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Reddy SV, Sinha SP. Lymphatic Interventions in Congenital Heart Disease. Interv Cardiol Clin 2024; 13:343-354. [PMID: 38839168 DOI: 10.1016/j.iccl.2024.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024]
Abstract
Lymphatic disorders in congenital heart disease can be broadly classified into chest compartment, abdominal compartment, or multicompartment disorders. Heavily T2-weighted noninvasive lymphatic imaging (for anatomy) and invasive dynamic contrast magnetic resonance lymphangiography (for flow) have become the main diagnostic modalities of choice to identify the cause of lymphatic disorders. Selective lymphatic duct embolization (SLDE) has largely replaced total thoracic duct embolization as the main lymphatic therapeutic procedure. Recurrence of symptoms needing repeat interventions is more common in patients who underwent SLDE. Novel surgical and transcatheter thoracic duct decompression strategies are promising, but long-term follow-up is critical and eagerly awaited.
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Affiliation(s)
- Surendranath Veeram Reddy
- Childrens/UT Southwestern Medical Center, Heart Center, B 405, Childrens Medical Center, 1935 Medical District Drive, Dallas, TX 75235, USA
| | - Sanjay Prakash Sinha
- CHOC/CS Cardiology, UC Irvine School of Medicine, UCLA Mattel Children's Hospital.
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Kelly B, Mohanakumar S, Ford B, Smith CL, Pinto E, Biko DM, Hjortdal VE, Dori Y. Sequential MRI Evaluation of Lymphatic Abnormalities over the Course of Fontan Completion. Radiol Cardiothorac Imaging 2024; 6:e230315. [PMID: 38814187 DOI: 10.1148/ryct.230315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2024]
Abstract
Purpose To evaluate lymphatic abnormalities before and after Fontan completion using noncontrast lymphatic imaging and relate findings with postoperative outcomes. Materials and Methods This study is a retrospective review of noncontrast T2-weighted lymphatic imaging performed at The Children's Hospital of Philadelphia from June 2012 to February 2023 in patients with single ventricle physiology. All individuals with imaging at both pre-Fontan and Fontan stages were eligible. Lymphatic abnormalities were classified into four types based on severity and location of lymphatic vessels. Classifications were compared between images and related to clinical outcomes such as postoperative drainage and hospitalization, lymphatic complications, heart transplant, and death. Results Forty-three patients (median age, 10 years [IQR, 8-11]; 20 [47%] boys, 23 [53%] girls) were included in the study. Lymphatic abnormalities progressed in 19 individuals after Fontan completion (distribution of lymphatic classifications: type 1, 23; type 2, 11; type 3, 6; type 4, 3 vs type 1, 10; type 2, 18; type 3, 10; type 4, 5; P = .04). Compared with individuals showing no progression of lymphatic abnormalities, those progressing to a high-grade lymphatic classification had longer postoperative drainage (median time, 9 days [IQR, 6-14] vs 17 days [IQR, 10-23]; P = .04) and hospitalization (median time, 13 days [IQR, 9-25] vs 26 days [IQR, 18-30]; P = .03) after Fontan completion and were more likely to develop chylothorax (12% [three of 24] vs 75% [six of eight]; P < .01) and/or protein-losing enteropathy (0% [0 of 24] vs 38% [three of eight]; P < .01) during a median follow-up of 8 years (IQR, 5-9). Progression to any type was not associated with an increased risk of adverse events. Conclusion The study demonstrated that lymphatic structural abnormalities may progress in select individuals with single ventricle physiology after Fontan completion, and progression of abnormalities to a high-grade classification was associated with worse postoperative outcomes. Keywords: Congenital Heart Disease, Glenn, Fontan, Lymphatic Imaging, Cardiovascular MRI Supplemental material is available for this article. Published under a CC BY 4.0 license.
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Affiliation(s)
- Benjamin Kelly
- From the Departments of Cardiothoracic Surgery (B.K.) and Radiology (S.M.), Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark; Division of Cardiology (B.K., B.F., C.L.S., E.P., Y.D.) and Department of Radiology (D.M.B.), Children's Hospital of Philadelphia, Philadelphia, Pa; and Department of Cardiothoracic Surgery, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark (V.E.H.)
| | - Sheyanth Mohanakumar
- From the Departments of Cardiothoracic Surgery (B.K.) and Radiology (S.M.), Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark; Division of Cardiology (B.K., B.F., C.L.S., E.P., Y.D.) and Department of Radiology (D.M.B.), Children's Hospital of Philadelphia, Philadelphia, Pa; and Department of Cardiothoracic Surgery, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark (V.E.H.)
| | - Brooke Ford
- From the Departments of Cardiothoracic Surgery (B.K.) and Radiology (S.M.), Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark; Division of Cardiology (B.K., B.F., C.L.S., E.P., Y.D.) and Department of Radiology (D.M.B.), Children's Hospital of Philadelphia, Philadelphia, Pa; and Department of Cardiothoracic Surgery, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark (V.E.H.)
| | - Christopher L Smith
- From the Departments of Cardiothoracic Surgery (B.K.) and Radiology (S.M.), Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark; Division of Cardiology (B.K., B.F., C.L.S., E.P., Y.D.) and Department of Radiology (D.M.B.), Children's Hospital of Philadelphia, Philadelphia, Pa; and Department of Cardiothoracic Surgery, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark (V.E.H.)
| | - Erin Pinto
- From the Departments of Cardiothoracic Surgery (B.K.) and Radiology (S.M.), Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark; Division of Cardiology (B.K., B.F., C.L.S., E.P., Y.D.) and Department of Radiology (D.M.B.), Children's Hospital of Philadelphia, Philadelphia, Pa; and Department of Cardiothoracic Surgery, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark (V.E.H.)
| | - David M Biko
- From the Departments of Cardiothoracic Surgery (B.K.) and Radiology (S.M.), Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark; Division of Cardiology (B.K., B.F., C.L.S., E.P., Y.D.) and Department of Radiology (D.M.B.), Children's Hospital of Philadelphia, Philadelphia, Pa; and Department of Cardiothoracic Surgery, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark (V.E.H.)
| | - Vibeke E Hjortdal
- From the Departments of Cardiothoracic Surgery (B.K.) and Radiology (S.M.), Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark; Division of Cardiology (B.K., B.F., C.L.S., E.P., Y.D.) and Department of Radiology (D.M.B.), Children's Hospital of Philadelphia, Philadelphia, Pa; and Department of Cardiothoracic Surgery, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark (V.E.H.)
| | - Yoav Dori
- From the Departments of Cardiothoracic Surgery (B.K.) and Radiology (S.M.), Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark; Division of Cardiology (B.K., B.F., C.L.S., E.P., Y.D.) and Department of Radiology (D.M.B.), Children's Hospital of Philadelphia, Philadelphia, Pa; and Department of Cardiothoracic Surgery, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark (V.E.H.)
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3
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Smood B, Katsunari T, Smith C, Dori Y, Mavroudis CD, Morton S, Davis A, Chen JM, Gaynor JW, Kilbaugh T, Maeda K. Preliminary report of a thoracic duct-to-pulmonary vein lymphovenous anastomosis in swine: A novel technique and potential treatment for lymphatic failure. Semin Pediatr Surg 2024; 33:151427. [PMID: 38823193 DOI: 10.1016/j.sempedsurg.2024.151427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2024]
Abstract
OBJECTIVE The thoracic duct is the largest lymphatic vessel in the body, and carries fluid and nutrients absorbed in abdominal organs to the central venous circulation. Thoracic duct obstruction can cause significant failure of the lymphatic circulation (i.e., protein-losing enteropathy, plastic bronchitis, etc.). Surgical anastomosis between the thoracic duct and central venous circulation has been used to treat thoracic duct obstruction but cannot provide lymphatic decompression in patients with superior vena cava obstruction or chronically elevated central venous pressures (e.g., right heart failure, single ventricle physiology, etc.). Therefore, this preclinical feasibility study sought to develop a novel and optimal surgical technique for creating a thoracic duct-to-pulmonary vein lymphovenous anastomosis (LVA) in swine that could remain patent and preserve unidirectional lymphatic fluid flow into the systemic venous circulation to provide therapeutic decompression of the lymphatic circulation even at high central venous pressures. METHODS A thoracic duct-to-pulmonary vein LVA was attempted in 10 piglets (median age 80 [IQR 80-83] days; weight 22.5 [IQR 21.4-26.8] kg). After a right thoracotomy, the thoracic duct was mobilized, transected, and anastomosed to the right inferior pulmonary vein. Animals were systemically anticoagulated on post-operative day 1. Lymphangiography was used to evaluate LVA patency up to post-operative day 7. RESULTS A thoracic duct-to-pulmonary vein LVA was successfully completed in 8/10 (80.0%) piglets, of which 6/8 (75.0%) survived to the intended study endpoint without any complication (median 6 [IQR 4-7] days). Initially, 2/10 (20.0%) LVAs were aborted intraoperatively, and 2/10 (20.0%) animals were euthanized early due to post-operative complications. However, using an optimized surgical technique, the success rate for creating a thoracic duct-to-pulmonary vein LVA in six animals was 100%, all of which survived to their intended study endpoint without any complications (median 6 [IQR 4-7] days). LVAs remained patent for up to seven days. CONCLUSION A thoracic duct-to-pulmonary vein LVA can be completed safely and remain patent for at least one week with systemic anticoagulation, which provides an important proof-of-concept that this novel intervention could effectively offload the lymphatic circulation in patients with lymphatic failure and elevated central venous pressures.
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Affiliation(s)
- Benjamin Smood
- Division of Cardiovascular Surgery, Department of Surgery, The University of Pennsylvania, Philadelphia, PA, United States; Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, United States.
| | - Terakawa Katsunari
- Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Christopher Smith
- Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, Philadelphia, PA, United States; Department of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Yoav Dori
- Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, Philadelphia, PA, United States; Department of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Constantine D Mavroudis
- Division of Cardiovascular Surgery, Department of Surgery, The University of Pennsylvania, Philadelphia, PA, United States; Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Sarah Morton
- Resuscitation Science Center, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | - Anthony Davis
- Resuscitation Science Center, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | - Jonathan M Chen
- Division of Cardiovascular Surgery, Department of Surgery, The University of Pennsylvania, Philadelphia, PA, United States; Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - J William Gaynor
- Division of Cardiovascular Surgery, Department of Surgery, The University of Pennsylvania, Philadelphia, PA, United States; Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Todd Kilbaugh
- Resuscitation Science Center, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States; Department of Anesthesiology, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Katsuhide Maeda
- Division of Cardiovascular Surgery, Department of Surgery, The University of Pennsylvania, Philadelphia, PA, United States; Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, United States; Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, Philadelphia, PA, United States
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Smood B, Smith C, Dori Y, Mavroudis CD, Fuller S, Gaynor JW, Maeda K. Lymphatic failure and lymphatic interventions: Knowledge gaps and future directions for a new frontier in congenital heart disease. Semin Pediatr Surg 2024; 33:151426. [PMID: 38820801 DOI: 10.1016/j.sempedsurg.2024.151426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2024]
Abstract
Lymphatic failure is a broad term that describes the lymphatic circulation's inability to adequately transport fluid and solutes out of the interstitium and into the systemic venous circulation, which can result in dysfunction and dysregulation of immune responses, dietary fat absorption, and fluid balance maintenance. Several investigations have recently elucidated the nexus between lymphatic failure and congenital heart disease, and the associated morbidity and mortality is now well-recognized. However, the precise pathophysiology and pathogenesis of lymphatic failure remains poorly understood and relatively understudied, and there are no targeted therapeutics or interventions to reliably prevent its development and progression. Thus, there is growing enthusiasm towards the development and application of novel percutaneous and surgical lymphatic interventions. Moreover, there is consensus that further investigations are needed to delineate the underlying mechanisms of lymphatic failure, which could help identify novel therapeutic targets and develop innovative procedures to improve the overall quality of life and survival of these patients. With these considerations, this review aims to provide an overview of the lymphatic circulation and its vasculature as it relates to current understandings into the pathophysiology and pathogenesis of lymphatic failure in patients with congenital heart disease, while also summarizing strategies for evaluating and managing lymphatic complications, as well as specific areas of interest for future translational and clinical research efforts.
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Affiliation(s)
- Benjamin Smood
- Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, United States of America; Division of Cardiovascular Surgery, Department of Surgery, The University of Pennsylvania, Philadelphia, Pennsylvania, 19104, United States of America.
| | - Christopher Smith
- Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, Philadelphia, PA, United States; Department of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, 19104 United States of America
| | - Yoav Dori
- Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, Philadelphia, PA, United States; Department of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, 19104 United States of America
| | - Constantine D Mavroudis
- Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, United States of America; Division of Cardiovascular Surgery, Department of Surgery, The University of Pennsylvania, Philadelphia, Pennsylvania, 19104, United States of America
| | - Stephanie Fuller
- Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, United States of America; Division of Cardiovascular Surgery, Department of Surgery, The University of Pennsylvania, Philadelphia, Pennsylvania, 19104, United States of America
| | - J William Gaynor
- Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, United States of America; Division of Cardiovascular Surgery, Department of Surgery, The University of Pennsylvania, Philadelphia, Pennsylvania, 19104, United States of America
| | - Katsuhide Maeda
- Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, United States of America; Division of Cardiovascular Surgery, Department of Surgery, The University of Pennsylvania, Philadelphia, Pennsylvania, 19104, United States of America; Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, Philadelphia, PA, United States
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Lemley BA, Okunowo O, Ampah SB, Wu L, Shinohara RT, Goldberg DJ, Rychik J, Glatz AC, Amaral S, O'Byrne ML. Effect of patient factors, center, and era on Fontan timing: An observational study using the Pediatric Health Information Systems Database. Am Heart J 2024; 271:156-163. [PMID: 38412896 DOI: 10.1016/j.ahj.2024.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Accepted: 02/21/2024] [Indexed: 02/29/2024]
Abstract
BACKGROUND There are no consensus guidelines defining optimal timing for the Fontan operation, the last planned surgery in staged palliation for single-ventricle heart disease. OBJECTIVES Identify patient-level characteristics, center-level variation, and secular trends driving Fontan timing. METHODS A retrospective observational study of subjects who underwent Fontan from 2007 to 2021 at centers in the Pediatric Health Information Systems database was performed using linear mixed-effects modeling in which age at Fontan was regressed on patient characteristics and date of operation with center as random effect. RESULTS We included 10,305 subjects (40.4% female, 44% non-white) at 47 centers. Median age at Fontan was 3.4 years (IQR 2.6-4.4). Hypoplastic left heart syndrome (-4.4 months, 95%CI -5.5 to -3.3) and concomitant conditions (-2.6 months, 95%CI -4.1 to -1.1) were associated with younger age at Fontan. Subjects with technology-dependence (+4.6 months, 95%CI 3.1-6.1) were older at Fontan. Black (+4.1 months, 95%CI 2.5-5.7) and Asian (+8.3 months, 95%CI 5.4-11.2) race were associated with older age at Fontan. There was significant variation in Fontan timing between centers. Center accounted for 10% of variation (ICC 0.10, 95%CI 0.07-0.14). Center surgical volume was not associated with Fontan timing (P = .21). Operation year was associated with age at Fontan, with a 3.1 month increase in age for every 5 years (+0.61 months, 95%CI 0.48-0.75). CONCLUSIONS After adjusting for patient-level characteristics there remains significant inter-center variation in Fontan timing. Age at Fontan has increased. Future studies addressing optimal Fontan timing are warranted.
