacios P. Ophthalmological manifestations in 6 patients diagnosed with Williams-Beuren syndrome and literature review. ARCHIVOS DE LA SOCIEDAD ESPANOLA DE OFTALMOLOGIA 2022; 97:276-280. [PMID: 35292219 DOI: 10.1016/j.oftale.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 04/06/2021] [Indexed: 06/14/2023]
Abstract
Medical history of 6 patients diagnosed with Williams-Beuren Syndrome (SWB) in pediatric age was revised. All the patients presented characteristic elf facies and cardiovascular abnormalities. All presented good visual acuity, except one case of unilateral amblyopia. The most frequent refractive error was hyperopia (n = 6; 100%) and astigmatism (n = 5; 83.3%). Ocular motility alterations were found in 2 patients (1 case of exophoria with hyperfunction of right inferior oblique and another of congenital endotropia with bilateral hyperfunction of inferior oblique). On the cognitive function, 66.7% (n = 4) had visoperceptive disorders. Other findings were epicanthus (n = 6; 100%) and congenital obstruction of the nasolacrimal duct with unilateral epiphora (n = 1; 16.7%). SWB is a rare disorder with complex ophthalmological and systemic manifestations. For this reason, ophthalmological follow-up of these children is recommended.
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Affiliation(s)
- C Calleja-García
- Servicio de Oftalmología, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - A Muñoz-Gallego
- Servicio de Oftalmología, Hospital Universitario 12 de Octubre, Madrid, Spain.
| | | | - C López-López
- Servicio de Oftalmología, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - P Tejada-Palacios
- Servicio de Oftalmología, Hospital Universitario 12 de Octubre, Madrid, Spain; Instituto de investigación i+12, Hospital Universitario 12 de Octubre, Madrid, Spain; Departamento de Inmunología, Oftalmología y ORL, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
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Gronert BJ, Yitzhak B, Nelson JS, Bender KS. Preparation of children with heart disease for diagnostic and therapeutic procedures requiring anesthesia. PROGRESS IN PEDIATRIC CARDIOLOGY 2022. [DOI: 10.1016/j.ppedcard.2022.101523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Honjo RS, Monteleone VF, Aiello VD, Wagenfuhr J, Issa VS, Pomerantzeff PMA, Furusawa EA, Zanardo EA, Kulikowski LD, Bertola DR, Kim CA. Cardiovascular findings in Williams-Beuren Syndrome: Experience of a single center with 127 cases. Am J Med Genet A 2021; 188:676-682. [PMID: 34713566 DOI: 10.1002/ajmg.a.62542] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 09/10/2021] [Accepted: 09/15/2021] [Indexed: 11/12/2022]
Abstract
Williams-Beuren syndrome (WBS) is a rare, microdeletion syndrome characterized by facial dysmorphisms, intellectual disability, a friendly personality, cardiovascular and other abnormalities. Cardiovascular defects (CVD) are among the most prevalent characteristics in WBS, being supravalvular aortic stenosis (SVAS) the most frequent, followed by peripheral pulmonary stenosis (PPS). A comprehensive retrospective review of medical records of 127 patients with molecular diagnosis of WBS, in a period of 20 years, was done to evaluate the incidence, the natural history of cardiovascular disease, and the need for surgical intervention, including heart transplantation (HT). A total of 94/127 patients presented with CVD. Of these 94 patients, 50% presented with SVAS and 22.3% needed heart surgery and/or cardiac catheterization including one that required HT due to severe SVAS-related heart failure at 19 years of age. The patient died in the postoperative period due to infectious complications. Cardiovascular problems are the major cause of sudden death in patients with WBS, who have a significantly higher mortality risk associated with surgical interventions. There is a higher risk for anesthesia-related adverse events and for major adverse cardiac events following surgery. End-stage heart failure due to myocardial ischemia has been described in WBS patients and it is important to consider that HT can become their only viable option. To our knowledge, the case mentioned here is the first HT reported in an adolescent with WBS. HT can be a viable therapeutic option in WBS patients with adequate evaluation, planning, and a multidisciplinary team to provide the required perioperative care and follow-up.
