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Onohara D, Hagen M, Louey S, Giraud G, Jonker S, Padala M. Chronic in utero mitral inflow obstruction unloads left ventricular volume in a novel late gestation fetal lamb model. JTCVS OPEN 2023; 16:698-707. [PMID: 38204723 PMCID: PMC10775114 DOI: 10.1016/j.xjon.2023.09.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 09/26/2023] [Accepted: 09/28/2023] [Indexed: 01/12/2024]
Abstract
Objective The in utero no flow/no grow hypothesis postulates that reduced inflow of blood into the left ventricle due to a stenotic mitral valve could lead to ventricular hypoplasia and hypoplastic left heart syndrome. This has been demonstrated in chick embryos, but less so in large animals. We investigated the impact of mitral obstruction on left and right ventricular growth in fetal lambs. Methods Twelve pregnant ewes, most bearing twins, were instrumented at 119 ± 1 days gestational age. Carotid artery and jugular vein catheters, an ascending aorta flow probe, and a left atrial deflated balloon catheter were implanted into 1 fetus (left atrial balloon group), and the twin remained an uninstrumented control. The balloon was inflated gradually over 8 days until net antegrade aortic flow was eliminated. Fetal transesophageal echocardiography was performed at the time of surgery and just before termination in both groups. Results Terminal fetal body weights were comparable between groups. Terminal heart/body weight ratio was higher in left atrial balloon group fetuses (6.9 ± 0.8 g/kg) compared with controls (5.9 ± 0.6 g, P = .0126). The left ventricular/right ventricular weight ratio was 24% (P = .0077) lower in left atrial balloon group fetuses than in controls. Left ventricular/heart weight (0.24 ± 0.04 g/g vs 0.30 ± 0.04 g/g, P = .0009), left ventricular end-diastolic volume (2.3 ± 0.7 mL vs 7.1 ± 0.8 mL; P = .0012), and left ventricular end-systolic volume (1.01 mL [0.95-1.95 mL] vs 3.38 mL [3.28-3.57 mL], P = .0042) were lower in left atrial balloon group fetuses compared with controls. Right ventricular weight (g/kg), right ventricular end-diastolic volume, and right ventricular end-systolic volume were similar between groups. Conclusions In this late-gestation fetal lamb model, in utero obstruction of mitral inflow slowed left ventricular growth and caused right ventricular remodeling.
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Affiliation(s)
- Daisuke Onohara
- Structural Heart Research and Innovation Laboratory, Carlyle Fraser Heart Center at Emory University Hospital Midtown, Atlanta, Ga
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Matthew Hagen
- Center for Development Health, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Ore
| | - Samantha Louey
- Center for Development Health, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Ore
| | - George Giraud
- Center for Development Health, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Ore
- Department of Cardiology, Portland Veterans Affairs Medical Center, Portland, Ore
| | - Sonnet Jonker
- Center for Development Health, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Ore
| | - Muralidhar Padala
- Structural Heart Research and Innovation Laboratory, Carlyle Fraser Heart Center at Emory University Hospital Midtown, Atlanta, Ga
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Ga
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Hoffman JR, Park HJ, Bheri S, Platt MO, Hare JM, Kaushal S, Bettencourt JL, Lai D, Slesnick TC, Mahle WT, Davis ME. Statistical modeling of extracellular vesicle cargo to predict clinical trial outcomes for hypoplastic left heart syndrome. iScience 2023; 26:107980. [PMID: 37868626 PMCID: PMC10589850 DOI: 10.1016/j.isci.2023.107980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 08/24/2023] [Accepted: 09/15/2023] [Indexed: 10/24/2023] Open
Abstract
Cardiac-derived c-kit+ progenitor cells (CPCs) are under investigation in the CHILD phase I clinical trial (NCT03406884) for the treatment of hypoplastic left heart syndrome (HLHS). The therapeutic efficacy of CPCs can be attributed to the release of extracellular vesicles (EVs). To understand sources of cell therapy variability we took a machine learning approach: combining bulk CPC-derived EV (CPC-EV) RNA sequencing and cardiac-relevant in vitro experiments to build a predictive model. We isolated CPCs from cardiac biopsies of patients with congenital heart disease (n = 29) and the lead-in patients with HLHS in the CHILD trial (n = 5). We sequenced CPC-EVs, and measured EV inflammatory, fibrotic, angiogeneic, and migratory responses. Overall, CPC-EV RNAs involved in pro-reparative outcomes had a significant fit to cardiac development and signaling pathways. Using a model trained on previously collected CPC-EVs, we predicted in vitro outcomes for the CHILD clinical samples. Finally, CPC-EV angiogenic performance correlated to clinical improvements in right ventricle performance.
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Affiliation(s)
- Jessica R. Hoffman
- Wallace H. Coulter Department of Biomedical Engineering, Emory University School of Medicine & Georgia Institute of Technology, Atlanta, GA 30322, USA
- Molecular & Systems Pharmacology Graduate Training Program, Laney Graduate School, Emory University, Atlanta, GA 30322, USA
| | - Hyun-Ji Park
- Wallace H. Coulter Department of Biomedical Engineering, Emory University School of Medicine & Georgia Institute of Technology, Atlanta, GA 30322, USA
| | - Sruti Bheri
- Wallace H. Coulter Department of Biomedical Engineering, Emory University School of Medicine & Georgia Institute of Technology, Atlanta, GA 30322, USA
| | - Manu O. Platt
- Wallace H. Coulter Department of Biomedical Engineering, Emory University School of Medicine & Georgia Institute of Technology, Atlanta, GA 30322, USA
| | - Joshua M. Hare
- Miller School of Medicine, University of Miami, Miami, FL 33136, USA
| | - Sunjay Kaushal
- Departments of Surgery and Pediatrics, Ann and Robert H. Lurie Children’s Hospital of Chicago, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
| | - Judith L. Bettencourt
- Coordinating Center for Clinical Trials, Department of Biostatistics and Data Science, University of Texas Health Science Center School of Public Health, Houston, TX 77030, USA
| | - Dejian Lai
- Coordinating Center for Clinical Trials, Department of Biostatistics and Data Science, University of Texas Health Science Center School of Public Health, Houston, TX 77030, USA
| | - Timothy C. Slesnick
- Division of Pediatric Cardiology, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA 30322, USA
- Children’s Heart Research & Outcomes (HeRO) Center, Children’s Healthcare of Atlanta & Emory University, Atlanta, GA 30322, USA
| | - William T. Mahle
- Division of Pediatric Cardiology, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA 30322, USA
- Children’s Heart Research & Outcomes (HeRO) Center, Children’s Healthcare of Atlanta & Emory University, Atlanta, GA 30322, USA
| | - Michael E. Davis
- Wallace H. Coulter Department of Biomedical Engineering, Emory University School of Medicine & Georgia Institute of Technology, Atlanta, GA 30322, USA
- Molecular & Systems Pharmacology Graduate Training Program, Laney Graduate School, Emory University, Atlanta, GA 30322, USA
- Children’s Heart Research & Outcomes (HeRO) Center, Children’s Healthcare of Atlanta & Emory University, Atlanta, GA 30322, USA
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Kaushal S, Hare JM, Hoffman JR, Boyd RM, Ramdas KN, Pietris N, Kutty S, Tweddell JS, Husain SA, Menon SC, Lambert LM, Danford DA, Kligerman SJ, Hibino N, Korutla L, Vallabhajosyula P, Campbell MJ, Khan A, Naioti E, Yousefi K, Mehranfard D, McClain-Moss L, Oliva AA, Davis ME. Intramyocardial cell-based therapy with Lomecel-B during bidirectional cavopulmonary anastomosis for hypoplastic left heart syndrome: the ELPIS phase I trial. EUROPEAN HEART JOURNAL OPEN 2023; 3:oead002. [PMID: 36950450 PMCID: PMC10026620 DOI: 10.1093/ehjopen/oead002] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 12/19/2022] [Accepted: 01/06/2023] [Indexed: 01/13/2023]
Abstract
Aims Hypoplastic left heart syndrome (HLHS) survival relies on surgical reconstruction of the right ventricle (RV) to provide systemic circulation. This substantially increases the RV load, wall stress, maladaptive remodelling, and dysfunction, which in turn increases the risk of death or transplantation. Methods and results We conducted a phase 1 open-label multicentre trial to assess the safety and feasibility of Lomecel-B as an adjunct to second-stage HLHS surgical palliation. Lomecel-B, an investigational cell therapy consisting of allogeneic medicinal signalling cells (MSCs), was delivered via intramyocardial injections. The primary endpoint was safety, and measures of RV function for potential efficacy were obtained. Ten patients were treated. None experienced major adverse cardiac events. All were alive and transplant-free at 1-year post-treatment, and experienced growth comparable to healthy historical data. Cardiac magnetic resonance imaging (CMR) suggested improved tricuspid regurgitant fraction (TR RF) via qualitative rater assessment, and via significant quantitative improvements from baseline at 6 and 12 months post-treatment (P < 0.05). Global longitudinal strain (GLS) and RV ejection fraction (EF) showed no declines. To understand potential mechanisms of action, circulating exosomes from intramyocardially transplanted MSCs were examined. Computational modelling identified 54 MSC-specific exosome ribonucleic acids (RNAs) corresponding to changes in TR RF, including miR-215-3p, miR-374b-3p, and RNAs related to cell metabolism and MAPK signalling. Conclusion Intramyocardially delivered Lomecel-B appears safe in HLHS patients and may favourably affect RV performance. Circulating exosomes of transplanted MSC-specific provide novel insight into bioactivity. Conduct of a controlled phase trial is warranted and is underway.Trial registration number NCT03525418.
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Affiliation(s)
- Sunjay Kaushal
- The Heart Center, Division of Cardiovascular-Thoracic Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E. Chicago Avenue, Chicago, IL 60611, USA
| | - Joshua M Hare
- Longeveron Inc, 1951 NW 7th Avenue, Suite 520, Miami, FL 33136, USA
- Department of Medicine and Interdisciplinary Stem Cell Institute, University of Miami Miller School of Medicine, 1501 NW 10th Avenue, Miami, FL 33136, USA
| | - Jessica R Hoffman
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology & Emory University School of Medicine, 313 Ferst Drive, Atlanta, GA 30332, USA
| | - Riley M Boyd
- The Heart Center, Division of Cardiovascular-Thoracic Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E. Chicago Avenue, Chicago, IL 60611, USA
| | - Kevin N Ramdas
- Longeveron Inc, 1951 NW 7th Avenue, Suite 520, Miami, FL 33136, USA
| | - Nicholas Pietris
- Division of Pediatric Cardiology, Department of Pediatrics, University of Maryland School of Medicine, 110 S. Paca Street, Baltimore, MD 21201, USA
| | - Shelby Kutty
- Helen B. Taussig Heart Center, The Johns Hopkins Hospital and Johns Hopkins University, 1800 Orleans St., Baltimore, MD 21287, USA
| | - James S Tweddell
- Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229, USA
| | - S Adil Husain
- Division of Pediatric Cardiothoracic Surgery, University of Utah/Primary Children's Medical Center, 295 Chipeta Way, Salt Lake City, Utah 84108, USA
| | - Shaji C Menon
- Department of Radiology, University of Utah/Primary Children's Medical Center, 295 Chipeta Way, Salt Lake City, UT 84108, USA
| | - Linda M Lambert
- Division of Pediatric Cardiology, University of Utah/Primary Children's Medical Center, 295 Chipeta Way, Salt Lake City, UT 84108, USA
| | - David A Danford
- Division of Cardiology, Children's Hospital & Medical Center, Nebraska Medicine, Department of Pediatrics, University of Nebraska, 983332 Nebraska Medical Center, Omaha, NE 68198, USA
| | - Seth J Kligerman
- Department of Radiology, University of California San Diego, 200 W. Arbor Drive, San Diego, CA 92103, USA
| | - Narutoshi Hibino
- Department of Surgery, The University of Chicago Medical Center, 5841 S. Maryland Avenue, Chicago, IL 60637, USA
| | - Laxminarayana Korutla
- Department of Surgery (Cardiac), Yale School of Medicine, Yale University, 789 Howard Avenue, New Haven, CT 06510, USA
| | - Prashanth Vallabhajosyula
- Department of Surgery (Cardiac), Yale School of Medicine, Yale University, 789 Howard Avenue, New Haven, CT 06510, USA
| | - Michael J Campbell
- Department of Pediatrics, Duke University School of Medicine, 2301 Erwin Road, Durham, NC 27705, USA
| | - Aisha Khan
- Department of Medicine and Interdisciplinary Stem Cell Institute, University of Miami Miller School of Medicine, 1501 NW 10th Avenue, Miami, FL 33136, USA
| | - Eric Naioti
- Longeveron Inc, 1951 NW 7th Avenue, Suite 520, Miami, FL 33136, USA
| | - Keyvan Yousefi
- Longeveron Inc, 1951 NW 7th Avenue, Suite 520, Miami, FL 33136, USA
| | | | | | - Anthony A Oliva
- Longeveron Inc, 1951 NW 7th Avenue, Suite 520, Miami, FL 33136, USA
| | - Michael E Davis
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology & Emory University School of Medicine, 313 Ferst Drive, Atlanta, GA 30332, USA
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Ahmed H, Anderson JB, Bates KE, Natarajan S, Ghanayem NS, Lannon CM, Brown DW. Characteristics of Interstage Death After Discharge from Stage I Palliation. Pediatr Cardiol 2021; 42:1372-1378. [PMID: 33948710 DOI: 10.1007/s00246-021-02621-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 04/15/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Interstage mortality (IM) remains high for patients with single-ventricle congenital heart disease (SVCHD) in the period between Stage 1 Palliation (S1P) and Glenn operation. We sought to characterize IM. METHODS This was a descriptive analysis of 2184 patients with SVCHD discharged home after S1P from 60 National Pediatric Cardiology Quality Improvement Collaborative sites between 2008 and 2015. Patients underwent S1P with right ventricle-pulmonary artery conduit (RVPAC), modified Blalock-Taussig-Thomas shunt (BTT), or Hybrid; transplants were excluded. RESULTS IM occurred in 153 (7%) patients (median gestational age 38 weeks, 54% male, 77% white), at 88 (IQR 60,136) days of life, and 39 (IQR 17,84) days after hospital discharge; 13 (8.6%) occurred ≤ 30 days after S1P. The mortality rate for RVPAC was lower (5.2%; 59/1138) than BTT (9.1%; 65/712) and Hybrid (20.1%; 27/134). More than half of deaths occurred at home (20%) or in the emergency department (33%). The remainder occurred while inpatient at center of S1P (cardiac intensive care unit 36%, inpatient ward 5%) or at a different center (5%). Fussiness and breathing problems were most often cited as harbingers of death; distance to surgical center was the biggest barrier cited to seeking care. Cause of death was unknown in 44% of cases overall; in the subset of patients who underwent post-mortem autopsy, the cause of death remained unknown in 30% of patients, with the most common diagnosis being low cardiac output. CONCLUSIONS Most IM occurred in the outpatient setting, with non-specific preceding symptoms and unknown cause of death. These data indicate the need for research to identify occult causes of death, including arrhythmia.