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Affiliation(s)
- Bethan A Lemley
- Division of Cardiology, Lurie Children's Hospital and Department of Pediatrics, Feinberg School of Medicine Northwestern University, Chicago IL.
| | - Oluwatimilehin Okunowo
- Department of Computational and Quantitative Medicine, Division of Biostatistics, Beckman Research Institute of City of Hope, Duarte, CA
| | - Steve B Ampah
- Department of Biomedical and Health Informatics, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Lezhou Wu
- Department of Biomedical and Health Informatics, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Russell T Shinohara
- Department of Biostatistics Epidemiology and Informatics, Perelman School of Medicine at The University of Pennsylvania, Philadelphia PA
| | - David J Goldberg
- Division of Cardiology, The Children's Hospital of Philadelphia Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania, Philadelphia PA
| | - Jack Rychik
- Division of Cardiology, The Children's Hospital of Philadelphia Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania, Philadelphia PA
| | - Andrew C Glatz
- Division of Cardiology, St. Louis Children's Hospital and Department of Pediatrics Washington University School of Medicine, St. Louis MO
| | - Sandra Amaral
- Division of Nephrology, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at The University of Pennsylvania, Philadelphia PA
| | - Michael L O'Byrne
- Division of Cardiology, The Children's Hospital of Philadelphia Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania, Philadelphia PA; Clinical Futures, The Children's Hospital of Philadelphia and Leonard Davis Institute and Cardiovascular Outcomes, Quality, and Evaluative Research Center, Perelman School of Medicine at The University of Pennsylvania, Philadelphia PA
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Yanovskiy A, Martelius L, Nyman N, Vepsäläinen T, Mattila I, Rahkonen O, Ojala T. Systemic-to-pulmonary collateral flow associations with antegrade pulmonary flow in single ventricle patients: insights from cardiac magnetic resonance imaging. Front Cardiovasc Med 2024; 11:1304087. [PMID: 38455717 PMCID: PMC10917948 DOI: 10.3389/fcvm.2024.1304087] [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: 10/09/2023] [Accepted: 02/12/2024] [Indexed: 03/09/2024] Open
Abstract
Purpose In the palliated single ventricle anomalies, a considerable amount of the aortic flow may be absorbed by the systemic-pulmonary collateral flow (SPCF), which can be noninvasively assessed by cardiac magnetic resonance (CMR). The aims of this study were to (1) identify factors associated with SCPF in pediatric single ventricle patients, and (2) establish a cutoff values indicating an association between SCPF and a reduction in antegrade pulmonary flow. Methods A retrospective single-tertiary-center cohort study included 158 consecutive CMR studies of patients with a single ventricle. In the uni- and multivariable analysis, SPCF was presented as a percentage of the total pulmonary venous flow (SPCF%PV). The minimal clinically important difference in QP/QS ratios was estimated as ≥0.50, and an optimal cutoff value was defined using the receiver operating characteristic (ROC) curve. Results SPCF%PV was significantly smaller in the post-total cavopulmonary connection (TCPC) group than in the pre-TCPC patients (p < 0.001). The patient's higher age and a higher antegrade pulmonary flow were associated with a lower SPCF%PV. A negative weak association was observed between the SPCF%PV and systemic saturation (r = -0.39, p < 0.001). SPCF%PV did not associate with ventricular volumes nor ejection fraction. The SPCF%PV was significantly smaller in patients that were palliated primarily with a pulmonary artery banding compared to those palliated with a BT-shunt (p = 0.002) or RV-PA- shunt (p = 0.044). In the ROC analysis, for pre-TCPC patient's, a cutoff of SPCF%PV 42% yielded a sensitivity of 100% and specificity of 80% for significantly reduced antegrade pulmonary flow (AUC 0.97). In the post-TCPC group, the optimal SPCF%PV cutoff was 34% (sensitivity 100%, specificity 98%, AUC 0.99). Conclusion SPCF results in a considerable left-to-right shunt, which subsequently diminishes spontaneously after TCPC. Our findings indicated that for pre-TCPC patients, an SPCF%PV threshold of 42% (sensitivity 100%, specificity 80%), and for the post-TCPC group, a threshold of 34% (sensitivity 100%, specificity 98%) were effective in identifying reduced antegrade pulmonary flow.
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Affiliation(s)
- Anna Yanovskiy
- HUS Medical Imaging Center, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Laura Martelius
- HUS Medical Imaging Center, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Nicolina Nyman
- Department of Pediatric Cardiology, Children’s Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Teemu Vepsäläinen
- Department of Pediatric Cardiology, Children’s Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Ilkka Mattila
- Pediatric Cardiac Surgery, Children’s Hospital, Helsinki University and Helsinki University Hospital, Helsinki, Finland
| | - Otto Rahkonen
- Department of Pediatric Cardiology, Children’s Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Tiina Ojala
- Department of Pediatric Cardiology, Children’s Hospital, HUS Medical Imaging Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Schaffner D, Perez MH, Duran R, Pretre R, Di Bernardo S. Case Report: Transcatheter interventional procedure to innominate vein turn-down procedure for failing fontan circulation. Front Pediatr 2024; 12:1341443. [PMID: 38379912 PMCID: PMC10876887 DOI: 10.3389/fped.2024.1341443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 01/17/2024] [Indexed: 02/22/2024] Open
Abstract
Fontan physiology creates a chronic state of decreased cardiac output and systemic venous congestion, leading to liver cirrhosis/malignancy, protein-losing enteropathy, chylothorax, or plastic bronchitis. Creating a fenestration improves cardiac output and relieves some venous congestion. The anatomic connection of the thoracic duct to the subclavian-jugular vein junction exposes the lymphatic system to systemic venous hypertension and could induce plastic bronchitis. To address this complication, two techniques have been developed. A surgical method that decompresses the thoracic duct by diverting the innominate vein to the atrium, and a percutaneous endovascular procedure that uses a covered stent to create an extravascular connection between the innominate vein and the left atrium. We report a novel variant transcatheter intervention of the innominate vein turn-down procedure without creating an extravascular connection in a 39-month-old patient with failing Fontan circulation complicated by plastic bronchitis and a 2-year post-intervention follow-up.
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Affiliation(s)
- Damien Schaffner
- Pediatric Cardiology Unit, Women Mother and Child Department, Lausanne University Hospital, Lausanne, Switzerland
| | - Maria-Helena Perez
- Pediatric Intensive Care Unit, Women Mother and Child Department, Lausanne University Hospital, Lausanne, Switzerland
| | - Rafael Duran
- Department of Radiology and Interventional Radiology, Lausanne University Hospital, Lausanne, Switzerland
| | - René Pretre
- Department of Cardiac Surgery, Lausanne University Hospital, Lausanne, Switzerland
| | - Stefano Di Bernardo
- Pediatric Cardiology Unit, Women Mother and Child Department, Lausanne University Hospital, Lausanne, Switzerland
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8
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Tedla BA, Kim YY, Vaikunth S. Novel Approaches to the Failing Congenital Heart. Curr Cardiol Rep 2023; 25:1633-1647. [PMID: 37889420 DOI: 10.1007/s11886-023-01979-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/04/2023] [Indexed: 10/28/2023]
Abstract
PURPOSE OF REVIEW Heart failure is the leading cause of morbidity and mortality in adults with congenital heart disease and is characterized by a variety of underlying mechanisms. Here, we aim to elaborate on the medical and technological advancements in the management of heart failure in adult patients with congenital heart disease and highlight the use of imaging modalities to guide therapy. RECENT FINDINGS There have been several advances over the past decade with angiotensin receptor neprilysin and sodium-glucose cotransporter-2 inhibitors, atrioventricular valve clips, transcatheter pulmonary valves, catheter ablation, and cardiac resynchronization therapy, as well as the introduction of lymphatic interventions. Expanded use of echocardiography, cardiac magnetic resonance imaging, and cardiac computed tomography has guided many of these therapies. Significant innovations in the management of heart failure in adults with congenital heart disease have evolved with advancements in imaging modalities playing a critical role in guiding treatment therapies.
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Affiliation(s)
- Bruke A Tedla
- Philadelphia Adult Congenital Heart Center, Penn Medicine & Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Yuli Y Kim
- Philadelphia Adult Congenital Heart Center, Penn Medicine & Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Sumeet Vaikunth
- Philadelphia Adult Congenital Heart Center, Penn Medicine & Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA.
- Perelman Center for Advanced Medicine, 11th Floor, South Pavilion, 3400 Civic Center Boulevard, Philadelphia, PA, 19104-5127, USA.
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Bauer C, Scala M, Sekyra P, Fellner F, Tulzer G. Non-Contrast MR Lymphography and Intranodal Dynamic Contrast MR Lymphangiography in Children with Congenital Heart Disease-Imaging Findings as well as Impact on Patient Management and Outcome. Int J Mol Sci 2023; 24:14827. [PMID: 37834274 PMCID: PMC10573489 DOI: 10.3390/ijms241914827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 09/15/2023] [Accepted: 09/25/2023] [Indexed: 10/15/2023] Open
Abstract
Lymphatic flow disorders are rare but devastating complications in children with congenital heart disease. T2-weighted magnetic resonance lymphography and intranodal dynamic contrast magnetic resonance lymphangiography are imaging modalities that can depict central lymphatic anatomy and flow pattern. Our objective was to describe the technical aspects and our imaging findings of central lymphatic abnormalities and their impact on patient management and outcomes: We conducted a retrospective review of 26 children with congenital heart disease who presented for lymphatic imaging between 2015 and 2020 at our institution. Eleven had postoperative chylothorax, six had plastic bronchitis, seven had protein-losing enteropathy and three had Noonan syndrome. Our lymphatic imaging demonstrated severely abnormal lymphatic flow in all of the children, but only minor abnormalities in protein-losing enteropathy. No major procedure-related complication occurred. Lymphatic interventions were performed in six patients, thoracic duct decompression in two patients and chylothorax revision in three patients. This led to symptomatic improvements in all of the patients: Lymphatic imaging is safe and essential for the diagnosis of lymphatic flow disorders and therapy planning. Our intranodal lymphangiography depicts an abnormal lymphatic flow pattern from the central lymphatics but failed to demonstrate an abnormal lymphatic flow in protein-losing enteropathy. These imaging techniques are the basis for selective lymphatic interventions, which are promising to treat lymphatic flow disorders.
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Affiliation(s)
- Christoph Bauer
- Department of Paediatric Cardiology, Kepler University Hospital GmbH, Krankenhausstrasse 26–30, 4020 Linz, Austria (G.T.)
- Johannes Kepler University Linz, Altenbergerstrasse 68, 4040 Linz, Austria; (P.S.); (F.F.)
| | - Mario Scala
- Johannes Kepler University Linz, Altenbergerstrasse 68, 4040 Linz, Austria; (P.S.); (F.F.)
- Central Radiology Institute, Kepler University Hospital GmbH, Krankenhausstrasse 9, 4020 Linz, Austria
| | - Pavel Sekyra
- Johannes Kepler University Linz, Altenbergerstrasse 68, 4040 Linz, Austria; (P.S.); (F.F.)
- Central Radiology Institute, Kepler University Hospital GmbH, Krankenhausstrasse 9, 4020 Linz, Austria
| | - Franz Fellner
- Johannes Kepler University Linz, Altenbergerstrasse 68, 4040 Linz, Austria; (P.S.); (F.F.)
- Central Radiology Institute, Kepler University Hospital GmbH, Krankenhausstrasse 9, 4020 Linz, Austria
| | - Gerald Tulzer
- Department of Paediatric Cardiology, Kepler University Hospital GmbH, Krankenhausstrasse 26–30, 4020 Linz, Austria (G.T.)
- Johannes Kepler University Linz, Altenbergerstrasse 68, 4040 Linz, Austria; (P.S.); (F.F.)
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10
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Pieper CC. Back to the Future II-A Comprehensive Update on the Rapidly Evolving Field of Lymphatic Imaging and Interventions. Invest Radiol 2023; 58:610-640. [PMID: 37058335 DOI: 10.1097/rli.0000000000000966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/15/2023]
Abstract
ABSTRACT Lymphatic imaging and interventional therapies of disorders affecting the lymphatic vascular system have evolved rapidly in recent years. Although x-ray lymphangiography had been all but replaced by the advent of cross-sectional imaging and the scientific focus shifted to lymph node imaging (eg, for detection of metastatic disease), interest in lymph vessel imaging was rekindled by the introduction of lymphatic interventional treatments in the late 1990s. Although x-ray lymphangiography is still the mainstay imaging technique to guide interventional procedures, several other, often less invasive, techniques have been developed more recently to evaluate the lymphatic vascular system and associated pathologies. Especially the introduction of magnetic resonance, and even more recently computed tomography, lymphangiography with water-soluble iodinated contrast agent has furthered our understanding of complex pathophysiological backgrounds of lymphatic diseases. This has led to an improvement of treatment approaches, especially of nontraumatic disorders caused by lymphatic flow abnormalities including plastic bronchitis, protein-losing enteropathy, and nontraumatic chylolymphatic leakages. The therapeutic armamentarium has also constantly grown and diversified in recent years with the introduction of more complex catheter-based and interstitial embolization techniques, lymph vessel stenting, lymphovenous anastomoses, as well as (targeted) medical treatment options. The aim of this article is to review the relevant spectrum of lymphatic disorders with currently available radiological imaging and interventional techniques, as well as the application of these methods in specific, individual clinical situations.
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Affiliation(s)
- Claus C Pieper
- From the Division for Minimally Invasive Lymphatic Therapy, Department of Diagnostic and Interventional Radiology, University Hospital Bonn; and Center for Rare Congenital Lymphatic Diseases, Center of Rare Diseases Bonn, Bonn, Germany
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11
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Tomasulo CE, Dori Y, Smith CL. Understanding the next circulation: lymphatics and what the future holds. Curr Opin Cardiol 2023; 38:369-374. [PMID: 37195304 DOI: 10.1097/hco.0000000000001064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
PURPOSE OF REVIEW The lymphatic system was previously considered the forgotten circulation because of an absence of adequate options for imaging and intervention. However, recent advances over the last decade have improved management strategies for patients with lymphatic disease, including chylothorax, plastic bronchitis, ascites, and protein-losing enteropathy. RECENT FINDINGS New imaging modalities have enabled detailed visualization of lymphatic vessels to allow for a better understanding of the cause of lymphatic dysfunction in a variety of patient subsets. This sparked the development of multiple transcatheter and surgery-based techniques tailored to each patient based on imaging findings. In addition, the new field of precision lymphology has added medical management options for patients with genetic syndromes, who have global lymphatic dysfunction and typically do not respond as well to the more standard lymphatic interventions. SUMMARY Recent developments in lymphatic imaging have given insight into disease processes and changed the way patients are managed. Medical management has been enhanced and new procedures have given patients more options, leading to better long-term results.
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Affiliation(s)
| | - Yoav Dori
- Division of Cardiology, Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Christopher L Smith
- Division of Cardiology, Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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12
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Castellanos DA, Ahmad S, St Clair N, Sleeper LA, Lu M, Schidlow DN, Rathod RH, Yin SM, Esch JJ, Annese D, Powell AJ, Quiñonez L, Shaikh R, Ghelani SJ. Magnetic resonance three-dimensional steady-state free precession imaging of the thoracic duct in patients with Fontan circulation and its relationship to outcomes. J Cardiovasc Magn Reson 2023; 25:28. [PMID: 37303061 PMCID: PMC10258944 DOI: 10.1186/s12968-023-00937-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 05/11/2023] [Indexed: 06/13/2023] Open
Abstract
BACKGROUND Lymphatic complications are common in patients with Fontan circulation. Three-dimensional balanced steady-state free precession (3D bSSFP) angiography by cardiovascular magnetic resonance (CMR) is widely used for cardiovascular anatomical assessment. We sought to determine the frequency of thoracic duct (TD) visualization using 3D bSSFP images and assess whether TD characteristics are associated with clinical outcomes. METHODS This was a retrospective, single-center study of patients with Fontan circulation who underwent CMR. Frequency matching of age at CMR was used to construct a comparison group of patients with repaired tetralogy of Fallot (rTOF). TD characteristics included maximum diameter and a qualitative assessment of tortuosity. Clinical outcomes included protein-losing enteropathy (PLE), plastic bronchitis, listing for heart transplantation, and death. A composite outcome was defined as presence of any of these events. RESULTS The study included 189 Fontan patients (median age 16.1 years, IQR 11.0-23.2 years) and 36 rTOF patients (median age 15.7 years, IQR 11.1-23.7 years). The TD diameter was larger (median 2.50 vs. 1.95 mm, p = 0.002) and more often well visualized (65% vs. 22%, p < 0.001) in Fontan patients vs. rTOF patients. TD dimension increased mildly with age in Fontan patients, R = 0.19, p = 0.01. In Fontan patients, the TD diameter was larger in those with PLE vs. without PLE (age-adjusted mean 4.11 vs. 2.72, p = 0.005), and was more tortuous in those with NYHA class ≥ II vs. class I (moderate or greater tortuosity 75% vs. 28.5%, p = 0.02). Larger TD diameter was associated with a lower ventricular ejection fraction that was independent of age (partial correlation = - 0.22, p = 0.02). More tortuous TDs had a higher end-systolic volume (mean 70.0 mL/m2 vs. 57.3 mL/m2, p = 0.03), lower creatinine (mean 0.61 mg/dL vs. 0.70 mg/dL, p = 0.04), and a higher absolute lymphocyte count (mean 1.80 K cells/µL vs. 0.76 K cells/µL, p = 0.003). The composite outcome was present in 6% of Fontan patients and was not associated with TD diameter (p = 0.50) or tortuosity (p = 0.09). CONCLUSIONS The TD is well visualized in two-thirds of patients with Fontan circulation on 3D-bSSFP images. Larger TD diameter is associated with PLE and increased TD tortuosity is associated with an NYHA class ≥ II.
