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Hu LW, Zhao X, Leng S, Ouyang R, Wang Q, Sun AM, Liu YM, Dong W, Zhong L, Zhong YM. Assessment of hemodynamic disturbances and impaired ventricular filling in asymptomatic fontan patients: A 4D flow CMR study. Eur J Radiol Open 2025; 14:100631. [PMID: 39868414 PMCID: PMC11762912 DOI: 10.1016/j.ejro.2024.100631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2024] [Revised: 12/09/2024] [Accepted: 12/27/2024] [Indexed: 01/28/2025] Open
Abstract
Background The Fontan procedure is a surgical intervention designed for patients with single ventricle physiology, wherein the systemic venous return is redirected into the pulmonary circulation, thereby facilitating passive pulmonary blood flow without the assistance of ventricular propulsion. Consequently, long-term follow-up of individuals who have undergone the asymptomatic Fontan procedure is essential. Objectives The aims of this investigation were to: 1) examine the impact of flow components and kinetic energy (KE) parameters on hemodynamic disturbances in asymptomatic Fontan patients and control group; 2) Assess left ventricular diastolic dysfunction through the analysis of 4D flow parameters across different Fontan sub-groups; 3) Compare intracardiac flow parameters among Fontan sub-groups based on morphological features of the left ventricle (LV) and right ventricle (RV). Methods Twenty-five Fontan patients (mean age: 10 ± 3 years, male/female: 15/10) and fourteen control subjects (mean age: 10 ± 2 years, male/female: 8/6) were recruited retrospectively for the study. The Fontan patients were further categorized into three groups based on their ventricular function: left ventricular (LV), right ventricular (RV), and biventricular (BiV). Each participant underwent cardiovascular magnetic resonance (CMR) imaging, including cine and 4D flow sequences on a 3.0 T scanner. Ventricular flow components and KE were assessed using 4D flow. The study utilized cine images to analyze cardiac function and inter-ventricular mechanical dyssynchrony. Echocardiography evaluated functional ventricular diastolic dysfunction. Results Fontan patients had a higher median functional single ventricle (FSV) residual volume compared to controls (28 % vs. 23 %, P = 0.034), with lower median FSV direct flow (32 % vs. 40 %, P = 0.005) and delayed ejection flow (17 % vs. 24 %, P = 0.024). The parameters of FSV normalized to the ventricular end-diastolic volume (KEiEDV) were found to be significantly lower in Fontan patients (all P < 0.05). In both left ventricle (LV) and biventricular (BiV) Fontan subgroups, direct flow was identified as an independent predictor of LV diastolic dysfunction (AUC=0.76, Sensitivity=86 %, Specificity=70 %). Furthermore, residual volume and E-wave KEiEDV were observed to be significantly different between LV and right ventricle (RV) Fontan subgroups. Conclusions The altered flow pattern and reduced kinetic energy observed in Fontan patients may indicate hemodynamic disturbances and compromised ventricular filling. Reduced direct flow is associated with LV diastolic dysfunction in LV and BiV Fontan subgroups. Systemic LV exhibited a more efficient intracardiac flow pattern compare with systemic RV in Fontan patients.
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Affiliation(s)
- Li-Wei Hu
- Department of Radiology, Shanghai Children’s Medical Center, Shanghai Jiao Tong University School of Medicine, 1678 Dong Fang Road, Shanghai 200127, PR China
| | - Xiaodan Zhao
- National Heart Research Institute Singapore, National Heart Centre Singapore, 5 Hospital Drive, Singapore 169609, Singapore
| | - Shuang Leng
- National Heart Research Institute Singapore, National Heart Centre Singapore, 5 Hospital Drive, Singapore 169609, Singapore
- Duke-NUS Medical School, Singapore, National University of Singapore, 8 College Road, Singapore 169857, Singapore
| | - RongZhen Ouyang
- Department of Radiology, Shanghai Children’s Medical Center, Shanghai Jiao Tong University School of Medicine, 1678 Dong Fang Road, Shanghai 200127, PR China
| | - Qian Wang
- Department of Radiology, Shanghai Children’s Medical Center, Shanghai Jiao Tong University School of Medicine, 1678 Dong Fang Road, Shanghai 200127, PR China
| | - Ai-Min Sun
- Department of Radiology, Shanghai Children’s Medical Center, Shanghai Jiao Tong University School of Medicine, 1678 Dong Fang Road, Shanghai 200127, PR China
| | - Yi-Man Liu
- Department of Pediatric Cardiology, Shanghai Children’s Medical Center, Shanghai Jiao Tong University School of Medicine, 1678 Dong Fang Road, Shanghai 200127, PR China
| | - Wei Dong
- Department of Cardiothoracic Surgery, Shanghai Children’s Medical Center, Shanghai Jiaotong University School of Medicine, 1678 Dong Fang Road, Shanghai 200127, PR China
| | - Liang Zhong
- National Heart Research Institute Singapore, National Heart Centre Singapore, 5 Hospital Drive, Singapore 169609, Singapore
- Duke-NUS Medical School, Singapore, National University of Singapore, 8 College Road, Singapore 169857, Singapore
| | - Yu-Min Zhong
- Department of Radiology, Shanghai Children’s Medical Center, Shanghai Jiao Tong University School of Medicine, 1678 Dong Fang Road, Shanghai 200127, PR China
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Meziab O, Dereszkiewicz E, Guerrero CE, Hoyer AW, Barber BJ, Klewer SE, Seckeler MD. Adverse Effect of Bundle Branch Block on Exercise Performance in Patients with Fontan Physiology: From the Pediatric Heart Network Fontan Public Data Set. Pediatr Cardiol 2025; 46:813-818. [PMID: 38724762 DOI: 10.1007/s00246-024-03500-1] [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: 01/02/2024] [Accepted: 04/15/2024] [Indexed: 03/14/2025]
Abstract
Patients with Fontan physiology have reduced exercise performance compared to their peers as well as a higher incidence of bundle branch block (BBB). This study aims to investigate the association between BBB and exercise performance in the Fontan population through a retrospective review of the Pediatric Heart Network Fontan study public use dataset. "Low Performers" were defined as ≤ 25th percentile (for Fontan patients) for each exercise parameter at anaerobic threshold (AT) for gender and age and "Normal Performers" were all other patients. A total of 303 patients with Fontan physiology who underwent exercise testing reached AT and had complete data for BBB. BBB occurred more frequently in Low Performers for VO2 [OR (95% CI): 2.6 (1.4, 4.8)] and Work [OR (95% CI): 2.7 (1.4, 5.1)], suggesting that BBB in the Fontan population is associated with reduced exercise performance. This data adds to the existing clinical evidence of the adverse effects of conduction abnormalities on single ventricle cardiac output and adds support for consideration of cardiac resynchronization and multi-site ventricular pacing in this patient population.
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Affiliation(s)
- Omar Meziab
- Department of Pediatrics (Cardiology), University of Arizona, 1501 N. Campbell Ave, PO Box 245073, Tucson, AZ, 85724, USA.
| | | | - Claudia E Guerrero
- Department of Pediatrics (Cardiology), University of Arizona, 1501 N. Campbell Ave, PO Box 245073, Tucson, AZ, 85724, USA
| | - Andrew W Hoyer
- Department of Pediatrics (Cardiology), University of Arizona, 1501 N. Campbell Ave, PO Box 245073, Tucson, AZ, 85724, USA
| | - Brent J Barber
- Department of Pediatrics (Cardiology), University of Arizona, 1501 N. Campbell Ave, PO Box 245073, Tucson, AZ, 85724, USA
| | - Scott E Klewer
- Department of Pediatrics (Cardiology), University of Arizona, 1501 N. Campbell Ave, PO Box 245073, Tucson, AZ, 85724, USA
| | - Michael D Seckeler
- Department of Pediatrics (Cardiology), University of Arizona, 1501 N. Campbell Ave, PO Box 245073, Tucson, AZ, 85724, USA
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Houska N, Albertz M, Frank B, Ing RJ. 2024 Guidelines for Performing a Comprehensive Pediatric Transthoracic Echocardiogram: Recommendations From the American Society of Echocardiography. J Cardiothorac Vasc Anesth 2024; 38:1627-1629. [PMID: 38834446 DOI: 10.1053/j.jvca.2024.03.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 03/24/2024] [Indexed: 06/06/2024]
Affiliation(s)
- Nicholas Houska
- Department of Anesthesiology, University of Colorado School of Medicine, Children's Hospital Colorado, Anschutz Medical Campus, Aurora, CO
| | - Megan Albertz
- Department of Anesthesiology, University of Colorado School of Medicine, Children's Hospital Colorado, Anschutz Medical Campus, Aurora, CO
| | - Benjamin Frank
- Department of Pediatric Cardiology, University of Colorado School of Medicine, Children's Hospital Colorado, Anschutz Medical Campus, Aurora, CO
| | - Richard J Ing
- Department of Anesthesiology, University of Colorado School of Medicine, Children's Hospital Colorado, Anschutz Medical Campus, Aurora, CO.
