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Joosen RS, Voskuil M, Krings GJ, Handoko ML, Dickinson MG, van de Veerdonk MC, Breur JMPJ. The impact of unilateral pulmonary artery stenosis on right ventricular to pulmonary arterial coupling in patients with transposition of the great arteries. Catheter Cardiovasc Interv 2024; 103:943-948. [PMID: 38577955 DOI: 10.1002/ccd.31036] [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: 01/18/2024] [Revised: 03/21/2024] [Accepted: 03/26/2024] [Indexed: 04/06/2024]
Abstract
BACKGROUND Unilateral pulmonary artery (PA) stenosis is common in the transposition of the great arteries (TGA) after arterial switch operation (ASO) but the effects on the right ventricle (RV) remain unclear. AIMS To assess the effects of unilateral PA stenosis on RV afterload and function in pediatric patients with TGA-ASO. METHODS In this retrospective study, eight TGA patients with unilateral PA stenosis underwent heart catheterization and cardiac magnetic resonance (CMR) imaging. RV pressures, RV afterload (arterial elastance [Ea]), PA compliance, RV contractility (end-systolic elastance [Ees]), RV-to-PA (RV-PA) coupling (Ees/Ea), and RV diastolic stiffness (end-diastolic elastance [Eed]) were analyzed and compared to normal values from the literature. RESULTS In all TGA patients (mean age 12 ± 3 years), RV afterload (Ea) and RV pressures were increased whereas PA compliance was reduced. RV contractility (Ees) was decreased resulting in RV-PA uncoupling. RV diastolic stiffness (Eed) was increased. CMR-derived RV volumes, mass, and ejection fraction were preserved. CONCLUSION Unilateral PA stenosis results in an increased RV afterload in TGA patients after ASO. RV remodeling and function remain within normal limits when analyzed by CMR but RV pressure-volume loop analysis shows impaired RV diastolic stiffness and RV contractility leading to RV-PA uncoupling.
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Affiliation(s)
- Renée S Joosen
- Department of Pediatric Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Michiel Voskuil
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Gregor J Krings
- Department of Pediatric Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - M Louis Handoko
- Department of Cardiology, Amsterdam University Medical Centers, Amsterdam Cardiovascular Sciences, University of Amsterdam, Amsterdam, The Netherlands
| | - Michael G Dickinson
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marielle C van de Veerdonk
- Department of Cardiology, Amsterdam University Medical Centers, Amsterdam Cardiovascular Sciences, University of Amsterdam, Amsterdam, The Netherlands
| | - Johannes M P J Breur
- Department of Pediatric Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
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2
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Joosen RS, Frissen JPB, van den Hoogen A, Krings GJ, Voskuil M, Slieker MG, Breur JMPJ. The effects of percutaneous branch pulmonary artery interventions on exercise capacity, lung perfusion, and right ventricular function in biventricular CHD: a systematic review. Cardiol Young 2024; 34:473-482. [PMID: 38258453 DOI: 10.1017/s1047951124000015] [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] [Indexed: 01/24/2024]
Abstract
BACKGROUND Branch pulmonary artery stenosis is common after surgical repair in patients with biventricular CHD and often requires reinterventions. However, (long-term) effects of percutaneous branch pulmonary artery interventions on exercise capacity, right ventricular function, and lung perfusion remain unclear. This review describes the (long-term) effects of percutaneous branch pulmonary artery interventions on exercise capacity, right ventricular function, and lung perfusion following PRISMA guidelines. METHODS We performed a systematic search in PubMed, Embase, and Cochrane including studies about right ventricular function, exercise capacity, and lung perfusion after percutaneous branch pulmonary artery interventions. Study selection, data extraction, and quality assessment were performed by two researchers independently. RESULTS In total, 7 eligible studies with low (n = 2) and moderate (n = 5) risk of bias with in total 330 patients reported on right ventricular function (n = 1), exercise capacity (n = 2), and lung perfusion (n = 7). Exercise capacity and lung perfusion seem to improve after a percutaneous intervention for branch pulmonary artery stenosis. No conclusions about right ventricular function or remodelling, differences between balloon and stent angioplasty or specific CHD populations could be made. CONCLUSION Although pulmonary artery interventions are frequently performed in biventricular CHD, data on relevant outcome parameters such as exercise capacity, lung perfusion, and right ventricular function are largely lacking. An increase in exercise capacity and improvement of lung perfusion to the affected lung has been described in case of mild to more severe pulmonary artery stenosis during relatively short follow-up. However, there is need for future studies to evaluate the effect of pulmonary artery interventions in various CHD populations.