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Affiliation(s)
- Humera Ahmed
- Departments of Cardiology, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
| | | | - Katherine E Bates
- C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA
| | | | - Nancy S Ghanayem
- Cardiology, Advocate Children's Heart Institute, Oak Lawn, IL, USA
| | - Carole M Lannon
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - David W Brown
- Division of Cardiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA.
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Morell E, Miller MK, Lu M, Friedman KG, Breitbart RE, Reichman JR, McDermott J, Sleeper LA, Blume ED. Parent and Physician Understanding of Prognosis in Hospitalized Children With Advanced Heart Disease. J Am Heart Assoc 2021; 10:e018488. [PMID: 33442989 PMCID: PMC7955315 DOI: 10.1161/jaha.120.018488] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Background The unpredictable trajectory of pediatric advanced heart disease makes prognostication difficult for physicians and informed decision‐making challenging for families. This study evaluated parent and physician understanding of disease burden and prognosis in hospitalized children with advanced heart disease. Methods and Results A longitudinal survey study of parents and physicians caring for patients with advanced heart disease age 30 days to 19 years admitted for ≥7 days was performed over a 1‐year period (n=160 pairs). Percentage agreement and weighted kappa statistics were used to assess agreement. Median patient age was 1 year (interquartile range, 1–5), 39% had single‐ventricle lesions, and 37% were in the cardiac intensive care unit. Although 92% of parents reported understanding their child's prognosis “extremely well” or “well,” 28% of physicians thought parents understood the prognosis only “a little,” “somewhat,” or “not at all.” Better parent‐reported prognostic understanding was associated with greater preparedness for their child's medical problems (odds ratio, 4.7; 95% CI, 1.4–21.7, P=0.02). There was poor parent–physician agreement in assessing functional class, symptom burden, and likelihood of limitations in physical activity and learning/behavior; on average, parents were more optimistic. Many parents (47%) but few physicians (6%) expected the child to have normal life expectancy. Conclusions Parents and physicians caring for children with advanced heart disease differed in their perspectives regarding prognosis and disease burden. Physicians tended to underestimate the degree of parent‐reported symptom burden. Parents were less likely to expect limitations in physical activity, learning/behavior, and life expectancy. Combined interventions involving patient‐reported outcomes, parent education, and physician communication tools may be beneficial.
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Affiliation(s)
- Emily Morell
- Division of Cardiology Department of Pediatrics Children's Hospital Los Angeles Los Angeles CA
| | | | - Minmin Lu
- Department of Cardiology Boston Children's Hospital Boston MA
| | | | | | | | - Julie McDermott
- Department of Cardiology Boston Children's Hospital Boston MA
| | - Lynn A Sleeper
- Department of Cardiology Boston Children's Hospital Boston MA
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Wolfe KR, Liptzin DR, Brigham D, Kelly SL, Rafferty C, Albertz M, Younoszai AK, Di Maria MV. Relationships between Physiologic and Neuropsychologic Functioning after Fontan. J Pediatr 2020; 227:239-246. [PMID: 32687915 DOI: 10.1016/j.jpeds.2020.07.043] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 06/12/2020] [Accepted: 07/14/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To investigate potential relationships between neuropsychologic functioning and cardiac, gastroenterologic/hepatologic, and pulmonary complications in the single ventricle heart disease (SVHD) post-Fontan population. STUDY DESIGN Following the initiation of a Fontan Multidisciplinary Clinic, patients with SVHD were evaluated systematically according to a clinical care pathway, and data from multiple subspecialty evaluations were collected prospectively from 2016 to 2019. Biomarkers of cardiology, pulmonary, and hepatology/gastroenterology functioning were abstracted, along with neuropsychologic testing results. Bivariate correlations and regression analyses examined cross-sectional relationships between physiologic predictors and neuropsychologic outcomes. RESULTS The sample included a cohort of 68 youth with SVHD age 3-19 years, after Fontan palliation. Sleep-disordered breathing was related to poorer visual-motor integration skills (r = -0.33; P < .05) and marginally related to poorer executive functioning (r = -0.33; P = .05). Lower arterial blood oxygen content was related to poorer executive functioning (r = .45; P < .05). Greater atrioventricular valve regurgitation was related to lower parent-rated adaptive functioning (ρ = -0.34; P < .01). These results were maintained in regression analyses controlling for history of stroke and/or seizures. CONCLUSIONS We demonstrated associations between neuropsychologic functioning and potentially modifiable aspects of physiologic functioning in a prospectively evaluated cohort of patients with SVHD with Fontan physiology. Our findings emphasize the importance of multidisciplinary screening and care after a Fontan procedure and suggest avenues for intervention that may improve patient outcomes and quality of life.
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Affiliation(s)
- Kelly R Wolfe
- Section of Neurology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO.
| | - Deborah R Liptzin
- Section of Pulmonology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Dania Brigham
- Section of Gastroenterology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Sarah L Kelly
- Section of Cardiology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Carey Rafferty
- Section of Cardiology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Megan Albertz
- Section of Anesthesiology, University of Colorado School of Medicine, Aurora, CO
| | - Adel K Younoszai
- Section of Cardiology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Michael V Di Maria
- Section of Cardiology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
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Alphonso N, Angelini A, Barron DJ, Bellsham-Revell H, Blom NA, Brown K, Davis D, Duncan D, Fedrigo M, Galletti L, Hehir D, Herberg U, Jacobs JP, Januszewska K, Karl TR, Malec E, Maruszewski B, Montgomerie J, Pizzaro C, Schranz D, Shillingford AJ, Simpson JM. Guidelines for the management of neonates and infants with hypoplastic left heart syndrome: The European Association for Cardio-Thoracic Surgery (EACTS) and the Association for European Paediatric and Congenital Cardiology (AEPC) Hypoplastic Left Heart Syndrome Guidelines Task Force. Eur J Cardiothorac Surg 2020; 58:416-499. [DOI: 10.1093/ejcts/ezaa188] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Affiliation(s)
- Nelson Alphonso
- Queensland Pediatric Cardiac Service, Queensland Children’s Hospital, University of Queensland, Brisbane, QLD, Australia
| | - Annalisa Angelini
- Department of Cardiac, Thoracic Vascular Sciences and Public health, University of Padua Medical School, Padua, Italy
| | - David J Barron
- Department of Cardiovascular Surgery, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | | | - Nico A Blom
- Division of Pediatric Cardiology, Department of Pediatrics, Leiden University Medical Center, Leiden, Netherlands
| | - Katherine Brown
- Paediatric Intensive Care, Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Deborah Davis
- Department of Anesthesiology, Thomas Jefferson University, Philadelphia, PA, USA
- Nemours Cardiac Center, A.I. Du Pont Hospital for Children, Wilmington, DE, USA
| | - Daniel Duncan
- Nemours Cardiac Center, A.I. Du Pont Hospital for Children, Wilmington, DE, USA
| | - Marny Fedrigo
- Department of Cardiac, Thoracic Vascular Sciences and Public Health, University of Padua Medical School, Padua, Italy
| | - Lorenzo Galletti
- Unit of Pediatric Cardiac Surgery, Bambino Gesù Children's Hospital, Rome, Italy
| | - David Hehir
- Division of Cardiology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ulrike Herberg
- Department of Pediatric Cardiology, University Hospital Bonn, Bonn, Germany
| | | | - Katarzyna Januszewska
- Division of Pediatric Cardiac Surgery, University Hospital Muenster, Westphalian-Wilhelm’s-University, Muenster, Germany
| | | | - Edward Malec
- Division of Pediatric Cardiac Surgery, University Hospital Muenster, Westphalian-Wilhelm’s-University, Muenster, Germany
| | - Bohdan Maruszewski
- Department for Pediatric Cardiothoracic Surgery, Children's Memorial Health Institute, Warsaw, Poland
| | - James Montgomerie
- Department of Anesthesia, Birmingham Children’s Hospital, Birmingham, UK
| | - Christian Pizzaro
- Nemours Cardiac Center, A.I. Du Pont Hospital for Children, Wilmington, DE, USA
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Dietmar Schranz
- Pediatric Heart Center, Justus-Liebig University, Giessen, Germany
| | - Amanda J Shillingford
- Division of Cardiology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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Mahat U, Ahuja S, Talati R. Shunt thrombosis in pediatric patients undergoing staged cardiac reconstruction for cyanotic congenital heart disease. PROGRESS IN PEDIATRIC CARDIOLOGY 2020. [DOI: 10.1016/j.ppedcard.2019.101190] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Abstract
BACKGROUND The Fontan procedure is the final stage of surgical palliation for a single-ventricle circulation. Significant complications are common including rhythm disturbance necessitating implantation of a permanent pacemaker. This has been widely considered a negative prognostic indicator. METHODS This single-centre, retrospective case control study involved all patients who underwent the Fontan procedure at the Leeds Congenital Heart Unit between 1990 and 2015 and have had regular follow-up in Yorkshire and Humber, United Kingdom. 167 Fontan patients were identified of which 2 were excluded for having a pre-procedure pacemaker. Of the remainder, 23 patients required a pacemaker. Outcomes were survival, early and late complications, need for further intervention and oxygen saturation in long-term follow-up. RESULTS There was no difference in survival (30-day survival pacemaker 92.6%, sinus rhythm 90.5%, p = 0.66, 1-year pacemaker 11.1%, sinus rhythm 10.1%, p = 1). The pacemaker group was more likely to have cerebral or renal complications in the first-year post-procedure (acute kidney injury: sinus rhythm 0.8%, pacemaker 19.1%, p = 0.002). No difference was observed in longer term complications including protein losing enteropathy (sinus rhythm 3.5%, pacemaker 0% p = 1). There was no difference in saturations between the two groups at follow-up. Paced patients were more likely to have required further intervention, with a higher incidence of cardiopulmonary bypass procedures (sinus rhythm 6.3%, pacemaker 35%, p < 0.001). CONCLUSIONS Despite an increase in early complications and the need for further interventions, pacemaker requirement does not appear to affect long-term survival following the Fontan procedure.
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Fontan with lateral tunnel is associated with improved survival compared with extracardiac conduit. J Thorac Cardiovasc Surg 2019; 159:1480-1491.e2. [PMID: 31928823 DOI: 10.1016/j.jtcvs.2019.11.048] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 11/07/2019] [Accepted: 11/08/2019] [Indexed: 11/22/2022]
Abstract
OBJECTIVES The study aim was to compare Fontan patients undergoing lateral tunnel (LT) versus extracardiac conduit (ECC) technique. METHODS Fontan patients (LT vs ECC) from January 2000 to December 2017 were analyzed retrospectively. Baseline characteristics were analyzed as covariates. Primary outcomes (ie, mortality, Fontan failure, thrombosis, and pacemaker implantation) were compared using time-to-event models. Subgroup analysis including only initially fenestrated cases and propensity score matching were performed. RESULTS Eight hundred one Fontan patients: LT (n = 638) versus ECC (n = 163) were included. Median follow-up time was 4.8 years (range, 1.1-10.8 years). Baseline characteristics were similar except for age: LT versus ECC: 2.6 years (range, 2.2-3.2 years) versus 3.1 years (range, 2.6-4.7 years) (P < .01) and mean pulmonary artery pressure: LT versus ECC: 12 mm Hg (11-15 mm Hg) versus 11 mm Hg (10-13 mm Hg) (P < .05). Early mortality was significantly higher in ECC versus LT group (3.1%; vs 0.5%; P < .05). Freedom from death, heart transplantation and Fontan failure were significantly longer in LT vs ECC (P < .01). After correcting for age, diagnosis, surgical technique, surgeon, mean pulmonary artery pressure, and fenestration, the ECC group showed worse freedom from death (hazard ratio, 2.8; P < .01) and Fontan failure (hazard ratio, 3.0; P < .01). No difference in pacemaker implantation rate was demonstrated (P = .25). Early fenestration closure was associated with higher risk of early (hazard ratio, 30.5) and late mortality (hazard ratio, 3.5). After matching, log-rank tests showed significant differences between the 2 groups for Fontan failure at 5 and 10 years (P < .01) and mortality at 5 years (P = .02). CONCLUSIONS When compared with ECC, LT Fontan is associated with better short and midterm outcomes. Spontaneous fenestration closure is an independent risk factor for early/late mortality.