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Affiliation(s)
- Rachel Sayuri Honjo
- Genetics Unit, Instituto da Criança do Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Vanessa Figueiredo Monteleone
- Genetics Unit, Instituto da Criança do Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Vera Demarchi Aiello
- Pathology Laboratory, Instituto do Coração do Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Jaqueline Wagenfuhr
- Pediatric Cardiology Unit, Instituto da Criança do Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | | | - Pablo Maria Alberto Pomerantzeff
- Heart Transplantation Unit, Instituto do Coraçao do Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Erika Arai Furusawa
- Pediatric Nephrology Unit, Instituto da Criança do Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Evelin Aline Zanardo
- Cytogenomic Laboratory, LIM 03, Pathology Department, Faculdade de Medicina HC-FMUSP, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Leslie Domenici Kulikowski
- Cytogenomic Laboratory, LIM 03, Pathology Department, Faculdade de Medicina HC-FMUSP, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Debora Romeo Bertola
- Genetics Unit, Instituto da Criança do Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Chong Ae Kim
- Genetics Unit, Instituto da Criança do Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
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Kozel BA, Barak B, Ae Kim C, Mervis CB, Osborne LR, Porter M, Pober BR. Williams syndrome. Nat Rev Dis Primers 2021; 7:42. [PMID: 34140529 PMCID: PMC9437774 DOI: 10.1038/s41572-021-00276-z] [Citation(s) in RCA: 84] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/13/2021] [Indexed: 11/09/2022]
Abstract
Williams syndrome (WS) is a relatively rare microdeletion disorder that occurs in as many as 1:7,500 individuals. WS arises due to the mispairing of low-copy DNA repetitive elements at meiosis. The deletion size is similar across most individuals with WS and leads to the loss of one copy of 25-27 genes on chromosome 7q11.23. The resulting unique disorder affects multiple systems, with cardinal features including but not limited to cardiovascular disease (characteristically stenosis of the great arteries and most notably supravalvar aortic stenosis), a distinctive craniofacial appearance, and a specific cognitive and behavioural profile that includes intellectual disability and hypersociability. Genotype-phenotype evidence is strongest for ELN, the gene encoding elastin, which is responsible for the vascular and connective tissue features of WS, and for the transcription factor genes GTF2I and GTF2IRD1, which are known to affect intellectual ability, social functioning and anxiety. Mounting evidence also ascribes phenotypic consequences to the deletion of BAZ1B, LIMK1, STX1A and MLXIPL, but more work is needed to understand the mechanism by which these deletions contribute to clinical outcomes. The age of diagnosis has fallen in regions of the world where technological advances, such as chromosomal microarray, enable clinicians to make the diagnosis of WS without formally suspecting it, allowing earlier intervention by medical and developmental specialists. Phenotypic variability is considerable for all cardinal features of WS but the specific sources of this variability remain unknown. Further investigation to identify the factors responsible for these differences may lead to mechanism-based rather than symptom-based therapies and should therefore be a high research priority.
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Affiliation(s)
- Beth A. Kozel
- Translational Vascular Medicine Branch, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, USA
| | - Boaz Barak
- The Sagol School of Neuroscience and The School of Psychological Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Chong Ae Kim
- Department of Pediatrics, Universidade de São Paulo, São Paulo, Brazil
| | - Carolyn B. Mervis
- Department of Psychological and Brain Sciences, University of Louisville, Louisville, USA
| | - Lucy R. Osborne
- Department of Medicine, University of Toronto, Ontario, Canada
| | - Melanie Porter
- Department of Psychology, Macquarie University, Sydney, Australia
| | - Barbara R. Pober
- Department of Pediatrics, Massachusetts General Hospital and Harvard Medical School, Boston, USA