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Affiliation(s)
- Renée S Joosen
- Department of Pediatric Cardiology, University Medical Center Utrecht, Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | - Jules P B Frissen
- Department of Pediatric Cardiology, University Medical Center Utrecht, Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | - Agnes van den Hoogen
- Department of Neonatology, University Medical Center Utrecht, Wilhelmina Children's Hospital, Utrecht, The Netherlands
- Utrecht University, Utrecht, The Netherlands
| | - Gregor J Krings
- Department of Pediatric Cardiology, University Medical Center Utrecht, Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | - Michiel Voskuil
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Martijn G Slieker
- Department of Pediatric Cardiology, University Medical Center Utrecht, Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | - Johannes M P J Breur
- Department of Pediatric Cardiology, University Medical Center Utrecht, Wilhelmina Children's Hospital, Utrecht, The Netherlands
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3
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Barak-Corren Y, Herz C, Lasso A, Dori Y, Tang J, Smith CL, Callahan R, Rome JJ, Gillespie MJ, Jolley MA, O’Byrne ML. Calculating Relative Lung Perfusion Using Fluoroscopic Sequences and Image Analysis: The Fluoroscopic Flow Calculator. Circ Cardiovasc Interv 2024; 17:e013204. [PMID: 38152881 PMCID: PMC10872906 DOI: 10.1161/circinterventions.123.013204] [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: 05/02/2023] [Accepted: 10/03/2023] [Indexed: 12/29/2023]
Abstract
BACKGROUND Maldistribution of pulmonary blood flow in patients with congenital heart disease impacts exertional performance and pulmonary artery growth. Currently, measurement of relative pulmonary perfusion can only be performed outside the catheterization laboratory. We sought to develop a tool for measuring relative lung perfusion using readily available fluoroscopy sequences. METHODS A retrospective cohort study was conducted on patients with conotruncal anomalies who underwent lung perfusion scans and subsequent cardiac catheterizations between 2011 and 2022. Inclusion criteria were nonselective angiogram of pulmonary vasculature, oblique angulation ≤20°, and an adequate view of both lung fields. A method was developed and implemented in 3D Slicer's SlicerHeart extension to calculate the amount of contrast that entered each lung field from the start of contrast injection and until the onset of levophase. The predicted perfusion distribution was compared with the measured distribution of pulmonary blood flow and evaluated for correlation, accuracy, and bias. RESULTS In total, 32% (79/249) of screened studies met the inclusion criteria. A strong correlation between the predicted flow split and the measured flow split was found (R2=0.83; P<0.001). The median absolute error was 6%, and 72% of predictions were within 10% of the true value. Bias was not systematically worse at either extreme of the flow distribution. The prediction was found to be more accurate for either smaller and younger patients (age 0-2 years), for right ventricle injections, or when less cranial angulations were used (≤20°). In these cases (n=40), the prediction achieved R2=0.87, median absolute error of 5.5%, and 78% of predictions were within 10% of the true flow. CONCLUSIONS The current study demonstrates the feasibility of a novel method for measuring relative lung perfusion using conventional angiograms. Real-time measurement of lung perfusion at the catheterization laboratory has the potential to reduce unnecessary testing, associated costs, and radiation exposure. Further optimization and validation is warranted.
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Affiliation(s)
- Yuval Barak-Corren
- Division of Cardiology, The Children’s Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Christian Herz
- Division of Pediatric Cardiac Anesthesia, The Children’s Hospital of Philadelphia and Department of Anesthesia and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Andras Lasso
- Laboratory for Percutaneous Surgery, Queen’s University, Kingston, ON
| | | | - Jessica Tang
- Division of Cardiology, The Children’s Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Christopher L Smith
- Division of Cardiology, The Children’s Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Ryan Callahan
- Division of Cardiology, The Children’s Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Jonathan J Rome