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Affiliation(s)
- Daniel A Castellanos
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Ave, BCH 3215, Boston, MA, 02115, USA.
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA.
| | - Sidra Ahmad
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Ave, BCH 3215, Boston, MA, 02115, USA
| | - Nicole St Clair
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Ave, BCH 3215, Boston, MA, 02115, USA
| | - Lynn A Sleeper
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Ave, BCH 3215, Boston, MA, 02115, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Minmin Lu
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Ave, BCH 3215, Boston, MA, 02115, USA
| | - David N Schidlow
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Ave, BCH 3215, Boston, MA, 02115, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Rahul H Rathod
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Ave, BCH 3215, Boston, MA, 02115, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Suellen M Yin
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Ave, BCH 3215, Boston, MA, 02115, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Jesse J Esch
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Ave, BCH 3215, Boston, MA, 02115, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - David Annese
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Ave, BCH 3215, Boston, MA, 02115, USA
| | - Andrew J Powell
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Ave, BCH 3215, Boston, MA, 02115, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Luis Quiñonez
- Department of Cardiac Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Raja Shaikh
- Department of Radiology, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Sunil J Ghelani
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Ave, BCH 3215, Boston, MA, 02115, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
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13
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Hanser A, Hofbeck M, Hofmeister M, Martirosian P, Hornung A, Esser M, Schick F, Kaulitz R, Michel J, Nikolaou K, Schäfer J, Schlensak C, Sieverding L. Thoracic lymphatic anomalies in patients with univentricular hearts: correlation of morphologic findings in isotropic T2-weighted MRI with the outcome after fontan palliation. Front Cardiovasc Med 2023; 10:1145613. [PMID: 37229222 PMCID: PMC10203211 DOI: 10.3389/fcvm.2023.1145613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 04/19/2023] [Indexed: 05/27/2023] Open
Abstract
Objectives In this study we examined the correlation between the extent of thoracic lymphatic anomalies in patients after surgical palliation by total cavopulmonary connection (TCPC) and their outcome in terms of clinical and laboratory parameters. Materials and methods We prospectively examined 33 patients after TCPC with an isotropic heavily T2-weighted MRI sequence on a 3.0 T scanner. Examinations were performed after a solid meal, slice thickness of 0.6 mm, TR of 2400 ms, TE of 692 ms, FoV of 460 mm, covering thoracic and abdominal regions. Findings of the lymphatic system were correlated with clinical and laboratory parameters obtained at the annual routine check-up. Results Eight patients (group 1) showed type 4 lymphatic abnormalities. Twentyfive patients (group 2) presented less severe anomalies (type 1-3). In the treadmill CPET, group 2 reached step 7.0;6.0/8.0 vs. 6.0;3.5/6.8 in group 1 (p = 0.006*) and a distance of 775;638/854 m vs. 513;315/661 m (p = 0.006*). In the laboratory examinations, group 2 showed significantly lower levels of AST, ALT and stool calprotectin as compared to group 1. There were no significant differences in NT-pro-BNP, total protein, IgG, lymphocytes or platelets, but trends. A history of ascites showed 5/8 patients in group 1 vs. 4/25 patients in group 2 (p = 0.02*), PLE occurred in 4/8 patient in group 1 vs. 1/25 patients in group 2 (p = 0.008*). Conclusion In the long-term follow-up after TCPC, patients with severe thoracic and cervical lymphatic abnormalities showed restrictions in exercise capacity, higher liver enzymes and an increased rate of symptoms of imminent Fontan-failure such as ascites and PLE.
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Affiliation(s)
- Anja Hanser
- Department of Pediatric Cardiology, University Children's Hospital, University of Tübingen, Tübingen, Germany
| | - Michael Hofbeck
- Department of Pediatric Cardiology, University Children's Hospital, University of Tübingen, Tübingen, Germany
| | - Melanie Hofmeister
- Department of Pediatric Cardiology, University Children's Hospital, University of Tübingen, Tübingen, Germany
| | - Petros Martirosian
- Section on Experimental Radiology, University Hospital of Tübingen, Tübingen, Germany
| | - Andreas Hornung
- Department of Pediatric Cardiology, University Children's Hospital, University of Tübingen, Tübingen, Germany
| | - Michael Esser
- Department of Diagnostic and Interventional Radiology, University Hospital of Tübingen, Tübingen, Germany
| | - Fritz Schick
- Section on Experimental Radiology, University Hospital of Tübingen, Tübingen, Germany
| | - Renate Kaulitz
- Department of Pediatric Cardiology, University Children's Hospital, University of Tübingen, Tübingen, Germany
| | - Jörg Michel
- Department of Pediatric Cardiology, University Children's Hospital, University of Tübingen, Tübingen, Germany
| | - Konstantin Nikolaou
- Department of Diagnostic and Interventional Radiology, University Hospital of Tübingen, Tübingen, Germany
| | - Jürgen Schäfer
- Department of Diagnostic and Interventional Radiology, University Hospital of Tübingen, Tübingen, Germany
| | - Christian Schlensak
- Department of Cardiothoracic and Vascular Surgery, University Hospital of Tübingen, Tübingen, Germany
| | - Ludger Sieverding
- Department of Pediatric Cardiology, University Children's Hospital, University of Tübingen, Tübingen, Germany
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14
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Fusion imaging of single-photon emission computed tomography and magnetic resonance lymphangiography for post-Fontan chylothorax. Radiol Case Rep 2023; 18:1471-1476. [PMID: 36798069 PMCID: PMC9925839 DOI: 10.1016/j.radcr.2023.01.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 01/07/2023] [Indexed: 02/04/2023] Open
Abstract
A preschool male patient with an extensive cardiac surgical history developed refractory chylothorax after a total cavopulmonary connection. Neither lymphoscintigraphy nor single-photon emission computed tomography (SPECT)/computed tomography could identify the lymphatic system leakage sites. Non-contrast heavy T2-weighted magnetic resonance lymphangiography (MRL) was performed to visualize the lymphatic system. Nevertheless, distinguishing lymphatic ducts from other watery structures of the patient remained difficult. Therefore, non-contrast MRL and SPECT images were fused. This hybrid diagnostic tool elucidated the pathophysiology of the prolonged chylothorax; pulmonary lymphatic perfusion syndrome and illustrated the anatomical connection of the thoracic duct and an abnormally dilated lymphatic network in the neck and left hilar regions. Subsequent intranodal lymphangiography with ethiodized oil confirmed these findings. SPECT/MRL may become an alternative modality for revealing the mechanism of prolonged chylothorax by visualizing the lymphatic system when dynamic contrast-enhanced magnetic resonance lymphangiography is unavailable.
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15
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Vaikom House A, David D, Aguet J, Dipchand AI, Honjo O, Jean-St-Michel E, Seed M, Yoo SJ, Barron DJ, Lam CZ. Quantification of lymphatic burden in patients with Fontan circulation by T2 MR lymphangiography and associations with adverse Fontan status. Eur Heart J Cardiovasc Imaging 2023; 24:241-249. [PMID: 36327421 DOI: 10.1093/ehjci/jeac216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 09/28/2022] [Accepted: 10/05/2022] [Indexed: 11/06/2022] Open
Abstract
AIMS To quantify thoracic lymphatic burden in paediatric Fontan patients using MRI and correlate with clinical status. METHODS AND RESULTS Paediatric Fontan patients (<18-years-old) with clinical cardiac MRI that had routine lymphatic 3D T2 fast spin echo (FSE) imaging performed from May 2017 to October 2019 were included. 'Lymphatic burden' was quantified by thresholding-based segmentation of the 3D T2 FSE maximum intensity projection image and indexed to body surface area, performed by two independent readers blinded to patient status. There were 48 patients (27 males) with median age at MRI of 12.9 (9.4-14.7) years, time from Fontan surgery to MRI of 9.1 (5.9-10.4) years, and follow-up time post-Fontan surgery of 9.4 (6.6-11.0) years. Intraclass correlation coefficient between two observers for lymphatic burden was 0.96 (0.94-0.98). Greater lymphatic burden correlated with post-Fontan operation hospital length of stay and duration of chest tube drainage (rs = 0.416, P = 0.004 and rs = 0.439, P = 0.002). Median lymphatic burden was greater in patients with chylous effusions immediately post-Fontan (178 (118-393) vs. 113 (46-190) mL/m2, P = 0.028), and in patients with composite adverse Fontan status (n = 13) defined by heart failure (n = 3), transplant assessment (n = 2), recurrent effusions (n = 6), Fontan thrombus (n = 2), and/or PLE (n = 6) post-Fontan (435 (137-822) vs. 114 (51-178) mL/m2, P = 0.003). Lymphatic burden > 600 mL/m2 was associated with late adverse Fontan status with sensitivity of 57% and specificity of 95%. CONCLUSION Quantification of MR lymphatic burden is a reliable tool to assess the lymphatics post-Fontan and is associated with clinical status.
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Affiliation(s)
- Aswathy Vaikom House
- Division of Pediatric Cardiology, Department of Pediatrics, Oklahoma University Health Sciences Center, Oklahoma City, OK 73104, USA.,Division of Cardiology, Department of Paediatrics, Hospital for Sick Children, Toronto, Ontario M5G 1X8, Canada
| | - Dawn David
- Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario M5G 1X8, Canada
| | - Julien Aguet
- Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario M5G 1X8, Canada.,Department of Medical Imaging, University of Toronto, Toronto, Ontario M5T 1W7, Canada
| | - Anne I Dipchand
- Division of Cardiology, Department of Paediatrics, Hospital for Sick Children, Toronto, Ontario M5G 1X8, Canada
| | - Osami Honjo
- Division of Cardiovascular Surgery, Department of Surgery, Hospital for Sick Children, Toronto, Ontario M5G 1X8, Canada
| | - Emilie Jean-St-Michel
- Division of Cardiology, Department of Paediatrics, Hospital for Sick Children, Toronto, Ontario M5G 1X8, Canada
| | - Mike Seed
- Division of Cardiology, Department of Paediatrics, Hospital for Sick Children, Toronto, Ontario M5G 1X8, Canada.,Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario M5G 1X8, Canada
| | - Shi-Joon Yoo
- Division of Cardiology, Department of Paediatrics, Hospital for Sick Children, Toronto, Ontario M5G 1X8, Canada.,Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario M5G 1X8, Canada.,Department of Medical Imaging, University of Toronto, Toronto, Ontario M5T 1W7, Canada
| | - David J Barron
- Division of Cardiovascular Surgery, Department of Surgery, Hospital for Sick Children, Toronto, Ontario M5G 1X8, Canada
| | - Christopher Z Lam
- Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario M5G 1X8, Canada.,Department of Medical Imaging, University of Toronto, Toronto, Ontario M5T 1W7, Canada
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16
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Segar DE, Pan AY, McLennan DI, Kindel SJ, Handler SS, Ginde S, Woods RK, Goot BH, Spearman AD. Clinical Variables Associated with Pre-Fontan Aortopulmonary Collateral Burden. Pediatr Cardiol 2023; 44:228-236. [PMID: 36156171 PMCID: PMC10155213 DOI: 10.1007/s00246-022-03014-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 09/18/2022] [Indexed: 01/25/2023]
Abstract
Aortopulmonary collaterals (APCs) develop universally, but to varying degrees, in patients with single ventricle congenital heart disease (CHD). Despite their ubiquitous presence, APCs remain poorly understood. We sought to evaluate the association between APC burden and common non-invasive clinical variables. We conducted a single center, retrospective study of patients with single ventricle CHD and previous Glenn palliation who underwent pre-Fontan cardiac magnetic resonance (CMR) imaging from 3/2018 to 3/2021. CMR was used to quantify APC flow, which was normalized to aortic (APC/QAo) and pulmonary vein (APC/QPV) blood flow. Univariate, multivariable, and classification and regression tree (CART) analyses were done to investigate the potential relationship between CMR-quantified APC burden and clinical variables. A total of 29 patients were included, all of whom had increased APC flow (APC/QAo: 26.9, [22.0, 39.1]%; APC/QPV: 39.4 [33.3, 46.9]%), but to varying degrees (APC/QAo: range 11.9-44.4%; APC/QPV: range 17.7-60.0%). Pulmonary artery size (Nakata index, at pre-Fontan CMR) was the only variable associated with APC flow on multivariable analysis (APC/QAo: p = 0.020, R2 = 0.19; APC/QPV: p = 0.0006, R2 = 0.36) and was the most important variable associated with APC burden identified by CART analysis (size inversely related to APC flow). APC flow is universally increased but highly variable in patients with single ventricle CHD and Glenn circulation. Small branch pulmonary artery size is a key factor associated with increased APC burden; however, the pathogenesis of APCs is likely multifactorial. Further research is needed to better understand APC pathogenesis, including predisposing and mitigating factors.
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Affiliation(s)
- David E Segar
- Division of Cardiology, Department of Pediatrics, Herma Heart Institute, Medical College of Wisconsin, Children's Wisconsin, 9000 West Wisconsin Avenue, Milwaukee, WI, 53226, USA
- Cardiovascular Center, Medical College of Wisconsin, 8701 West Watertown Plank Road, Milwaukee, WI, 53226, USA
| | - Amy Y Pan
- Cardiovascular Center, Medical College of Wisconsin, 8701 West Watertown Plank Road, Milwaukee, WI, 53226, USA
- Division of Quantitative Health Sciences, Department of Pediatrics, Medical College of Wisconsin, Children's Wisconsin, 9000 West Wisconsin Avenue, Milwaukee, WI, 53226, USA
| | - Daniel I McLennan
- Division of Cardiology, Department of Pediatrics, Herma Heart Institute, Medical College of Wisconsin, Children's Wisconsin, 9000 West Wisconsin Avenue, Milwaukee, WI, 53226, USA
- Cardiovascular Center, Medical College of Wisconsin, 8701 West Watertown Plank Road, Milwaukee, WI, 53226, USA
| | - Steven J Kindel
- Division of Cardiology, Department of Pediatrics, Herma Heart Institute, Medical College of Wisconsin, Children's Wisconsin, 9000 West Wisconsin Avenue, Milwaukee, WI, 53226, USA
- Cardiovascular Center, Medical College of Wisconsin, 8701 West Watertown Plank Road, Milwaukee, WI, 53226, USA
| | - Stephanie S Handler
- Division of Cardiology, Department of Pediatrics, Herma Heart Institute, Medical College of Wisconsin, Children's Wisconsin, 9000 West Wisconsin Avenue, Milwaukee, WI, 53226, USA
- Cardiovascular Center, Medical College of Wisconsin, 8701 West Watertown Plank Road, Milwaukee, WI, 53226, USA
| | - Salil Ginde
- Division of Cardiology, Department of Pediatrics, Herma Heart Institute, Medical College of Wisconsin, Children's Wisconsin, 9000 West Wisconsin Avenue, Milwaukee, WI, 53226, USA
- Cardiovascular Center, Medical College of Wisconsin, 8701 West Watertown Plank Road, Milwaukee, WI, 53226, USA
- Division of Cardiology, Department of Medicine, Medical College of Wisconsin, 8701 West Watertown Plank, Milwaukee, WI, 53226, USA
| | - Ronald K Woods
- Cardiovascular Center, Medical College of Wisconsin, 8701 West Watertown Plank Road, Milwaukee, WI, 53226, USA
- Division of Congenital Cardiac Surgery, Department of Surgery, Medical College of Wisconsin, 8701 West Watertown Plank, Milwaukee, WI, 53226, USA
| | - Benjamin H Goot
- Division of Cardiology, Department of Pediatrics, Herma Heart Institute, Medical College of Wisconsin, Children's Wisconsin, 9000 West Wisconsin Avenue, Milwaukee, WI, 53226, USA
- Cardiovascular Center, Medical College of Wisconsin, 8701 West Watertown Plank Road, Milwaukee, WI, 53226, USA
| | - Andrew D Spearman
- Division of Cardiology, Department of Pediatrics, Herma Heart Institute, Medical College of Wisconsin, Children's Wisconsin, 9000 West Wisconsin Avenue, Milwaukee, WI, 53226, USA.