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Salve GG, Datar GM, Perumal G, Singh AAV, Ayer JG, Roberts P, Sholler GF, Cole AD, Pigott N, Loughran-Fowlds A, Weatherall A, Alahakoon TI, Orr Y, Nicholson IA, Winlaw DS. Impact of High-Risk Characteristics in Hypoplastic Left Heart Syndrome. World J Pediatr Congenit Heart Surg 2019; 10:475-484. [PMID: 31307299 DOI: 10.1177/2150135119852319] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Management of hypoplastic left heart syndrome (HLHS) presents many challenges. We describe our institutional outcomes for management of patients with HLHS over the past 12 years and highlight our strategy for those with highly restrictive/intact interatrial septum (R/I-IAS). METHODS Eighty-eight neonates with HLHS underwent surgical treatment, divided equally into Era-I (n = 44, April 2006 to February 2013) and Era-II (n = 44, March 2013 to June 2018). Up to 2013, all patients with R/I-IAS were delivered at an adjacent adult hospital and then moved to our hospital for intensive care and management. From 2014, these patients were delivered at a co-located theatre in our hospital with immediate atrial septectomy. The hybrid approach was occasionally used with preference for the Norwood procedure for suitable candidates. RESULTS One-year survival after Norwood procedure was 62.5% and 80% for Era-I and Era-II (P = not significant (ns)), respectively, and 41% of patients were categorized as high risk using conventional criteria. Survival at 1 year differed significantly between high-risk and standard-risk patients (P = 0.01). For high-risk patients, survival increased from 42% to 65% between eras (P = ns). In the R/I-IAS subgroup (n = 15), 11 underwent Norwood procedure after emergency atrial septectomy. Of these, seven born at the adjacent adult hospital had 40% survival to stage II versus 60% for the four born at the colocated theatre. Delivery in a colocated theatre reduced the birth-to-cardiopulmonary bypass median time from 445 (150-660) to 62 (52-71) minutes. CONCLUSION Reported surgical outcomes are comparable to multicenter reports and international databases. Proactive management for risk factors such as R/I-IAS may contribute to improved overall outcomes.
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Affiliation(s)
- Gananjay G Salve
- 1 Heart Centre for Children, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Gauri M Datar
- 1 Heart Centre for Children, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Gopinath Perumal
- 1 Heart Centre for Children, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Aakansha Ajay Vir Singh
- 1 Heart Centre for Children, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Julian G Ayer
- 1 Heart Centre for Children, The Children's Hospital at Westmead, Westmead, New South Wales, Australia.,2 Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Philip Roberts
- 1 Heart Centre for Children, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Gary F Sholler
- 1 Heart Centre for Children, The Children's Hospital at Westmead, Westmead, New South Wales, Australia.,2 Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Andrew D Cole
- 1 Heart Centre for Children, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Nick Pigott
- 3 Paediatric Intensive Care, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Alison Loughran-Fowlds
- 2 Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia.,4 Grace Centre for Newborn Intensive Care, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Andrew Weatherall
- 2 Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia.,5 Department of Anaesthetics, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - T Indika Alahakoon
- 2 Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia.,6 Department of Maternal Fetal Medicine, Westmead Hospital, Westmead, New South Wales, Australia
| | - Yishay Orr
- 1 Heart Centre for Children, The Children's Hospital at Westmead, Westmead, New South Wales, Australia.,2 Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Ian A Nicholson
- 1 Heart Centre for Children, The Children's Hospital at Westmead, Westmead, New South Wales, Australia.,2 Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - David S Winlaw
- 1 Heart Centre for Children, The Children's Hospital at Westmead, Westmead, New South Wales, Australia.,2 Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
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Rai V, Gładki M, Dudyńska M, Skalski J. Hypoplastic left heart syndrome [HLHS]: treatment options in present era. Indian J Thorac Cardiovasc Surg 2019; 35:196-202. [PMID: 33061005 PMCID: PMC7525540 DOI: 10.1007/s12055-018-0742-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 09/02/2018] [Accepted: 09/07/2018] [Indexed: 11/29/2022] Open
Abstract
Hypoplastic left heart syndrome (HLHS) is the most severe form of congenital heart defect (CHD). The first successful intervention for it was undertaken by Norwood in 1983. Since then, there have been much development in the pre, intra, and postoperative treatment option in staged palliative surgical procedures. Early diagnostic management, prenatal interventions, innovative diagnostic methods, constantly modified surgical techniques, and hybridization contribute to a significant progress in treatment options. This will allow for defining an optimal strategy of improving survival and quality of life in HLHS patients. The development of intervention cardiology makes possible the stepwise treatment of the defect with one operation only. The first and third stage may be done by hybrid or interventional methods, then only the second stage of treatment needs to be done surgically. The world experience and all the available literature says that the 1st-stage procedure could be done now safely either directly or with a bridge to Norwood followed by the stage 2 with a Glen or Hemi-Fontan and followed by a Fontan down the lane surgically.
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Affiliation(s)
- Vivek Rai
- Department of Pediatric Cardiac Surgery, Jagiellonian University Children’s Hospital, Ul. Wielicka 265, 30-663 Krakow, Poland
| | - Marcin Gładki
- Department of Pediatric Cardiac Surgery, Jagiellonian University Children’s Hospital, Ul. Wielicka 265, 30-663 Krakow, Poland
| | - Mirosława Dudyńska
- Department of Pediatric Cardiac Surgery, Jagiellonian University Children’s Hospital, Ul. Wielicka 265, 30-663 Krakow, Poland
| | - Janusz Skalski
- Department of Pediatric Cardiac Surgery, Jagiellonian University Children’s Hospital, Ul. Wielicka 265, 30-663 Krakow, Poland
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Mohammad Nijres B, Huntington JH, Baliulis G, Vettukattil JJ. Intracoronary recombinant tissue plasminogen activator in an infant with hypoplastic left heart syndrome and complete left main coronary artery thrombosis. Catheter Cardiovasc Interv 2019; 93:E381-E384. [PMID: 30702202 DOI: 10.1002/ccd.28092] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 12/27/2018] [Accepted: 12/29/2018] [Indexed: 11/10/2022]
Affiliation(s)
- Bassel Mohammad Nijres
- Congenital Heart Center; Spectrum Health Helen DeVos Children's Hospital; Grand Rapids Michigan
| | - John H. Huntington
- West Michigan Anesthesia; PC; Grand Rapids Michigan
- College of Human Medicine; Michigan State University; Grand Rapids Michigan
| | - Giedrius Baliulis
- Congenital Heart Center; Spectrum Health Helen DeVos Children's Hospital; Grand Rapids Michigan
- College of Human Medicine; Michigan State University; Grand Rapids Michigan
| | - Joseph J. Vettukattil
- Congenital Heart Center; Spectrum Health Helen DeVos Children's Hospital; Grand Rapids Michigan
- College of Human Medicine; Michigan State University; Grand Rapids Michigan
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Reagor JA, Clingan S, Kulat BT, Matte GS, Voss J, Tweddell JS. The Norwood Stage 1 procedure - conduct of perfusion: 2017 Survey results from NPC-QIC member institutions. Perfusion 2018; 33:667-678. [DOI: 10.1177/0267659118781173] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Hypoplastic left heart syndrome (HLHS) is a rare and severe congenital cardiac defect. Approximately 1000 infants are born with HLHS in the United States every year. Healthcare collaboratives over the last decade have focused on sharing patient experiences and techniques in an effort to improve outcomes. In 2010, cardiologists and patient families joined together to improve the care of HLHS patients by forming the National Pediatric Cardiology Quality Improvement Collaborative (NPC-QIC). Sixty-six of the approximately 110 institutions caring for patients with HLHS in the United States and Canada are now members of NPC-QIC. In 2017, cardiovascular perfusionists joined the collaborative as another specialty involved in the care of HLHS patients. Perfusionists and cardiac surgeons developed the collaborative’s first conduct of perfusion survey for the Norwood Stage 1 procedure, specifically targeting the provision of cardiopulmonary bypass for patients with HLHS. This manuscript discusses the results of this survey, unveiling a significant variance in the conduct of perfusion for this patient population.
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Affiliation(s)
- James A. Reagor
- Department of Cardiovascular Perfusion, Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Sean Clingan
- Department of Cardiovascular Perfusion, Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Bradley T. Kulat
- Department of Cardiovascular Surgery, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA
| | | | - Jordan Voss
- The Heart Center, Nationwide Children’s Hospital, Columbus, OH, USA
| | - James S. Tweddell
- Division of Cardiothoracic Surgery Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
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15
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Outcome of Norwood operation for hypoplastic left heart syndrome. Indian J Thorac Cardiovasc Surg 2018; 34:337-344. [PMID: 33060891 DOI: 10.1007/s12055-017-0603-1] [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: 06/01/2017] [Revised: 09/26/2017] [Accepted: 10/06/2017] [Indexed: 10/18/2022] Open
Abstract
Purpose The Norwood procedure, the first surgical step of staged palliation for hypoplastic left heart syndrome (HLHS), is also applied for other complex single ventricle lesions. This study aimed to evaluate the outcome of the Norwood operation in a single center over 4 years and to identify clinical and anatomic risk factors for overall mortality. Methods A retrospective review of the pediatric cardiovascular surgery database was performed to identify infants with HLHS who underwent NP (Norwood procedure) at our institution between January 2007 and December 2011. Our study population consisted of 85 patients with HLHS. Results Early mortality (30 days postoperative period) between January 2007 and December 2011 for Norwood operation was 7 (8.2%) out of 85 patient, and overall mortality was 24 (28.2%). Conclusion Our single-center experience shows that the Norwood operation can be performed for complex single ventricle lesions with similarly good early outcomes regardless of the underlying anatomy.
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Abstract
PURPOSE OF REVIEW Hypoplastic left heart syndrome (HLHS) is characterized by underdevelopment of the mitral valve, left ventricle, and aorta and is ultimately palliated with a single-ventricle repair. Universally fatal in infancy prior to the advent of modern surgical techniques, the majority of HLHS patients will now reach adulthood. However, despite improvements in early survival, the HLHS population continues to face significant morbidity and early mortality. This review delineates common sources of patient morbidity and highlights areas in need of additional research for this growing segment of the adult congenital heart disease population. RECENT FINDINGS It has become increasingly clear that palliated adult single ventricle patients, like those with HLHS, face significant life-long morbidity from elevated systemic venous pressures as a consequence of the Fontan procedure. Downstream organ dysfunction secondary to elevated Fontan pressures has the potential to significantly impact long-term management decisions, including strategies of organ allocation. Because of the presence of a morphologic systemic right ventricle, HLHS patients may be at even higher risk than other adult patients with a Fontan. Because the adult HLHS population continues to grow, recognition of common sources of patient morbidity and mortality is becoming increasingly important. A coordinated effort between patients and providers is necessary to address the many remaining areas of clinical uncertainty to help ensure continued improvement in patient prognosis and quality of life.
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Meza JM, Jaquiss RDB, Anderson BR, Moga MA, Kirklin JK, Sarris G, Williams WG, McCrindle BW. Current Practices in the Timing of Stage 2 Palliation. World J Pediatr Congenit Heart Surg 2017; 8:135-141. [PMID: 28329463 DOI: 10.1177/2150135116677253] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Mortality through single-ventricle palliation remains high and the effect of the timing of stage 2 palliation (S2P) is not well understood. We investigated current practice patterns in the timing of S2P across two professional societies and compared them to actual practice patterns from two databases of patients who underwent S2P. METHODS A ten-question survey was distributed to the members of the Congenital Heart Surgeons' Society (CHSS) and the European Congenital Heart Surgeons' Association (ECHSA). Results were summarized using descriptive statistics. Surgeon-reported preferences were compared to clinical data from the CHSS Critical Left Ventricular Outflow Tract Obstruction (LVOTO) Registry and the Pediatric Heart Network Single Ventricle Reconstruction (SVR) database. RESULTS Overall, 38% (88 of 232) of surgeons from 74 institutions responded, of which 70% (62 of 88) were CHSS members and 30% (26 of 88) were ECHSA members. Surgeons reported performing S2P at a median of five months after stage 1 (interquartile range [IQR]: 4.5-6), with no difference between CHSS and ECHSA surgeons. Surgeons reported performing nonelective S2P at a median of 4.5 months after stage 1 (IQR: 3.5-5.5), again with no difference by society. No difference existed between the surgeon-reported preferences and patient data in the Critical LVOTO and SVR databases for the timing of elective (5 vs 5.1 vs 5.3 months, P = .19) or nonelective S2P (4.5 vs 4.6 vs 4.2 months, P = .06). CONCLUSION There was a remarkable lack of variation in surgeon preferences regarding the timing of S2P. This may represent a natural standardization of practice across congenital heart surgery, which is notable, given the current lack of guidelines regarding the timing of S2P.
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Affiliation(s)
- James M Meza
- 1 John W. Kirklin/David Ashburn Fellow, Congenital Heart Surgeons' Society Data Center, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Robert D B Jaquiss
- 2 Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Brett R Anderson
- 3 Division of Cardiology, Department of Pediatrics, Morgan-Stanley Children's Hospital/New York Presbyterian Hospital, New York, NY, USA
| | - Michael-Alice Moga
- 4 Division of Critical Care Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - James K Kirklin
- 5 Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - George Sarris
- 6 Department of Pediatric Heart Surgery, IASO Children's Hospital, Athens, Greece
| | - William G Williams
- 7 Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Brian W McCrindle
- 8 Division of Pediatric Cardiology, The Hospital for Sick Children, Toronto, Ontario, Canada
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19
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Ohye RG, Schranz D, D'Udekem Y. Current Therapy for Hypoplastic Left Heart Syndrome and Related Single Ventricle Lesions. Circulation 2017; 134:1265-1279. [PMID: 27777296 DOI: 10.1161/circulationaha.116.022816] [Citation(s) in RCA: 122] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Universally fatal only 4 decades ago, the progress in the 3-stage palliation of hypoplastic left heart syndrome and related single right ventricular lesions has drastically improved the outlook for these patients. Although the stage II operation (hemi-Fontan or bidirectional Glenn) and stage III Fontan procedure have evolved into relatively low-risk operations, the stage I Norwood procedure remains one of the highest-risk and costliest common operations performed in congenital heart surgery. Yet, despite this fact, experienced centers now report hospital survivals of >90% for the Norwood procedure. This traditional 3-stage surgical palliation has seen several innovations in the past decade aimed at improving outcomes, particularly for the Norwood procedure. One significant change is a renewed interest in the right ventricle-to-pulmonary artery shunt as the source of pulmonary blood flow, rather than the modified Blalock-Taussig shunt for the Norwood. The multi-institutional Single Ventricle Reconstruction trial randomly assigned 555 patients to one or the other shunt, and these subjects continue to be followed closely as they now approach 10 years postrandomization. In addition to modifications to the Norwood procedure, the hybrid procedure, a combined catheter-based and surgical approach, avoids the Norwood procedure in the newborn period entirely. The initial hybrid procedure is then followed by a comprehensive stage II, which combines components of both the Norwood and the traditional stage II, and later completion of the Fontan. Proponents of this approach hope to improve not only short-term survival, but also potentially longer-term outcomes, such as neurodevelopment, as well. Regardless of the approach, traditional surgical staged palliation or the hybrid procedure, survivals have vastly improved, and large numbers of these patients are surviving not only through their Fontan in early childhood, but also into adolescence and young adulthood. As this population grows, it becomes increasingly important to understand the longer-term outcomes of these Fontan patients, not only in terms of survival, but also in terms of the burden of disease, neurodevelopmental outcomes, psychosocial development, and quality of life.