- Division of Cardiology, The Children’s Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Matthew J Gillespie
- Division of Cardiology, The Children’s Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Matthew A Jolley
- Division of Cardiology, The Children’s Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
- Division of Pediatric Cardiac Anesthesia, The Children’s Hospital of Philadelphia and Department of Anesthesia and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Michael L O’Byrne
- Division of Cardiology, The Children’s Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
- Clinical Futures, The Children’s Hospital of Philadelphia, Pennsylvania, Philadelphia, PA
- Leonard Davis Institute and Center for Cardiovascular Outcomes, Quality, and Evaluative Research, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA
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4
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Panaioli E, Khraiche D, Derridj N, Bonnet D, Raimondi F, Legendre A. Rightward imbalanced pulmonary perfusion predicts better exercise stroke volume in children after Fallot repair. Arch Cardiovasc Dis 2023; 116:373-381. [PMID: 37422422 DOI: 10.1016/j.acvd.2023.06.002] [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: 03/26/2023] [Revised: 06/07/2023] [Accepted: 06/08/2023] [Indexed: 07/10/2023]
Abstract
BACKGROUND Residual lesions following Fallot repair are primarily pulmonary regurgitation and right ventricular outflow tract obstruction. These lesions may impact exercise tolerance, particularly because of a poor increase in left ventricular stroke volume. Pulmonary perfusion imbalance is also common, but its effect on cardiac adaptation to exercise is not known. AIM To assess the association between pulmonary perfusion asymmetry and peak indexed exercise stroke volume (pSVi) in young patients. METHODS We retrospectively studied 82 consecutive patients with Fallot repair (mean age 15.2±3.8 years) who underwent echocardiography, four-dimensional flow magnetic resonance imaging and cardiopulmonary testing with pSVi measurement by thoracic bioimpedance. Normal pulmonary flow distribution was defined as right pulmonary artery perfusion between 43 and 61%. RESULTS Normal, rightward and leftward flow distributions were found in 52 (63%), 26 (32%) and four (5%) patients, respectively. Independent predictors of pSVi were right pulmonary artery perfusion (β=0.368, 95% confidence interval [CI] 0.188 to 0.548; P=0.0003), right ventricular ejection fraction (β=0.205, 95% CI 0.026 to 0.383; P=0.049), pulmonary regurgitation fraction (β=-0.283, 95% CI -0.495 to -0.072; P=0.006) and Fallot variant with pulmonary atresia (β=-0.213, 95% CI -0.416 to -0.009; P=0.041). The pSVi prediction was similar when the categorical variable right pulmonary artery perfusion>61% was used (β=0.210, 95% CI 0.006 to 0.415; P=0.044). CONCLUSION In addition to right ventricular ejection fraction, pulmonary regurgitation fraction and Fallot variant with pulmonary atresia, right pulmonary artery perfusion is a predictor of pSVi, in that rightward imbalanced pulmonary perfusion favours greater pSVi.
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Affiliation(s)
- Elena Panaioli
- Cardiologie pédiatrique, M3C-Necker, hôpital universitaire Necker-enfants malades, AP-HP, 149, rue de Sèvres, 75743 Paris cedex 15, France; Radiology Department, hôpital universitaire Necker-enfants malades, AP-HP, 75743 Paris, France
| | - Diala Khraiche
- Cardiologie pédiatrique, M3C-Necker, hôpital universitaire Necker-enfants malades, AP-HP, 149, rue de Sèvres, 75743 Paris cedex 15, France
| | - Neil Derridj
- Cardiologie pédiatrique, M3C-Necker, hôpital universitaire Necker-enfants malades, AP-HP, 149, rue de Sèvres, 75743 Paris cedex 15, France
| | - Damien Bonnet
- Cardiologie pédiatrique, M3C-Necker, hôpital universitaire Necker-enfants malades, AP-HP, 149, rue de Sèvres, 75743 Paris cedex 15, France; Paris Cité University, 75006 Paris, France
| | - Francesca Raimondi
- Cardiologie pédiatrique, M3C-Necker, hôpital universitaire Necker-enfants malades, AP-HP, 149, rue de Sèvres, 75743 Paris cedex 15, France; Radiology Department, hôpital universitaire Necker-enfants malades, AP-HP, 75743 Paris, France; Paris Cité University, 75006 Paris, France
| | - Antoine Legendre
- Cardiologie pédiatrique, M3C-Necker, hôpital universitaire Necker-enfants malades, AP-HP, 149, rue de Sèvres, 75743 Paris cedex 15, France.