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Tikenoğullar i OZ, Peirlinck M, Chubb H, Dubin AM, Kuhl E, Marsden AL. Effects of cardiac growth on electrical dyssynchrony in the single ventricle patient. Comput Methods Biomech Biomed Engin 2024; 27:1011-1027. [PMID: 37314141 PMCID: PMC10719423 DOI: 10.1080/10255842.2023.2222203] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 04/27/2023] [Accepted: 05/04/2023] [Indexed: 06/15/2023]
Abstract
Single ventricle patients, including those with hypoplastic left heart syndrome (HLHS), typically undergo three palliative heart surgeries culminating in the Fontan procedure. HLHS is associated with high rates of morbidity and mortality, and many patients develop arrhythmias, electrical dyssynchrony, and eventually ventricular failure. However, the correlation between ventricular enlargement and electrical dysfunction in HLHS physiology remains poorly understood. Here we characterize the relationship between growth and electrophysiology in HLHS using computational modeling. We integrate a personalized finite element model, a volumetric growth model, and a personalized electrophysiology model to perform controlled in silico experiments. We show that right ventricle enlargement negatively affects QRS duration and interventricular dyssynchrony. Conversely, left ventricle enlargement can partially compensate for this dyssynchrony. These findings have potential implications on our understanding of the origins of electrical dyssynchrony and, ultimately, the treatment of HLHS patients.
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Affiliation(s)
- O. Z. Tikenoğullar i
- Department of Mechanical Engineering, Stanford University, Stanford, California, USA
| | - M. Peirlinck
- Department of Biomechanical Engineering, Delft University of Technology, Delft, Netherlands
| | - H. Chubb
- Department of Pediatrics (Cardiology), Stanford University, Stanford, California, USA
| | - A. M. Dubin
- Department of Pediatrics (Cardiology), Stanford University, Stanford, California, USA
| | - E. Kuhl
- Department of Mechanical Engineering, Stanford University, Stanford, California, USA
| | - A. L. Marsden
- Department of Mechanical Engineering, Stanford University, Stanford, California, USA
- Department of Pediatrics (Cardiology), Stanford University, Stanford, California, USA
- Department of Bioengineering, Stanford University, Stanford, California, USA
- Institute for Computational and Mathematical Engineering, Stanford University, Stanford, California, USA
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Venkatesh P, Gao H, Abudayyeh I, Pai RG, Varadarajan P. Contemporary Management of the Failing Fontan. J Clin Med 2024; 13:3049. [PMID: 38892760 PMCID: PMC11172880 DOI: 10.3390/jcm13113049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Revised: 05/19/2024] [Accepted: 05/21/2024] [Indexed: 06/21/2024] Open
Abstract
Adult patients with congenital heart disease have now surpassed the pediatric population due to advances in surgery and improved survival. One such complex congenital heart disease seen in adult patients is the Fontan circulation. These patients have complex physiology and are at risk for several complications, including thrombosis of the Fontan pathway, pulmonary vascular disease, heart failure, atrial arrhythmias, atrioventricular valve regurgitation, and protein-losing enteropathy. This review discusses the commonly encountered phenotypes of Fontan circulatory failure and their contemporary management.
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Affiliation(s)
- Prashanth Venkatesh
- Smidt Heart Institute, Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA; (P.V.); (H.G.)
| | - Hans Gao
- Smidt Heart Institute, Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA; (P.V.); (H.G.)
| | | | - Ramdas G. Pai
- California University of Science and Medicine, Colton, CA 92324, USA;
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Lopez L, Saurers DL, Barker PCA, Cohen MS, Colan SD, Dwyer J, Forsha D, Friedberg MK, Lai WW, Printz BF, Sachdeva R, Soni-Patel NR, Truong DT, Young LT, Altman CA. Guidelines for Performing a Comprehensive Pediatric Transthoracic Echocardiogram: Recommendations From the American Society of Echocardiography. J Am Soc Echocardiogr 2024; 37:119-170. [PMID: 38309834 DOI: 10.1016/j.echo.2023.11.015] [Citation(s) in RCA: 30] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2024]
Abstract
Echocardiography is a fundamental component of pediatric cardiology, and appropriate indications have been established for its use in the setting of suspected, congenital, or acquired heart disease in children. Since the publication of guidelines for pediatric transthoracic echocardiography in 2006 and 2010, advances in knowledge and technology have expanded the scope of practice beyond the use of traditional modalities such as two-dimensional, M-mode, and Doppler echocardiography to evaluate the cardiac segmental structures and their function. Adjunct modalities such as contrast, three-dimensional, and speckle-tracking echocardiography are now used routinely at many pediatric centers. Guidelines and recommendations for the use of traditional and newer adjunct modalities in children are described in detail in this document. In addition, suggested protocols related to standard operations, infection control, sedation, and quality assurance and improvement are included to provide an organizational structure for centers performing pediatric transthoracic echocardiograms.
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Affiliation(s)
- Leo Lopez
- Department of Pediatrics Cardiology, Stanford University School of Medicine and Lucile Packard Children's Hospital Stanford, Palo Alto, California.
| | - Daniel L Saurers
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Piers C A Barker
- Duke Children's Hospital & Health Center, Duke University, Durham, North Carolina
| | - Meryl S Cohen
- Cardiac Center and Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Steven D Colan
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Jeanine Dwyer
- Pediatric Heart Institute, Children's Hospital Colorado, Aurora, Colorado
| | - Daniel Forsha
- Ward Family Heart Center, Children's Mercy Kansas City Hospital, Kansas City, Missouri
| | - Mark K Friedberg
- Labatt Family Heart Centre, Division of Cardiology, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Wyman W Lai
- Division of Pediatric Cardiology, University of California School of Medicine, Irvine, California; Department of Pediatrics, Children's Hospital of Orange County, Orange, California
| | - Beth F Printz
- Rady Children's Hospital San Diego and University of California, San Diego, San Diego, California
| | - Ritu Sachdeva
- Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Neha R Soni-Patel
- Pediatric & Adult Congenital Heart Center, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Dongngan T Truong
- University of Utah and Division of Pediatric Cardiology, Primary Children's Hospital, Salt Lake City, Utah
| | - Luciana T Young
- Seattle Children's Hospital and Pediatric Cardiology, University of Washington School of Medicine, Seattle, Washington
| | - Carolyn A Altman
- Baylor College of Medicine and Texas Children's Heart Center, Texas Children's Hospital, Houston, Texas
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Karpawich PP, Chubb H. Indications for Cardiac Resynchronization Therapy in Patients with Congenital Heart Disease. Card Electrophysiol Clin 2023; 15:433-445. [PMID: 37865517 DOI: 10.1016/j.ccep.2023.07.005] [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] [Indexed: 10/23/2023]
Abstract
Heart failure in patients with congenital heart disease (CHD) stems from unique causes compared with the elderly. Patients with CHD face structural abnormalities and malformations present from birth, leading to altered cardiac function and potential complications. In contrast, elderly individuals primarily experience heart failure due to age-related changes and underlying cardiovascular conditions. Cardiac resynchronization therapy (CRT) can benefit patients with CHD, although it presents numerous challenges. The complexities of CHD anatomy and limited access to appropriate venous sites for lead placement make CRT implantation demanding.
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Affiliation(s)
- Peter P Karpawich
- Department of Pediatrics, Central Michigan University College of Medicine, Cardiac Electrophysiology, The Children's Hospital of Michigan, Detroit, MI, USA.
| | - Henry Chubb
- Stanford University School of Medicine, Stanford Medicine Children's Health, Palo Alto, CA, USA; Pediatric Heart Center, 725 Welch Road, Suite 120, MC 5912, Palo Alto, CA 94304, USA
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8
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Vaikunth S, Sundaravel S, Saef J, Ortega-Legaspi J. Novel Therapeutic Strategies in Heart Failure in Adult Congenital Heart Disease: of Medicines and Devices. Curr Heart Fail Rep 2023; 20:401-416. [PMID: 37582901 DOI: 10.1007/s11897-023-00621-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/18/2023] [Indexed: 08/17/2023]
Abstract
PURPOSE OF REVIEW This paper reviews the latest literature on the growing field of heart failure in the adult congenital heart disease population. RECENT FINDINGS After highlighting the increasing prevalence and a few of the unique potential causes, including the concept of early senescence, this review begins with novel medical management strategies such as the angiotensin II receptor blocker and neprilysin inhibitors and sodium glucose cotransporter-2 inhibitors. Then, it addresses the latest applications of percutaneous techniques like implantable hemodynamic monitoring, transcatheter pulmonary and aortic valve replacement, and mitral clips. Cardiac resynchronization therapy and novel lymphatic system imaging and intervention are then described. Finally, the use of mechanical support devices, temporary and durable, is discussed as well as heart and combined heart and liver transplantation. There have been recent exciting advances in the strategies used to manage adult congenital heart disease patients with heart failure. As this population continues to grow, it is likely we will see further rapid evolution in this field.