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Affiliation(s)
- Richard G Ohye
- From University of Michigan C. S. Mott Children's Hospital, Ann Arbor (R.G.O.); Pediatric Heart Center, Justus Liebig University Giessen, Germany (D.S.); and Department of Cardiac Surgery, Royal Children's Hospital, Melbourne, Australia (Y.D'U.).
| | - Dietmar Schranz
- From University of Michigan C. S. Mott Children's Hospital, Ann Arbor (R.G.O.); Pediatric Heart Center, Justus Liebig University Giessen, Germany (D.S.); and Department of Cardiac Surgery, Royal Children's Hospital, Melbourne, Australia (Y.D'U.)
| | - Yves D'Udekem
- From University of Michigan C. S. Mott Children's Hospital, Ann Arbor (R.G.O.); Pediatric Heart Center, Justus Liebig University Giessen, Germany (D.S.); and Department of Cardiac Surgery, Royal Children's Hospital, Melbourne, Australia (Y.D'U.)
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Urencio M, Greenleaf C, Salazar JD, Dodge-Khatami A. Resource and cost considerations in treating hypoplastic left heart syndrome. PEDIATRIC HEALTH MEDICINE AND THERAPEUTICS 2016; 7:149-153. [PMID: 29388599 PMCID: PMC5683290 DOI: 10.2147/phmt.s98327] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Hypoplastic left heart syndrome (HLHS) was a uniformly fatal diagnosis before 1983, when surgical treatment was first undertaken with the Norwood I operation as the first of 3-staged operations. Since then, operative survival rate of stage I has risen from 53% to over 90% in the current era, not only thanks to technical advances in surgery but also through prenatal diagnosis and imaging, enhanced cardiopulmonary bypass technology, better perioperative intensive care, and closer interstage monitoring. The improvements in patient outcomes achieved through rigorous multidisciplinary teamwork have come at a tremendous cost in manpower and resources, making HLHS still a challenge to all congenital heart programs, established or emerging. We review the various surgical steps to treat HLHS and their current expected outcomes, and put into perspective cost considerations compared to other more “simple” congenital heart defects.
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Affiliation(s)
| | | | - Jorge D Salazar
- Children's Heart Center, University of Mississippi Medical Center, Jackson, MS, USA
| | - Ali Dodge-Khatami
- Children's Heart Center, University of Mississippi Medical Center, Jackson, MS, USA
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Brown KL, Wray J, Knowles RL, Crowe S, Tregay J, Ridout D, Barron DJ, Cunningham D, Parslow R, Franklin R, Barnes N, Hull S, Bull C. Infant deaths in the UK community following successful cardiac surgery: building the evidence base for optimal surveillance, a mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2016. [DOI: 10.3310/hsdr04190] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundWhile early outcomes of paediatric cardiac surgery have improved, less attention has been given to later outcomes including post-discharge mortality and emergency readmissions.ObjectivesOur objectives were to use a mixed-methods approach to build an evidenced-based guideline for postdischarge management of infants undergoing interventions for congenital heart disease (CHD).MethodsSystematic reviews of the literature – databases used: MEDLINE (1980 to 1 February 2013), EMBASE (1980 to 1 February 2013), Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1981 to 1 February 2013), The Cochrane Library (1999 to 1 February 2013), Web of Knowledge (1980 to 1 February 2013) and PsycINFO (1980 to 1 February 2013). Analysis of audit data from the National Congenital Heart Disease Audit and Paediatric Intensive Care Audit Network databases pertaining to records of infants undergoing interventions for CHD between 1 January 2005 and 31 December 2010. Qualitative analyses of online discussion posted by 73 parents, interviews with 10 helpline staff based at user groups, interviews with 20 families whose infant either died after discharge or was readmitted urgently to intensive care, and interviews with 25 professionals from tertiary care and 13 professionals from primary and secondary care. Iterative multidisciplinary review and discussion of evidence incorporating the views of parents on suggestions for improvement.ResultsDespite a wide search strategy, the studies identified for inclusion in reviews related only to patients with complex CHD, for whom adverse outcome was linked to non-white ethnicity, lower socioeconomic status, comorbidity, age, complexity and feeding difficulties. There was evidence to suggest that home monitoring programmes (HMPs) are beneficial. Of 7976 included infants, 333 (4.2%) died postoperatively, leaving 7634 infants, of whom 246 (3.2%) experienced outcome 1 (postdischarge death) and 514 (6.7%) experienced outcome 2 (postdischarge death plus emergency intensive care readmissions). Multiple logistic regression models for risk of outcomes 1 and 2 had areas under the receiver operator curve of 0.78 [95% confidence interval (CI) 0.75 to 0.82] and 0.78 (95% CI 0.75 to 0.80), respectively. Six patient groups were identified using classification and regression tree analysis to stratify by outcome 2 (range 3–24%), which were defined in terms of neurodevelopmental conditions, high-risk cardiac diagnosis (hypoplastic left heart, single ventricle or pulmonary atresia), congenital anomalies and length of stay (LOS) > 1 month. Deficiencies and national variability were noted for predischarge training and information, the process of discharge to non-specialist services including documentation, paediatric cardiology follow-up including HMP, psychosocial support post discharge and the processes for accessing help when an infant becomes unwell.ConclusionsNational standardisation may improve discharge documents, training and guidance on ‘what is normal’ and ‘signs and symptoms to look for’, including how to respond. Infants with high-risk cardiac diagnoses, neurodevelopmental conditions or LOS > 1 month may benefit from discharge via their local hospital. HMP is suggested for infants with hypoplastic left heart, single ventricle or pulmonary atresia. Discussion of postdischarge deaths for infant CHD should occur at a network-based multidisciplinary meeting. Audit is required of outcomes for this stage of the patient journey.Future workFurther research may determine the optimal protocol for HMPs, evaluate the use of traffic light tools for monitoring infants post discharge and develop the analytical steps and processes required for audit of postdischarge metrics.Study registrationThis study is registered as PROSPERO CRD42013003483 and CRD42013003484.FundingThe National Institute for Health Research Health Services and Delivery Research programme. The National Congenital Heart Diseases Audit (NCHDA) and Paediatric Intensive Care Audit Network (PICANet) are funded by the National Clinical Audit and Patient Outcomes Programme, administered by the Healthcare Quality Improvement Partnership (HQIP). PICAnet is also funded by Welsh Health Specialised Services Committee; NHS Lothian/National Service Division NHS Scotland, the Royal Belfast Hospital for Sick Children, National Office of Clinical Audit Ireland, and HCA International. The study was supported by the National Institute for Health Research Biomedical Research Centre at Great Ormond Street Hospital for Children NHS Foundation Trust and University College London. Sonya Crowe was supported by the Health Foundation, an independent charity working to continuously improve the quality of health care in the UK.
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Affiliation(s)
- Katherine L Brown
- Cardiac Unit, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Jo Wray
- Cardiac Unit, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Rachel L Knowles
- Population Policy and Practice Programme, University College London Institute of Child Health, London, UK
| | - Sonya Crowe
- Clinical Operational Research Unit, University College London, London, UK
| | - Jenifer Tregay
- Cardiac Unit, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Deborah Ridout
- Population Policy and Practice Programme, University College London Institute of Child Health, London, UK
| | - David J Barron
- Cardiac Surgery Department, Birmingham Children’s Hospital NHS Foundation Trust, Birmingham, UK
| | - David Cunningham
- National Institute for Cardiovascular Outcomes Research, University College London, London, UK
| | - Roger Parslow
- Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Rodney Franklin
- Paediatric Cardiac Unit, Royal Brompton and Harefield Hospitals NHS Trust, London, UK
| | - Nick Barnes
- Department of Paediatrics, Northampton General Hospital NHS Trust, Northampton, UK
| | - Sally Hull
- Primary Care Department, Queen Mary University of London, London, UK
| | - Catherine Bull
- Cardiac Unit, Great Ormond Street Hospital NHS Foundation Trust, London, UK
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Brown DW, Mangeot C, Anderson JB, Peterson LE, King EC, Lihn SL, Neish SR, Fleishman C, Phelps C, Hanke S, Beekman RH, Lannon CM. Digoxin Use Is Associated With Reduced Interstage Mortality in Patients With No History of Arrhythmia After Stage I Palliation for Single Ventricle Heart Disease. J Am Heart Assoc 2016; 5:JAHA.115.002376. [PMID: 26755552 PMCID: PMC4859359 DOI: 10.1161/jaha.115.002376] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background Interstage mortality (IM) remains significant after stage 1 palliation (S1P) for single‐ventricle heart disease (SVD), with many deaths sudden and unexpected. We sought to determine whether digoxin use post‐S1P is associated with reduced IM, utilizing the multicenter database of the National Pediatric Cardiology Quality Improvement Collaborative (NPCQIC). Methods and Results From June 2008 to July 2013, 816 infants discharged after S1P from 50 surgical sites completed the interstage to stage II palliation, transplant, or IM. Arrhythmia during S1P hospitalization or discharge on antiarrhythmic medications were exclusions (n=270); 2 patients were lost to follow‐up. Two analyses were performed: (1) propensity‐score adjusted logistic regression with IM as outcome and (2) retrospective cohort analysis for patients discharged on digoxin versus not, matched for surgical site and other established IM risk factors. Of 544 study patients, 119 (21.9%) were discharged on digoxin. Logistic regression analysis with propensity score, site‐size group, and digoxin use as predictor variables showed an increased risk of IM in those not discharged on digoxin (odds ratio, 8.6; lower confidence limit, 1.9; upper confidence limit, 38.3; P<0.01). The retrospective cohort analysis for 60 patients on digoxin (matched for site of care, type of S1P, post‐S1P ECMO use, genetic syndrome, discharge feeding route, ventricular function, tricuspid regurgitation, and aortic arch gradient) showed 0% IM in the digoxin at discharge group and an estimated IM difference between the 2 groups of 9% (P=0.04). Conclusions Among SVD infants in the NPCQIC database discharged post‐S1P with no history of arrhythmia, use of digoxin at discharge was associated with reduced IM.
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Affiliation(s)
- David W Brown
- Department of Cardiology, Boston Children's Hospital, Boston, MA (D.W.B.)
| | - Colleen Mangeot
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH (C.M., J.B.A., E.C.K., S.H., R.H.B., C.M.L.)
| | - Jeffrey B Anderson
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH (C.M., J.B.A., E.C.K., S.H., R.H.B., C.M.L.)
| | | | - Eileen C King
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH (C.M., J.B.A., E.C.K., S.H., R.H.B., C.M.L.)
| | | | - Steven R Neish
- University of Texas Health Science Center, San Antonio, TX (S.R.N.)
| | | | | | - Samuel Hanke
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH (C.M., J.B.A., E.C.K., S.H., R.H.B., C.M.L.)
| | - Robert H Beekman
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH (C.M., J.B.A., E.C.K., S.H., R.H.B., C.M.L.)
| | - Carole M Lannon
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH (C.M., J.B.A., E.C.K., S.H., R.H.B., C.M.L.)
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Urcelay G, Arancibia F, Retamal J, Springmuller D, Clavería C, Garay F, Frangini P, González R, Heusser F, Arretz C, Zelada P, Becker P. [Hypoplastic left heart syndrome: 10 year experience with staged surgical management]. ACTA ACUST UNITED AC 2015; 87:121-8. [PMID: 26455701 DOI: 10.1016/j.rchipe.2015.07.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Revised: 06/11/2015] [Accepted: 07/01/2015] [Indexed: 10/22/2022]
Abstract
UNLABELLED Hypoplastic left heart syndrome (HLHS) is a lethal congenital heart disease in 95% of non-treated patients. Surgical staging is the main form of treatment, consisting of a 3-stage approach, beginning with the Norwood operation. Long term survival of treated patients is unknown in our country. OBJECTIVES 1) To review our experience in the management of all patients seen with HLHS between January 2000 and June 2012. 2) Identify risk factors for mortality. PATIENTS AND METHOD Retrospective analysis of a single institution experience with a cohort of patients with HLHS. Clinical, surgical, and follow-up records were reviewed. RESULTS Of the 76 patients with HLHS, 9 had a restrictive atrial septal defect (ASD), and 8 had an ascending aorta ≤2mm. Of the 65 out of 76 patients that were treated, 77% had a Norwood operation with pulmonary blood flow supplied by a right ventricle to pulmonary artery conduit, 17% had a Norwood with a Blalock-Taussig shunt, and 6% other surgical procedure. Surgical mortality at the first stage was 23%, and for Norwood operation 21.3%. For the period between 2000-2005, surgical mortality at the first stage was 36%, and between 2005-2010, 15% (P=.05). Actuarial survival was 64% at one year, and 57% at 5years. Using a multivariate analysis, a restrictive ASD and a diminutive aorta were high risk factors for mortality. CONCLUSIONS Our immediate and long term outcome for staged surgical management of HLHS is similar to that reported by large centres. There is an improvement in surgical mortality in the second half of our experience. Risk factors for mortality are also identified.