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5
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Xia S, Li J, Ma L, Cui Y, Liu T, Wang Z, Li F, Liu X, Li S, Sun L, Hu L, Liu Y, Ma X, Chen X, Zhang X. Ultra-high pressure balloon angioplasty for pulmonary artery stenosis in children with congenital heart defects: Short- to mid-term follow-up results from a retrospective cohort in a single tertiary center. Front Cardiovasc Med 2023; 9:1078172. [PMID: 36756639 PMCID: PMC9899851 DOI: 10.3389/fcvm.2022.1078172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 12/27/2022] [Indexed: 01/24/2023] Open
Abstract
Objective Balloon angioplasty (BA) has been the treatment of choice for pulmonary artery stenosis (PAS) in children. There remains, however, a significant proportion of resistant lesions. The ultra-high pressure (UHP) balloons might be effective in a subset of these lesions. In this study, we analyzed the safety and efficacy with short- to mid-term follow-up results of UHP BA for PAS in children with congenital heart defects (CHD) in our center. Methods This is a retrospective cohort study in a single tertiary heart center. Children diagnosed with PAS associated with CHD were referred for UHP BA. All data with these children were collected for analysis with updated follow-up. Results A total of 37 UHP BAs were performed consecutively in 28 children. The success rate was 78.4%. A significantly (P = 0.005) larger ratio of the balloon to the minimal luminal diameter at the stenotic waist (balloon/waist ratio) was present in the success group (median 3.00, 1.64-8.33) compared to that in the failure group (median 1.94, 1.41 ± 4.00). Stepwise logistic regression analysis further identified that the balloon/waist ratio and the presence of therapeutic tears were two independent predictors of procedural success. The receiver operating characteristic curve revealed a cut-off value of 2.57 for the balloon/waist ratio to best differentiate success from failure cases. Signs of therapeutic tears were present in eight cases, all of whom were in the success group. Perioperative acute adverse events were recorded in 16 patients, including 11 pulmonary artery injuries, three pulmonary hemorrhages, and two pulmonary artery aneurysms. During a median follow-up period of 10.4 (0.1-21.0) months, nine cases experienced restenosis at a median time of 40 (4-325) days after angioplasty. Conclusions The UHP BA is safe and effective for the primary treatment of PAS in infants and children with CHD. The success rate is high with a low incidence of severe complications. The predictors of success are a larger balloon/waist ratio and the presence of therapeutic tears. The occurrence of restenosis during follow-up, however, remains a problem. A larger number of cases and longer periods of follow-up are needed for further study.
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Affiliation(s)
- Shuliang Xia
- Department of Cardiovascular Surgery, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China,Guangdong Provincial Key Laboratory of Research in Structural Birth Defect Disease, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou, China
| | - Jianbin Li
- Department of Cardiovascular Surgery, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China,Guangdong Provincial Key Laboratory of Research in Structural Birth Defect Disease, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou, China
| | - Li Ma
- Department of Cardiovascular Surgery, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China,Guangdong Provincial Key Laboratory of Research in Structural Birth Defect Disease, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou, China
| | - Yanqin Cui
- Department of Cardiovascular Surgery, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China,Guangdong Provincial Key Laboratory of Research in Structural Birth Defect Disease, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou, China
| | - Techang Liu
- Guangdong Provincial Key Laboratory of Research in Structural Birth Defect Disease, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou, China,Department of Echocardiogram Room, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Zhouping Wang
- Guangdong Provincial Key Laboratory of Research in Structural Birth Defect Disease, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou, China,Department of Pediatric Cardiology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Fengxiang Li
- Department of Cardiovascular Surgery, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China,Guangdong Provincial Key Laboratory of Research in Structural Birth Defect Disease, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou, China
| | - Xumei Liu
- Guangdong Provincial Key Laboratory of Research in Structural Birth Defect Disease, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou, China,Department of Echocardiogram Room, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Shan Li
- Guangdong Provincial Key Laboratory of Research in Structural Birth Defect Disease, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou, China,Department of Echocardiogram Room, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Lu Sun
- Department of Cardiovascular Surgery, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China,Guangdong Provincial Key Laboratory of Research in Structural Birth Defect Disease, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou, China
| | - Lin Hu
- Department of Cardiovascular Surgery, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China,Guangdong Provincial Key Laboratory of Research in Structural Birth Defect Disease, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou, China
| | - Yubin Liu
- Department of Interventional and Vascular Anomalies, Guangzhou Women and Children's Medical Center, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou Medical University, Guangzhou, China
| | - Xun Ma
- Department of Cardiovascular Surgery, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China,Guangdong Provincial Key Laboratory of Research in Structural Birth Defect Disease, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou, China
| | - Xinxin Chen
- Department of Cardiovascular Surgery, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China,Guangdong Provincial Key Laboratory of Research in Structural Birth Defect Disease, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou, China,Xinxin Chen ✉
| | - Xu Zhang
- Guangdong Provincial Key Laboratory of Research in Structural Birth Defect Disease, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou, China,Department of Pediatric Cardiology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China,*Correspondence: Xu Zhang ✉
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6
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Current Status and Outlook of Temporary Implants (Magnesium/Zinc) in Cardiovascular Applications. METALS 2022. [DOI: 10.3390/met12060999] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Medical application materials must meet multiple requirements, and the designed material must mimic the structure, shape. and support the formation of the replacing tissue. Magnesium (Mg) and Zinc alloys (Zn), as a “smart” biodegradable material and as “the green engineering material in the 21st century”, have become an outstanding implant material due to their natural degradability, smart biocompatibility, and desirable mechanical properties. Magnesium and Zinc are recognized as the next generation of cardiovascular stents and bioresorbable scaffolds. At the same time, improving the properties and corrosion resistance of these alloys is an urgent challenge. particularly to promote the application of magnesium alloys. A relatively fast deterioration rate of magnesium-based materials generally results in premature mechanical integrity compromise and local hydrogen build-up, resulting in restricted applicability. This review article aims to give a comprehensive comparison between Zn-based alloys and Mg-based alloys, focusing primarily on degradation and biocompatibility for cardiovascular applications. The recent clinical trials using these biodegradable metals have also been addressed.