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Affiliation(s)
- Sumeet Vaikunth
- Philadelphia Adult Congenital Heart Center, Penn Medicine & Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA.
| | - Swethika Sundaravel
- Advanced Heart Failure Section, Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Joshua Saef
- Philadelphia Adult Congenital Heart Center, Penn Medicine & Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Juan Ortega-Legaspi
- Advanced Heart Failure Section, Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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Buddhavarapu A, Chauhan D, Erickson LA, Elliott MD, Warren M, Forsha DE. The Evolution of Longitudinal Strain Across Various Univentricular Morphologies Prior to Superior Cavopulmonary Anastomosis. J Am Soc Echocardiogr 2023; 36:1100-1109. [PMID: 37141928 DOI: 10.1016/j.echo.2023.04.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 04/22/2023] [Accepted: 04/25/2023] [Indexed: 05/06/2023]
Abstract
BACKGROUND Infants with single-ventricle physiology have increased morbidity, mortality, and ventricular dysfunction in the pre-superior cavopulmonary anastomosis (pre-SCPA) period. Echocardiography-derived longitudinal strain (LS) is emerging as a reliable marker of single-ventricle performance. We aim to assess evolution of LS during the pre-SCPA period across univentricular morphologies and explore associations of LS with modifiable and nonmodifiable factors. METHODS Ninety-four term infants (36 females) with univentricular physiology who were discharged home prior to stage 2 palliation were serially analyzed for LS (single apical view) and other echo measures at initial hospital discharge and the last pre-SCPA encounter. Ventricular myocardium was tracked for strain along the septum and respective lateral wall for single right ventricular (RV) and left ventricular (LV) groups, and along both right and left lateral walls in functionally univentricular hearts with biventricular (BiV) morphology. Clinical data were obtained from the medical record. RESULTS Longitudinal strain improved in the total cohort during the pre-SCPA period (16.48% ± 3.31% to 17.57% ± 3.81%, P = .003). Longitudinal strain improved between encounters in the single LV (P = .04) and BiV groups (P = .02). However, LS failed to improve in the RV group (P = .7) with lower LS at both visits compared with the other groups. The RV group, mostly composed of hypoplastic left heart syndrome patients-87% of cases-had a higher incidence of arrhythmias (57%) and unplanned reinterventions (60%), most of which were arch reinterventions. A subanalysis based on arch reintervention showed that LS improves between encounters in the single LV group needing arch reintervention (P = .05) compared with the single RV group needing arch reintervention (P = .89). Lower LS was independently associated with unplanned reinterventions at both encounters (P = .008 and .02). CONCLUSIONS Single-ventricle LS evolves differently across ventricular morphologies during the pre-SCPA period and is related to the need for unplanned cardiac reinterventions. Lower LS is noted in the single RV group, who mostly have hypoplastic left heart syndrome.
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Affiliation(s)
- Amulya Buddhavarapu
- Department of Pediatric Cardiology, Ward Family Heart Center, Children's Mercy Hospital, University of Missouri at Kansas City, Kansas City, Missouri
| | - Dhaval Chauhan
- Department of Pediatric Cardiology, Ward Family Heart Center, Children's Mercy Hospital, University of Missouri at Kansas City, Kansas City, Missouri
| | - Lori A Erickson
- Department of Strategic Planning and Innovation, Children's Mercy Hospital, Kansas City, Missouri
| | - Melissa D Elliott
- Department of Pediatric Cardiology, Ward Family Heart Center, Children's Mercy Hospital, University of Missouri at Kansas City, Kansas City, Missouri
| | - Matthew Warren
- Department of Pediatric Cardiology, Children's Memorial Hermann Hospital, University of Texas Health Science Center at Houston, Houston, Texas
| | - Daniel E Forsha
- Department of Pediatric Cardiology, Ward Family Heart Center, Children's Mercy Hospital, University of Missouri at Kansas City, Kansas City, Missouri.
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Yu JJ, Grosse-Wortmann L, Slorach C, Mertens L, Dragulescu A, Friedberg MK. Diastolic myocardial mechanics and their relation to ventricular filling pressures and postoperative course in functionally single ventricles. J Appl Physiol (1985) 2023; 135:621-630. [PMID: 37471215 DOI: 10.1152/japplphysiol.00295.2022] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 06/28/2023] [Accepted: 07/05/2023] [Indexed: 07/22/2023] Open
Abstract
Diastolic dysfunction affects clinical outcomes in patients with a functionally single ventricle (FSV). The objective of this work is to study the association of ventricular mechanics and interventricular dependence on diastolic parameters and early post-Fontan outcomes. Sixty-one patients with FSV underwent echocardiography, cardiac catheterization, and magnetic resonance imaging on the same day before or after the Fontan procedure. Echocardiographic diastolic parameters, ventricular mass, and incoordinate wall motion, defined by the number of dyskinetic segments or by the lateral wall delay, were determined and studied for relationships with invasively measured hemodynamics and early postoperative Fontan course. In subjects with a sizable secondary ventricle, incoordinate motion was additionally analyzed at the left- and right-sided ventricular free walls. Resting ventricular end-diastolic pressure (VEDP) was ≤10 mmHg in most subjects. Individual echocardiographic parameters of the diastolic flow and tissue velocities did not correlate with VEDP, other hemodynamics, or post-Fontan clinical course. Incoordinate wall motion in the dominant and in the sizeable secondary ventricle, defined by the lateral wall delay or by the number of dyskinetic segments, was the only echo parameter that correlated, albeit weakly, with VEDP (r = 0.247, P = 0.040), oxygen saturation (r = -0.417, P = 0.001), pulmonary vascular resistance and flow (Qp) (r = -0.303, P = 0.011), Fontan fenestration flow (r = 0.512, P = 0.009), and duration of endotracheal intubation (r = 0.292, P = 0.022). When the nondominant (secondary) ventricle was accounted for in the analysis of incoordinate wall motion, these associations strengthened. The degree of incoordinate ventricular wall motion in diastole was associated with VEDP and postoperative Fontan course in FSV. Analysis of incoordinate wall motion of the dominant and sizeable secondary ventricle may be warranted and should be included in the assessment of the FSV after the Fontan procedure.NEW & NOTEWORTHY Diastolic dysfunction affects outcomes in patients with functionally single ventricles (FSVs) but is difficult to assess. We found that incoordinate wall motion was the only echo parameter that correlated with FSV end-diastolic pressure, oxygen saturation, pulmonary vascular resistance and flow, and duration of endotracheal intubation. Analysis of incoordinate wall motion in the nondominant (secondary) ventricle strengthened these associations. Analyzing incoordinate wall motion should be included in the assessment of the FSV after the Fontan procedure.
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Affiliation(s)
- Jeong Jin Yu
- Division of Pediatric Cardiology, College of Medicine, University of Ulsan, Seoul, South Korea
| | - Lars Grosse-Wortmann
- Division of Cardiology, School of Medicine, Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon, United States
- Division of Cardiology, Labatt Family Heart Centre, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Cameron Slorach
- Division of Cardiology, Labatt Family Heart Centre, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Luc Mertens
- Division of Cardiology, Labatt Family Heart Centre, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Andreea Dragulescu
- Division of Cardiology, Labatt Family Heart Centre, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Mark K Friedberg
- Division of Cardiology, Labatt Family Heart Centre, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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Schäfer M, Mitchell MB, Frank BS, Barker AJ, Stone ML, Jaggers J, von Alvensleben JC, Hunter KS, Friesen RM, Ivy DD, Jacobsen R, Di Maria MV. Myocardial strain-curve deformation patterns after Fontan operation. Sci Rep 2023; 13:11912. [PMID: 37488167 PMCID: PMC10366156 DOI: 10.1038/s41598-023-39226-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Accepted: 07/21/2023] [Indexed: 07/26/2023] Open
Abstract
Myocardial deformation analysis by cardiac MRI (CMR) yielding global circumferential and longitudinal strain (GCS and GLS) is an increasingly utilized method to accurately quantify systolic function and predict clinical events in patients with Fontan circulation. The purpose of this study was to use principal component analysis (PCA) to investigate myocardial temporal deformation patterns derived from strain-time curves to learn about latent strain features beyond peak values. We conducted the study with specific attention to dominant single left or right ventricle (SLV and SRV) morphologies. Methods and Results: Patients remote from Fontan operation who underwent follow-up CMR were analyzed for standard volumetric and function hemodynamics including myocardial deformation parameters including GCS and GLS. We applied PCA to investigate in an unbiased fashion the strain-time curve morphology and to calculate patient specific shape scores. All variables were subjected to single variable Cox regression analysis to detect composite clinical outcome including death, heart transplant, protein losing enteropathy and plastic bronchitis. A total of 122 patients, (SLV = 67, SRV = 55) with a mean age of 12.7 years underwent comprehensive CMR analysis. The PCA revealed 3 primary modes of strain-curve variation regardless of single ventricle morphology and type of strain investigated. Principle components (PCs) described changes in (1) strain-time curve amplitude, (2) time-to-peak strain, and (3) post-systolic slope of the strain-time curve. Considering only SLV patients, GCS was only CMR variable predictive of clinical events (HR 1.46, p = 0.020). In the SRV group, significant CMR predictors of clinical events were derived indexed end-diastolic (HR 1.02, p = 0.023) and end-systolic (HR 1.03, p = 0.022) volumes, GCS (HR 1.91, p = 0.003) and its related first component score (HR 1.20, p = 0.005), GLS (HR 1.32, p = 0.029) and its third component score (HR 1.58, p = 0.017). CMR derived global strain measures are sensitive markers of clinical outcomes in patients with Fontan circulation, particularly in patients with the SRV morphology. Myocardial strain-time curve morphology specific to SLV and SRV patients inspired by unbiased PCA technique can further aid with predicting clinical outcomes.