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Affiliation(s)
- Gonzalo Urcelay
- Departamento de Cardiología y Enfermedades Respiratorias, División de Pediatría, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile.
| | - Francisca Arancibia
- Departamento de Cardiología y Enfermedades Respiratorias, División de Pediatría, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Javiera Retamal
- Departamento de Cardiología y Enfermedades Respiratorias, División de Pediatría, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Daniel Springmuller
- Departamento de Cardiología y Enfermedades Respiratorias, División de Pediatría, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Cristián Clavería
- Departamento de Cardiología y Enfermedades Respiratorias, División de Pediatría, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Francisco Garay
- Departamento de Cardiología y Enfermedades Respiratorias, División de Pediatría, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Patricia Frangini
- Departamento de Cardiología y Enfermedades Respiratorias, División de Pediatría, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Rodrigo González
- División de Enfermedades Cardiovasculares, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Felipe Heusser
- Departamento de Cardiología y Enfermedades Respiratorias, División de Pediatría, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | | | - Pamela Zelada
- Departamento de Cardiología y Enfermedades Respiratorias, División de Pediatría, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Pedro Becker
- División de Enfermedades Cardiovasculares, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
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Murphy MO, Bellsham-Revell H, Morgan GJ, Krasemann T, Rosenthal E, Qureshi SA, Salih C, Austin CB, Anderson DR. Hybrid Procedure for Neonates With Hypoplastic Left Heart Syndrome at High-Risk for Norwood: Midterm Outcomes. Ann Thorac Surg 2015; 100:2286-90; discussion 2291-2. [PMID: 26433522 DOI: 10.1016/j.athoracsur.2015.06.098] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Revised: 05/17/2015] [Accepted: 06/26/2015] [Indexed: 01/08/2023]
Abstract
BACKGROUND Hybrid procedure offers patients with severe congenital heart disease an alternative initial procedure to conventional surgical reconstruction. We report the midterm outcomes of a cohort of neonates who had a hybrid procedure for variants of hypoplastic left heart syndrome because they were at high risk for the Norwood procedure. METHODS Between December 2005 and January 2013, 41 neonates underwent bilateral pulmonary artery banding followed by ductal stenting by means of a sternotomy at a median age of 6 days (range, 2 to 18 days) and weight of 2.6 kg (range, 1.5 to 3.7 kg). Thirty-five patients had hypoplastic left heart syndrome, and 6 patients had critical aortic stenosis with hypoplastic left ventricle. Primary indications for the hybrid procedure were low birth weight in 17 patients, hypoplastic left ventricle with the possibility of later biventricular repair in 6 patients, intact or near-intact atrial septum in 5 patients, and poor patient condition in 13 patients. Echocardiographic, angiographic, operative, and clinical data were reviewed. Outcomes were summarized with descriptive statistics and risk factors for mortality identified. RESULTS All but 6 patients had an antenatal diagnosis, and 24 patients were from other congenital cardiac centers. Nine patients had perioperative balloon aortic valvuloplasty, 1 patient had fetal balloon aortic valvuloplasty, and 17 patients had intervention to their atrial septum (41.4%). There were 9 inpatient deaths (21.9%) and 4 interstage deaths (9.8%) after the hybrid procedure. Twenty-eight patients subsequently underwent either the Norwood procedure (11 patients), combined stage I and II (14 patients), or biventricular repair (3 patients). No patient had heart transplantation. Among the patients who had combined stage I and II as a second procedure after the hybrid procedure, there were 2 early deaths, 1 late death before the Fontan, and 1 late death after the Fontan completion after combined stage I and II. All patients who had subsequent Norwood procedure were midterm survivors. Three of the 4 patients who had biventricular repair were midterm survivors. Overall survival was 56.1% at a median follow-up of 32.0 months. By univariate analysis, patient factors, intact or near-intact atrial septum, and aortic atresia were associated with nonsurvival. CONCLUSIONS Hybrid procedure as an alternative to the Norwood procedure offers good midterm survival in patients deemed at high risk for neonatal reconstruction.
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Affiliation(s)
- Michael O Murphy
- Department of Cardiology and Cardiac Surgery, Evelina London Children's Hospital, Guy's & St. Thomas' NHS Foundation Trust, London, United Kingdom.
| | - Hannah Bellsham-Revell
- Department of Cardiology and Cardiac Surgery, Evelina London Children's Hospital, Guy's & St. Thomas' NHS Foundation Trust, London, United Kingdom
| | - Gareth J Morgan
- Department of Cardiology and Cardiac Surgery, Evelina London Children's Hospital, Guy's & St. Thomas' NHS Foundation Trust, London, United Kingdom
| | - Thomas Krasemann
- Department of Cardiology and Cardiac Surgery, Evelina London Children's Hospital, Guy's & St. Thomas' NHS Foundation Trust, London, United Kingdom
| | - Eric Rosenthal
- Department of Cardiology and Cardiac Surgery, Evelina London Children's Hospital, Guy's & St. Thomas' NHS Foundation Trust, London, United Kingdom
| | - Shakeel A Qureshi
- Department of Cardiology and Cardiac Surgery, Evelina London Children's Hospital, Guy's & St. Thomas' NHS Foundation Trust, London, United Kingdom
| | - Caner Salih
- Department of Cardiology and Cardiac Surgery, Evelina London Children's Hospital, Guy's & St. Thomas' NHS Foundation Trust, London, United Kingdom
| | - Conal B Austin
- Department of Cardiology and Cardiac Surgery, Evelina London Children's Hospital, Guy's & St. Thomas' NHS Foundation Trust, London, United Kingdom
| | - David R Anderson
- Department of Cardiology and Cardiac Surgery, Evelina London Children's Hospital, Guy's & St. Thomas' NHS Foundation Trust, London, United Kingdom
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Siffel C, Riehle-Colarusso T, Oster ME, Correa A. Survival of Children With Hypoplastic Left Heart Syndrome. Pediatrics 2015; 136:e864-70. [PMID: 26391936 PMCID: PMC4663985 DOI: 10.1542/peds.2014-1427] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/10/2015] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To examine the survival of infants with hypoplastic left heart syndrome (HLHS) and potential influence of demographic and clinical characteristics on survival using population-based data. METHODS Infants with nonsyndromic HLHS (n = 212) born between 1979 and 2005 were identified through the Metropolitan Atlanta Congenital Defects Program. Vital status was ascertained through 2009 based on linkage with vital records. We estimated Kaplan-Meier survival probabilities stratified by select demographic and clinical characteristics. RESULTS The overall survival probability to 2009 was 24% and significantly improved over time: from 0% in 1979-1984 to 42% in 1999-2005. Survival probability was 66% during the first week, 27% during the first year of life, and 24% during the first 10 years. Survival of very low and low birth weight or preterm infants and those born in high-poverty neighborhoods was significantly poorer. For children with information on surgical intervention (n = 88), the overall survival was 52%, and preterm infants had significantly poorer survival (31%) compared with term infants (56%). For children who survived to 1 year of age, long-term survival was ∼90%. CONCLUSIONS Survival to adolescence of children with nonsyndromic HLHS born in metropolitan Atlanta has significantly improved in recent years, with those born full term, with normal birth weight, or in a low-poverty neighborhood having a higher survival probability. Survival beyond infancy to adolescence is high. A better understanding of the growing population of survivors with HLHS is needed to inform resource planning.
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Affiliation(s)
- Csaba Siffel
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia,College of Allied Health Sciences, Georgia Regents University, Augusta, Georgia
| | - Tiffany Riehle-Colarusso
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia;
| | - Matthew E. Oster
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia,Children's Healthcare of Atlanta, Emory University, Atlanta, Georgia
| | - Adolfo Correa
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia,Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi
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Abstract
PURPOSE OF REVIEW Much data exist concerning Norwood discharge mortality. Less is known about late survival. Examining the available data in light of the Single Ventricle Reconstruction trial is insightful as focus shifts toward long-term survival. RECENT FINDINGS Data from 2000 to 2001 demonstrated approximately 40-50% 10-year survival, 30-40% or less between 10 and 15 years. The shape of the curves was characteristic; the majority of deaths within the first year, followed by a late constant phase. Publications from 2001 to 2005 suggested that various combinations of technical and perioperative modifications allowed hospital discharge survivals as high as 90-94%. As results matured (2005-2010) a consistent message was that, although the shape of the newer curves was similar (highest hazard in the first 1 year), higher hospital survival shifted the later phase to yield better long-term survival (70-85% between 5 and 10 years). Some emphasized right ventricle-based shunts as a 'cause' of improving results. Since 2010, the Single Ventricle Reconstruction trial has matured and has increasingly shifted opinion away from the right ventricle shunt as a 'cause' of improved results. The survival of the right ventricle shunt group is slightly higher at 3 years, but the 1-year statistical significance has been lost and the two groups converge. As the Single Ventricle Reconstruction study was based on the interaction between randomized shunt and survival, the secondary and other endpoint analyses must be cautiously considered. SUMMARY The current English-language literature suggests a 60-80% 5-10 year survival expectation. The shape of the survival curve remains; the highest hazard remains the first year before a later, stable phase is reached. Rather than a 'magic bullet' theory surrounding one technique or practice, centers have differentially adopted various combinations to optimize Norwood survival. Optimizing interstage I survival is a challenge to further increase the percentage of patients reaching the late, stable phase.
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27
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Pushparajah K, Wong JK, Bellsham-Revell HR, Hussain T, Valverde I, Bell A, Tzifa A, Greil G, Simpson JM, Kutty S, Razavi R. Magnetic resonance imaging catheter stress haemodynamics post-Fontan in hypoplastic left heart syndrome. Eur Heart J Cardiovasc Imaging 2015; 17:644-51. [PMID: 26188193 DOI: 10.1093/ehjci/jev178] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2015] [Accepted: 06/18/2015] [Indexed: 11/13/2022] Open
Abstract
AIMS Exercise limitation is common post-Fontan. Hybrid X-ray and magnetic resonance imaging (XMR) catheterization allows haemodynamic assessment by means of measurement of ventricular volumes and flow in major vessels with simultaneous invasive pressures. We aim to assess haemodynamic response to stress in patients with hypoplastic left heart syndrome (HLHS) post-Fontan. METHODS AND RESULTS Prospective study of 13 symptomatic children (NHYA 2) with HLHS post-Fontan using XMR catheterization. Three conditions were applied: baseline (Stage 1), dobutamine at 10 µg/kg/min (Stage 2), and dobutamine at 20 µg/kg/min (Stage 3). Seven consecutive patients received inhaled nitric oxide (iNO) at peak stress. Control MRI data were from normal healthy adults. In the HLHS patients, baseline mean pulmonary vascular resistance (PVR) was 1.51 ± 0.59 WU m(2) and aortopulmonary collateral flow was 17.7 ± 13.6% of systemic cardiac output. Mean right ventricular end-diastolic pressure was 6.7 ± 2.5 mmHg which did not rise with stress. Cardiac index (CI) increased at Stage 2 in HLHS (40%) and controls (61%) but continued to increase at Stage 3 only in controls (19%) but not in HLHS. The blunted rise in CI in HLHS was due to a continuing fall in end-diastolic volume throughout stress, with no significant change in PVR or CI at peak stress in response to iNO. CONCLUSION Cardiac output post-Fontan in HLHS at peak stress is blunted due to a limitation in preload which is not responsive to inhaled pulmonary vasodilators in the setting of normal PVR.
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Affiliation(s)
- Kuberan Pushparajah
- Division of Imaging Sciences, King's College London BHF Centre, NIHR Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust, London, UK Department of Congenital Heart Disease, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - James K Wong
- Division of Imaging Sciences, King's College London BHF Centre, NIHR Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Hannah R Bellsham-Revell
- Department of Congenital Heart Disease, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Tarique Hussain
- Division of Imaging Sciences, King's College London BHF Centre, NIHR Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust, London, UK Department of Congenital Heart Disease, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Israel Valverde
- Division of Imaging Sciences, King's College London BHF Centre, NIHR Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Aaron Bell
- Department of Congenital Heart Disease, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Aphrodite Tzifa
- Division of Imaging Sciences, King's College London BHF Centre, NIHR Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Gerald Greil
- Division of Imaging Sciences, King's College London BHF Centre, NIHR Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust, London, UK Department of Congenital Heart Disease, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - John M Simpson
- Division of Imaging Sciences, King's College London BHF Centre, NIHR Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust, London, UK Department of Congenital Heart Disease, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Shelby Kutty
- University of Nebraska/Creighton University Joint Division of Pediatric Cardiology, Omaha, NE, USA
| | - Reza Razavi
- Division of Imaging Sciences, King's College London BHF Centre, NIHR Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust, London, UK Department of Congenital Heart Disease, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK Paediatric Cardiovascular Sciences, Rayne Institute, King's College London and Evelina London Children's Hospital, Westminster Bridge Road, London SE1 7EH, UK
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28
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Lahm H, Schön P, Doppler S, Dreßen M, Cleuziou J, Deutsch MA, Ewert P, Lange R, Krane M. Tetralogy of Fallot and Hypoplastic Left Heart Syndrome - Complex Clinical Phenotypes Meet Complex Genetic Networks. Curr Genomics 2015; 16:141-58. [PMID: 26069455 PMCID: PMC4460219 DOI: 10.2174/1389202916666150303232520] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Revised: 02/28/2015] [Accepted: 03/03/2015] [Indexed: 01/06/2023] Open
Abstract
In many cases congenital heart disease (CHD) is represented by a complex phenotype and
an array of several functional and morphological cardiac disorders. These malformations will be
briefly summarized in the first part focusing on two severe CHD phenotypes, hypoplastic left heart
syndrome (HLHS) and tetralogy of Fallot (TOF). In most cases of CHD the genetic origin remains
largely unknown, though the complexity of the clinical picture strongly argues against a dysregulation which can be attributed
to a single candidate gene but rather suggests a multifaceted polygenetic origin with elaborate interactions. Consistent
with this idea, genome-wide approaches using whole exome sequencing, comparative sequence analysis of multiplex
families to identify de novo mutations and global technologies to identify single nucleotide polymorphisms, copy
number variants, dysregulation of the transcriptome and epigenetic variations have been conducted to obtain information
about genetic alterations and potential predispositions possibly linked to the occurrence of a CHD phenotype. In the second
part of this review we will summarize and discuss the available literature on identified genetic alterations linked to
TOF and HLHS.