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Schmidt AR, Collins RT, Adusumelli Y, Ramamoorthy C, Weng Y, MacMillen KL, Navaratnam M. Impact of Modified Anesthesia Management for Pediatric Patients With Williams Syndrome. J Cardiothorac Vasc Anesth 2021; 35:3667-3674. [PMID: 34049787 DOI: 10.1053/j.jvca.2021.04.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 04/07/2021] [Accepted: 04/12/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE This study compared the percent change in systolic blood pressure and the incidence of adverse cardiac events (ACEs; defined as cardiac arrest, cardiopulmonary resuscitation, arrhythmias, or ST-segment changes) during anesthesia induction in patients with Williams syndrome (WS) before and after implementation of a perioperative management strategy. DESIGN Retrospective observational cohort study. SETTING Single quaternary academic referral center. PARTICIPANTS The authors reviewed the records of all children with WS at the authors' institution who underwent general anesthesia for cardiac catheterization, diagnostic imaging, or any type of surgery between November 2008 and August 2019. The authors identified 142 patients with WS, 48 of whom underwent 118 general anesthesia administrations. A historic group (HG) was compared with the intervention group (IG). INTERVENTIONS Change in perioperative management (three-stage risk stratification: preoperative intravenous hydration, intravenous anesthesia induction, and early use of vasoactives). MEASUREMENTS AND MAIN RESULTS The authors determined event rates within 60 minutes of anesthesia induction. Standardized mean difference (SMD) was calculated (SMD >0.2 suggests clinically meaningful difference). Sixty-seven general anesthesia encounters were recorded in the HG (mean age, 4.8 years; mean weight, 16.3 kg) and 51 in the IG (mean age, 6.0 years; mean weight, 18.2 kg). The change in systolic blood pressure was -17.5% (-30.0, -5.0) in the HG versus -9% (-18.0, 5.0) in the IG (p = 0.015; SMD = 0.419), and the incidence of ACEs was 6% in the HG and 2% in the IG (p = 0.542; SMD = 0.207). CONCLUSIONS Preoperative risk stratification, preoperative intravenous hydration, intravenous induction, and early use of continuous vasoactives resulted in greater hemodynamic stability, with a 2% incidence of ACEs.
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Affiliation(s)
- Alexander R Schmidt
- Division of Pediatric Cardiac Anesthesia, Lucile Packard Children's Hospital Stanford and Stanford University School of Medicine, Palo Alto, CA.
| | - R Thomas Collins
- Divisions of Pediatric Cardiology, Lucile Packard Children's Hospital Stanford and Stanford University School of Medicine, Palo Alto, CA
| | - Yamini Adusumelli
- Division of Pediatric Cardiac Anesthesia, Lucile Packard Children's Hospital Stanford and Stanford University School of Medicine, Palo Alto, CA
| | - Chandra Ramamoorthy
- Division of Pediatric Cardiac Anesthesia, Lucile Packard Children's Hospital Stanford and Stanford University School of Medicine, Palo Alto, CA
| | - Yingjie Weng
- Quantitative Sciences Unit, Stanford Center for Biomedical Informatics Research, Stanford University School of Medicine, Palo Alto, CA
| | - Kirstie L MacMillen
- Divisions of Pediatric Cardiology, Lucile Packard Children's Hospital Stanford and Stanford University School of Medicine, Palo Alto, CA
| | - Manchula Navaratnam
- Division of Pediatric Cardiac Anesthesia, Lucile Packard Children's Hospital Stanford and Stanford University School of Medicine, Palo Alto, CA
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Martin A, Rycus PT, Farooqi A, Dentel J, Cashen K. Extracorporeal membrane oxygenation outcomes in children with Williams syndrome: a review of the ELSO registry. Perfusion 2021; 37:359-366. [PMID: 33653195 DOI: 10.1177/0267659121999299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Williams syndrome (WS) results from a microdeletion that usually involves the elastin gene, leading to generalized arteriopathy. Cardiovascular anomalies are seen in 80% of WS patients, including supravalvular aortic stenosis (SVAS), pulmonary artery stenosis (PAS), and pulmonary stenosis (PS). Sudden death associated with procedural sedation and in the perioperative period in WS children have been reported. This study aims to describe extracorporeal membrane oxygenation (ECMO) use in WS children, identify risk factors for hospital mortality of WS patients, and compare outcomes between WS children and non-WS children with SVAS, PAS, and PS. METHODS Children 0-18 years-old in the Extracorporeal Life Support Organization (ELSO) Registry with a primary or secondary diagnosis of WS, SVAS, PAS, or PAS were included. RESULTS Included were 50 WS children and 1222 non-WS children with similar cardiac diagnoses. ECMO use increased over time in both groups (p = 0.93), with most cases occurring in the current era. WS children were younger (p = 0.004), weighed less (p = 0.048), had a pulmonary indication for ECMO (50% vs 10%, p < 0.001), and were placed more on high frequency ventilation (p < 0.001) than non-WS patients. Despite reporting a respiratory indication, most (84%) WS patients were placed on VA-ECMO. There were no significant differences between the two groups in terms of pre-ECMO cardiac arrest, ECMO duration, or reason for ECMO discontinuation. Both groups had a mortality rate of 48% (p = 1.00). No risk factors for WS mortality were identified.