- Cardiovascular Center, Medical College of Wisconsin, 8701 West Watertown Plank Road, Milwaukee, WI, 53226, USA.
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17
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Kristensen R, Omann C, Gaynor JW, Rode L, Ekelund CK, Hjortdal VE. Increased nuchal translucency in children with congenital heart defects and normal karyotype-is there a correlation with mortality? Front Pediatr 2023; 11:1104179. [PMID: 36873643 PMCID: PMC9981958 DOI: 10.3389/fped.2023.1104179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 01/09/2023] [Indexed: 02/19/2023] Open
Abstract
OBJECTIVES Our objective was to investigate if an increased nuchal translucency (NT) was associated with higher mortality in chromosomally normal children with congenital heart defects (CHD). METHODS In a nationwide cohort using population-based registers, we identified 5,633 liveborn children in Denmark with a pre- or postnatal diagnosis of CHD from 2008 to 2018 (incidence of CHD 0.7%). Children with chromosomal abnormalities and non-singletons were excluded. The final cohort compromised 4,469 children. An increased NT was defined as NT > 95th-centile. Children with a NT > 95th-centile vs. NT < 95th-centile including subgroups of simple- and complex CHD were compared. Mortality was defined as death from natural causes, and mortalities were compared among groups. Survival analysis with Cox-regression was used to compare rates of mortality. Analyses were adjusted for mediators (possibly explanatory factors between increased NT and higher mortality): preeclampsia, preterm birth and small for gestational age. And for confounding effects of extracardiac anomalies and cardiac intervention, due to their close association to both the exposure and the outcome (i.e., confounders). RESULTS Of the 4,469 children with CHD, 754 (17%) had complex CHD and 3,715 (83%) simple CHD. In the combined group of CHDs the mortality rate was not increased when comparing those with a NT > 95th-centile to those with a NT < 95th-centile [Hazard ratio (HR) 1.6, 95%CI 0.8;3.4, p = 0.2]. In simple CHD there was a significantly higher mortality rate with a HR of 3.2 (95%CI: 1.1;9.2, p = 0.03) when having a NT > 95th centile. Complex CHD had no differences in mortality rate between a NT > 95th-centile and NT < 95th-centile (HR 1.1, 95%CI: 0.4;3.2, p = 0.8). All analysis adjusted for severity of CHD, cardiac operation and extracardiac anomalies. Due to limited numbers the association to mortality for a NT > 99th centile (>3.5 mm) could not be assessed. Adjustment for mediating (preeclampsia, preterm birth, small for gestational age) and confounding variables (extracardiac anomalies, cardiac intervention) did not alter the associations significantly, except for extracardiac anomalies in simple CHD. CONCLUSION An increased NT > 95th-centile is correlated with higher mortality in children with simple CHD, but the underlying cause is unknown and undetected abnormal genetics might explain the correlation rather than the increased NT itself, hence further research is warranted.
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Affiliation(s)
- Rasmus Kristensen
- Department of Cardiothoracic Surgery, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Camilla Omann
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Cardiothoracic & Vascular Surgery, Aarhus University Hospital, Skejby, Denmark
| | - J William Gaynor
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Line Rode
- Department of Obstetrics, Center for Fetal Medicine, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Biochemistry, Copenhagen University Hospital-Rigshospitalet Glostrup, Glostrup, Denmark
| | - Charlotte K Ekelund
- Department of Obstetrics, Center for Fetal Medicine, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Vibeke E Hjortdal
- Department of Cardiothoracic Surgery, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
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de Lange C, Möller T, Hebelka H. Fontan-associated liver disease: Diagnosis, surveillance, and management. Front Pediatr 2023; 11:1100514. [PMID: 36937979 PMCID: PMC10020358 DOI: 10.3389/fped.2023.1100514] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 02/09/2023] [Indexed: 03/06/2023] Open
Abstract
The Fontan operation is a lifesaving procedure for patients with functional single-ventricle congenital heart disease, where hypoplastic left heart syndrome is the most frequent anomaly. Hemodynamic changes following Fontan circulation creation are now increasingly recognized to cause multiorgan affection, where the development of a chronic liver disease, Fontan-associated liver disease (FALD), is one of the most important morbidities. Virtually, all patients with a Fontan circulation develop liver congestion, resulting in fibrosis and cirrhosis, and most patients experience childhood onset. FALD is a distinctive type of congestive hepatopathy, and its pathogenesis is thought to be a multifactorial process driven by increased nonpulsatile central venous pressure and decreased cardiac output, both of which are inherent in the Fontan circulation. In the advanced stage of liver injury, complications of portal hypertension often occur, and there is a risk of developing secondary liver cancer, reported at young age. However, FALD develops with few clinical symptoms, a surprisingly variable degree of severity in liver disease, and with little relation to poor cardiac function. The disease mechanisms and modifying factors of its development are still not fully understood. As one of the more important noncardiac complications of the Fontan circulation, FALD needs to be diagnosed in a timely manner with a structured monitoring scheme of disease development, early detection of malignancy, and determination of the optimal time point for transplantation. There is also a clear need for consensus on the best surveillance strategy for FALD. In this regard, imaging plays an important role together with clinical scoring systems, biochemical workups, and histology. Patients operated on with a Fontan circulation are generally followed up in cardiology units. Ultimately, the resulting multiorgan affection requires a multidisciplinary team of healthcare personnel to address the different organ complications. This article discusses the current concepts, diagnosis, and management of FALD, with special emphasis on the role of different imaging techniques in the diagnosis and monitoring of disease progression, as well as current recommendations for liver disease surveillance.
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Affiliation(s)
- Charlotte de Lange
- Department of Pediatric Radiology, Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
- Institution of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Thomas Möller
- Department of Pediatric Cardiology, Oslo University Hospital, Oslo, Norway
| | - Hanna Hebelka
- Department of Pediatric Radiology, Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
- Institution of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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19
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Bauer C, Dori Y, Scala M, Tulzer A, Tulzer G. Current diagnostic and therapeutic strategies for the management of lymphatic insufficiency in patients with hypoplastic left heart syndrome. Front Pediatr 2023; 11:1058567. [PMID: 36911024 PMCID: PMC9999027 DOI: 10.3389/fped.2023.1058567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 01/31/2023] [Indexed: 03/14/2023] Open
Abstract
Children with hypoplastic left heart syndrome share unique hemodynamic features that alter lymphatic integrity at all stages of palliation. Lymphatic congestion is almost universal in this patient group to some extent. It may lead to reversal of lymphatic flow, the development of abnormal lymphatic channels and ultimately decompression and loss of protein rich lymphatic fluid into extra lymphatic compartments in prone individuals. Some of the most devastating complications that are associated with single ventricle physiology, notably plastic bronchitis and protein losing enteropathy, have now been proven to be lymphatic in origin. Based on the new pathophysiologic concept new diagnostic and therapeutic strategies have recently been developed. Dynamic contrast magnetic resonance lymphangiography is now mainstay in diagnosis of lymphatic insufficiency and allows a thorough assessment of anatomy and function of the main lymphatic compartments through intranodal, intrahepatic and intramesenteric lymphatic imaging. Contrast enhanced ultrasound can evaluate thoracic duct patency and conventional fluoroscopic lymphangiography has been refined for evaluation of patients where magnetic resonance imaging cannot be performed. Novel lymphatic interventional techniques, such as thoracic duct embolization, selective lymphatic duct embolization and liver lymphatic embolization allow to seal abnormal lymphatic networks minimally invasive and have shown to resolve symptoms. Innominate vein turn-down procedures, whether surgical or interventional, have been designed to reduce lymphatic afterload and increase systemic preload effectively in the failing Fontan circulation. Outflow obstruction can now be managed with new microsurgical techniques that create lympho-venous anastomosis. Short term results for all of these new approaches are overall promising but evidence is sparse and long-term outcome still has to be defined. This review article aims to summarize current concepts of lymphatic flow disorders in single ventricle patients, discuss new emerging diagnostic and therapeutic strategies and point out lacks in evidence and needs for further research on this rapidly growing topic.
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Affiliation(s)
- Christoph Bauer
- Department of Paediatric Cardiology, Kepler University Hospital GmbH, Linz, Austria.,Johannes Kepler University Linz, Linz, Austria
| | - Yoav Dori
- Department of Cardiology, Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Mario Scala
- Johannes Kepler University Linz, Linz, Austria.,Central Radiology Institute, Kepler University Hospital GmbH, Linz, Austria
| | - Andreas Tulzer
- Department of Paediatric Cardiology, Kepler University Hospital GmbH, Linz, Austria.,Johannes Kepler University Linz, Linz, Austria
| | - Gerald Tulzer
- Department of Paediatric Cardiology, Kepler University Hospital GmbH, Linz, Austria.,Johannes Kepler University Linz, Linz, Austria
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20
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Vollbrecht TM, Luetkens JA. [Cardiac MRI of congenital heart disease : From fetus to adult]. RADIOLOGIE (HEIDELBERG, GERMANY) 2022; 62:933-940. [PMID: 35976404 DOI: 10.1007/s00117-022-01062-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/27/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Cardiac magnetic resonance imaging (MRI) is an important diagnostic tool for initial diagnostic workup and follow-up of patients with congenital heart disease (CHD) of different age groups. OBJECTIVES This review provides an overview of clinically applied MRI sequences for the assessment of CHD, highlights technical developments, and demonstrates key aspects of reporting in specific heart defects. MATERIALS AND METHODS Presentation of epidemiologic data, summary of studies on MRI sequences and their clinical application, and demonstration of clinical examples. RESULTS The broad spectrum of congenital heart defects requires the use of various sequences, which can be modified depending on patient age or treatment status. Cine imaging can be used to assess cardiac function and volumes, phase contrast flow measurements allow for the assessment of vessel hemodynamics, and various techniques of MR angiography allow visualization of the thoracic vessels with high spatiotemporal resolution. New developments allow high-resolution vascular imaging without the need for contrast agents, assessment of additional hemodynamic parameters, or fetal cardiac MRI. CONCLUSION Cardiac MRI can be employed in children as well as in adults with CHD. By using different sequences and considering the treatment status and surgery-related complications, the vast majority of clinical questions can be answered.
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Affiliation(s)
- Thomas M Vollbrecht
- Klinik für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Bonn, Venusberg-Campus 1, 53127, Bonn, Deutschland
- Quantitative Imaging Lab Bonn (QILaB), Bonn, Deutschland
| | - Julian A Luetkens
- Klinik für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Bonn, Venusberg-Campus 1, 53127, Bonn, Deutschland.
- Quantitative Imaging Lab Bonn (QILaB), Bonn, Deutschland.
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21
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Savla JJ, Kelly B, Krogh E, Smith CL, Krishnamurthy G, Glatz AC, DeWitt AG, Pinto EM, Ravishankar C, Gillespie MJ, O’Byrne ML, Escobar FA, Rome JJ, Hjortdal V, Dori Y. Occlusion Pressure of the Thoracic Duct in Fontan Patients With Lymphatic Failure: Does Dilatation Challenge Contractility? World J Pediatr Congenit Heart Surg 2022; 13:737-744. [DOI: 10.1177/21501351221119394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The Fontan circulation challenges the lymphatic system. Increasing production of lymphatic fluid and impeding lymphatic return, increased venous pressure may cause lymphatic dilatation and decrease lymphatic contractility. In-vitro studies have reported a lymphatic diameter-tension curve, with increasing passive stretch affecting the intrinsic contractile properties of each thoracic duct segment. We aimed to describe thoracic duct occlusion pressure and asses if thoracic duct dilation impairs contractility in individuals with a Fontan circulation and lymphatic failure. Methods Central venous pressure and thoracic duct measurements were retrospectively collected from 31 individuals with a Fontan circulation. Thoracic duct occlusion pressure was assessed during a period of external manual compression and used as an indicator of lymphatic vessel contractility. Measurements of pressure were correlated with measurements of the thoracic duct diameter in images obtained by dynamic contrast-enhanced MR lymphangiography. Results The average central venous pressure and average pressure of the thoracic duct were 17 mm Hg. During manual occlusion, the thoracic duct pressure significantly increased to 32 mm Hg. The average thoracic duct diameter was 3.3 mm. Thoracic duct diameter correlated closely with the central venous pressure. The rise in pressure following manual occlusion showed an inverse correlation with the diameter of the thoracic duct. Conclusion Higher central venous pressures are associated with increasing diameters of the thoracic duct. When challenged by manual occlusion, dilated thoracic ducts display a decreased ability to increase pressure. Dilatation and a resulting decreased contractility may partly explain the challenged lymphatic system in individuals with a Fontan circulation.
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Affiliation(s)
- Jill J. Savla
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Benjamin Kelly
- Department of Cardiothoracic Surgery, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Emil Krogh
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Christopher L. Smith
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- The Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, PA, USA
| | - Ganesh Krishnamurthy
- The Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, PA, USA
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Andrew C. Glatz
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Aaron G. DeWitt
- The Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, PA, USA
- Division of Critical Care, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Erin M. Pinto
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- The Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, PA, USA
| | - Chitra Ravishankar
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- The Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, PA, USA
| | - Matthew J. Gillespie
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Michael L. O’Byrne
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Fernando A. Escobar
- The Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, PA, USA
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jonathan J. Rome
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- The Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, PA, USA
| | - Vibeke Hjortdal
- Department of Cardiothoracic Surgery, Rigshospitalet, Aarhus, Denmark
| | - Yoav Dori
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- The Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, PA, USA
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22
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Yang Q, Bai X, Bao H, Li Y, Men W, Lv L, Liu Z, Han X, Li W. Invasive treatment of persistent postoperative chylothorax secondary to thoracic duct variation injury: Two case reports and literature review. Medicine (Baltimore) 2022; 101:e31383. [PMID: 36316910 PMCID: PMC9622594 DOI: 10.1097/md.0000000000031383] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
RATIONALE Postoperative chylothorax is a rare complication after pulmonary resection. Thoracic duct variations may play a key role in postoperative chylothorax occurrence and make treatment difficult. No studies in the literature have reported the successful treatment of chylothorax second to thoracic duct variation by lipiodol-based lymphangiography. PATIENT CONCERNS A 63-year-old male and a 28-year-old female with primary lung adenocarcinoma were treated by video-assisted thoracoscopic cancer resection, and suffered postoperative chylothorax. Conservative treatment was ineffective, including nil per os, persistent thoracic drainage, fatty food restriction, and somatostatin administration. DIAGNOSIS Postoperative chylothorax. INTERVENTIONS Patients received lipiodol-based lymphangiography under fluoroscopic guidance. Iatrogenic injuries were identified at thoracic duct variations, including an additional channel in case 1 and the lymphatic plexus instead of the thoracic duct in case 2. OUTCOMES Thoracic duct variations were identified by lipiodol-based lymphangiography, and postoperative chylothorax was successfully treated by lipiodol embolizing effect. LESSONS Thoracic duct variations should be considered after the failure of conservative treatment for postoperative chylothorax secondary to pulmonary resection. Lipiodol-based lymphangiography is valuable for identifying the thoracic duct variations and embolizing chylous leakage.