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Affiliation(s)
- Michal Schäfer
- Division of Pediatric Cardiology, Children's Hospital Colorado, Heart Institute, University of Colorado Denver, Anschutz Medical Campus, 13123 E 16th Ave, Aurora, CO, USA.
- Division of Cardiothoracic Surgery, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA.
| | - Max B Mitchell
- Division of Cardiothoracic Surgery, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
| | - Benjamin S Frank
- Division of Pediatric Cardiology, Children's Hospital Colorado, Heart Institute, University of Colorado Denver, Anschutz Medical Campus, 13123 E 16th Ave, Aurora, CO, USA
| | - Alex J Barker
- Department of Radiology, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
- Department of Bioengineering, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
| | - Matthew L Stone
- Division of Cardiothoracic Surgery, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
| | - James Jaggers
- Division of Cardiothoracic Surgery, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
| | - Johannes C von Alvensleben
- Division of Pediatric Cardiology, Children's Hospital Colorado, Heart Institute, University of Colorado Denver, Anschutz Medical Campus, 13123 E 16th Ave, Aurora, CO, USA
| | - Kendall S Hunter
- Department of Bioengineering, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
| | - Richard M Friesen
- Division of Pediatric Cardiology, Children's Hospital Colorado, Heart Institute, University of Colorado Denver, Anschutz Medical Campus, 13123 E 16th Ave, Aurora, CO, USA
| | - D Dunbar Ivy
- Division of Pediatric Cardiology, Children's Hospital Colorado, Heart Institute, University of Colorado Denver, Anschutz Medical Campus, 13123 E 16th Ave, Aurora, CO, USA
| | - Roni Jacobsen
- Division of Pediatric Cardiology, Children's Hospital Colorado, Heart Institute, University of Colorado Denver, Anschutz Medical Campus, 13123 E 16th Ave, Aurora, CO, USA
| | - Michael V Di Maria
- Division of Pediatric Cardiology, Children's Hospital Colorado, Heart Institute, University of Colorado Denver, Anschutz Medical Campus, 13123 E 16th Ave, Aurora, CO, USA
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12
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Goudar S, Forsha D, White DA, Sherman A, Shirali G. Single ventricular strain measures correlate with peak oxygen consumption in children and adolescents with Fontan circulation. Cardiol Young 2023; 33:1136-1142. [PMID: 35864813 DOI: 10.1017/s1047951122002323] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Children with a single ventricle post-Fontan palliation are at increased risk of poor outcomes with peak oxygen consumption acting as a surrogate outcome marker. The purpose of this study is to evaluate the relationship between peak oxygen consumption and echocardiographic measures of ventricular function and deformation, including ventricular global longitudinal strain and dyssynchrony, in children and adolescents following Fontan palliation. METHODS Patients (age 8-21 years) with single ventricle post-Fontan palliation were prospectively recruited and participated in an echocardiogram, including views optimised for two-dimensional speckle tracking, and a cardiopulmonary exercise test on a cycle ergometer to maximal volitional fatigue. RESULTS Thirty-eight patients (mean age 13.7 ± 2.3 years) post-Fontan palliation had either a single left ventricular (n = 20), single right ventricular (n = 14), or biventricular (n = 4) morphology. Peak oxygen consumption (24.9 ± 5.6 ml/kg/minute) was correlated with global longitudinal strain (r = -0.435, p = 0.007), a strain discoordination time to peak index (r = -0.48, p = 0.003), and the presence of an electro-mechanical dyssynchrony strain pattern (p = 0.008). On multivariate regression modelling, these three variables were associated with peak oxygen consumption independently of age and sex. The single right ventricular group had evidence of possible diastolic dysfunction by E/e' compared to the single left ventricular and biventricular groups (p = 0.001). CONCLUSIONS Strain analysis measures are correlated with peak oxygen consumption in this cohort of children, adolescents, and young adults following Fontan palliation, suggesting that ventricular mechanics may influence the efficiency of the Fontan circulation.
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Affiliation(s)
- Suma Goudar
- Children's National Heart Institute, Department of Pediatrics, Washington, DC, USA
| | - Daniel Forsha
- Children's Mercy Hospital, Ward Family Heart Center, Department of Pediatrics, Kansas City, MO, USA
- University of Missouri-Kansas City, Department of Pediatrics, Kansas City, MO, USA
| | - David A White
- Children's Mercy Hospital, Ward Family Heart Center, Department of Pediatrics, Kansas City, MO, USA
- University of Missouri-Kansas City, Department of Pediatrics, Kansas City, MO, USA
| | - Ashley Sherman
- Children's Mercy Hospital, Department of Biostatistics, Kansas City, MO, USA
| | - Girish Shirali
- Children's Mercy Hospital, Ward Family Heart Center, Department of Pediatrics, Kansas City, MO, USA
- University of Missouri-Kansas City, Department of Pediatrics, Kansas City, MO, USA
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13
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Chen LJ, Wu LP, Zhao LS, Zhang ZF, Liu JL, Hong WJ, Zhong SW, Bao SF, Yang J, Zhang YQ. Comparison of cardiac function between single left ventricle and tricuspid atresia: assessment using echocardiography combined with computational fluid dynamics. Front Pediatr 2023; 11:1159342. [PMID: 37138576 PMCID: PMC10150005 DOI: 10.3389/fped.2023.1159342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Accepted: 03/24/2023] [Indexed: 05/05/2023] Open
Abstract
Patients with single left ventricle (SLV) and tricuspid atresia (TA) have impaired systolic and diastolic function. However, there are few comparative studies among patients with SLV, TA and children without heart disease. The current study includes 15 children in each group. The parameters measured by two-dimensional echocardiography, three-dimensional speckle tracking echocardiography (3DSTE), and vortexes calculated by computational fluid dynamics were compared among these three groups. Twist is best correlated with ejection fraction measured by 3DSTE. Twist, torsion, apical rotation, average radial strain, peak velocity of systolic wave in left lateral wall by tissue Doppler imaging (sL), and myocardial performance index are better in the TA group than those in the SLV group. sL by tissue Doppler imaging in the TA group are even higher than those in the Control group. In patients with SLV, blood flow spreads out in a fan-shaped manner and forms two small vortices. In the TA group, the main vortex is similar to the one in a normal LV chamber, but smaller. The vortex rings during diastolic phase are incomplete in the SLV and TA groups. In summary, patients with SLV or TA have impaired systolic and diastolic function. Patients with SLV had poorer cardiac function than those with TA due to less compensation and more disordered streamline. Twist may be good indicator for LV function.