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Affiliation(s)
- Amarilis Martin
- Division of Critical Care Medicine, Children's Hospital of Michigan, Detroit, MI, USA.,Central Michigan University College of Medicine, Mount Pleasant, MI, USA.,Wayne State University School of Medicine, Detroit, MI, USA
| | - Peter T Rycus
- Extracorporeal Life Support Organization (ELSO), Ann Arbor, MI, USA
| | - Ahmad Farooqi
- Department of Biostatistics, Central Michigan University College of Medicine, Detroit, MI, USA
| | - John Dentel
- Department of Cardiovascular Surgery, Children's Hospital of Michigan, Detroit, MI, USA
| | - Katherine Cashen
- Division of Critical Care Medicine, Children's Hospital of Michigan, Detroit, MI, USA.,Central Michigan University College of Medicine, Mount Pleasant, MI, USA.,Wayne State University School of Medicine, Detroit, MI, USA
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Addis DR, Townsley MM. Implications of Congenital Coronary Anomalies for the Cardiothoracic Anesthesiologist: An Overview of the 2020 American Society of Echocardiography Recommendations for Multimodality Assessment of Congenital Coronary Anomalies. J Cardiothorac Vasc Anesth 2020; 34:2291-2296. [DOI: 10.1053/j.jvca.2020.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 05/09/2020] [Indexed: 11/11/2022]
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Dunlap JD, Green MC, Shah AM, Kibby BT, Billmire DF. Cardiac arrest after induction of anesthesia in a 2-month-old infant with undiagnosed Williams syndrome. Ann Card Anaesth 2020; 22:210-212. [PMID: 30971606 PMCID: PMC6489387 DOI: 10.4103/aca.aca_38_18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
A 2-month-old male infant presented for elective repair of inguinal hernias. His preoperative medical history and physical examination were unremarkable. During induction of anesthesia, the infant sustained an adverse cardiac event. The event was characterized by tachycardia, hypotension, and massive ST-segment elevation. Despite vigorous resuscitation, spontaneous hemodynamic stability could not be achieved and extracorporeal membrane oxygenation was required. A transthoracic echocardiogram revealed severe hypoplasia of the ascending aorta. As effective cardiac function did not recover and there was evidence of diffuse ischemic brain injury, life support was withdrawn. Genetic testing performed postoperatively was definitive for Williams syndrome.
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Affiliation(s)
- Julie D Dunlap
- Department of Clinical Anaesthesia, Riley Hospital for Children, Indianapolis, IN 46202-5200, USA
| | - Morton C Green
- Department of Clinical Anaesthesia, Riley Hospital for Children, Indianapolis, IN 46202-5200, USA
| | - Aali M Shah
- Department of Clinical Anaesthesia, Riley Hospital for Children, Indianapolis, IN 46202-5200, USA
| | - Brandon T Kibby
- Department of Clinical Anaesthesia, Riley Hospital for Children, Indianapolis, IN 46202-5200, USA
| | - Deborah F Billmire
- Department of Surgery, Riley Hospital for Children, Indianapolis, IN 46202-5200, USA
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Staudt GE, Eagle SS. Anesthetic Considerations for Patients With Williams Syndrome. J Cardiothorac Vasc Anesth 2020; 35:176-186. [PMID: 32127269 DOI: 10.1053/j.jvca.2020.01.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Revised: 12/28/2019] [Accepted: 01/10/2020] [Indexed: 11/11/2022]
Abstract
Williams syndrome (WS) is a relatively rare congenital disorder which manifests across multiple organ systems with a wide spectrum of severity. Cardiovascular anomalies are the most common and concerning manifestations of WS, with supravalvar aortic stenosis present in up to 70% of patients with WS. Although a relatively rare disease, these patients frequently require sedation or anesthesia for a variety of medical procedures. The risk of sudden death in this population is 25 to 100 times that of the general population, with many documented deaths associated with sedation or anesthesia. This increased risk coupled with a disproportionately frequent need for anesthetic care renders it prudent for the anesthesiologist to have a firm understanding of the manifestations of WS. In the following review, the authors discuss pertinent clinical characteristics of WS along with particular anesthetic considerations for the anesthesiologist caring for patients with WS presenting for non-cardiac surgery.