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Affiliation(s)
- Qiwei Yang
- Department of Thorax, The First Hospital of China Medical University, Shenyang, Liaoning, China
| | - Xu Bai
- Department of Interventional Radiology, The First Hospital of China Medical University, Shenyang, Liaoning, China
| | - Han Bao
- Department of Interventional Radiology, The First Hospital of China Medical University, Shenyang, Liaoning, China
| | - Yukang Li
- Department of Interventional Radiology, The First Hospital of China Medical University, Shenyang, Liaoning, China
| | - Wanfu Men
- Department of Thorax, The First Hospital of China Medical University, Shenyang, Liaoning, China
| | - Ling Lv
- Department of Thorax, The First Hospital of China Medical University, Shenyang, Liaoning, China
| | - Zhenghua Liu
- Department of Thorax, The First Hospital of China Medical University, Shenyang, Liaoning, China
| | - Xiangjun Han
- Department of Interventional Radiology, The First Hospital of China Medical University, Shenyang, Liaoning, China
- *Correspondence: Xiangjun Han, Department of Interventional Radiology, The First Hospital of China Medical University, Shenyang 110001, Liaoning, China (e-mail: )
| | - Wenya Li
- Department of Thorax, The First Hospital of China Medical University, Shenyang, Liaoning, China
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23
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Ramirez-Suarez KI, Tierradentro-Garcia LO, Stern JA, Dori Y, Escobar FA, Otero HJ, Rapp JB, Smith CL, Krishnamurthy G, Biko DM. State-of-the-art imaging for lymphatic evaluation in children. Pediatr Radiol 2022:10.1007/s00247-022-05469-6. [PMID: 35980463 DOI: 10.1007/s00247-022-05469-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 06/22/2022] [Accepted: 07/21/2022] [Indexed: 11/24/2022]
Abstract
The lymphatic system has been poorly understood and its importance neglected for decades. Growing understanding of lymphatic flow pathophysiology through peripheral and central lymphatic flow imaging has improved diagnosis and treatment options in children with lymphatic diseases. Flow dynamics can now be visualized by different means including dynamic contrast-enhanced magnetic resonance lymphangiography (DCMRL), the current standard technique to depict central lymphatics. Novel imaging modalities including intranodal, intrahepatic and intramesenteric DCMRL are quickly evolving and have shown important advances in the understanding and guidance of interventional procedures in children with intestinal lymphatic leaks. Lymphatic imaging is gaining importance in the radiologic and clinical fields and new techniques are emerging to overcome its limitations.
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Affiliation(s)
- Karen I Ramirez-Suarez
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.
| | | | - Joseph A Stern
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
| | - Yoav Dori
- Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA, USA.,Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Fernando A Escobar
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.,Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA, USA
| | - Hansel J Otero
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.,Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA, USA
| | - Jordan B Rapp
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.,Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA, USA
| | - Christopher L Smith
- Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA, USA.,Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ganesh Krishnamurthy
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
| | - David M Biko
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.,Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA, USA
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24
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Smith CL, Dori Y, O'Byrne ML, Glatz AC, Gillespie MJ, Rome JJ. Transcatheter Thoracic Duct Decompression for Multicompartment Lymphatic Failure After Fontan Palliation. Circ Cardiovasc Interv 2022; 15:e011733. [PMID: 35708032 DOI: 10.1161/circinterventions.121.011733] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Lymphatic embolization therapy has proven effective for Fontan failure from plastic bronchitis or protein-losing enteropathy but not when multiple lymphatic compartments are involved; furthermore, embolization does not alter the underlying pathophysiology of lymphatic dysfunction. A technique for transcatheter thoracic duct decompression (TDD), rerouting the thoracic duct to the pulmonary venous atrium to treat multicompartment lymphatic failure is described and early outcomes presented. METHODS Initially covered stents were used to channel the innominate vein flow inside of the cavopulmonary pathway into the pulmonary venous atrium. A modified approach was developed where covered stents redirected innominate vein directly to the left atrium via an extravascular course. Baseline and follow-up data on all patients undergoing TDD were reviewed. RESULTS Twelve patients underwent TDD between March 2018 and February 2021 at a median age of 12 (range: 2-22) years. Lymphatic failure occurred in median of 3 compartments per patient (protein-losing enteropathy, ascites, pleural effusions, plastic bronchitis); 10 patients had lymphatic embolizations before TDD. TDD method was intra-Fontan tunnel in 4, direct approach in 7, and other in 1. There were no major procedural complications; 6 patients underwent subsequent procedures, most commonly to treat endoleaks. Lymphatic failure resolved in 6 patients, improved in 2, and was unchanged in 4 at 6 (range: 1-20) months follow-up. One patient died after TDD from Fontan failure. CONCLUSIONS TDD is a promising new treatment for the failing Fontan physiology from multicompartment lymphatic failure. Additional work is needed to refine the technique and define optimal candidates.
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Affiliation(s)
- Christopher L Smith
- Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania
| | - Yoav Dori
- Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania
| | - Michael L O'Byrne
- Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania
| | - Andrew C Glatz
- Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania
| | - Matthew J Gillespie
- Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania
| | - Jonathan J Rome
- Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania
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25
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Puricelli F, Voges I, Gatehouse P, Rigby M, Izgi C, Pennell DJ, Krupickova S. Performance of Cardiac MRI in Pediatric and Adult Patients with Fontan Circulation. Radiol Cardiothorac Imaging 2022; 4:e210235. [PMID: 35833165 PMCID: PMC9274315 DOI: 10.1148/ryct.210235] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Revised: 04/11/2022] [Accepted: 04/18/2022] [Indexed: 06/15/2023]
Abstract
Cardiac MRI has become a widely accepted standard for anatomic and functional assessment of complex Fontan physiology, because it is noninvasive and suitable for comprehensive follow-up evaluation after Fontan completion. The use of cardiac MRI in pediatric and adult patients after completion of the Fontan procedure are described, and a practical and experience-based cardiac MRI protocol for evaluating these patients is provided. The current approach and study protocol in use at the authors' institution are presented, which address technical considerations concerning sequences, planning, and optimal image acquisition in patients with Fontan circulation. Additionally, for each sequence, the information that can be obtained and guidance on how to integrate it into clinical decision-making is discussed. Keywords: Pediatrics, MRI, MRI Functional Imaging, Heart, Congenital © RSNA, 2022.
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26
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Kelly B, Smith CL, Saravanan M, Dori Y, Hjortdal VE. Spontaneous contractions of the human thoracic duct-Important for securing lymphatic return during positive pressure ventilation? Physiol Rep 2022; 10:e15258. [PMID: 35581742 PMCID: PMC9114659 DOI: 10.14814/phy2.15258] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Revised: 03/18/2022] [Accepted: 03/20/2022] [Indexed: 04/17/2023] Open
Abstract
The thoracic duct is responsible for the circulatory return of most lymphatic fluid. The return is a well-timed synergy between the pressure in the thoracic duct, venous pressure at the thoracic duct outlet, and intrathoracic pressures during respiration. However, little is known about the forces determining thoracic duct pressure and how these respond to mechanical ventilation. We aimed to assess human thoracic duct pressure and identify elements affecting it during positive pressure ventilation and a brief ventilatory pause. The study examined pressures of 35 patients with severe congenital heart defects undergoing lymphatic interventions. Thoracic duct pressure and central venous pressure were measured in 25 patients during mechanical ventilation and in ten patients during both ventilation and a short pause in ventilation. TD contractions, mechanical ventilation, and arterial pulsations influenced the thoracic duct pressure. The mean pressure of the thoracic duct was 16 ± 5 mmHg. The frequency of the contractions was 5 ± 1 min-1 resulting in an average increase in pressure of 4 ± 4 mmHg. During mechanical ventilation, the thoracic duct pressure correlated closely to the central venous pressure. TD contractions were able to increase thoracic duct pressure by 25%. With thoracic duct pressure correlating closely to the central venous pressure, this intrinsic force may be an important factor in securing a successful return of lymphatic fluid. Future studies are needed to examine the return of lymphatic fluid and the function of the thoracic duct in the absence of both lymphatic complications and mechanical ventilation.
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Affiliation(s)
- Benjamin Kelly
- Department of Cardiothoracic and Vascular SurgeryAarhus University HospitalAarhusDenmark
- Department of Clinical MedicineAarhus UniversityAarhusDenmark
| | - Christopher L. Smith
- Division of CardiologyDepartment of PediatricsChildren's Hospital of PhiladelphiaPhiladelphiaPennsylvaniaUSA
| | - Madhumitha Saravanan
- Division of CardiologyDepartment of PediatricsChildren's Hospital of PhiladelphiaPhiladelphiaPennsylvaniaUSA
| | - Yoav Dori
- Division of CardiologyDepartment of PediatricsChildren's Hospital of PhiladelphiaPhiladelphiaPennsylvaniaUSA
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27
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Serial T2-Weighted Thoracic and Abdominal Lymphatic Imaging in Fontan Patients—New Insights into Dynamics of Lymphatic Abnormalities after Total Cavopulmonary Connection. J Cardiovasc Dev Dis 2022; 9:jcdd9050138. [PMID: 35621849 PMCID: PMC9144783 DOI: 10.3390/jcdd9050138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 04/26/2022] [Accepted: 04/27/2022] [Indexed: 11/24/2022] Open
Abstract
Lymphatic congestion in single-ventricle patients has been associated with increased morbidity and poor outcomes. Little is known about the dynamics of lymphatic abnormalities over time, on their association with clinical presentation or response to catheter interventions. This retrospective, single-center study describes Fontan patients who underwent at least two magnetic resonance imaging (MRI) studies. T2-weighted lymphatic imaging was used to classify thoracic and abdominal (para-aortic and portal-venous) lymphatic abnormalities. The relationship between lymphatic congestion and hemodynamic changes after cardiac catheter interventions, clinical presentation and MRI data was analyzed. A total of 33 Fontan patients underwent at least two cardiac MRI studies. Twenty-two patients had two, eight had three and three had four lymphatic imaging studies (total of 80 MRIs studies). No significant changes in lymphatic classification between MRI 1 and 2 were observed for thoracic (p = 0.400), para-aortic (0.670) and portal-venous (p = 0.822) abnormalities. No significant correlation between lymphatic classification and hemodynamic changes after intervention or MRI parameters was found. This study illustrates thoracic and abdominal lymphatic abnormalities in serial T2-weighted imaging after Fontan. Fontan patients did not demonstrate significant changes in their lymphatic perfusion, despite clinical or hemodynamic changes. We assume that lymphatic congestion might develop after total cavopulmonary connection (TCPC) and remain relatively stable, despite further intervention targeting hemodynamic parameters.
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28
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Lee E, Biko DM, Sherk W, Masch WR, Ladino-Torres M, Agarwal PP. Understanding Lymphatic Anatomy and Abnormalities at Imaging. Radiographics 2022; 42:487-505. [PMID: 35179984 DOI: 10.1148/rg.210104] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Lymphatic abnormalities encompass a wide range of disorders spanning solitary common cystic lymphatic malformations (LMs) to entities involving multiple organ systems such as lymphangioleiomyomatosis. Many of these disorders are rare, yet some, such as secondary lymphedema from the treatment of malignancy (radiation therapy and/or lymph node dissection), affect millions of patients worldwide. Owing to complex and variable anatomy, the lymphatics are not as well understood as other organ systems. Further complicating this is the variability in the description of lymphatic disease processes and their nomenclature in the medical literature. In recent years, medical imaging has begun to facilitate a deeper understanding of the physiology and pathologic processes that involve the lymphatic system. Radiology is playing an important and growing role in the diagnosis and treatment of many lymphatic conditions. The authors describe both normal and common variant lymphatic anatomy. Various imaging modalities including nuclear medicine lymphoscintigraphy, conventional lymphangiography, and MR lymphangiography used in the diagnosis and treatment of lymphatic disorders are highlighted. The authors discuss imaging many of the common and uncommon lymphatic disorders, including primary LMs described by the International Society for the Study of Vascular Anomalies 2018 classification system (microcystic, mixed, and macrocystic LMs; primary lymphedema). Secondary central lymphatic disorders are also detailed, including secondary lymphedema and chylous leaks, as well as lymphatic disorders not otherwise easily classified. The authors aim to provide the reader with an overview of the anatomy, pathology, imaging findings, and treatment of a wide variety of lymphatic conditions. ©RSNA, 2022.
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Affiliation(s)
- Elizabeth Lee
- From the Department of Radiology, Divisions of Cardiothoracic Imaging (E.L., P.P.A.), Interventional Radiology (W.S.), and Body Imaging (W.R.M.), University of Michigan, University Hospital Floor B1, Reception C, 1500 E Medical Center Dr, SPC 5030, Ann Arbor, MI 48109; University of Pennsylvania Perelman School of Medicine, Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pa (D.M.B.); and Department of Radiology, Division of Pediatric Radiology, University of Michigan, C.S. Mott Children's Hospital, Ann Arbor, Mich (M.L.T.)
| | - David M Biko
- From the Department of Radiology, Divisions of Cardiothoracic Imaging (E.L., P.P.A.), Interventional Radiology (W.S.), and Body Imaging (W.R.M.), University of Michigan, University Hospital Floor B1, Reception C, 1500 E Medical Center Dr, SPC 5030, Ann Arbor, MI 48109; University of Pennsylvania Perelman School of Medicine, Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pa (D.M.B.); and Department of Radiology, Division of Pediatric Radiology, University of Michigan, C.S. Mott Children's Hospital, Ann Arbor, Mich (M.L.T.)
| | - William Sherk
- From the Department of Radiology, Divisions of Cardiothoracic Imaging (E.L., P.P.A.), Interventional Radiology (W.S.), and Body Imaging (W.R.M.), University of Michigan, University Hospital Floor B1, Reception C, 1500 E Medical Center Dr, SPC 5030, Ann Arbor, MI 48109; University of Pennsylvania Perelman School of Medicine, Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pa (D.M.B.); and Department of Radiology, Division of Pediatric Radiology, University of Michigan, C.S. Mott Children's Hospital, Ann Arbor, Mich (M.L.T.)
| | - William R Masch
- From the Department of Radiology, Divisions of Cardiothoracic Imaging (E.L., P.P.A.), Interventional Radiology (W.S.), and Body Imaging (W.R.M.), University of Michigan, University Hospital Floor B1, Reception C, 1500 E Medical Center Dr, SPC 5030, Ann Arbor, MI 48109; University of Pennsylvania Perelman School of Medicine, Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pa (D.M.B.); and Department of Radiology, Division of Pediatric Radiology, University of Michigan, C.S. Mott Children's Hospital, Ann Arbor, Mich (M.L.T.)
| | - Maria Ladino-Torres
- From the Department of Radiology, Divisions of Cardiothoracic Imaging (E.L., P.P.A.), Interventional Radiology (W.S.), and Body Imaging (W.R.M.), University of Michigan, University Hospital Floor B1, Reception C, 1500 E Medical Center Dr, SPC 5030, Ann Arbor, MI 48109; University of Pennsylvania Perelman School of Medicine, Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pa (D.M.B.); and Department of Radiology, Division of Pediatric Radiology, University of Michigan, C.S. Mott Children's Hospital, Ann Arbor, Mich (M.L.T.)
| | - Prachi P Agarwal
- From the Department of Radiology, Divisions of Cardiothoracic Imaging (E.L., P.P.A.), Interventional Radiology (W.S.), and Body Imaging (W.R.M.), University of Michigan, University Hospital Floor B1, Reception C, 1500 E Medical Center Dr, SPC 5030, Ann Arbor, MI 48109; University of Pennsylvania Perelman School of Medicine, Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pa (D.M.B.); and Department of Radiology, Division of Pediatric Radiology, University of Michigan, C.S. Mott Children's Hospital, Ann Arbor, Mich (M.L.T.)
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Mackie AS, Veldtman GR, Thorup L, Hjortdal VE, Dori Y. Plastic Bronchitis and Protein-Losing Enteropathy in the Fontan Patient: Evolving Understanding and Emerging Therapies. Can J Cardiol 2022; 38:988-1001. [DOI: 10.1016/j.cjca.2022.03.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 03/08/2022] [Accepted: 03/12/2022] [Indexed: 12/17/2022] Open
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Dynamic contrast-enhanced magnetic resonance lymphangiography. Pediatr Radiol 2022; 52:285-294. [PMID: 33830292 DOI: 10.1007/s00247-021-05051-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 01/25/2021] [Accepted: 03/09/2021] [Indexed: 10/21/2022]
Abstract
Lymphatic flow disorders include a broad spectrum of abnormalities that can originate in the lymphatic or the venous system. The development of these disorders is multifactorial and is most commonly associated with congenital heart diseases and palliative surgeries that these patients undergo. Central lymphatic disorders might be secondary to traumatic leaks, lymphatic overproduction, conduction abnormalities or lymphedema, and they can progress to perfusion anomalies. Several imaging modalities have been used to visualize the lymphatic system. However, the imaging of central lymphatic flow has always been challenging. Dynamic contrast-enhanced magnetic resonance lymphangiography (DCMRL) allows for visualization of central lymphatic flow disorders and has been recently applied for the assessment of plastic bronchitis, protein-losing enteropathy, chylothorax and chylopericardium, among other lymphatic disorders. The hepatic and mesenteric accesses are innovative and promising techniques for better identification and understanding of these abnormalities. The main objectives of this review are to discuss the physiology and anatomy of the lymphatic system and review the current uses of DCMRL in the diagnosis and management of lymphatic flow disorders.