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7
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Cao BL, Mervis J, Adams P, Roberts P, Ayer J. Branch pulmonary artery stent angioplasty in infants less than 10 kg. INTERNATIONAL JOURNAL OF CARDIOLOGY CONGENITAL HEART DISEASE 2022. [DOI: 10.1016/j.ijcchd.2022.100368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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8
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Hager A. Minute ventilation/carbon dioxide production in congenital heart disease. Eur Respir Rev 2021; 30:30/161/200178. [PMID: 34526311 PMCID: PMC9488851 DOI: 10.1183/16000617.0178-2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 11/17/2020] [Indexed: 11/24/2022] Open
Abstract
This review summarises various applications of how ventilatory equivalent (ventilatory efficiency or better still ventilatory inefficiency) and the minute ventilation (VʹE)/carbon dioxide production (VʹCO2) slope obtained from cardiopulmonary exercise testing (CPET) can be used in the diagnostic or prognostic workup of patients with congenital heart disease. The field of congenital heart disease comprises not only a very heterogeneous patient group with various heart diseases, but also various conditions in different stages of repair, as well as the different residuals seen in long-term follow-up. As such, various physiologic disarrangements must be considered in the analysis of increased VʹE/VʹCO2 slope from CPET in patients with congenital heart disease. In addition to congestive heart failure (CHF), cyanosis, unilateral pulmonary stenosis and pulmonary hypertension (PH) provide the background for this finding. The predictive value of increased VʹE/VʹCO2 slope on prognosis seems to be more important in conditions where circulatory failure is associated with failure of the systemic ventricle. In cyanotic patients, those with Fontan circulation, or those with substantial mortality from arrhythmia, the impact of VʹE/VʹCO2 on prognosis is not that important. VʹE/VʹCO2 elevation is a common finding in patients with congenital heart disease. It can be used as a sign for right-to-left shunting, unilateral pulmonary stenosis, pulmonary hypertension and circulatory failure. It is predictive for clinical worsening.https://bit.ly/33gj3NQ
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Affiliation(s)
- Alfred Hager
- Dept of Pediatric Congenital Heart Disease and Pediatric Cardiology, Deutsches Herzzentrum München, Technical University of Munich, Munich, Germany
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9
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Pewowaruk R, Ralphe J, Lamers L, Roldán-Alzate A. Non-invasive MRI Derived Hemodynamic Simulation to Predict Successful vs. Unsuccessful Catheter Interventions for Branch Pulmonary Artery Stenosis: Proof-of-Concept and Experimental Validation in Swine. Cardiovasc Eng Technol 2021; 12:494-504. [PMID: 34008077 DOI: 10.1007/s13239-021-00543-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 05/07/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE This study assessed the ability of hemodynamic simulations to predict the success of catheter interventions in a swine model of branch pulmonary artery stenosis (bPAS). BACKGROUND bPAS commonly occurs in congenital heart disease and is often managed with catheter based interventions. However, despite technical success, bPAS interventions do not lead to improved distal pulmonary blood flow (PBF) distribution in approximately 1/3rd of patients. New tools are needed to better identify which patients with bPAS would most benefit from catheter interventions. METHODS For 13 catheter intervention cases in swine with surgically created left PAS (LPAS), PA pressures from right heart catheterization (RHC) and PBF distributions from MRI were measured before and after catheter interventions. Hemodynamic simulations with a reduced order computational fluid dynamics (CFD) model were performed using non-invasive PBF measurements derived from MRI, and then correlated with changes in invasive measures of hemodynamics and PBF distributions before and after catheter intervention to relieve bPAS. RESULTS Compared to experimentally measured changes in left PBF distribution, simulations had a small bias (3.4 ± 11.1%), moderate agreement (ICC = 0.69 [0.24-0.90], 0.71 [0.23-0.91]), and good diagnostic capability to predict successful interventions (> 20% PBF increase) (AUC 0.83 [0.59-1.0]). Simulations had poorer prediction of changes in stenotic pressure gradient (ICC = 0.28 [- 0.33 to 0.73], r = 0.57 [- 0.04 to 0.87]) and MPA systolic pressure (ICC = 0.00 [- 0.52 to 0.53], r = 0.29 [- 0.32 to 0.72]). CONCLUSION While there was only weak to moderate agreement between predicted and measured changes in PA pressures and pulmonary blood flow distributions, hemodynamic simulations did show good diagnostic value for predicting successful versus unsuccessful catheter based interventions to relieve bPAS. The results of this proof of concept study are promising and should encourage future development for using hemodynamic models in planning interventions for patients with bPAS.