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Affiliation(s)
- Harald Lahm
- Department of Cardiovascular Surgery, Division of Experimental Surgery, German Heart Center Munich, Technische Universität München, Munich Heart Alliance, D-80636 Munich, Germany
| | - Patric Schön
- Department of Paediatric Cardiology and Congenital Heart Defects, German Heart Center Munich, Technische Universität München, D-80636 Munich, Germany
| | - Stefanie Doppler
- Department of Cardiovascular Surgery, Division of Experimental Surgery, German Heart Center Munich, Technische Universität München, Munich Heart Alliance, D-80636 Munich, Germany
| | - Martina Dreßen
- Department of Cardiovascular Surgery, Division of Experimental Surgery, German Heart Center Munich, Technische Universität München, Munich Heart Alliance, D-80636 Munich, Germany
| | - Julie Cleuziou
- Department of Cardiovascular Surgery, Division of Experimental Surgery, German Heart Center Munich, Technische Universität München, Munich Heart Alliance, D-80636 Munich, Germany
| | - Marcus-André Deutsch
- Department of Cardiovascular Surgery, Division of Experimental Surgery, German Heart Center Munich, Technische Universität München, Munich Heart Alliance, D-80636 Munich, Germany
| | - Peter Ewert
- Department of Paediatric Cardiology and Congenital Heart Defects, German Heart Center Munich, Technische Universität München, D-80636 Munich, Germany; ; DZHK (German Center for Cardiovascular Research) - partner site Munich Heart Alliance, Munich, Germany
| | - Rüdiger Lange
- Department of Cardiovascular Surgery, Division of Experimental Surgery, German Heart Center Munich, Technische Universität München, Munich Heart Alliance, D-80636 Munich, Germany; ; DZHK (German Center for Cardiovascular Research) - partner site Munich Heart Alliance, Munich, Germany
| | - Markus Krane
- Department of Cardiovascular Surgery, Division of Experimental Surgery, German Heart Center Munich, Technische Universität München, Munich Heart Alliance, D-80636 Munich, Germany; ; DZHK (German Center for Cardiovascular Research) - partner site Munich Heart Alliance, Munich, Germany
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Unexpected deaths and unplanned re-admissions in infants discharged home after cardiac surgery: a systematic review of potential risk factors. Cardiol Young 2015; 25:839-52. [PMID: 25547262 DOI: 10.1017/s1047951114002492] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Babies with CHDs are a particularly vulnerable population with significant mortality in their 1st year. Although most deaths occur in the hospital within the early postoperative period, around one-fifth of postoperative deaths in the 1st year of life may occur after hospital discharge in infants who have undergone apparently successful cardiac surgery. Aim To systematically review the published literature and identify risk factors for adverse outcomes, specifically deaths and unplanned re-admissions, following hospital discharge after infant surgery for life-threatening CHDs. METHODS A systematic search was conducted in MEDLINE, EMBASE, CINAHL, Cochrane Library, Web of Knowledge, and PsycINFO electronic databases, supplemented by manual searching of conference abstracts. RESULTS A total of 15 studies were eligible for inclusion. Almost exclusively, studies were conducted in single US centres and focussed on children with complex single ventricle diagnoses. A wide range of risk factors were evaluated, and those more frequently identified as having a significant association with higher mortality or unplanned re-admission risk were non-Caucasian ethnicity, lower socio-economic status, co-morbid conditions, age at surgery, operative complexity and procedure type, and post-operative feeding difficulties. CONCLUSIONS Studies investigating risk factors for adverse outcomes post-discharge following diverse congenital heart operations in infants are lacking. Further research is needed to systematically identify higher risk groups, and to develop interventions targeted at supporting the most vulnerable infants within an integrated primary and secondary care pathway.
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Davidson J, Gringras P, Fairhurst C, Simpson J. Physical and neurodevelopmental outcomes in children with single-ventricle circulation. Arch Dis Child 2015; 100:449-53. [PMID: 25480924 DOI: 10.1136/archdischild-2014-306449] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Accepted: 11/14/2014] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To investigate longer-term physical and neurodevelopmental outcomes of patients with hypoplastic left heart syndrome (HLHS) compared with other patients with functionally single-ventricle circulation surviving beyond the age of 10 years. DESIGN A retrospective, observational study from a UK tertiary centre for paediatric cardiology. RESULTS 58 patients with HLHS and 44 non-HLHS patients with single-ventricle physiology were included. Subjective reduction in exercise tolerance was reported in 72% (95% CI 61% to 84%) of patients with HLHS and 45% (31% to 60%) non-HLHS patients. Compared with non-HLHS patients, educational concerns were reported more frequently in patients with HLHS, 41% (29% to 54%) vs 23% (10% to 35%), as was a diagnosis of a behaviour disorder (autism or attention deficit hyperactivity disorder) 12% (4% to 21%) vs 0%, and referral to other specialist services 67% (55% to 79%) vs 48% (33% to 63%). CONCLUSIONS Within a group of young people with complex congenital heart disease, those with HLHS are likely to have worse physical, psychological and educational outcomes.
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Affiliation(s)
| | - Paul Gringras
- Department of Paediatric Neurology, Evelina London Children's Hospital, Guy's and St Thomas' NHS Fiundation Trust, London, UK
| | - Charlie Fairhurst
- Department of Paediatric Neurology, Evelina London Children's Hospital, Guy's and St Thomas' NHS Fiundation Trust, London, UK
| | - John Simpson
- Department of Congenital Heart Disease, Evelina London Children's Hospital, Guy's and St Thomas' NHS Fiundation Trust, London, UK
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Brown DW, Cohen KE, O'Brien P, Gauvreau K, Klitzner TS, Beekman RH, Kugler JD, Martin GR, Neish SR, Rosenthal GL, Lannon C, Jenkins KJ. Impact of prenatal diagnosis in survivors of initial palliation of single ventricle heart disease: analysis of the National Pediatric Cardiology Quality Improvement Collaborative database. Pediatr Cardiol 2015; 36:314-21. [PMID: 25135602 DOI: 10.1007/s00246-014-1005-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Accepted: 08/07/2014] [Indexed: 11/30/2022]
Abstract
Among infants with single ventricle congenital heart disease (SVD) requiring Stage I palliation (S1P), the impact of prenatal diagnosis (PD) on outcomes has been variably characterized. We investigated the impact of PD in a large multi-center cohort of survivors of S1P in the National Pediatric Cardiology Quality Improvement Collaborative (NPCQIC) registry. Retrospective analysis of demographic and outcomes data among infants enrolled in the NPCQIC database; eligibility includes SVD requiring S1P and survival to discharge. From 43 contributing surgical centers, 591 infants had data available through time of BDG (519) or interstage death (55). Median gestational age was 39 weeks (31-46), and 66% had variants of hypoplastic left heart syndrome. PD was made in 445 (75%), with significant variation by center (p = 0.004). While infants with PD had slightly lower gestational age at birth (p < 0.001), there were no differences in birth weight, the presence of major syndromes or other organ system anomalies. Those without PD were more likely to have atrioventricular valve regurgitation (p = .002), ventricular dysfunction (p = 0.06), and pre-operative risk factors including acidosis (p < 0.001), renal insufficiency (p = 0.007), and shock (p = 0.05). Post-operative ventilation was shorter in the PD group (9 vs. 12 d, p = 0.002). Other early post-operative outcomes, interstage course, and outcomes at BDG were similar between groups. In a large cohort of infants with SVD surviving to hospital discharge after S1P, PD showed significant inter-site variation and was associated with improved pre-operative status and shorter duration of mechanical ventilation. The significance of such associations merits further study.
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Affiliation(s)
- David W Brown
- Departments of Cardiology and Cardiac Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA,
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32
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Başaran M, Tunçer E, Güzelmeriç F, Cine N, Oner N, Yildirim A, Savluk O, Tüzün B, Ceyran H. Introduction to a Norwood program in an emerging economy: learning curve of a single center. Heart Surg Forum 2015; 16:E313-8. [PMID: 24370799 DOI: 10.1532/hsf98.2013222] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND There has been a notable improvement in the outcome of stage 1 palliation for hypoplastic left heart syndrome (HLHS) in recent years. Nevertheless, developing a new Norwood program requires a steep learning curve, especially in emerging economies where rapid population growth brings a high volume of patients but, on the other hand, resources are limited. In this paper we aimed to summarize the initial results of a single center. METHODS Hospital records of 21 patients were reviewed for all patients having a stage 1 palliation procedure for HLHS between May 2011 and May 2013. There were 13 male (62%) and 8 female (38%) patients. Median age was 14 days (range, 4-74 days) and median weight was 3030 g (2600-3900 g). HLHS was defined as mitral or aortic stenosis or atresia (or both) in the presence of normally related great vessels and a hypoplastic left ventricle. Transthoracic echocardiography was the diagnostic modality used in all patients. All procedures but one were performed using an antegrade selective cerebral perfusion method and moderate hypothermia. Cerebral perfusion was monitored with cerebral oximetry in all patients. Modified ultrafiltration was routinely used in all patients. RESULTS Overall hospital mortality was 47.6% (n = 10). Mortality rates considerably decreased from the first year to second year (69% and 12.5% respectively). No risk factors were identified for mortality. CONCLUSIONS Surgical palliation of neonates with hypoplastic left heart syndrome continues to be a challenge. To decrease the overall mortality nationwide and improve outcomes, a referral center with a dedicated team is necessary in emerging economies.
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Affiliation(s)
- Murat Başaran
- Department of Pediatric Cardiac Surgery, Kosuyolu Heart Center, Istanbul, Turkey
| | - Eylem Tunçer
- Department of Pediatric Cardiac Surgery, Kosuyolu Heart Center, Istanbul, Turkey
| | - Füsun Güzelmeriç
- Department of Anesthesiology and Reanimation, Kosuyolu Heart Center, Istanbul, Turkey
| | - Nihat Cine
- Department of Pediatric Cardiac Surgery, Kosuyolu Heart Center, Istanbul, Turkey
| | - Naci Oner
- Department of Pediatric Cardiology, Kosuyolu Heart Center, Istanbul, Turkey
| | - Ayşe Yildirim
- Department of Pediatric Cardiology, Kosuyolu Heart Center, Istanbul, Turkey
| | - Omer Savluk
- Department of Anesthesiology and Reanimation, Kosuyolu Heart Center, Istanbul, Turkey
| | - Behzat Tüzün
- Department of Pediatric Cardiac Surgery, Kosuyolu Heart Center, Istanbul, Turkey
| | - Hakan Ceyran
- Department of Pediatric Cardiac Surgery, Kosuyolu Heart Center, Istanbul, Turkey
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Schranz D, Bauer A, Reich B, Steinbrenner B, Recla S, Schmidt D, Apitz C, Thul J, Valeske K, Bauer J, Müller M, Jux C, Michel-Behnke I, Akintürk H. Fifteen-year single center experience with the "Giessen Hybrid" approach for hypoplastic left heart and variants: current strategies and outcomes. Pediatr Cardiol 2015; 36:365-73. [PMID: 25179460 PMCID: PMC4303711 DOI: 10.1007/s00246-014-1015-2] [Citation(s) in RCA: 107] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Accepted: 08/22/2014] [Indexed: 11/28/2022]
Abstract
Presented is a retrospective outcome study of a 15-year single institutional experience with a contemporary cohort of patients with hypoplastic left heart syndrome and complex that underwent a "Giessen Hybrid" stage I as initial palliation. Hybrid approach consisting of surgical bilateral pulmonary artery banding and percutaneous duct stenting with or without atrial septum manipulation was developed from a rescue approach to a first-line procedure. Comprehensive Aristotle score defined pre-operative condition. Fifteen-year follow-up mortality is reported as occurring within the staged univentricular palliation or before and after biventricular repair. Hybrid stage I was performed in 154 patients; 107 should be treated by single ventricle palliation, 33 by biventricular repair (BVR), 7 received heart transplantation, and 7 were treated by comfort care, respectively. Overall 34 children died. The Aristotle score (mean value 18.2 ± 3) classified for univentricular circulations in newborns did not have statistical impact on the outcome. Two patients died during stage I (1.2%), and the interstage I mortality was 6.7%, and stage II mortality 9%, respectively. Stage III was up to now performed in 57 patients without mortality. At 1 year, the overall unadjusted survival of HLHS and variants was 84% and following BVR 89%, respectively. The Fifteen-year survival rate for HLHS and variants was 77%, with no significant impact of birth weight of less than 2.5 kg. In conclusion, Hybrid stage I fulfilled the criteria of life-saving approach. In our institution, Hybrid procedure replaced Norwood-staged palliation with a considerable mid- and long-term survival rate. Considering interstage mortality close surveillance is mandatory.