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Affiliation(s)
- Genevieve E Staudt
- Division of Pediatric Cardiac Anesthesiology, Vanderbilt University Medical Center, Nashville, TN.
| | - Susan S Eagle
- Division of Cardiothoracic Anesthesiology, Vanderbilt University Medical Center, Nashville, TN
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Nasr VG, Gottlieb EA, Adler AC, Evans MA, Sawardekar A, DiNardo JA, Mossad EB, Mittnacht AJ. Selected 2018 Highlights in Congenital Cardiac Anesthesia. J Cardiothorac Vasc Anesth 2019; 33:2833-2842. [DOI: 10.1053/j.jvca.2019.03.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 03/05/2019] [Indexed: 01/19/2023]
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Collins RT, Mainwaring RD, MacMillen KL, Hanley FL. Outcomes of Pulmonary Artery Reconstruction in Williams Syndrome. Ann Thorac Surg 2019; 108:146-153. [DOI: 10.1016/j.athoracsur.2019.02.013] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 01/30/2019] [Accepted: 02/04/2019] [Indexed: 12/01/2022]
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Brown ML, DiNardo JA, Nasr VG. Anesthesia in Pediatric Patients With Congenital Heart Disease Undergoing Noncardiac Surgery: Defining the Risk. J Cardiothorac Vasc Anesth 2019; 34:470-478. [PMID: 31345716 DOI: 10.1053/j.jvca.2019.06.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Revised: 06/08/2019] [Accepted: 06/10/2019] [Indexed: 01/13/2023]
Abstract
The incidence of moderate to severe congenital heart disease (CHD) in the United States is estimated to be 6 per 1,000 live-born, full-term infants. Recent advances in pediatric cardiology, surgery, and critical care have improved significantly the survival rates of patients with CHD leading to an increase in prevalence in both children and adults. Children with CHD significant enough to require cardiac surgery frequently also undergo noncardiac surgical procedures. With this increased demand for procedures that require anesthesia, all anesthesiologists, and more specifically, pediatric anesthesiologists will encounter patients with repaired or unrepaired CHD and other cardiac diseases in their practice. They often are faced with the question, "Is this patient too high risk for anesthesia?" The objective of this literature review is to provide a greater understanding of patients at high risk and to quantify the risk for patients, their families, and clinicians. In addition, specific high-risk lesions (single ventricle, Williams-Beuren syndrome, pulmonary hypertension, cardiomyopathies, and ventricular assist devices) are described.
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Affiliation(s)
- Morgan L Brown
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - James A DiNardo
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Viviane G Nasr
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA.
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18
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Twite MD, Stenquist S, Ing RJ. Williams syndrome. Paediatr Anaesth 2019; 29:483-490. [PMID: 30811742 DOI: 10.1111/pan.13620] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 02/12/2019] [Accepted: 02/24/2019] [Indexed: 01/06/2023]
Abstract
Williams syndrome affects approximately one in 10 000 people and is caused by the deletion of genes on chromosome 7q11.23 which code for elastin. The phenotypic appearance of people with Williams syndrome is well characterized, but there continues to be new genetic and therapeutic discoveries. Patients with Williams syndrome have increased morbidity and mortality under sedation and anesthesia, largely as a result of cardiovascular abnormalities. This review article focuses on new information about Williams syndrome and outlines a structured approach to patients with Williams syndrome in the perioperative period.
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Affiliation(s)
- Mark D Twite
- Department of Anesthesiology, University of Colorado Anschutz Medical Campus & Children's Hospital Colorado, Aurora, Colorado
| | - Scott Stenquist
- Department of Anesthesiology, University of Colorado Anschutz Medical Campus & Children's Hospital Colorado, Aurora, Colorado
| | - Richard J Ing
- Department of Anesthesiology, University of Colorado Anschutz Medical Campus & Children's Hospital Colorado, Aurora, Colorado
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