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Affiliation(s)
- Ryan Pewowaruk
- Cardiovascular Research Center, University of Wisconsin - Madison, Madison, USA. .,Division of Cardiology, Department of Medicine, William S. Middleton Memorial Veteran's Hospital, Office: D222, 2500 Overlook Terrace, Madison, WI, 53705-4108, USA.
| | - John Ralphe
- Division of Cardiology, Department of Pediatrics, University of Wisconsin - Madison, Madison, USA
| | - Luke Lamers
- Division of Cardiology, Department of Pediatrics, University of Wisconsin - Madison, Madison, USA
| | - Alejandro Roldán-Alzate
- Mechanical Engineering, University of Wisconsin - Madison, Madison, USA.,Department of Radiology, University of Wisconsin - Madison, Madison, USA
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10
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Pewowaruk R, Lamers L, Roldán-Alzate A. Accelerated Estimation of Pulmonary Artery Stenosis Pressure Gradients with Distributed Lumped Parameter Modeling vs. 3D CFD with Instantaneous Adaptive Mesh Refinement: Experimental Validation in Swine. Ann Biomed Eng 2021; 49:2365-2376. [PMID: 33948748 DOI: 10.1007/s10439-021-02780-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 04/11/2021] [Indexed: 11/30/2022]
Abstract
Branch pulmonary artery stenosis (PAS) commonly occurs in congenital heart disease and the pressure gradient over a stenotic PA lesion is an important marker for re-intervention. Image based computational fluid dynamics (CFD) has shown promise for non-invasively estimating pressure gradients but one limitation of CFD is long simulation times. The goal of this study was to compare accelerated predictions of PAS pressure gradients from 3D CFD with instantaneous adaptive mesh refinement (AMR) versus a recently developed 0D distributed lumped parameter CFD model. Predictions were then experimentally validated using a swine PAS model (n = 13). 3D CFD simulations with AMR improved efficiency by 5 times compared to fixed grid CFD simulations. 0D simulations further improved efficiency by 6 times compared to the 3D simulations with AMR. Both 0D and 3D simulations underestimated the pressure gradients measured by catheterization (- 1.87 ± 4.20 and - 1.78 ± 3.70 mmHg respectively). This was partially due to simulations neglecting the effects of a catheter in the stenosis. There was good agreement between 0D and 3D simulations (ICC 0.88 [0.66-0.96]) but only moderate agreement between simulations and experimental measurements (0D ICC 0.60 [0.11-0.86] and 3D ICC 0.66 [0.21-0.88]). Uncertainty assessment indicates that this was likely due to limited medical imaging resolution causing uncertainty in the segmented stenosis diameter in addition to uncertainty in the outlet resistances. This study showed that 0D lumped parameter models and 3D CFD with instantaneous AMR both improve the efficiency of hemodynamic modeling, but uncertainty from medical imaging resolution will limit the accuracy of pressure gradient estimations.
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Affiliation(s)
- Ryan Pewowaruk
- Biomedical Engineering, University of Wisconsin, Madison, WI, USA
| | - Luke Lamers
- Pediatrics, Division of Cardiology, University of Wisconsin, Madison, WI, USA
| | - Alejandro Roldán-Alzate
- Biomedical Engineering, University of Wisconsin, Madison, WI, USA. .,Mechanical Engineering, University of Wisconsin, Madison, WI, USA. .,Radiology, University of Wisconsin, Madison, WI, USA.
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Pewowaruk RJ, Barton GP, Johnson C, Ralphe JC, Francois CJ, Lamers L, Roldán-Alzate A. Stent interventions for pulmonary artery stenosis improve bi-ventricular flow efficiency in a swine model. J Cardiovasc Magn Reson 2021; 23:13. [PMID: 33627121 PMCID: PMC7905680 DOI: 10.1186/s12968-021-00709-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 01/06/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Branch pulmonary artery (PA) stenosis (PAS) commonly occurs in patients with congenital heart disease (CHD). Prior studies have documented technical success and clinical outcomes of PA stent interventions for PAS but the impact of PA stent interventions on ventricular function is unknown. The objective of this study was to utilize 4D flow cardiovascular magnetic resonance (CMR) to better understand the impact of PAS and PA stenting on ventricular contraction and ventricular flow in a swine model of unilateral branch PA stenosis. METHODS 18 swine (4 sham, 4 untreated left PAS, 10 PAS stent intervention) underwent right heart catheterization and CMR at 20 weeks age (55 kg). CMR included ventricular strain analysis and 4D flow CMR. RESULTS 4D flow CMR measured inefficient right ventricular (RV) and left ventricular (LV) flow patterns in the PAS group (RV non-dimensional (n.d.) vorticity: sham 82 ± 47, PAS 120 ± 47; LV n.d. vorticity: sham 57 ± 5, PAS 78 ± 15 p < 0.01) despite the PAS group having normal heart rate, ejection fraction and end-diastolic volume. The intervention group demonstrated increased ejection fraction that resulted in more efficient ventricular flow compared to untreated PAS (RV n.d. vorticity: 59 ± 12 p < 0.01; LV n.d. vorticity: 41 ± 7 p < 0.001). CONCLUSION These results describe previously unknown consequences of PAS on ventricular function in an animal model of unilateral PA stenosis and show that PA stent interventions improve ventricular flow efficiency. This study also highlights the sensitivity of 4D flow CMR biomarkers to detect earlier ventricular dysfunction assisting in identification of patients who may benefit from PAS interventions.