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Affiliation(s)
- Li-Jun Chen
- Department of Pediatric Cardiology, Shanghai Children’s Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Lan-Ping Wu
- Department of Pediatric Cardiology, Shanghai Children’s Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Lei-Sheng Zhao
- Department of Pediatric Cardiology, Shanghai Children’s Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Zhi-Fang Zhang
- Department of Pediatric Cardiology, Shanghai Children’s Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jin-Long Liu
- Institute of Pediatric Translational Medicine, Shanghai Children’s Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Wen-Jing Hong
- Department of Pediatric Cardiology, Shanghai Children’s Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Shu-Wen Zhong
- Department of Pediatric Cardiology, Shanghai Children’s Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Sheng-Fang Bao
- Department of Pediatric Cardiology, Shanghai Children’s Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jing Yang
- Department of Ultrasound, Jiaxing University Affiliated Women and Children Hospital, Jiaxing, China
| | - Yu-Qi Zhang
- Department of Pediatric Cardiology, Shanghai Children’s Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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14
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Chubb H, Bulic A, Mah D, Moore JP, Janousek J, Fumanelli J, Asaki SY, Pflaumer A, Hill AC, Escudero C, Kwok SY, Mangat J, Ochoa Nunez LA, Balaji S, Rosenthal E, Regan W, Horndasch M, Asakai H, Tanel R, Czosek RJ, Young ML, Bradley DJ, Paul T, Fischbach P, Malloy-Walton L, McElhinney DB, Dubin AM. Impact and Modifiers of Ventricular Pacing in Patients With Single Ventricle Circulation. J Am Coll Cardiol 2022; 80:902-914. [PMID: 36007989 DOI: 10.1016/j.jacc.2022.05.053] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 05/04/2022] [Accepted: 05/23/2022] [Indexed: 10/15/2022]
Abstract
BACKGROUND Palliation of the single ventricle (SV) circulation is associated with a burden of lifelong complications. Previous studies have identified that the need for a permanent ventricular pacing system (PPMv) may be associated with additional adverse long-term outcomes. OBJECTIVES The goal of this study was to quantify the attributable risk of PPMv in patients with SV, and to identify modifiable risk factors. METHODS This international study was sponsored by the Pediatric and Congenital Electrophysiology Society. Centers contributed baseline and longitudinal data for functionally SV patients with PPMv. Enrollment was at implantation. Controls were matched 1:1 to PPMv subjects by ventricular morphology and sex, identified within center, and enrolled at matched age. Primary outcome was transplantation or death. RESULTS In total, 236 PPMv subjects and 213 matched controls were identified (22 centers, 9 countries). Median age at enrollment was 5.3 years (quartiles: 1.5-13.2 years), follow-up 6.9 years (3.4-11.6 years). Median percent ventricular pacing (Vp) was 90.8% (25th-75th percentile: 4.3%-100%) in the PPMv cohort. Across 213 matched pairs, multivariable HR for death/transplant associated with PPMv was 3.8 (95% CI 1.9-7.6; P < 0.001). Within the PPMv population, higher Vp (HR: 1.009 per %; P = 0.009), higher QRS z-score (HR: 1.19; P = 0.009) and nonapical lead position (HR: 2.17; P = 0.042) were all associated with death/transplantation. CONCLUSIONS PPMv in patients with SV is associated with increased risk of heart transplantation and death, despite controlling for increased associated morbidity of the PPMv cohort. Increased Vp, higher QRS z-score, and nonapical ventricular lead position are all associated with higher risk of adverse outcome and may be modifiable risk factors.
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Affiliation(s)
- Henry Chubb
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University, Stanford, California, USA; Division of Pediatric Cardiothoracic Surgery, Department of Cardiothoracic Surgery, Stanford University, Stanford, California, USA.
| | - Anica Bulic
- Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Douglas Mah
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Jeremy P Moore
- Division of Cardiology, Department of Pediatrics, UCLA Health System, Los Angeles, California, USA; Division of Cardiology, Department of Medicine, Ahmanson/UCLA Adult Congenital Heart Disease Center, Los Angeles, California, USA; UCLA Cardiac Arrhythmia Center, UCLA Health System, Los Angeles, California, USA
| | - Jan Janousek
- Children's Heart Centre, Second Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czech Republic
| | - Jennifer Fumanelli
- Children's Heart Centre, Second Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czech Republic; Pediatric Cardiology Unit, Department of Women's and Child's Health, University of Padova, Padova, Italy
| | - S Yukiko Asaki
- Primary Children's Hospital, University of Utah, Salt Lake City, Utah, USA
| | - Andreas Pflaumer
- The Royal Children's Hospital, MCRI and University of Melbourne, Melbourne, Victoria, Australia
| | - Allison C Hill
- Division of Cardiology, Children's Hospital Los Angeles, Los Angeles, California, USA; Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Carolina Escudero
- Department of Pediatrics, Division of Pediatric Cardiology, University of Alberta, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Sit Yee Kwok
- Cardiology Centre, Department of Paediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong SAR, China
| | - Jasveer Mangat
- Paediatric Cardiology, Great Ormond Street, London, United Kingdom
| | | | - Seshadri Balaji
- Department of Pediatrics, Division of Cardiology, Oregon Health & Science University, Portland, Oregon, USA
| | - Eric Rosenthal
- Paediatric Cardiology, Evelina London Children's Hospital, London, United Kingdom
| | - William Regan
- Paediatric Cardiology, Evelina London Children's Hospital, London, United Kingdom
| | - Michaela Horndasch
- Department of Congenital Heart Diseases and Pediatric Cardiology, German Heart Center Munich, Munich, Germany
| | - Hiroko Asakai
- Department of Paediatrics, University of Tokyo Hospital, Tokyo, Japan
| | - Ronn Tanel
- Division of Pediatric Cardiology, Department of Pediatrics, UCSF School of Medicine, San Francisco, California, USA
| | - Richard J Czosek
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Ohio, USA
| | - Ming-Lon Young
- Joe DiMaggio Children's Hospital, Hollywood, Florida, USA
| | - David J Bradley
- University of Michigan, CS Mott Children's Hospital, Ann Arbor, Michigan, USA
| | - Thomas Paul
- Department of Pediatric Cardiology, Georg-August-University Medical Center, Göttingen, Germany
| | | | | | - Doff B McElhinney
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University, Stanford, California, USA; Division of Pediatric Cardiothoracic Surgery, Department of Cardiothoracic Surgery, Stanford University, Stanford, California, USA
| | - Anne M Dubin
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University, Stanford, California, USA
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15
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Mondésert B, Moore JP, Khairy P. Cardiac Implantable Electronic Devices in the Fontan Patient. Can J Cardiol 2022; 38:1048-1058. [PMID: 35588949 DOI: 10.1016/j.cjca.2022.04.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Revised: 04/18/2022] [Accepted: 04/19/2022] [Indexed: 12/22/2022] Open
Abstract
As a result of remarkable progress in operative techniques and cardiology care during childhood, Fontan patients continue to age and require team-based multidisciplinary expertise to manage complications encountered in adulthood. They face particular challenges in terms of altered hemodynamic stressors, cardiac and hepatic failure, and arrhythmias. Arrhythmias in Fontan patients are highly prevalent and associated with underlying anatomy, surgical technique, and postoperative sequelae. Diagnostic tools, treatments, and device strategies for arrhythmias in Fontan patients should be adapted to the specific anatomy, type of surgical repair, and clinical status. Great strides in our understanding of arrhythmia mechanisms, options and techniques to obtain access to relevant cardiac structures, and application of both old and new technologies have contributed to improving cardiac implantable electronic device (CIED) therapies for this unique population. In this state-of-the-art review, we discuss the various arrhythmias encountered in Fontan patients, their diagnosis, and options for treatment and prevention, with a focus on CIEDs. Throughout, access challenges particular to the Fontan circulation are considered. Recently developed technologies, such as the sub-cutaneous implantable cardioverter defibrillator carry the potential to be transformative but require awareness of Fontan-specific issues. Moreover, new leadless pacing technology represents a promising strategy that may soon become applicable to Fontan patients with sinus node dysfunction. CIEDs are essential tools in managing Fontan patients but the complex clinical scenarios that arise in this patient population are among the most challenging for the congenital electrophysiologist.
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Affiliation(s)
- Blandine Mondésert
- Adult Congenital Heart Disease Center, Montreal Heart Institute, Medicine Department, Université de Montréal, Montreal, Canada.
| | - Jeremy P Moore
- Division of Cardiology, Department of Medicine, Ahmanson/UCLA Adult Congenital Heart Disease Center, Los Angeles, CA; UCLA Cardiac Arrhythmia Center, UCLA Health System, Los Angeles, CA; Division of Cardiology, Department of Pediatrics, UCLA Health System, Los Angeles, CA
| | - Paul Khairy
- Adult Congenital Heart Disease Center, Montreal Heart Institute, Medicine Department, Université de Montréal, Montreal, Canada
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16
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Classic pattern dyssynchrony is associated with outcome in patients with Fontan circulation. J Am Soc Echocardiogr 2022; 35:513-522. [DOI: 10.1016/j.echo.2022.01.012] [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: 07/06/2021] [Revised: 01/08/2022] [Accepted: 01/21/2022] [Indexed: 11/24/2022]
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17
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Ma J, Chen J, Tan T, Liu X, Liufu R, Qiu H, Zhang S, Wen S, Zhuang J, Yuan H. Complications and management of functional single ventricle patients with Fontan circulation: From surgeon's point of view. Front Cardiovasc Med 2022; 9:917059. [PMID: 35966528 PMCID: PMC9374127 DOI: 10.3389/fcvm.2022.917059] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Accepted: 07/07/2022] [Indexed: 02/05/2023] Open
Abstract
Fontan surgery by step-wise completing the isolation of originally mixed pulmonary and systemic circulation provides an operative approach for functional single-ventricle patients not amenable to biventricular repair and allows their survival into adulthood. In the absence of a subpulmonic pumping chamber, however, the unphysiological Fontan circulation consequently results in diminished cardiac output and elevated central venous pressure, in which multiple short-term or long-term complications may develop. Current understanding of the Fontan-associated complications, particularly toward etiology and pathophysiology, is extremely incomplete. What's more, ongoing efforts have been made to manage these complications to weaken the Fontan-associated adverse impact and improve the life quality, but strategies are ill-defined. Herein, this review summarizes recent studies on cardiac and non-cardiac complications associated with Fontan circulation, focusing on significance or severity, etiology, pathophysiology, prevalence, risk factors, surveillance, or diagnosis. From the perspective of surgeons, we also discuss the management of the Fontan circulation based on current evidence, including post-operative administration of antithrombotic agents, ablation, pacemaker implantation, mechanical circulatory support, and final orthotopic heart transplantation, etc., to standardize diagnosis and treatment in the future.