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OUP accepted manuscript. Eur J Cardiothorac Surg 2022; 62:6537500. [DOI: 10.1093/ejcts/ezac103] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 01/15/2022] [Accepted: 01/27/2022] [Indexed: 11/13/2022] Open
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Dori Y, Smith CL. Lymphatic Disorders in Patients With Single Ventricle Heart Disease. Front Pediatr 2022; 10:828107. [PMID: 35757132 PMCID: PMC9226478 DOI: 10.3389/fped.2022.828107] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 05/11/2022] [Indexed: 11/13/2022] Open
Abstract
Lymphatic abnormalities in patients with single ventricle physiology can lead to early Fontan failure and severe Fontan complications, such as protein-losing enteropathy (PLE), plastic bronchitis (PB), chylothorax, and edema. Recent developments in lymphatic imaging and interventions have shed new light on the lymphatic dysfunction in this patient population and the role of the lymphatic circulation in PLE, PB, and chylothorax. In this study, we reviewed some of the latest developments in this field and discuss new treatment options for these patients.
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Affiliation(s)
- Yoav Dori
- Department of Cardiology, Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Christopher L Smith
- Department of Cardiology, Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, Philadelphia, PA, United States
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Kamsheh AM, O'Connor MJ, Rossano JW. Management of circulatory failure after Fontan surgery. Front Pediatr 2022; 10:1020984. [PMID: 36425396 PMCID: PMC9679629 DOI: 10.3389/fped.2022.1020984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 10/18/2022] [Indexed: 11/11/2022] Open
Abstract
With improvement in survival after Fontan surgery resulting in an increasing number of older survivors, there are more patients with a Fontan circulation experiencing circulatory failure each year. Fontan circulatory failure may have a number of underlying etiologies. Once Fontan failure manifests, prognosis is poor, with patient freedom from death or transplant at 10 years of only about 40%. Medical treatments used include traditional heart failure medications such as renin-angiotensin-aldosterone system blockers and beta-blockers, diuretics for symptomatic management, antiarrhythmics for rhythm control, and phosphodiesterase-5 inhibitors to decrease PVR and improve preload. These oral medical therapies are typically not very effective and have little data demonstrating benefit; if there are no surgical or catheter-based interventions to improve the Fontan circulation, patients with severe symptoms often require inotropic medications or mechanical circulatory support. Mechanical circulatory support benefits patients with ventricular dysfunction but may not be as useful in patients with other forms of Fontan failure. Transplant remains the definitive treatment for circulatory failure after Fontan, but patients with a Fontan circulation face many challenges both before and after transplant. There remains significant room and urgent need for improvement in the management and outcomes of patients with circulatory failure after Fontan surgery.
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Affiliation(s)
- Alicia M Kamsheh
- Division of Cardiology, Children's Hospital of Philadelphia, United States
| | - Matthew J O'Connor
- Division of Cardiology, Children's Hospital of Philadelphia, United States
| | - Joseph W Rossano
- Division of Cardiology, Children's Hospital of Philadelphia, United States
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Affiliation(s)
- Jack Rychik
- Corresponding author. Cardiac Center, the Children’s Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA. Tel: +1 215 5902192, Fax: +1 267 426 5082,
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35
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Management of patients with single ventricle physiology across the lifespan: contributions from magnetic resonance and computed tomography imaging. Can J Cardiol 2022; 38:946-962. [DOI: 10.1016/j.cjca.2022.01.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 12/27/2021] [Accepted: 01/02/2022] [Indexed: 12/12/2022] Open
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36
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Raimondi F, Martins D, Coenen R, Panaioli E, Khraiche D, Boddaert N, Bonnet D, Atkins M, El-Said H, Alshawabkeh L, Hsiao A. Prevalence of Venovenous Shunting and High-Output State Quantified with 4D Flow MRI in Patients with Fontan Circulation. Radiol Cardiothorac Imaging 2021; 3:e210161. [PMID: 34934948 PMCID: PMC8686005 DOI: 10.1148/ryct.210161] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 11/04/2021] [Accepted: 11/12/2021] [Indexed: 11/11/2022]
Abstract
PURPOSE To assess the ability of four-dimensional (4D) flow MRI to quantify flow volume of the Fontan circuit, including the frequency and hemodynamic contribution of systemic-to-pulmonary venovenous collateral vessels. MATERIALS AND METHODS In this retrospective study, patients with Fontan circulation were included from three institutions (2017-2021). Flow measurements were performed at several locations along the circuit by two readers, and collateral shunt volumes were quantified. The frequency of venovenous collaterals and structural defects were tabulated from concurrent MR angiography, contemporaneous CT, or catheter angiography and related to Fontan clinical status. Statistical analysis included Pearson and Spearman correlation and Bland-Altman analysis. RESULTS Seventy-five patients (mean age, 20 years; range, 5-58 years; 46 female and 29 male patients) were included. Interobserver agreement was high for aortic output, pulmonary arteries, pulmonary veins, superior vena cava (Glenn shunt), and inferior vena cava (Fontan conduit) (range, ρ = 0.913-0.975). Calculated shunt volume also showed strong agreement, on the basis of the difference between aortic and pulmonary flow (ρ = 0.935). A total of 37 of 75 (49%) of the patients exhibited shunts exceeding 1.00 L/min, 81% (30 of 37) of whom had pulmonary venous or atrial flow volume step-ups and corresponding venovenous collaterals. A total of 12% of patients (nine of 75) exhibited a high-output state (>4 L/min/m2), most of whom had venovenous shunts exceeding 30% of cardiac output. CONCLUSION Fontan flow and venovenous shunting can be reliably quantified at 4D flow MRI; high-output states were found in a higher proportion of patients than expected, among whom venovenous collaterals were common and constituted a substantial proportion of cardiac output.Keywords: Pediatrics, MR Angiography, Cardiac, Technology Assessment, Hemodynamics/Flow Dynamics, Congenital Supplemental material is available for this article. © RSNA, 2021.
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Affiliation(s)
- Francesca Raimondi
- From the Unité Médico-Chirurgicale de Cardiologie
Congénitale et Pédiatrique, Centre de Référence des
Maladies Cardiaques Congénitales Complexes-M3C, Hôpital
Universitaire Necker-Enfants Malades, Université de Paris, Paris, France
(F.R., D.K., D.B.); Pediatric Radiology Unit, Hôpital Universitaire
Necker-Enfants Malades, Université de Paris, Paris, France (F.R., E.P.,
N.B.); Decision and Bayesian Computation, Computation Biology Department, CNRS,
URS 3756, Neuroscience Department, CNRS UMR 3571, Institut Pasteur, Paris,
France (F.R.); School of Biomedical Engineering & Imaging Sciences,
King’s College London, Lambeth Wing, St Thomas’ Hospital, London,
England (F.R.); Department of Pediatric Cardiology, Hospital de Santa Cruz,
Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal (D.M.); Radiology and
Cardiology Unit, Erasmus MC, Rotterdam, the Netherlands (R.C.); Fairfax
Radiological Consultants, Fairfax, Va (M.A.); and Departments of Pediatric
Cardiology (H.E.S.), Cardiovascular Medicine (L.A.), and Radiology (A.H.),
University of California, San Diego, 9300 Campus Point Dr, Room 7756, La Jolla,
CA 92037-7756
| | - Duarte Martins
- From the Unité Médico-Chirurgicale de Cardiologie
Congénitale et Pédiatrique, Centre de Référence des
Maladies Cardiaques Congénitales Complexes-M3C, Hôpital
Universitaire Necker-Enfants Malades, Université de Paris, Paris, France
(F.R., D.K., D.B.); Pediatric Radiology Unit, Hôpital Universitaire
Necker-Enfants Malades, Université de Paris, Paris, France (F.R., E.P.,
N.B.); Decision and Bayesian Computation, Computation Biology Department, CNRS,
URS 3756, Neuroscience Department, CNRS UMR 3571, Institut Pasteur, Paris,
France (F.R.); School of Biomedical Engineering & Imaging Sciences,
King’s College London, Lambeth Wing, St Thomas’ Hospital, London,
England (F.R.); Department of Pediatric Cardiology, Hospital de Santa Cruz,
Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal (D.M.); Radiology and
Cardiology Unit, Erasmus MC, Rotterdam, the Netherlands (R.C.); Fairfax
Radiological Consultants, Fairfax, Va (M.A.); and Departments of Pediatric
Cardiology (H.E.S.), Cardiovascular Medicine (L.A.), and Radiology (A.H.),
University of California, San Diego, 9300 Campus Point Dr, Room 7756, La Jolla,
CA 92037-7756
| | - Raluca Coenen
- From the Unité Médico-Chirurgicale de Cardiologie
Congénitale et Pédiatrique, Centre de Référence des
Maladies Cardiaques Congénitales Complexes-M3C, Hôpital
Universitaire Necker-Enfants Malades, Université de Paris, Paris, France
(F.R., D.K., D.B.); Pediatric Radiology Unit, Hôpital Universitaire
Necker-Enfants Malades, Université de Paris, Paris, France (F.R., E.P.,
N.B.); Decision and Bayesian Computation, Computation Biology Department, CNRS,
URS 3756, Neuroscience Department, CNRS UMR 3571, Institut Pasteur, Paris,
France (F.R.); School of Biomedical Engineering & Imaging Sciences,
King’s College London, Lambeth Wing, St Thomas’ Hospital, London,
England (F.R.); Department of Pediatric Cardiology, Hospital de Santa Cruz,
Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal (D.M.); Radiology and
Cardiology Unit, Erasmus MC, Rotterdam, the Netherlands (R.C.); Fairfax
Radiological Consultants, Fairfax, Va (M.A.); and Departments of Pediatric
Cardiology (H.E.S.), Cardiovascular Medicine (L.A.), and Radiology (A.H.),
University of California, San Diego, 9300 Campus Point Dr, Room 7756, La Jolla,
CA 92037-7756
| | - Elena Panaioli
- From the Unité Médico-Chirurgicale de Cardiologie
Congénitale et Pédiatrique, Centre de Référence des
Maladies Cardiaques Congénitales Complexes-M3C, Hôpital
Universitaire Necker-Enfants Malades, Université de Paris, Paris, France
(F.R., D.K., D.B.); Pediatric Radiology Unit, Hôpital Universitaire
Necker-Enfants Malades, Université de Paris, Paris, France (F.R., E.P.,
N.B.); Decision and Bayesian Computation, Computation Biology Department, CNRS,
URS 3756, Neuroscience Department, CNRS UMR 3571, Institut Pasteur, Paris,
France (F.R.); School of Biomedical Engineering & Imaging Sciences,
King’s College London, Lambeth Wing, St Thomas’ Hospital, London,
England (F.R.); Department of Pediatric Cardiology, Hospital de Santa Cruz,
Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal (D.M.); Radiology and
Cardiology Unit, Erasmus MC, Rotterdam, the Netherlands (R.C.); Fairfax
Radiological Consultants, Fairfax, Va (M.A.); and Departments of Pediatric
Cardiology (H.E.S.), Cardiovascular Medicine (L.A.), and Radiology (A.H.),
University of California, San Diego, 9300 Campus Point Dr, Room 7756, La Jolla,
CA 92037-7756
| | - Diala Khraiche
- From the Unité Médico-Chirurgicale de Cardiologie
Congénitale et Pédiatrique, Centre de Référence des
Maladies Cardiaques Congénitales Complexes-M3C, Hôpital
Universitaire Necker-Enfants Malades, Université de Paris, Paris, France
(F.R., D.K., D.B.); Pediatric Radiology Unit, Hôpital Universitaire
Necker-Enfants Malades, Université de Paris, Paris, France (F.R., E.P.,
N.B.); Decision and Bayesian Computation, Computation Biology Department, CNRS,
URS 3756, Neuroscience Department, CNRS UMR 3571, Institut Pasteur, Paris,
France (F.R.); School of Biomedical Engineering & Imaging Sciences,
King’s College London, Lambeth Wing, St Thomas’ Hospital, London,
England (F.R.); Department of Pediatric Cardiology, Hospital de Santa Cruz,
Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal (D.M.); Radiology and
Cardiology Unit, Erasmus MC, Rotterdam, the Netherlands (R.C.); Fairfax
Radiological Consultants, Fairfax, Va (M.A.); and Departments of Pediatric
Cardiology (H.E.S.), Cardiovascular Medicine (L.A.), and Radiology (A.H.),
University of California, San Diego, 9300 Campus Point Dr, Room 7756, La Jolla,
CA 92037-7756
| | - Nathalie Boddaert
- From the Unité Médico-Chirurgicale de Cardiologie
Congénitale et Pédiatrique, Centre de Référence des
Maladies Cardiaques Congénitales Complexes-M3C, Hôpital
Universitaire Necker-Enfants Malades, Université de Paris, Paris, France
(F.R., D.K., D.B.); Pediatric Radiology Unit, Hôpital Universitaire
Necker-Enfants Malades, Université de Paris, Paris, France (F.R., E.P.,
N.B.); Decision and Bayesian Computation, Computation Biology Department, CNRS,
URS 3756, Neuroscience Department, CNRS UMR 3571, Institut Pasteur, Paris,
France (F.R.); School of Biomedical Engineering & Imaging Sciences,
King’s College London, Lambeth Wing, St Thomas’ Hospital, London,
England (F.R.); Department of Pediatric Cardiology, Hospital de Santa Cruz,
Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal (D.M.); Radiology and
Cardiology Unit, Erasmus MC, Rotterdam, the Netherlands (R.C.); Fairfax
Radiological Consultants, Fairfax, Va (M.A.); and Departments of Pediatric
Cardiology (H.E.S.), Cardiovascular Medicine (L.A.), and Radiology (A.H.),
University of California, San Diego, 9300 Campus Point Dr, Room 7756, La Jolla,
CA 92037-7756
| | - Damien Bonnet
- From the Unité Médico-Chirurgicale de Cardiologie
Congénitale et Pédiatrique, Centre de Référence des
Maladies Cardiaques Congénitales Complexes-M3C, Hôpital
Universitaire Necker-Enfants Malades, Université de Paris, Paris, France
(F.R., D.K., D.B.); Pediatric Radiology Unit, Hôpital Universitaire
Necker-Enfants Malades, Université de Paris, Paris, France (F.R., E.P.,
N.B.); Decision and Bayesian Computation, Computation Biology Department, CNRS,
URS 3756, Neuroscience Department, CNRS UMR 3571, Institut Pasteur, Paris,
France (F.R.); School of Biomedical Engineering & Imaging Sciences,
King’s College London, Lambeth Wing, St Thomas’ Hospital, London,
England (F.R.); Department of Pediatric Cardiology, Hospital de Santa Cruz,
Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal (D.M.); Radiology and
Cardiology Unit, Erasmus MC, Rotterdam, the Netherlands (R.C.); Fairfax
Radiological Consultants, Fairfax, Va (M.A.); and Departments of Pediatric
Cardiology (H.E.S.), Cardiovascular Medicine (L.A.), and Radiology (A.H.),
University of California, San Diego, 9300 Campus Point Dr, Room 7756, La Jolla,
CA 92037-7756
| | - Melany Atkins
- From the Unité Médico-Chirurgicale de Cardiologie
Congénitale et Pédiatrique, Centre de Référence des
Maladies Cardiaques Congénitales Complexes-M3C, Hôpital
Universitaire Necker-Enfants Malades, Université de Paris, Paris, France
(F.R., D.K., D.B.); Pediatric Radiology Unit, Hôpital Universitaire
Necker-Enfants Malades, Université de Paris, Paris, France (F.R., E.P.,
N.B.); Decision and Bayesian Computation, Computation Biology Department, CNRS,
URS 3756, Neuroscience Department, CNRS UMR 3571, Institut Pasteur, Paris,
France (F.R.); School of Biomedical Engineering & Imaging Sciences,
King’s College London, Lambeth Wing, St Thomas’ Hospital, London,