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Affiliation(s)
- Dietmar Schranz
- Pediatric Heart Center, Justus-Liebig University, Feulgenstr. 12, 30385, Giessen, Germany,
| | - Anna Bauer
- Pediatric Heart Center, Justus-Liebig University, Feulgenstr. 12, 30385 Giessen, Germany
| | - Bettina Reich
- Pediatric Heart Center, Justus-Liebig University, Feulgenstr. 12, 30385 Giessen, Germany
| | - Blanka Steinbrenner
- Pediatric Heart Center, Justus-Liebig University, Feulgenstr. 12, 30385 Giessen, Germany
| | - Sabine Recla
- Pediatric Heart Center, Justus-Liebig University, Feulgenstr. 12, 30385 Giessen, Germany
| | - Dorle Schmidt
- Pediatric Heart Center, Justus-Liebig University, Feulgenstr. 12, 30385 Giessen, Germany
| | - Christian Apitz
- Pediatric Heart Center, Justus-Liebig University, Feulgenstr. 12, 30385 Giessen, Germany
| | - Josef Thul
- Pediatric Heart Center, Justus-Liebig University, Feulgenstr. 12, 30385 Giessen, Germany
| | - Klaus Valeske
- Pediatric Heart Center, Justus-Liebig University, Feulgenstr. 12, 30385 Giessen, Germany
| | - Jürgen Bauer
- Pediatric Heart Center, Justus-Liebig University, Feulgenstr. 12, 30385 Giessen, Germany
| | - Matthias Müller
- Pediatric Heart Center, Justus-Liebig University, Feulgenstr. 12, 30385 Giessen, Germany
| | - Christian Jux
- Pediatric Heart Center, Justus-Liebig University, Feulgenstr. 12, 30385 Giessen, Germany
| | - Ina Michel-Behnke
- Pediatric Heart Center, Justus-Liebig University, Feulgenstr. 12, 30385 Giessen, Germany
| | - Hakan Akintürk
- Pediatric Heart Center, Justus-Liebig University, Feulgenstr. 12, 30385 Giessen, Germany
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Albanese SB, Zannini LV, Perri G, Crupi G, Turinetto B, Pongiglione G. "Baby Heart Project": the Italian project for accreditation and quality management in pediatric cardiology and cardiac surgery. Pediatr Cardiol 2014; 35:1162-73. [PMID: 24880465 DOI: 10.1007/s00246-014-0910-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2014] [Accepted: 03/26/2014] [Indexed: 11/29/2022]
Abstract
Optimization of the relationship between the supply and the demand for medical services should ideally be taken into consideration for the planning within each national Health System. Although government national health organizations embrace this policy specifically, the contribution of expert committees (under the scientific societies' guarantee in any specific medical field) should be advocated for their capability to collect and analyze the data reported by the various national institutions. In addition, these committees have the competence to analyze the need for the resources necessary to the operation of these centers. The field of pediatric cardiology and cardiac surgery may represent a model of clinical governance of particular interest with regard to programming and to a definition of the quality standards that may be extended to highly specialized institutions and ideally to the entire Health System. The "Baby Heart Project," which represents a model of governance and clinical quality in the field of pediatric cardiology and cardiac surgery, was born from the spontaneous aggregation of a committee of experts, supported by duly appointed Italian Scientific Societies and guided by a national agency for accreditation. The ultimate aim is to standardize both procedures and results for future planning within the national Health System.
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Affiliation(s)
- Sonia B Albanese
- Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital IRCCS, P.zza S. Onofrio, 4-00165, Rome, Italy,
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Bergemann A, Hansen JH, Rotermann I, Voges I, Scheewe J, Otto-Morris C, Geiger F, Kramer HH. Neuropsychological performance of school-aged children after staged surgical palliation of hypoplastic left heart syndrome. Eur J Cardiothorac Surg 2014; 47:803-11. [DOI: 10.1093/ejcts/ezu299] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Accepted: 06/26/2014] [Indexed: 11/12/2022] Open
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Ishii Y, Inamura N, Kayatani F, Iwai S, Kawata H, Arakawa H, Kishimoto H. Evaluation of bilateral pulmonary artery banding for initial palliation in single-ventricle neonates and infants: risk factors for mortality before the bidirectional Glenn procedure. Interact Cardiovasc Thorac Surg 2014; 19:807-11. [DOI: 10.1093/icvts/ivu240] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Abstract
AIM To analyse the current practice and contribution of catheter interventions in the staged management of patients with hypoplastic left heart syndrome. METHODS This study is a retrospective case note review of 527 patients undergoing staged Norwood/Fontan palliation at a single centre between 1993 and 2010. Indications and type of catheter interventions were reviewed over a median follow-up period of 7.5 years. RESULTS A staged Norwood/Fontan palliation for hypoplastic left heart syndrome was performed in 527 patients. The 30-day survival rate after individual stages was 76.5% at Stage I, 96.3% at Stage II, and 99.4% at Stage III. A total of 348 interventions were performed in 189 out of 527 patients. Freedom from catheter intervention in survivors was 58.2% before Stage II and 46.7% before Stage III. Kaplan-Meier freedom from intervention post Fontan completion was 55% at 10.8 years of follow-up. Post-stage I interventions were mostly directed to relieve aortic arch obstruction--84 balloon angioplasties--and augment pulmonary blood flow--15 right ventricle-to-pulmonary conduit interventions; post-Stage II interventions centred on augmenting size of the left pulmonary artery--73 procedures and abolishing systemic venous collaterals--32 procedures. After Stage III, the focus was on manipulating the size of the fenestration--42 interventions--and the left pulmonary artery -31 procedures. CONCLUSION Interventional cardiac catheterisation constitutes an integral part in the staged palliative management of patients with hypoplastic left heart syndrome. Over one-third (37%) of patients undergoing staged palliation required catheter intervention over the follow-up period.
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Wilkinson KL, Brunskill SJ, Doree C, Trivella M, Gill R, Murphy MF. Red cell transfusion management for patients undergoing cardiac surgery for congenital heart disease. Cochrane Database Syst Rev 2014; 2014:CD009752. [PMID: 24510598 PMCID: PMC11066839 DOI: 10.1002/14651858.cd009752.pub2] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Congenital heart disease is the most commonly diagnosed neonatal congenital condition. Without surgery, only 30% to 40% of patients affected will survive to 10 years old. Mortality has fallen since the 1990s with 2006 to 2007 figures showing surgical survival at one year of 95%. Patients with congenital heart disease are potentially exposed to red cell transfusion at many points in the surgical pathway. There are a number of risks associated with red cell transfusion that may be translated into increased patient morbidity and mortality. OBJECTIVES To evaluate the effects of red cell transfusion on mortality and morbidity on patients with congenital heart disease at the time of cardiac surgery. SEARCH METHODS We searched 11 bibliographic databases and three ongoing trials databases including the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 5, 2013), MEDLINE (Ovid, 1950 to 11 June 2013), EMBASE (Ovid, 1980 to 11 June 2013), ClinicalTrials.gov, World Health Organization (WHO) ICTRP and the ISRCTN Register (to June 2013). We also searched references of all identified trials, relevant review articles and abstracts from between 2006 and 2010 of the most relevant conferences. We did not limit the searches by language of publication. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing red cell transfusion interventions in patients undergoing cardiac surgery for congenital heart disease. We included participants of any age (neonates, paediatrics and adults) and with any type of congenital heart disease (cyanotic or acyanotic). We excluded patients with congenital heart disease undergoing non-cardiac surgery. No co-morbidities were excluded. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial quality and extracted data. We contacted study authors for additional information. MAIN RESULTS We identified 11 trials (862 participants). All trials were in neonatal or paediatric populations. The trials covered only three areas of interest: restrictive versus liberal transfusion triggers (two trials), leukoreduction versus non-leukoreduction (two trials) and standard versus non-standard cardiopulmonary bypass (CPB) prime (seven trials). Owing to the clinical diversity in the participant groups (cyanotic (three trials), acyanotic (four trials) or mixed (four trials)) and the intervention groups, it was not appropriate to pool data in a meta-analysis. No study reported data for all the outcomes of interest to this review. Risk of bias was mixed across the included trials, with only attrition bias being low across all trials. Blinding of study personnel and participants was not always possible, depending on the intervention being used.Five trials (628 participants) reported the primary outcome: 30-day mortality. In three trials (a trial evaluating restrictive and liberal transfusion (125 participants), a trial of cell salvage during CPB (309 participants) and a trial of washed red blood cells during CPB (128 participants)), there was no clear difference in mortality at 30 days between the intervention arms. In two trials comparing standard and non-standard CPB prime, there were no deaths in either randomised group. Long-term mortality was similar between randomised groups in one trial each comparing restrictive and liberal transfusion or standard and non-standard CPB prime.Four trials explored a range of adverse effects following red cell transfusion. Kidney failure was the only adverse event that was significantly different: patients receiving cell salvaged red blood cells during CPB were less likely to have renal failure than patients not exposed to cell salvage (risk ratio (RR) 0.26, 95% confidence interval (CI) 0.09 to 0.79, 1 study, 309 participants). There was insufficient evidence to determine whether there was a difference between transfusion strategies for any other severe adverse events.The duration of mechanical ventilation was measured in seven trials (768 participants). Overall, there was no consistent difference in the duration of mechanical ventilation between the intervention and control arms.The duration of intensive care unit (ICU) stay was measured in six trials (459 participants). There was no clear difference in the duration of ICU stay between the intervention arms in the transfusion trigger and leukoreduction trials. In the standard versus non-standard CPB prime trials, one trial examining the impact of washing transfused bypass prime red blood cells showed no clear difference in duration of ICU stay between the intervention arms, while the trial assessing ultrafiltration of the priming blood showed a shorter duration of ICU stay in the ultrafiltration group. AUTHORS' CONCLUSIONS There are only a small number of small and heterogeneous trials so there is insufficient evidence to assess the impact of red cell transfusion on patients with congenital heart disease undergoing cardiac surgery accurately. It is possible that the presence or absence of cyanosis impacts on trial outcomes, which would necessitate different clinical management of two groups. Further adequately powered, specific, high-quality trials are warranted to assess this fully.
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Affiliation(s)
- Kirstin L Wilkinson
- Southampton University NHS HospitalPaediatric and Adult Cardiothoracic AnaesthesiaTremona RoadSouthamptonUKSO16 6YD
| | - Susan J Brunskill
- NHS Blood and TransplantSystematic Review InitiativeLevel 2, John Radcliffe HospitalHeadingtonOxfordOxonUKOX3 9BQ
| | - Carolyn Doree
- NHS Blood and TransplantSystematic Review InitiativeLevel 2, John Radcliffe HospitalHeadingtonOxfordOxonUKOX3 9BQ
| | - Marialena Trivella
- University of OxfordCentre for Statistics in MedicineBotnar Research CentreWindmill RoadOxfordUKOX3 7LD
| | - Ravi Gill
- Southampton University Hospital NHS TrustDepartment of AnaestheticsTremona RoadSouthamptonHampshireUKSO16 6YD
| | - Michael F Murphy
- John Radcliffe HospitalNHS Blood and TransplantHeadley WayHeadingtonOxfordUKOX3 9BQ
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Dean PN, McHugh KE, Conaway MR, Hillman DG, Gutgesell HP. Effects of race, ethnicity, and gender on surgical mortality in hypoplastic left heart syndrome. Pediatr Cardiol 2013; 34:1829-36. [PMID: 23722968 PMCID: PMC4023351 DOI: 10.1007/s00246-013-0723-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2013] [Accepted: 05/17/2013] [Indexed: 10/26/2022]
Abstract
Information is limited regarding the effect of race, ethnicity, and gender on the outcomes of the three palliative procedures for hypoplastic left heart syndrome (HLHS). This study examined the effects of race, ethnicity, gender, type of admission, and surgical volume on in-hospital mortality associated with palliative procedures for HLHS between 1998 and 2007 using data from the University HealthSystem Consortium. According to the data, 1,949 patients underwent stage 1 palliation (S1P) with a mortality rate of 29 %, 1,279 patients underwent stage 2 palliations (S2P) with a mortality rate of 5.4 %, and 1,084 patients underwent stage 3 palliation (S3P) with a mortality rate of 4.1 %. The risk factors for increased mortality with S1P were black and "other" race, smaller surgical volume, and early surgical era. The only risk factors for increased mortality with S2P were black race (11 % mortality; odds ratio [OR], 3.19; 95 % confidence interval [CI] 1.69-6.02) and Hispanic ethnicity (11 % mortality; OR 3.30; 95 % CI 1.64-6.64). For S2P, no racial differences were seen in the top five surgical volume institutions, but racial differences were seen in the non-top-five surgical volume institutions. Mortality with S1P was significantly higher for patients discharged after birth (37 vs 24 %; p = 0.004), and blacks were more likely to be discharged after birth (12 vs 5 % for all other races; p < 0.001). No racial differences with S3P were observed. The risk factors for increased mortality at S1P were black and "other" race, smaller surgical volume, and early surgical era. The risk factors for increased in-hospital mortality with S2P were black race and Hispanic ethnicity.
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Affiliation(s)
- Peter N. Dean
- Division of Cardiology, Children’s National Medical Center, 111 Michigan Avenue, Washington, DC 20010-2970, USA
| | - Kimberly E. McHugh
- Division of Cardiology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - Mark R. Conaway
- Division of Translational Research and Applied Statistics, Department of Public Health Sciences, University of Virginia Health System, Charlottesville, VA, USA
| | - Diane G. Hillman
- Department of Public Health Sciences, University of Virginia Health System, Charlottesville, VA, USA
| | - Howard P. Gutgesell
- Division of Cardiology, Department of Pediatrics, University of Virginia Health System, Charlottesville, VA, USA
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Choi JM, Choi YH, Kim SK, Ahn KH, Won JH, Lim JH, Jang YJ, Lee S, Kim DH, Kim DK. (S)-tetrahydroisoquinoline alkaloid inhibits LPS-induced arachidonic acid release through downregulation of cPLA2 expression. Mol Cells 2013; 36:400-9. [PMID: 24293010 PMCID: PMC3887938 DOI: 10.1007/s10059-013-0078-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2013] [Revised: 09/10/2013] [Accepted: 09/15/2013] [Indexed: 01/24/2023] Open
Abstract
Sepsis, a systemic inflammatory response syndrome, remains a potentially lethal condition. (S)-1-α-Naphthylmethyl-6,7-dihydroxy-1,2,3,4-tetrahydroisoquinoline (CKD712) is noted as a drug candidate for sepsis. Many studies have demonstrated its significant anti-inflammatory effects. Here we first examined whether CKD712 inhibits lipopolysaccharide (LPS)-induced arachidonic acid (AA) release in the RAW 264.7 mouse monocyte cell line, and subsequently, its inhibitory mechanisms. CKD712 reversed LPS-associated morphological changes in the RAW 264.7 cells, and inhibited LPS-induced release of AA in a concentrationdependent manner. The inhibition was apparently due to the diminished expression of a cytosolic form of phospholipase A2 (cPLA2) by CKD712, resulting from reduced NF-κB activation. Furthermore, CKD712 inhibited the activation of ERK1/2 and SAP/JNK, but not of p38 MAPK. CKD712 had no effect on the activity or phosphorylation of cPLA2 and on calcium influx. Our results collectively suggest that CKD712 inhibits LPS-induced AA release through the inhibition of a MAPKs/NF-κB pathway leading to reduced cPLA2 expression in RAW 264.7 cells.