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MESH Headings
- Animals
- Computed Tomography Angiography
- Disease Models, Animal
- Endovascular Procedures/instrumentation
- Magnetic Resonance Imaging, Cine
- Myocardial Contraction
- Myocardial Perfusion Imaging
- Pulmonary Artery/diagnostic imaging
- Pulmonary Artery/physiopathology
- Recovery of Function
- Stenosis, Pulmonary Artery/diagnostic imaging
- Stenosis, Pulmonary Artery/physiopathology
- Stenosis, Pulmonary Artery/therapy
- Stents
- Sus scrofa
- Ventricular Dysfunction, Right/diagnostic imaging
- Ventricular Dysfunction, Right/physiopathology
- Ventricular Dysfunction, Right/therapy
- Ventricular Function, Left
- Ventricular Function, Right
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Affiliation(s)
- Ryan J Pewowaruk
- Biomedical Engineering, University of Wisconsin-Madison, Madison, WI, USA.
| | - Gregory P Barton
- University of Wisconsin-Madison, Madison, WI, USA
- Medical Physics, University of Wisconsin-Madison, Madison, WI, USA
| | - Cody Johnson
- University of Wisconsin-Madison, Madison, WI, USA
| | - J Carter Ralphe
- School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
- Division of Cardiology, University of Wisconsin-Madison, Madison, WI, USA
| | - Christopher J Francois
- University of Wisconsin-Madison, Madison, WI, USA
- School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
| | - Luke Lamers
- School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
- Division of Cardiology, University of Wisconsin-Madison, Madison, WI, USA
| | - Alejandro Roldán-Alzate
- Biomedical Engineering, University of Wisconsin-Madison, Madison, WI, USA
- University of Wisconsin-Madison, Madison, WI, USA
- Mechanical Engineering, University of Wisconsin-Madison, Madison, WI, USA
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Patel ND, Sullivan PM, Sabati A, Hill A, Maedler-Kron C, Zhou S, Shillingford N, Williams R, Takao C, Badran S. Routine Surveillance Catheterization is Useful in Guiding Management of Stable Fontan Patients. Pediatr Cardiol 2020; 41:624-631. [PMID: 31980851 DOI: 10.1007/s00246-020-02293-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 01/17/2020] [Indexed: 11/24/2022]
Abstract
We developed a Fontan surveillance catheterization protocol as part of routine assessment of stable patients 10 years after Fontan completion. The surveillance catherization includes hemodynamic assessment with inhaled nitric oxide, angiography, liver biopsy, and transcatheter intervention if indicated. We aimed to describe hemodynamic and liver biopsy findings, response to pulmonary vasoreactivity testing, rates of transcatheter intervention, and changes in medical therapy following surveillance catheterization in stable Fontan patients. A single-center retrospective review of Fontan patients undergoing surveillance catheterization between November 2014 and May 2019 was performed. Liver biopsies were independently scored by two pathologists. Sixty-three patients underwent surveillance catheterization (mean age 14.6 ± 3.0 years). The mean Fontan pressure was 11.8 ± 2.1 mmHg. The mean cardiac index was 2.9 ± 0.6 L/min/m2. In the 51 patients who underwent pulmonary vasoreactivity testing, there was a significant decrease in median pulmonary vascular resistance (1.8 [range 0.8-4.1] vs 1.4 [range 0.7-3.0] Wood units × m2; p < 0.001). The mean cardiac index increased (3.0 ± 0.6 vs 3.2 ± 0.7 L/min/m2, p = 0.009). The Fontan pressure did not change significantly. Fifty-seven patients underwent liver biopsy, and all but one showed fibrosis. Nineteen patients (33.3%) demonstrated bridging fibrosis or cirrhosis. Twenty-five patients underwent 34 transcatheter interventions. Pulmonary artery or Fontan stent placement was performed in 19 patients. Phosphodiesterase type 5 inhibitors were initiated in nine patients following surveillance catheterization. Routine surveillance catheterization with liver biopsy in adolescent Fontan patients reveals information that can guide interventional and medical management. Further long-term follow-up and assessment are indicated to assess the benefit of these interventions.