England (F.R.); Department of Pediatric Cardiology, Hospital de Santa Cruz,
Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal (D.M.); Radiology and
Cardiology Unit, Erasmus MC, Rotterdam, the Netherlands (R.C.); Fairfax
Radiological Consultants, Fairfax, Va (M.A.); and Departments of Pediatric
Cardiology (H.E.S.), Cardiovascular Medicine (L.A.), and Radiology (A.H.),
University of California, San Diego, 9300 Campus Point Dr, Room 7756, La Jolla,
CA 92037-7756
| | - Howaida El-Said
- From the Unité Médico-Chirurgicale de Cardiologie
Congénitale et Pédiatrique, Centre de Référence des
Maladies Cardiaques Congénitales Complexes-M3C, Hôpital
Universitaire Necker-Enfants Malades, Université de Paris, Paris, France
(F.R., D.K., D.B.); Pediatric Radiology Unit, Hôpital Universitaire
Necker-Enfants Malades, Université de Paris, Paris, France (F.R., E.P.,
N.B.); Decision and Bayesian Computation, Computation Biology Department, CNRS,
URS 3756, Neuroscience Department, CNRS UMR 3571, Institut Pasteur, Paris,
France (F.R.); School of Biomedical Engineering & Imaging Sciences,
King’s College London, Lambeth Wing, St Thomas’ Hospital, London,
England (F.R.); Department of Pediatric Cardiology, Hospital de Santa Cruz,
Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal (D.M.); Radiology and
Cardiology Unit, Erasmus MC, Rotterdam, the Netherlands (R.C.); Fairfax
Radiological Consultants, Fairfax, Va (M.A.); and Departments of Pediatric
Cardiology (H.E.S.), Cardiovascular Medicine (L.A.), and Radiology (A.H.),
University of California, San Diego, 9300 Campus Point Dr, Room 7756, La Jolla,
CA 92037-7756
| | - Laith Alshawabkeh
- From the Unité Médico-Chirurgicale de Cardiologie
Congénitale et Pédiatrique, Centre de Référence des
Maladies Cardiaques Congénitales Complexes-M3C, Hôpital
Universitaire Necker-Enfants Malades, Université de Paris, Paris, France
(F.R., D.K., D.B.); Pediatric Radiology Unit, Hôpital Universitaire
Necker-Enfants Malades, Université de Paris, Paris, France (F.R., E.P.,
N.B.); Decision and Bayesian Computation, Computation Biology Department, CNRS,
URS 3756, Neuroscience Department, CNRS UMR 3571, Institut Pasteur, Paris,
France (F.R.); School of Biomedical Engineering & Imaging Sciences,
King’s College London, Lambeth Wing, St Thomas’ Hospital, London,
England (F.R.); Department of Pediatric Cardiology, Hospital de Santa Cruz,
Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal (D.M.); Radiology and
Cardiology Unit, Erasmus MC, Rotterdam, the Netherlands (R.C.); Fairfax
Radiological Consultants, Fairfax, Va (M.A.); and Departments of Pediatric
Cardiology (H.E.S.), Cardiovascular Medicine (L.A.), and Radiology (A.H.),
University of California, San Diego, 9300 Campus Point Dr, Room 7756, La Jolla,
CA 92037-7756
| | - Albert Hsiao
- From the Unité Médico-Chirurgicale de Cardiologie
Congénitale et Pédiatrique, Centre de Référence des
Maladies Cardiaques Congénitales Complexes-M3C, Hôpital
Universitaire Necker-Enfants Malades, Université de Paris, Paris, France
(F.R., D.K., D.B.); Pediatric Radiology Unit, Hôpital Universitaire
Necker-Enfants Malades, Université de Paris, Paris, France (F.R., E.P.,
N.B.); Decision and Bayesian Computation, Computation Biology Department, CNRS,
URS 3756, Neuroscience Department, CNRS UMR 3571, Institut Pasteur, Paris,
France (F.R.); School of Biomedical Engineering & Imaging Sciences,
King’s College London, Lambeth Wing, St Thomas’ Hospital, London,
England (F.R.); Department of Pediatric Cardiology, Hospital de Santa Cruz,
Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal (D.M.); Radiology and
Cardiology Unit, Erasmus MC, Rotterdam, the Netherlands (R.C.); Fairfax
Radiological Consultants, Fairfax, Va (M.A.); and Departments of Pediatric
Cardiology (H.E.S.), Cardiovascular Medicine (L.A.), and Radiology (A.H.),
University of California, San Diego, 9300 Campus Point Dr, Room 7756, La Jolla,
CA 92037-7756
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37
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Kanakis M, Martens T, Kostolny M, Petsios K, Giannopoulos N, Muthialu N. Reappraisal of lung manifestations in the setting of Fontan circulation. Asian Cardiovasc Thorac Ann 2021; 30:627-634. [PMID: 34747207 DOI: 10.1177/02184923211056711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Fontan circulation is a well-established palliation in patients with functional single ventricles. Absence of a sub-pulmonary pumping chamber creates a unique physiology in which blood flow is mainly guided by negative intrathoracic and elevated central venous pressures. Various pulmonary anatomic or pathophysiologic changes can jeopardize optimal Fontan circulation. Long-term survival of patients who have undergone the contemporary total cavopulmonary connection is satisfactory. Thorough literature review in conjunction with accumulated clinical experience can lead clinicians to extract conclusions regarding Fontan and lung interactions indicating the purpose of this review.
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Affiliation(s)
- Meletios Kanakis
- Department of Pediatric and Congenital Heart Surgery, 69106Onassis Cardiac Center, Athens, Greece
| | - Thomas Martens
- Department of Cardiac Surgery, 54498Ghent University Hospital, Gent, Belgium
| | - Martin Kostolny
- Cardiothoracic Unit, 4956Great Ormond Street Hospital for Children, London, UK.,Slovak Medical University, Bratislava, Slovakia
| | - Konstantinos Petsios
- Department of Pediatric and Congenital Heart Surgery, 69106Onassis Cardiac Center, Athens, Greece
| | - Nicholas Giannopoulos
- Department of Pediatric and Congenital Heart Surgery, 69106Onassis Cardiac Center, Athens, Greece
| | - Nagarajan Muthialu
- Cardiothoracic Unit, 4956Great Ormond Street Hospital for Children, London, UK
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Hanser A, Martirosian P, Hornung A, Hofbeck M, Grosse U, Esser M, Schick F, Schäfer J, Nikolaou K, Sieverding L. T2-Weighted High-Resolution Isotropic Magnetic Resonance Lymphangiography of the Thoracic and Abdominal Lymphatic Vessels with and without Previous High-Fat Meal. Acad Radiol 2021; 28 Suppl 1:S218-S224. [PMID: 33183951 DOI: 10.1016/j.acra.2020.10.008] [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: 08/12/2020] [Revised: 09/29/2020] [Accepted: 10/01/2020] [Indexed: 10/23/2022]
Abstract
RATIONALE AND OBJECTIVES The aim of this study was to assess the potential benefit of a high-fat meal for preparation of patients before lymphangiography of the thoracic and abdominal lymphatic vessels by a heavily T2-weighted 3D magnetic resonance sequence at 3T. MATERIALS AND METHODS A heavily T2-weighted 3D Fast-Spin-Echo sequence was applied twice for lymphangiography in 15 healthy volunteers. One examination was performed following overnight fasting and the second examination was conducted 3 hours after a drinking of 200 ml of cream and a solid meal. The effect of a high-fat meal on the visualization of different segments of the thoracic and abdominal lymphatic vessels was analyzed by scoring of the image quality. RESULTS Evaluation of the summarized score of all four segments of the thoracic duct showed significantly improved general visualization of the lymphatic system in the postprandial examination when compared to the results obtained after overnight fasting (mean ± SD: 4.5 ± 1.7 vs. 5.9 ± 1.8, p = 0.007*). Regarding different segments of the lymphatic system significant differences between pre and post cream lymphangiographies were found in the cervical segment (p = 0.012*), the inferior thoracic segment (p = 0.003*) and the abdominal segment (p = 0.035*). In contrast, the visualization of the superior thoracic segment was not significantly improved by high fat meal preparation of the subjects (p = 0.388). CONCLUSION A high-fat meal 3 hours prior to T2-weighted MR-lymphangiography improves the visualization of the main lymphatic thoracic and abdominal vessels, particularly the abdominal and cervical part as well as the inferior segment of the thoracic duct.
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39
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Convolutional Neural Network-Processed MRI Images in the Diagnosis of Plastic Bronchitis in Children. CONTRAST MEDIA & MOLECULAR IMAGING 2021; 2021:2748830. [PMID: 34621144 PMCID: PMC8457940 DOI: 10.1155/2021/2748830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 08/27/2021] [Accepted: 08/30/2021] [Indexed: 11/24/2022]
Abstract
Objective The study focused on the features of the convolutional neural networks- (CNN-) processed magnetic resonance imaging (MRI) images for plastic bronchitis (PB) in children. Methods 30 PB children were selected as subjects, including 19 boys and 11 girls. They all received the MRI examination for the chest. Then, a CNN-based algorithm was constructed and compared with Active Appearance Model (AAM) algorithm for segmentation effects of MRI images in 30 PB children, factoring into occurring simultaneously than (OST), Dice, and Jaccard coefficient. Results The maximum Dice coefficient of CNN algorithm reached 0.946, while that of active AAM was 0.843, and the Jaccard coefficient of CNN algorithm was also higher (0.894 vs. 0.758, P < 0.05). The MRI images showed pulmonary inflammation in all subjects. Of 30 patients, 14 (46.66%) had complicated pulmonary atelectasis, 9 (30%) had the complicated pleural effusion, 3 (10%) had pneumothorax, 2 (6.67%) had complicated mediastinal emphysema, and 2 (6.67%) had complicated pneumopericardium. Also, of 30 patients, 19 (63.33%) had lung consolidation and atelectasis in a single lung lobe and 11 (36.67%) in both two lung lobes. Conclusion The algorithm based on CNN can significantly improve the segmentation accuracy of MRI images for plastic bronchitis in children. The pleural effusion was a dangerous factor for the occurrence and development of PB.
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40
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Lemley BA, Biko DM, Dewitt AG, Glatz AC, Goldberg DJ, Saravanan M, O'Byrne ML, Pinto E, Ravishankar C, Rome JJ, Smith CL, Dori Y. Intrahepatic Dynamic Contrast-Enhanced Magnetic Resonance Lymphangiography: Potential Imaging Signature for Protein-Losing Enteropathy in Congenital Heart Disease. J Am Heart Assoc 2021; 10:e021542. [PMID: 34569246 PMCID: PMC8649156 DOI: 10.1161/jaha.121.021542] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Background Protein‐losing enteropathy (PLE) is a significant cause of morbidity and mortality in congenital heart disease patients with single ventricle physiology. Intrahepatic dynamic contrast‐enhanced magnetic resonance lymphangiography (IH‐DCMRL) is a novel diagnostic technique that may be useful in characterizing pathologic abdominal lymphatic flow in the congenital heart disease population and in diagnosing PLE. The objective of this study was to characterize differences in IH‐DCMRL findings in patients with single ventricle congenital heart disease with and without PLE. Methods and Results This was a single‐center retrospective study of IH‐DCMRL findings and clinical data in 41 consecutive patients, 20 with PLE and 21 without PLE, with single ventricle physiology referred for lymphatic evaluation. There were 3 distinct duodenal imaging patterns by IH‐DCMRL: (1) enhancement of the duodenal wall with leakage into the lumen, (2) enhancement of the duodenal wall without leakage into the lumen, and (3) no duodenal involvement. Patients with PLE were more likely to have duodenal involvement on IH‐DCMRL than patients without PLE (P<0.001). Conclusions IH‐DCMRL findings of lymphatic enhancement of the duodenal wall and leakage of lymph into the duodenal lumen are associated with PLE. IH‐DCMRL is a useful new modality for characterizing pathologic abdominal lymphatic flow in PLE and might be useful as a risk‐assessment tool for PLE in at‐risk patients.
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Affiliation(s)
- Bethan A Lemley
- Division of Cardiology The Children's Hospital of Philadelphia Philadelphia PA.,Department of Pediatrics Perelman School of Medicine, University of Pennsylvania Philadelphia PA
| | - Dave M Biko
- Department of Radiology Children's Hospital of Philadelphia Philadelphia PA.,Department of Radiology Perelman School of Medicine, University of Pennsylvania Philadelphia PA
| | - Aaron G Dewitt
- Department of Pediatrics Perelman School of Medicine, University of Pennsylvania Philadelphia PA.,Division of Critical Care The Children's Hospital of Philadelphiae Philadelphia PA
| | - Andrew C Glatz
- Division of Cardiology The Children's Hospital of Philadelphia Philadelphia PA.,Department of Pediatrics Perelman School of Medicine, University of Pennsylvania Philadelphia PA
| | - David J Goldberg
- Division of Cardiology The Children's Hospital of Philadelphia Philadelphia PA.,Department of Pediatrics Perelman School of Medicine, University of Pennsylvania Philadelphia PA
| | - Madhumitha Saravanan
- Division of Cardiology The Children's Hospital of Philadelphia Philadelphia PA.,Department of Pediatrics Perelman School of Medicine, University of Pennsylvania Philadelphia PA
| | - Michael L O'Byrne
- Division of Cardiology The Children's Hospital of Philadelphia Philadelphia PA.,Department of Pediatrics Perelman School of Medicine, University of Pennsylvania Philadelphia PA
| | - Erin Pinto
- Division of Cardiology The Children's Hospital of Philadelphia Philadelphia PA.,Department of Pediatrics Perelman School of Medicine, University of Pennsylvania Philadelphia PA
| | - Chitra Ravishankar
- Division of Cardiology The Children's Hospital of Philadelphia Philadelphia PA.,Department of Pediatrics Perelman School of Medicine, University of Pennsylvania Philadelphia PA
| | - Jonathan J Rome
- Division of Cardiology The Children's Hospital of Philadelphia Philadelphia PA.,Department of Pediatrics Perelman School of Medicine, University of Pennsylvania Philadelphia PA
| | - Christopher L Smith
- Division of Cardiology The Children's Hospital of Philadelphia Philadelphia PA.,Department of Pediatrics Perelman School of Medicine, University of Pennsylvania Philadelphia PA
| | - Yoav Dori
- Division of Cardiology The Children's Hospital of Philadelphia Philadelphia PA.,Department of Pediatrics Perelman School of Medicine, University of Pennsylvania Philadelphia PA
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Ntiamoah P, Mukhopadhyay S, Ghosh S, Mehta AC. Recycling plastic: diagnosis and management of plastic bronchitis among adults. Eur Respir Rev 2021; 30:30/161/210096. [PMID: 34407979 DOI: 10.1183/16000617.0096-2021] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 05/26/2021] [Indexed: 11/05/2022] Open
Abstract
Plastic bronchitis is a rare, underdiagnosed and potentially fatal condition. It is characterised by the formation and expectoration of branching gelatinous plugs that assume the shape of the airways. These airway plugs differ from the allergic mucin that characterises allergic bronchopulmonary aspergillosis and mucoid impaction of the bronchi. Plastic bronchitis is most often encountered in the paediatric population following corrective cardiac surgery, such as the Fontan procedure. It also occurs in adults. Plastic bronchitis in adults is rare, heterogeneous in its aetiology, and can lead to respiratory distress or even life-threatening airway obstruction. Plastic bronchitis in adulthood should not be overlooked, particularly in patients with chronic inflammatory lung diseases. This review presents current understanding of the presentation, aetiology, pathogenesis, pathology and management of plastic bronchitis in adults.