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Affiliation(s)
- Jong Min Choi
- Department of Environmental and Health Chemistry, College of Pharmacy, Chung-Ang University, Seoul 156-756, Korea
| | - Young Hwa Choi
- Department of Environmental and Health Chemistry, College of Pharmacy, Chung-Ang University, Seoul 156-756, Korea
| | - Seok Kyun Kim
- Department of Environmental and Health Chemistry, College of Pharmacy, Chung-Ang University, Seoul 156-756, Korea
| | - Kyong Hoon Ahn
- Department of Environmental and Health Chemistry, College of Pharmacy, Chung-Ang University, Seoul 156-756, Korea
| | - Jong Hoon Won
- Department of Environmental and Health Chemistry, College of Pharmacy, Chung-Ang University, Seoul 156-756, Korea
| | - Joo Hyuk Lim
- Department of Environmental and Health Chemistry, College of Pharmacy, Chung-Ang University, Seoul 156-756, Korea
| | - You Jin Jang
- Department of Environmental and Health Chemistry, College of Pharmacy, Chung-Ang University, Seoul 156-756, Korea
| | | | | | - Dae Kyong Kim
- Department of Environmental and Health Chemistry, College of Pharmacy, Chung-Ang University, Seoul 156-756, Korea
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Sherif L, Jain P, Shetty K, Badiger S. Emergency laparotomy for necrotising enterocolitis in a newborn with hypoplastic left heart syndrome. Indian J Anaesth 2013; 57:387-9. [PMID: 24163454 PMCID: PMC3800332 DOI: 10.4103/0019-5049.118562] [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] [Indexed: 11/30/2022] Open
Abstract
Necrotising enterocolitis (NEC) and congenital heart disease are two distinct disease processes, but they appear to be inter-related, particularly in patients with the congenital heart condition known as hypoplastic left heart syndrome (HLHS). Both NEC and HLHS are causes of significant morbidity and mortality in the neonatal population. As medical and surgical advances allow for the palliation and correction of complex heart lesions at an earlier gestational age and lower birth weight, the already high-risk of NEC in this population is likely to increase. In this article, we report a case of a neonate with unpalliated HLHS who underwent emergency laparotomy for NEC. We also discuss the pathophysiology of these two diseases and the perioperative care of this rare group of patients.
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Affiliation(s)
- Lulu Sherif
- Department of Anaesthesiology, Fr. Muller Medical College, Mangalore, Karnataka, India
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Collins RT, Fram RY, Tang X, Robbins JM, Sutton MSJ. Impact of anatomical subtype and medical comorbidities on hospitalizations in adults with single ventricle congenital heart disease. Int J Cardiol 2013; 168:4596-601. [DOI: 10.1016/j.ijcard.2013.07.164] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2013] [Revised: 07/14/2013] [Accepted: 07/19/2013] [Indexed: 10/26/2022]
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Outcomes of patients born with single-ventricle physiology and aortic arch obstruction: the 26-year Melbourne experience. J Thorac Cardiovasc Surg 2013; 148:194-201. [PMID: 24075567 DOI: 10.1016/j.jtcvs.2013.07.076] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2013] [Revised: 06/04/2013] [Accepted: 07/26/2013] [Indexed: 11/20/2022]
Abstract
BACKGROUND To review the long-term outcomes of patients born with single-ventricle physiology and aortic arch obstruction. METHODS Follow-up of 70 consecutive neonates undergoing single-ventricle palliation and arch repair, excluding hypoplastic left heart syndrome, between 1983 and 2008, was reviewed. Dominant arch anomalies were coarctation (n = 48), interrupted arch (n = 10), and hypoplastic arch alone (n = 12). Neonatal Damus procedure with arch repair and shunt became the dominant approach, being performed in 1 (10%) of 10 in 1983 to 1989, 9 (32%) of 28 in 1990 to 1999, and 23 (72%) of 32 in 2000 to 2008. RESULTS All patients underwent an initial procedure at a median of 6 days (range, 4-12 days): pulmonary artery banding and arch repair (n = 35); Damus, arch repair, and shunt (n = 33); and other (n = 2). Twenty-six patients died before Fontan completion. Of the 34 survivors of initial banding, 17 (50%) later required a Damus and 4 (12%) required subaortic stenosis relief. Forty patients underwent Fontan completion at a median age of 5 years (range, 4-7 years). After a mean of 5 ± 6 years after Fontan, there was 1 hospital death and 1 Fontan takedown. Overall survival was similar if patients initially underwent a Damus or pulmonary artery banding (P = .3). Overall survival at 10 years was 53% (95% confidence interval, 42%-67%). CONCLUSIONS Patients born with single-ventricle physiology and arch obstruction have a high risk of mortality in the first years of life. Their outcomes seem excellent once they reach Fontan status. It is likely that, in patients with single-ventricle and arch obstruction, strategies to avoid systemic outflow tract obstruction should be implemented in early life, and regular monitoring of blood pressure is warranted.
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Bell A, Rawlins D, Bellsham-Revell H, Miller O, Razavi R, Simpson J. Assessment of right ventricular volumes in hypoplastic left heart syndrome by real-time three-dimensional echocardiography: comparison with cardiac magnetic resonance imaging. Eur Heart J Cardiovasc Imaging 2013; 15:257-66. [PMID: 23946284 DOI: 10.1093/ehjci/jet145] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Accurate assessment of right ventricular (RV) volumes and function is important in patients with hypoplastic left heart syndrome (HLHS). We prospectively sought to determine the reproducibility of three-dimensional (3D) echocardiography and its agreement with cardiac magnetic resonance imaging (CMR) in HLHS. METHODS AND RESULTS Twenty-eight patients underwent CMR followed immediately by transthoracic 3D echocardiography under general anaesthesia. Semi-automated border detection software was used to determine echocardiographic RV volumes. Inter- and intra-observer variability, correlation and levels of agreement between techniques were determined. The median age was 0.37 years (0.18-9.28 years) and weight 6.24 kg (3.42-32.50 kg). Intra- and inter-observer variability was excellent for both techniques. Median (range) measurements for 3D echocardiography and CMR were; end-diastolic volume (EDV) 23.6 mL (6.5-63.2) and 30.6 mL (11.8-87.9), end-systolic volume (ESV) 12.6 mL (3.7-37.0) and 14.9 mL (5.8-33.9), stroke volume (SV) 11.2 mL (2.8-33.0) and 17.1 mL (6.0-54.1), ejection fraction (EF) 48.2% (31.2-64.9), and 56.5% (42.7-72.2). Correlation coefficients were r = 0.85, 0.84, 0.83, and 0.74, respectively (P < 0.01 for all). Volumetric data were expressed as a percentage of the echocardiographic volume to CMR volume. When compared with CMR, 3D echocardiography underestimated EDV, ESV and SV by 26.7% (SD ± 20.2), 10.6% (±28.1), and 37.5% (±20.1), respectively. The difference in volume appeared largest at low ventricular volumes. EF was 8.3% (±7.3) lower by 3D echocardiography compared with CMR. CONCLUSION Both 3D echocardiography and CMR volumes appear highly reproducible. Measurements obtained by 3D echocardiography are significantly lower than those obtained by CMR, with wide limits of agreement such that these two methods cannot be used interchangeably.
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Affiliation(s)
- Aaron Bell
- Paediatric Cardiology, Evelina London Children's Hospital, 6th Floor, Evelina Children's Hospital, 1 Westminster Bridge Road, London SE1 7EH, UK
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Gulack BCH, Adibe OO. Laparoscopic antireflux surgery in infants with single ventricle physiology: a review. J Laparoendosc Adv Surg Tech A 2013; 23:733-7. [PMID: 23859741 DOI: 10.1089/lap.2013.0076] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Laparoscopic fundoplication and gastrostomy tube placement have grown in popularity within the pediatric population for treatment of gastroesophageal reflux disease and failure to thrive, respectively. One population that has an increased need for gastric surgery in infancy is patients with congenital heart defects, especially those with "single ventricle physiology." The most common defect included in this population is hypoplastic left heart syndrome (HLHS). Because of the abnormal physiology present in this condition, there are concerns with regard to the use of laparoscopic procedures for gastric surgery in patients treated with a three-staged reconstruction. We review the staged reconstruction of infants with HLHS, address safety concerns of interstage noncardiac procedures on this patient population, and review the current literature regarding outcomes of laparoscopic gastric surgery on patients with single ventricle physiology.
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Affiliation(s)
- Brian C H Gulack
- Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
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Hoque T, Richmond M, Vincent JA, Bacha E, Torres A. Current outcomes of hypoplastic left heart syndrome with restrictive atrial septum: a single-center experience. Pediatr Cardiol 2013; 34:1181-9. [PMID: 23392623 DOI: 10.1007/s00246-012-0625-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2012] [Accepted: 12/26/2012] [Indexed: 11/28/2022]
Abstract
Advances in the management of hypoplastic left heart syndrome (HLHS) have resulted in improved survival. However, short and long-term mortality in patients with a restrictive atrial septum remains high. All neonates diagnosed with HLHS from 2003 to 2010 at our institution were evaluated. Patients who underwent atrial septostomy within the first 72 h conformed the restrictive atrial septum group (HLHS-RS). Patients with a non-restrictive communication (HLHS-NRS) formed the control group. Outcomes and survival status were determined from review of medical records. Of the 141 newborns diagnosed with HLHS, 20 (14 %) required intervention for a restrictive atrial septum. Procedural success was achieved in 17/20 (85 %) patients. Complications occurred in ten procedures, two of which were life threatening. No procedural deaths occurred. Overall median follow up was 35.5 months (0.4-104). Initial hospitalization survival was 16/20 (80 %) for the HLHS-RS group and 114/121(94 %) for the HLHS-NRS (p = 0.028). Twenty (14 %) patients were lost to follow up and 9 (6 %) underwent heart transplant. Overall survival was 10/16 (62 %) for HLHSRS patients and 77/95 (81 %) for HLHS-NRS (p = 0.1). Survival after initial discharge was 10/12 (83 %) for the HLHS-RS group and 77/88 (87 %) for the HLHS-NRS (p = 0.67). No predictors for HLHS-RS outcome were identified. Mortality at first-stage palliation in HLHS neonates with a restrictive atrial septum remains higher than in those with an unrestrictive communication. However, survival after initial hospital discharge is similar.
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Affiliation(s)
- Tasneem Hoque
- Division of Pediatric Cardiology, Morgan Stanley Children's Hospital of New York-Presbyterian, 3959 Broadway, 2North, New York, NY, USA
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Fonseca BM. Perioperative Imaging in Hypoplastic Left Heart Syndrome. Semin Cardiothorac Vasc Anesth 2013; 17:117-27. [DOI: 10.1177/1089253213480853] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Hypoplastic left heart syndrome is a constellation of left-sided congenital heart defects that result in variable hypoplasia of the left ventricle, left ventricular outflow tract, and aorta. Perioperative imaging with echocardiography, cardiac magnetic resonance imaging, and cardiac catheterization is vital for diagnosis, surgical planning, prognosis, and postoperative management.
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Orr Y, Leclair K, Jacobe S, Badawi N, Nicholson IA, Chard RB, Sholler GF, Winlaw DS. Early outcomes from a new regional programme for the surgical management of hypoplastic left heart syndrome. ANZ J Surg 2013; 85:466-71. [DOI: 10.1111/ans.12103] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/26/2012] [Indexed: 12/23/2022]
Affiliation(s)
- Yishay Orr
- Heart Centre for Children, The Children's Hospital at Westmead, Sydney Children's Hospitals Network; Sydney New South Wales Australia
| | - Karen Leclair
- Heart Centre for Children, The Children's Hospital at Westmead, Sydney Children's Hospitals Network; Sydney New South Wales Australia
| | - Stephen Jacobe
- Helen MacMillan Paediatric Intensive Care, The Children's Hospital at Westmead, Sydney Children's Hospitals Network; Sydney New South Wales Australia
| | - Nadia Badawi
- Grace Centre for Newborn Care, The Children's Hospital at Westmead, Sydney Children's Hospitals Network; Sydney New South Wales Australia
| | - Ian A. Nicholson
- Heart Centre for Children, The Children's Hospital at Westmead, Sydney Children's Hospitals Network; Sydney New South Wales Australia
| | - Richard B. Chard
- Heart Centre for Children, The Children's Hospital at Westmead, Sydney Children's Hospitals Network; Sydney New South Wales Australia
| | - Gary F. Sholler
- Heart Centre for Children, The Children's Hospital at Westmead, Sydney Children's Hospitals Network; Sydney New South Wales Australia
- Discipline of Paediatrics and Child Health; Sydney Medical School; University of Sydney; Sydney New South Wales Australia
| | - David S. Winlaw
- Heart Centre for Children, The Children's Hospital at Westmead, Sydney Children's Hospitals Network; Sydney New South Wales Australia
- Discipline of Paediatrics and Child Health; Sydney Medical School; University of Sydney; Sydney New South Wales Australia
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Lowry AW. Resuscitation and perioperative management of the high-risk single ventricle patient: first-stage palliation. CONGENIT HEART DIS 2013; 7:466-78. [PMID: 22985457 DOI: 10.1111/j.1747-0803.2012.00710.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Infants born with hypoplastic left heart syndrome or other lesions resulting in a single right ventricle face the highest risk of mortality among all forms of congenital heart disease. Before the modern era of surgical palliation, these conditions were universally lethal; recent refinements in surgical technique and perioperative management have translated into dramatic improvements in survival. Nonetheless, these infants remain at a high risk of morbidity and mortality, and an appreciation of single ventricle physiology is fundamental to the care of these high-risk patients. Herein, resuscitation and perioperative management of infants with hypoplastic left heart syndrome are reviewed. Basic neonatal and pediatric life support recommendations are summarized, and perioperative first-stage clinical management strategies are reviewed.
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Affiliation(s)
- Adam W Lowry
- Department of Pediatrics, Lillie Frank Abercrombie Section of Pediatric Cardiology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA.
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