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Affiliation(s)
- Jianrui Ma
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- Shantou University Medical College, Shantou, China
| | - Jimei Chen
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Tong Tan
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- Shantou University Medical College, Shantou, China
| | - Xiaobing Liu
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Rong Liufu
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Hailong Qiu
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Shuai Zhang
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Shusheng Wen
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Jian Zhuang
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Haiyun Yuan
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- Shantou University Medical College, Shantou, China
- *Correspondence: Haiyun Yuan,
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18
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Kamsheh AM, O'Connor MJ, Rossano JW. Management of circulatory failure after Fontan surgery. Front Pediatr 2022; 10:1020984. [PMID: 36425396 PMCID: PMC9679629 DOI: 10.3389/fped.2022.1020984] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 10/18/2022] [Indexed: 11/11/2022] Open
Abstract
With improvement in survival after Fontan surgery resulting in an increasing number of older survivors, there are more patients with a Fontan circulation experiencing circulatory failure each year. Fontan circulatory failure may have a number of underlying etiologies. Once Fontan failure manifests, prognosis is poor, with patient freedom from death or transplant at 10 years of only about 40%. Medical treatments used include traditional heart failure medications such as renin-angiotensin-aldosterone system blockers and beta-blockers, diuretics for symptomatic management, antiarrhythmics for rhythm control, and phosphodiesterase-5 inhibitors to decrease PVR and improve preload. These oral medical therapies are typically not very effective and have little data demonstrating benefit; if there are no surgical or catheter-based interventions to improve the Fontan circulation, patients with severe symptoms often require inotropic medications or mechanical circulatory support. Mechanical circulatory support benefits patients with ventricular dysfunction but may not be as useful in patients with other forms of Fontan failure. Transplant remains the definitive treatment for circulatory failure after Fontan, but patients with a Fontan circulation face many challenges both before and after transplant. There remains significant room and urgent need for improvement in the management and outcomes of patients with circulatory failure after Fontan surgery.
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Affiliation(s)
- Alicia M Kamsheh
- Division of Cardiology, Children's Hospital of Philadelphia, United States
| | - Matthew J O'Connor
- Division of Cardiology, Children's Hospital of Philadelphia, United States
| | - Joseph W Rossano
- Division of Cardiology, Children's Hospital of Philadelphia, United States
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Márquez-González H, Hernández-Vásquez JG, Del Valle-Lom M, Yáñez-Gutiérrez L, Klünder-Klünder M, Almeida-Gutiérrez E, Koretzky SG. Failures of the Fontan System in Univentricular Hearts and Mortality Risk in Heart Transplantation: A Systematic Review and Meta-Analysis. Life (Basel) 2021; 11:1363. [PMID: 34947894 PMCID: PMC8709145 DOI: 10.3390/life11121363] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Revised: 11/12/2021] [Accepted: 11/13/2021] [Indexed: 02/07/2023] Open
Abstract
The Fontan procedure (FP) is the standard surgical treatment for Univentricular heart diseases. Over time, the Fontan system fails, leading to pathologies such as protein-losing enteropathy (PLE), plastic bronchitis (PB), and heart failure (HF). FP should be considered as a transitional step to the final treatment: heart transplantation (HT). This systematic review and meta-analysis aims to establish the risk of death following HT according to the presence of FP complications. There was a total of 691 transplanted patients in the 18 articles, immediate survival 88% (n = 448), survival from 1 to 5 years of 78% (n = 427) and survival from 5.1 to 10 years of 69% (n = 208), >10 years 61% (n = 109). The relative risk (RR) was 1.12 for PLE (95% confidence interval [CI] = 0.89-1.40, p = 0.34), 1.03 for HF (0.7-1.51, p = 0.88), 0.70 for Arrhythmias (0.39-1.24, p = 0.22), 0.46 for PB (0.08-2.72, p = 0.39), and 5.81 for CKD (1.70-19.88, p = 0.005). In patients with two or more failures, the RR was 1.94 (0.99-3.81, p = 0.05). After FP, the risk of death after HT is associated with CKD and with the presence of two or more failures.
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Affiliation(s)
- Horacio Márquez-González
- Department of Clinical Research, Federico Gómez Children’s Hospital, Mexico City 06720, Mexico; (H.M.-G.); (J.G.H.-V.); (M.D.V.-L.); (M.K.-K.)
- Centro Médico Nacional Siglo XXI, IMSS, Department Congenital Heart Diseases, Mexico City 06720, Mexico; (L.Y.-G.); (E.A.-G.)
| | - Jose Gustavo Hernández-Vásquez
- Department of Clinical Research, Federico Gómez Children’s Hospital, Mexico City 06720, Mexico; (H.M.-G.); (J.G.H.-V.); (M.D.V.-L.); (M.K.-K.)
| | - Montserrat Del Valle-Lom
- Department of Clinical Research, Federico Gómez Children’s Hospital, Mexico City 06720, Mexico; (H.M.-G.); (J.G.H.-V.); (M.D.V.-L.); (M.K.-K.)
| | - Lucelli Yáñez-Gutiérrez
- Centro Médico Nacional Siglo XXI, IMSS, Department Congenital Heart Diseases, Mexico City 06720, Mexico; (L.Y.-G.); (E.A.-G.)
| | - Miguel Klünder-Klünder
- Department of Clinical Research, Federico Gómez Children’s Hospital, Mexico City 06720, Mexico; (H.M.-G.); (J.G.H.-V.); (M.D.V.-L.); (M.K.-K.)
| | - Eduardo Almeida-Gutiérrez
- Centro Médico Nacional Siglo XXI, IMSS, Department Congenital Heart Diseases, Mexico City 06720, Mexico; (L.Y.-G.); (E.A.-G.)
| | - Solange Gabriela Koretzky
- Department of Clinical Research, Nacional de Cardiología “Ignacio Chávez”, Mexico City 14080, Mexico
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20
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Vaikunth SS, Lui GK. Heart failure with reduced and preserved ejection fraction in adult congenital heart disease. Heart Fail Rev 2021; 25:569-581. [PMID: 31873841 DOI: 10.1007/s10741-019-09904-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Heart failure with reduced ejection fraction (HFrEF) is common in patients with adult congenital heart disease. Many of the most common congenital defects have a high prevalence of HFrEF, including left-sided obstructive lesions (aortic stenosis, coarctation of the aorta, Shone complex), tetralogy of Fallot, Ebstein anomaly, lesions in which there is a systemic right ventricle, and lesions palliated with a Fontan circulation. However, heart failure with preserved ejection fraction (HFpEF) is also prevalent in all these lesions. Comprehensive evaluation includes physical exam, biomarkers, echocardiography and advanced imaging, exercise stress testing, and, in some cases, invasive hemodynamics. Guideline-directed medical therapy for HFrEF can be applied to left-sided lesions and may be considered on an individual basis for systemic right ventricle and single-ventricle patients. Medical therapy is limited for HFpEF. However, in both HFrEF and HFpEF, ventricular dyssynchrony and arrhythmias play an important role, and medications for rhythm control, ablation, and cardiac resynchronization therapy should be considered. Finally, aggressive management of cardiovascular risk factors and comorbidities, including, but not limited to, hypertension, obesity, diabetes, dyslipidemia, and obstructive sleep apnea, cannot be overemphasized.