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Affiliation(s)
- Neil D Patel
- Division of Pediatric Cardiology, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, 4650 Sunset Blvd, Mailstop #34, Los Angeles, CA, 90027, USA.
| | - Patrick M Sullivan
- Division of Pediatric Cardiology, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, 4650 Sunset Blvd, Mailstop #34, Los Angeles, CA, 90027, USA
| | - Arash Sabati
- Division of Pediatric Cardiology, Phoenix Children's Hospital, University of Arizona College of Medicine, Phoenix, AZ, USA
| | - Allison Hill
- Division of Pediatric Cardiology, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, 4650 Sunset Blvd, Mailstop #34, Los Angeles, CA, 90027, USA
| | | | - Shengmei Zhou
- Department of Pathology, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Nick Shillingford
- Department of Pathology, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Roberta Williams
- Division of Pediatric Cardiology, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, 4650 Sunset Blvd, Mailstop #34, Los Angeles, CA, 90027, USA
| | - Cheryl Takao
- Division of Pediatric Cardiology, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, 4650 Sunset Blvd, Mailstop #34, Los Angeles, CA, 90027, USA
| | - Sarah Badran
- Division of Pediatric Cardiology, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, 4650 Sunset Blvd, Mailstop #34, Los Angeles, CA, 90027, USA
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13
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Editorial commentary: Challenges in the diagnosis and management of pulmonary artery stenosis. Trends Cardiovasc Med 2020; 31:185-186. [PMID: 32122731 DOI: 10.1016/j.tcm.2020.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 02/11/2020] [Indexed: 11/21/2022]
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Abstract
Peripheral pulmonary artery stenosis (PAS) is an abnormal narrowing of the pulmonary vasculature and can form anywhere within the pulmonary artery tree. PAS is a congenital or an acquired disease, and its severity depends on the etiology, location, and number of stenoses. Most often seen in infants and young children, some symptoms include shortness of breath, fatigue, and tachycardia. Symptoms can progressively worsen over time as right ventricular pressure increases, leading to further complications including pulmonary artery hypertension and systolic and diastolic dysfunctions. The current treatment options for PAS include simple balloon angioplasty, cutting balloon angioplasty, and stent placement. Simple balloon angioplasty is the most basic therapeutic option for proximally located PAS. Cutting balloon angioplasty is utilized for more dilation-resistant PAS vessels and for more distally located PAS. Stent placement is the most effective option seen to treat the majority of PAS; however, it requires multiple re-interventions for serial dilations and is generally reserved for PAS vessels that are resistant to angioplasty.
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Hiremath G, Qureshi AM, Meadows J, Aggarwal V. Treatment approach to unilateral branch pulmonary artery stenosis. Trends Cardiovasc Med 2020; 31:179-184. [PMID: 32081565 DOI: 10.1016/j.tcm.2020.02.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 02/02/2020] [Accepted: 02/03/2020] [Indexed: 11/17/2022]
Abstract
Unilateral proximal pulmonary artery stenosis is often seen in the setting of postoperative congenital heart disease. Accurate assessment of the hemodynamic significance of such a lesion is important so as to determine "When to intervene?" A thorough evaluation should include symptom assessment, anatomical assessment through detailed imaging, functional assessment using differential pulmonary blood flow measurement and cardiopulmonary exercise testing. Symptoms of exertional dyspnea or intolerance, decreased pulmonary blood flow to stenosed lung, and abnormal exertional performance would be factors to pursue therapy in the setting of significant anatomical narrowing. Safe and effective therapy can be offered through transcatheter or surgical techniques and has been shown to improve exertional performance.
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Affiliation(s)
- Gurumurthy Hiremath
- Division of Pediatric Cardiology, Department of Pediatrics, University of Minnesota Masonic Children's Hospital, 2450 Riverside Ave, Minneapolis, MN 55454, USA.
| | - Athar M Qureshi
- The Lillie Frank Abercrombie section of Pediatric Cardiology, Texas Children's Hospital and Baylor College of Medicine, Houston, TX 77030, USA
| | - Jeffery Meadows
- Department of Pediatrics, UCSF Benioff Children's Hospital and the University of California, San Francisco, San Francisco, CA 94118, USA
| | - Varun Aggarwal
- Division of Pediatric Cardiology, Department of Pediatrics, University of Minnesota Masonic Children's Hospital, 2450 Riverside Ave, Minneapolis, MN 55454, USA
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