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Affiliation(s)
- Sumeet S Vaikunth
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto, CA, USA.
| | - George K Lui
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto, CA, USA.,Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, CA, USA
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21
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Tsuda T, Kernizan D, Del Grippo E, Thacker D, Kharouf R, Srivastava S. Echocardiographic assessment of ventricular function: Conventional and advanced technologies and their clinical applications. PROGRESS IN PEDIATRIC CARDIOLOGY 2020. [DOI: 10.1016/j.ppedcard.2020.101269] [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: 11/27/2022]
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22
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Hayama Y, Shimizu S, Kawada T, Negishi J, Sakaguchi H, Miyazaki A, Ohuchi H, Yamada O, Kurosaki K, Sugimachi M. Impact of delayed ventricular wall area ratio on pathophysiology of mechanical dyssynchrony: implication from single-ventricle physiology and 0D modeling. J Physiol Sci 2020; 70:38. [PMID: 32762655 PMCID: PMC10716988 DOI: 10.1186/s12576-020-00765-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 07/18/2020] [Indexed: 11/10/2022]
Abstract
Electrical disparity can induce inefficient cardiac performance, representing an uncoordinated wall motion at an earlier activated ventricular wall: an early shortening followed by a systolic rebound stretch. Although regional contractility and distensibility modulate this pathological motion, the effect of a morphological factor has not been emphasized. Our strain analysis in 62 patients with single ventricle revealed that those with an activation delay in 60-70% of ventricular wall area suffered from cardiac dysfunction and mechanical discoordination along with prolonged QRS duration. A computational simulation with a two-compartment ventricular model also suggested that the ventricle with an activation delay in 70% of the total volume was most vulnerable to a large activation delay, accompanied by an uncoordinated motion at an earlier activated wall. Taken together, the ratio of the delayed ventricular wall has a significant impact on the pathophysiology due to an activation delay, potentially highlighting an indicator of cardiac dysfunction.
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Affiliation(s)
- Yohsuke Hayama
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center, 6-1, Kishibe-shimmachi, Suita, Osaka, 564-8565, Japan
- Department of Cardiovascular Science, Faculty of Medicine, Osaka University Graduate School of Medicine, 2-2, Yamada-oka, Suita, Osaka, 565-0871, Japan
| | - Shuji Shimizu
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center, 6-1, Kishibe-shimmachi, Suita, Osaka, 564-8565, Japan
| | - Toru Kawada
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center, 6-1, Kishibe-shimmachi, Suita, Osaka, 564-8565, Japan
| | - Jun Negishi
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, 6-1, Kishibe-shimmachi, Suita, Osaka, 564-8565, Japan
| | - Heima Sakaguchi
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, 6-1, Kishibe-shimmachi, Suita, Osaka, 564-8565, Japan
| | - Aya Miyazaki
- Department of Cardiology, Shizuoka Children's Hospital, 860, Urushiyama, Aoi-ku, Shizuoka, Shizuoka, 420-8660, Japan
| | - Hideo Ohuchi
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, 6-1, Kishibe-shimmachi, Suita, Osaka, 564-8565, Japan
| | - Osamu Yamada
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, 6-1, Kishibe-shimmachi, Suita, Osaka, 564-8565, Japan
| | - Kenichi Kurosaki
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, 6-1, Kishibe-shimmachi, Suita, Osaka, 564-8565, Japan
| | - Masaru Sugimachi
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center, 6-1, Kishibe-shimmachi, Suita, Osaka, 564-8565, Japan.
- Department of Cardiovascular Science, Faculty of Medicine, Osaka University Graduate School of Medicine, 2-2, Yamada-oka, Suita, Osaka, 565-0871, Japan.
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23
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Abstract
Arrhythmia management in adult congenital heart disease (ACHD) encompasses a wide range of problems from bradyarrhythmia to tachyarrhythmia, sudden death, and heart failure-related electrical dyssynchrony. Major advances in the understanding of the pathophysiology and treatments of these problems over the past decade have resulted in improved therapeutic strategies and outcomes. This article attempts to define these problems and review contemporary management for the patient with ACHD presenting with cardiac arrhythmia.
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Affiliation(s)
- Jeremy P Moore
- Ahmanson-UCLA/Adult Congenital Heart Disease Center, Los Angeles, CA, USA; Department of Pediatrics, UCLA Medical Center, Los Angeles, CA, USA.
| | - Paul Khairy
- Electrophysiology Service and Adult Congenital Heart Disease Center; Department of Medicine, Montreal Heart Institute, Université de Montréal, 5000 Bélanger Street, Montreal, Quebec H1T 1C8, Canada
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24
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Budts W, Ravekes WJ, Danford DA, Kutty S. Diastolic Heart Failure in Patients With the Fontan Circulation. JAMA Cardiol 2020; 5:590-597. [DOI: 10.1001/jamacardio.2019.5459] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Werner Budts
- University Hospitals Leuven, Congenital and Structural Cardiology, Catholic University of Leuven, Leuven, Belgium
| | - William J. Ravekes
- The Helen B. Taussig Heart Center, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - David A. Danford
- Pediatric Cardiology, University of Nebraska College of Medicine, Omaha
| | - Shelby Kutty
- The Helen B. Taussig Heart Center, Johns Hopkins University School of Medicine, Baltimore, Maryland
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25
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Hayama Y, Miyazaki A, Ohuchi H, Miike H, Negishi J, Sakaguchi H, Kurosaki K, Shimizu S, Kawada T, Sugimachi M. Septal Flash-like Motion of the Earlier Activated Ventricular Wall Represents the Pathophysiology of Mechanical Dyssynchrony in Single-Ventricle Anatomy. J Am Soc Echocardiogr 2020; 33:612-621.e2. [PMID: 32089381 DOI: 10.1016/j.echo.2019.11.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 11/07/2019] [Accepted: 11/30/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND In biventricular physiology, abnormal septal motion is a hallmark of mechanical dyssynchrony in the left bundle branch block. However, in single-ventricle (SV) physiology, morphologic variations in systemic ventricles pose a challenge in evaluating the negative impact of mechanical dyssynchrony. The present study aimed to characterize the pathologic dyssynchronous contraction patterns in patients with SV. METHODS In this retrospective study, 70 consecutive postoperative patients with SV anatomy with prolonged QRS duration (25 female patients; median age, 14 years) were enrolled. We divided each SV into two regions and analyzed independent strains using two-dimensional speckle-tracking echocardiography. From an earlier activated ventricular wall, we calculated the strain ratio (Rstrains) of two values (%) during the QRS period and the ejection period: (100 + Strainejection)/(100 + StrainQRS). We reviewed the clinical profiles, B-type natriuretic peptide plasma levels, exercise capacity, and morbidity. Six patients who underwent cardiac resynchronization therapy (CRT) were analyzed regarding changes in strain patterns and ventricular volume. RESULTS Higher Rstrains, indicating a preceding contraction and subsequent dyskinetic dilation of the earlier activated ventricular wall, was associated with increased B-type natriuretic peptide, reduced exercise capacity, and poor outcome. However, delayed contraction of the later activated ventricular wall was not associated with the effects. Decreases in Rstrains and ventricular volume reductions were observed in all patients after CRT. CONCLUSIONS A specific strain pattern in an earlier activated ventricular wall indicates mechanical dyssynchrony in patients with SV. This pattern is very similar to the septal flash in adult patients with left bundle branch block. This strategy might be a promising approach for selecting appropriate candidates for CRT in patients with SV.
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Affiliation(s)
- Yohsuke Hayama
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center, Osaka, Japan; Department of Cardiovascular Science, Faculty of Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Aya Miyazaki
- Department of Pediatric Cardiology, Congenital Heart Disease Center, Tenri Hospital, Nara, Japan
| | - Hideo Ohuchi
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Hikari Miike
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Jun Negishi
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Heima Sakaguchi
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Kenichi Kurosaki
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Shuji Shimizu
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Toru Kawada
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Masaru Sugimachi
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center, Osaka, Japan; Department of Cardiovascular Science, Faculty of Medicine, Osaka University Graduate School of Medicine, Osaka, Japan.
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26
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Huntgeburth M, Germund I, Geerdink LM, Sreeram N, Udink Ten Cate FEA. Emerging clinical applications of strain imaging and three-dimensional echocardiography for the assessment of ventricular function in adult congenital heart disease. Cardiovasc Diagn Ther 2019; 9:S326-S345. [PMID: 31737540 DOI: 10.21037/cdt.2018.11.08] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Management of congenital heart disease (CHD) in adults (ACHD) remains an ongoing challenge due to the presence of residual hemodynamic lesions and development of ventricular dysfunction in a large number of patients. Echocardiographic imaging plays a central role in clinical decision-making and selection of patients who will benefit most from catheter interventions or cardiac surgery.. Recent advances in both strain imaging and three-dimensional (3D)-echocardiography have significantly contributed to a greater understanding of the complex pathophysiological mechanisms involved in CHD. The aim of this paper is to provide an overview of emerging clinical applications of speckle-tracking imaging and 3D-echocardiography in ACHD with focus on functional assessment, ventriculo-ventricular interdependency, mechanisms of electromechanical delay, and twist abnormalities in adults with tetralogy of Fallot (TOF), a systemic RV after atrial switch repair or in double discordance ventricles, and in those with a Fontan circulation.
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Affiliation(s)
- Michael Huntgeburth
- Center for Grown-ups with congenital heart disease (GUCH), Clinic III for Internal Medicine, Department of Cardiology, Heart Center, University Hospital of Cologne, Germany
| | - Ingo Germund
- Department of Pediatric Cardiology, Heart Center, University Hospital of Cologne, Germany
| | - Lianne M Geerdink
- Academic Center for Congenital Heart Disease (ACAHA), Department of Pediatric Cardiology, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen.,Division of Pediatric Cardiology, Department of Pediatrics, Sophia Children's Hospital, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Narayanswami Sreeram
- Department of Pediatric Cardiology, Heart Center, University Hospital of Cologne, Germany
| | - Floris E A Udink Ten Cate
- Academic Center for Congenital Heart Disease (ACAHA), Department of Pediatric Cardiology, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen.,Division of Pediatric Cardiology, Department of Pediatrics, Sophia Children's Hospital, Erasmus Medical Center, Rotterdam, The Netherlands
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27
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Impact of Right Ventricular Geometry and Left Ventricular Hypertrophy on Right Ventricular Mechanics and Clinical Outcomes in Hypoplastic Left Heart Syndrome. J Am Soc Echocardiogr 2019; 32:1350-1358. [PMID: 31351794 DOI: 10.1016/j.echo.2019.06.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 06/05/2019] [Accepted: 06/06/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND Right ventricular (RV) function is a major determinant of survival in hypoplastic left heart syndrome (HLHS). However, the relation of RV geometry to myocardial mechanics and their relation to transplant-free survival are incompletely characterized. METHODS We retrospectively studied 48 HLHS patients from the Hospital for Sick Children, Toronto, (median age, 2.2; interquartile range, 3.62 years) at different surgical stages. Patients were grouped by the presence (n = 23) or absence (n = 25) of RV "apical bulging" defined as a sigmoid-shaped septum with the RV leftward apical segment contiguous with the left ventricular (LV) lateral wall. Regional and global RV strain were measured using speckle-tracking echocardiography, and regional strains were analyzed for patterns and peak values. These were compared between HLHS anatomical subtypes and between patients with versus without apical bulging. We further investigated the association between RV geometry and dysfunction with the outcomes of heart failure, death, or transplant. RESULTS RV global (-7.3% ± 2.8% vs -11.2% ± 4.4%; P = .001), basal septal (-3.8% ± 3.2% vs -11.4% ± 5.8%; P = .0001) and apicolateral (-5.1% ± 3.5% vs -8.0% ± 5.8%, P = .001) longitudinal strain were lower in patients with versus without apical bulging, respectively. Apical bulging was equally prevalent in all HLHS anatomical variants. Twenty of 22 (91%) patients with apical bulging displayed hypertrophy of the LV apical and lateral segments. Death or transplantation were approximately equal in both groups but related to reduced RV global strain in patients with (seven of seven) and not in those without apical bulging (two of eight; P = .022). CONCLUSIONS These results suggest that the finding of apical bulging is related to the presence of a hypertrophied hypoplastic LV, with a negative impact on regional and global RV function. Therefore, analysis of RV and LV geometry and mechanics may aid in the assessment and prognostication of this high-risk population.
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28
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Right Ventricular Mechanical Dyssynchrony in Hypoplastic Left Heart Syndrome: Correlation with Systolic Function and QRS Duration. Pediatr Cardiol 2019; 40:934-942. [PMID: 30895330 DOI: 10.1007/s00246-019-02091-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 03/13/2019] [Indexed: 10/27/2022]
Abstract
The single right ventricle (RV) in hypoplastic left heart syndrome (HLHS) often develops systolic dysfunction with time and this affects prognosis. Mechanical dyssynchrony has been reported in HLHS but has not consistently correlated with systolic function or electrical dyssynchrony. The aims of this study were to assess the relationship between RV mechanical dyssynchrony, RV systolic function, and QRS duration on surface electrocardiography. We hypothesized that surface QRS duration would not be an adequate indicator of mechanical dyssynchrony compared with dyssynchrony parameters. Retrospective analysis of echocardiograms of patients with HLHS divided into preserved vs reduced RV function. We measured two RV function parameters: (1) fractional area change (FAC) and (2) global longitudinal strain (RVGLS). We measured two dyssynchrony parameters: (1) the standard deviation of the time to peak strain for 9 segments (tPS-9) and (2) time difference between the earliest and latest time to peak strain (RV dyssynchrony index or RVDI) both corrected for R-R interval. We also measured the QRS duration from surface EKG. Mechanical dyssynchrony parameters were compared to both RV systolic function and to QRS duration. 41 patients with HLHS were identified: 21 had preserved function and 20 had reduced function defined by a FAC < 35%. The reduced function group had a significantly lower mean FAC and RVGLS. RVDI was higher in the dysfunction group and had a modest correlation with FAC (r = 0.48) and RVGLS (r = 0.57). tPS-9 was longer in the dysfunction group and had a modest correlation with FAC (r = 0.45) and RVGLS (r = 0.57). QRS duration was longer in the dysfunction group and had a modest correlation with FAC (r = 0.56) and RVGLS (r = 0.56). The weakest correlations were between QRS duration and tPS-9 (r = 0.32) and QRS duration and RVDI (r = 0.10). RV dysfunction measured by FAC was associated with mechanical dyssynchrony measured by increased RVDI and tPS-9. QRS duration was longer in the group with dysfunction but did not correlate with directly measured mechanical dyssynchrony. This may have potential implications for cardiac resynchronization therapy in univentricular patients as assessed by mechanical dyssynchrony parameters rather than QRS duration alone.
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29
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Udink Ten Cate FEA, Germund I, Goossens SS, Bennink G, Sreeram N. Successful biventricular cardiac resynchronization therapy in a failing Fontan patient: Implications of ventriculo-ventricular interdependency in single ventricle physiology. Echocardiography 2019; 36:1211-1216. [PMID: 31148229 DOI: 10.1111/echo.14376] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Revised: 05/01/2019] [Accepted: 05/02/2019] [Indexed: 11/29/2022] Open
Abstract
We describe a Fontan patient with severe heart failure who was successfully treated with biventricular cardiac resynchronization therapy (CRT). Our case shows that strain imaging might play a crucial role in guiding placement of pacing leads and in characterizing the electromechanical substrate associated with a favorable CRT response. Furthermore, we demonstrate for the first time that ventriculo-ventricular interdependency seems an important mechanical concept, which can be utilized to augment cardiac performance in failing Fontan patients with a functional hypoplastic ventricle.
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Affiliation(s)
- Floris E A Udink Ten Cate
- Department of Pediatric Cardiology, Heart Center Cologne, University Hospital of Cologne, Cologne, Germany.,Department of Pediatric Cardiology, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ingo Germund
- Department of Pediatric Cardiology, Heart Center Cologne, University Hospital of Cologne, Cologne, Germany
| | - Stijn S Goossens
- Department of Pediatric Cardiology, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Gerardus Bennink
- Department of Cardiac Surgery, Heart Center Cologne, University Hospital of Cologne, Cologne, Germany
| | - Narayanswami Sreeram
- Department of Pediatric Cardiology, Heart Center Cologne, University Hospital of Cologne, Cologne, Germany
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30
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Cardiac resynchronization therapy in congenital heart disease: Results from the German National Register for Congenital Heart Defects. Int J Cardiol 2018; 273:108-111. [DOI: 10.1016/j.ijcard.2018.10.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 10/03/2018] [Indexed: 12/28/2022]
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31
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Rösner A, Khalapyan T, Pedrosa J, Dalen H, McElhinney DB, Friedberg MK, Lui GK. Ventricular mechanics in adolescent and adult patients with a Fontan circulation: Relation to geometry and wall stress. Echocardiography 2018; 35:2035-2046. [DOI: 10.1111/echo.14169] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Revised: 09/21/2018] [Accepted: 09/24/2018] [Indexed: 01/30/2023] Open
Affiliation(s)
- Assami Rösner
- Department of Cardiology; Division of Cardiothoracic and Respiratory Medicine; University Hospital of North Norway; Tromsø Norway
| | - Tigran Khalapyan
- Department of Cardiothoracic Surgery; Stanford University School of Medicine; Stanford California
| | - João Pedrosa
- Department of Cardiovascular Sciences; K.U. Leuven; Leuven Belgium
| | - Håvard Dalen
- Department of Medicine; Levanger Hospital; Nord-Trøndelag Hospital Trust; Levanger Norway
- Department of Cardiology; St. Olav's University Hospital; Trondheim Norway
- Department of Circulation and Medical Imaging; Norwegian University of Science and Technology; Trondheim Norway
| | - Doff B. McElhinney
- Division of Pediatric Cardiology; Department of Pediatrics; Stanford University School of Medicine; Stanford California
| | - Mark K. Friedberg
- Division of Pediatric Cardiology; Hospital for Sick Children; Toronto Ontario Canada
| | - George K. Lui
- Division of Pediatric Cardiology; Department of Pediatrics; Stanford University School of Medicine; Stanford California
- Division of Cardiovascular Medicine; Department of Medicine; Stanford University School of Medicine; Stanford California
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