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Affiliation(s)
- Prince Ntiamoah
- Dept of Pulmonary and Critical Care Medicine, Cleveland Clinic, Cleveland, OH, USA
| | | | - Subha Ghosh
- Diagnostic Radiology, Cleveland Clinic, Cleveland, OH, USA
| | - Atul C Mehta
- Dept of Pulmonary and Critical Care Medicine, Cleveland Clinic, Cleveland, OH, USA
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42
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RochéRodríguez M, DiNardo JA. The Lymphatic System in the Fontan Patient-Pathophysiology, Imaging, and Interventions: What the Anesthesiologist Should Know. J Cardiothorac Vasc Anesth 2021; 36:2669-2678. [PMID: 34446325 DOI: 10.1053/j.jvca.2021.07.049] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 07/28/2021] [Indexed: 01/30/2023]
Abstract
The Fontan surgery was developed as a palliative intervention for congenital heart disease (CHD) patients with single-ventricle physiology who are not candidates for a biventricular repair. Improvements in the surgery and medical management of these patients have increased survival, yet this population remains at risk for complications and end-organ dysfunction due to Fontan failure. Lymphatic vessels maintain a fluid balance within the extracellular space, participate in fat reabsorption from the small intestine, and play an important role in the body's immune response. Altered Starling forces at the capillary level, capillary leak, and lymphatic obstruction contribute to lymphatic dysfunction in patients with Fontan physiology. These lymphatic complications include edema, pleural effusions, plastic bronchitis (PB), and protein-losing enteropathy (PLE). Over the past decade, there have been innovations in lymphatic imaging. These new imaging techniques include noncontrast magnetic resonance (MR) lymphangiography, intranodal lymphangiography (IL), dynamic contrast-enhanced magnetic resonance lymphangiography (DCMRL), and liver lymphangiography. These imaging techniques help in delineating anatomy and guiding the appropriate therapeutic approach. Lymphatic interventions then may be performed to decompress the lymphatic system or to identify and occlude abnormal lymphatic vessels and drainage pathways. The anesthesiologist should have an understanding of the effects of lymphatic disorders on the Fontan circulation and apply appropriate management techniques for the associated interventions. The Fontan surgery was developed as a palliative intervention for CHD patients with single-ventricle physiology who are not candidates for a biventricular repair. The surgery creates a series systemic and pulmonary circulation with the energy necessary to provide gradient-driven pulmonary blood flow generated by the ventricle.1 In the past decades, improvements in the surgery and medical management of these patients have increased survival, with 30-year survival rates close to 85%.2 Despite these improvements, this population remains at risk for complications and end-organ dysfunction due to Fontan failure, which is characterized by elevated systemic venous pressures and low cardiac output. These complications include arrhythmias, cardiac dysfunction, ascites, liver fibrosis/cirrhosis, renal dysfunction, pulmonary failure, and lymphatic complications such as edema, pleural effusions, PB, and PLE. Complications ultimately contribute to increased risk for hospitalization, death, and need for heart transplantation.3,4 For this reason, there has been increasing interest in the role of abnormal lymphatic circulation in the genesis of Fontan failure. The authors characterize the lymphatic pathophysiology associated with Fontan physiology and review the imaging and interventional strategies used to treat these patients.
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Affiliation(s)
- Maricarmen RochéRodríguez
- Division of Cardiac Anesthesia, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA.
| | - James A DiNardo
- Division of Cardiac Anesthesia, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
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43
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Mohanakumar S, Kelly B, Turquetto ALR, Alstrup M, Amato LP, Barnabe MSR, Silveira JBD, Amaral F, Manso PH, Jatene MB, Hjortdal VE. Functional lymphatic reserve capacity is depressed in patients with a Fontan circulation. Physiol Rep 2021; 9:e14862. [PMID: 34057301 PMCID: PMC8165731 DOI: 10.14814/phy2.14862] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/13/2021] [Indexed: 12/17/2022] Open
Abstract
Background Lymphatic abnormalities play a role in effusions in individuals with a Fontan circulation. Recent results using near‐infrared fluorescence imaging disclosed an increased contraction frequency of lymphatic vessels in Fontan patients compared to healthy controls. It is proposed that the elevated lymphatic pumping seen in the Fontan patients is necessary to maintain habitual interstitial fluid balance. Hyperthermia has previously been used as a tool for lymphatic stress test. By increasing fluid filtration in the capillary bed, the lymphatic workload and contraction frequency are increased accordingly. Using near‐infrared fluorescence imaging, the lymphatic functional reserve capacity in Fontan patients were explored with a lymphatic stress test. Methods Fontan patients (n = 33) were compared to a group of 15 healthy individuals of equal age, weight, and gender. The function of the superficial lymphatic vessels in the lower leg during rest and after inducing hyperthermia was investigated, using near‐infrared fluorescence imaging. Results Baseline values in the Fontan patients showed a 57% higher contraction frequency compared to the healthy controls (0.4 ± 0.3 min−1 vs. 0.3 ± 0.2 min−1, p = 0.0445). After inducing stress on the lymphatic vessels with hyperthermia the ability to increase contraction frequency was decreased in the Fontan patients compared to the controls (0.6 ± 0.5 min−1 vs. 1.2 ± 0.8 min−1, p = 0.0102). Conclusions Fontan patients had a higher lymphatic contraction frequency during normal circumstances. In the Fontan patients, the hyperthermia response is dampened indicating that the functional lymphatic reserve capacity is depressed. This diminished reserve capacity could be part of the explanation as to why some Fontan patients develop late‐onset lymphatic complications.
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Affiliation(s)
- Sheyanth Mohanakumar
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark.,Department of Radiology, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Cardiothoracic Surgery, Rigshospitalet, Copenhagen, Denmark
| | - Benjamin Kelly
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | | | - Mathias Alstrup
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | | | | | | | - Fernando Amaral
- Ribeirão Preto Medical School - University of São Paulo, Ribeirão Preto, Brazil.,Pediatric and Adult Congenital Heart Disease Unit, Hospital das Clínicas, Ribeirão Preto, Brazil
| | - Paulo Henrique Manso
- Ribeirão Preto Medical School - University of São Paulo, Ribeirão Preto, Brazil.,Pediatric and Adult Congenital Heart Disease Unit, Hospital das Clínicas, Ribeirão Preto, Brazil
| | | | - Vibeke Elisabeth Hjortdal
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Cardiothoracic Surgery, Rigshospitalet, Copenhagen, Denmark
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Hraska V, Hjortdal VE, Dori Y, Kreutzer C. Innominate vein turn-down procedure: Killing two birds with one stone. JTCVS Tech 2021; 7:253-260. [PMID: 34318266 PMCID: PMC8312117 DOI: 10.1016/j.xjtc.2021.01.045] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 01/19/2021] [Indexed: 11/18/2022] Open
Affiliation(s)
- Viktor Hraska
- Division of Pediatric Cardiothoracic Surgery, Herma Heart Institute, Children's Wisconsin, Milwaukee, Wis
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wis
- Address for reprints: Viktor Hraska, MD, PhD, Division of Pediatric Cardiothoracic Surgery, Herma Heart Institute, Children's Wisconsin, 9000 W. Wisconsin Ave, B730, Milwaukee, WI 53226.
| | - Vibeke E. Hjortdal
- Department of Cardiothoracic Surgery, Rigshospitalet, Copenhagen, Denmark
| | - Yoav Dori
- Jill and Mark Fishman Center for Lymphatic Disorders and Lymphatic Research, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Christian Kreutzer
- Division of Pediatric Cardiovascular Surgery, Hospital Universitario Austral, Universidad Austral, Pilar, Buenos Aires, Argentina
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45
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Hraska V, Mitchell ME, Woods RK, Hoffman GM, Kindel SJ, Ginde S. Innominate Vein Turn-down Procedure for Failing Fontan Circulation. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2021; 23:34-40. [PMID: 32354545 DOI: 10.1053/j.pcsu.2020.01.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 01/06/2020] [Accepted: 01/25/2020] [Indexed: 12/16/2022]
Abstract
After the Fontan, systemic venous hypertension induces pathophysiologic changes in the lymphatic system that can result in complications of pleural effusion, ascites, plastic bronchitis, and protein losing enteropathy. Advances in medical therapy and novel interventional approaches have not substantially improved the poor prognosis of these complications. A more physiological approach has been developed by decompression of the thoracic duct to the lower pressure common atrium with a concomitant increase of preload. Diverting the innominate vein to the common atrium increases the transport capacity of the thoracic duct, which in most patients enters the circulation at the left subclavian-jugular vein junction. Contrary to the fenestrated Fontan circulation, in which the thoracic duct is drained into the high pressure Fontan circulation, turn down of the innominate vein to the common atrium effectively decompresses the thoracic duct to the lower pressure system with "diastolic suctioning" of lymph. Innominate vein turn-down may be considered for medical-refractory post-Fontan lymphatic complications of persistent chylothorax, plastic bronchitis, and protein losing enteropathy. Prophylactic innominate vein turn-down may also be considered at time of the Fontan operation for patients that are higher risk for lymphatic complications.
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Affiliation(s)
- Viktor Hraska
- Division of Congenital Heart Surgery; Department of Surgery, Herma Heart Institute, Medical College of Wisconsin, Milwaukee, Wisconsin.
| | - Michael E Mitchell
- Division of Congenital Heart Surgery; Department of Surgery, Herma Heart Institute, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Ronald K Woods
- Division of Congenital Heart Surgery; Department of Surgery, Herma Heart Institute, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - George M Hoffman
- Department of Anesthesia, Herma Heart Institute, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Steven J Kindel
- Division of Pediatric Cardiology, Department of Pediatrics, Herma Heart Institute, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Salil Ginde
- Division of Pediatric Cardiology, Department of Pediatrics, Herma Heart Institute, Medical College of Wisconsin, Milwaukee, Wisconsin
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46
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Gooty VD, Veeram Reddy SR, Greer JS, Blair Z, Zahr RA, Arar Y, Castellanos DA, Pimplawar S, Greil GF, Dillenbeck J, Hussain T. Lymphatic pathway evaluation in congenital heart disease using 3D whole-heart balanced steady state free precession and T2-weighted cardiovascular magnetic resonance. J Cardiovasc Magn Reson 2021; 23:16. [PMID: 33641664 PMCID: PMC7919323 DOI: 10.1186/s12968-021-00707-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 01/06/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Due to passive blood flow in palliated single ventricle, central venous pressure increases chronically, ultimately impeding lymphatic drainage. Early visualization and treatment of these malformations is essential to reduce morbidity and mortality. Cardiovascular magnetic resonance (CMR) T2-weighted lymphangiography (T2w) is used for lymphatic assessment, but its low signal-to-noise ratio may result in incomplete visualization of thoracic duct pathway. 3D-balanced steady state free precession (3D-bSSFP) is commonly used to assess congenital cardiac disease anatomy. Here, we aimed to improve diagnostic imaging of thoracic duct pathway using 3D-bSSFP. METHODS Patients underwent CMR during single ventricle or central lymphatic system assessment using T2w and 3D-bSSFP. T2w parameters included 3D-turbo spin echo (TSE), TE/TR = 600/2500 ms, resolution = 1 × 1 × 1.8 mm, respiratory triggering with bellows. 3D-bSSFP parameters included electrocardiogram triggering and diaphragm navigator, 1.6 mm isotropic resolution, TE/TR = 1.8/3.6 ms. Thoracic duct was identified independently in T2w and 3D-bSSFP images, tracked completely from cisterna chyli to its drainage site, and classified based on severity of lymphatic abnormalities. RESULTS Forty-eight patients underwent CMR, 46 of whom were included in the study. Forty-five had congenital heart disease with single ventricle physiology. Median age at CMR was 4.3 year (range 0.9-35.1 year, IQR 2.4 year), and median weight was 14.4 kg (range, 7.9-112.9 kg, IQR 5.2 kg). Single ventricle with right dominant ventricle was noted in 31 patients. Thirty-eight patients (84%) were status post bidirectional Glenn and 7 (16%) were status post Fontan anastomosis. Thoracic duct visualization was achieved in 45 patients by T2w and 3D-bSSFP. Complete tracking to drainage site was attained in 11 patients (24%) by T2w vs 25 (54%) by 3D-bSSFP and in 28 (61%) by both. Classification of lymphatics was performed in 31 patients. CONCLUSION Thoracic duct pathway can be visualized by 3D-bSSFP combined with T2w lymphangiography. Cardiac triggering and respiratory navigation likely help retain lymphatic signal in the retrocardiac area by 3D-bSSFP. Visualizing lymphatic system leaks is challenging on 3D-bSSFP images alone, but 3D-bSSFP offers good visualization of duct anatomy and landmark structures to help plan interventions. Together, these sequences can define abnormal lymphatic pathway following single ventricle palliative surgery, thus guiding lymphatic interventional procedures.
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Affiliation(s)
- Vasu D Gooty
- Department of Pediatrics, Division of Pediatric Cardiology, University of Tennessee Health Science Center, Le Bonheur Children's Hospital, 49N Dunlap Street, 3rd Floor, Memphis, TN, 38015, USA.
- Department of Pediatrics, Division of Pediatric Cardiology, University of Texas Southwestern Medical Center, Dallas Children's Medical Center, Dallas, TX, USA.
| | - Surendranath R Veeram Reddy
- Department of Pediatrics, Division of Pediatric Cardiology, University of Texas Southwestern Medical Center, Dallas Children's Medical Center, Dallas, TX, USA
| | - Joshua S Greer
- Department of Pediatrics, Division of Pediatric Cardiology, University of Texas Southwestern Medical Center, Dallas Children's Medical Center, Dallas, TX, USA
| | - Zachary Blair
- University of Texas Southwestern Medical School, Dallas, TX, USA
| | - Riad Abou Zahr
- Department of Pediatrics, Division of Pediatric Cardiology, University of Texas Southwestern Medical Center, Dallas Children's Medical Center, Dallas, TX, USA
| | - Yousef Arar
- Department of Pediatrics, Division of Pediatric Cardiology, University of Texas Southwestern Medical Center, Dallas Children's Medical Center, Dallas, TX, USA
| | - Daniel A Castellanos
- Department of Pediatrics, Division of Pediatric Cardiology, University of Texas Southwestern Medical Center, Dallas Children's Medical Center, Dallas, TX, USA
| | - Sheena Pimplawar
- Department of Pediatric Radiology, University of Texas Southwestern Medical Center, Dallas Children's Medical Center, Dallas, TX, USA
| | - Gerald F Greil
- Department of Pediatrics, Division of Pediatric Cardiology, University of Texas Southwestern Medical Center, Dallas Children's Medical Center, Dallas, TX, USA
| | - Jeanne Dillenbeck
- Department of Pediatric Radiology, University of Texas Southwestern Medical Center, Dallas Children's Medical Center, Dallas, TX, USA
| | - Tarique Hussain
- Department of Pediatrics, Division of Pediatric Cardiology, University of Texas Southwestern Medical Center, Dallas Children's Medical Center, Dallas, TX, USA
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Moosmann J, Toka O, Lukassen S, Ekici AB, Mackensen A, Völkl S, Dittrich S. Lymphocyte Immune Response and T Cell Differentiation in Fontan Patients with protein-losing enteropathy. Thorac Cardiovasc Surg 2021; 69:e10-e20. [PMID: 33607694 PMCID: PMC7909601 DOI: 10.1055/s-0041-1723781] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Background
Protein-losing enteropathy (PLE) is a severe complication of the Fontan circulation. There is increasing discussion about whether lymphatic dysregulation is involved as pathomechanism of PLE. This investigation focuses on the interplay between alteration of lymphatic cells and immunologic pathway alterations.
Methods
Micro-ribonucleic acid (miRNA) expression profiling was performed in 49 patients (
n
= 10 Fontan patients with PLE,
n
= 30 Fontan patients without PLE, and
n
= 9 patients with dextro-transposition of the great arteries (dTGA). miRNA pathway analysis was performed to identify significantly enriched pathways. To determine lymphocyte populations and subtypes multiparameter flow cytometry was used.
Results
miRNAs pathway analysis of Fontan patients with PLE revealed 20 significantly changed networks of which four of the ten largest were associated with immunologic processes. This finding is supported by significant T cell deficiency with decreased CD4+ count (
p
= 0.0002), altered CD4 +/CD8+ ratio, and significantly modified CD4+ (
p
< 0.0001) and CD8+ (
p
= 0.0002) T cell differentiation toward effector and terminal differentiated T cells in Fontan patients with PLE. Analyses of CD4+ T cell subsets demonstrated significantly increased frequencies of CD4+ CD25+ CD127– regulatory T cells (Treg) in Fontan patients with PLE (
p
= 0.0011).
Conclusion
PLE in Fontan patients is associated with severe lymphopenia, T cell deficiency, significant alterations of T cell differentiation, and increased Treg frequency reflecting an immune status of chronic inflammation and shortened protection against pathogens and autoimmunity. These cellular alterations seemed to be dysregulated by several miRNA controlled immunological pathways.
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Affiliation(s)
- Julia Moosmann
- Department of Pediatric Cardiology, Friedrich-Alexander Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Okan Toka
- Pediatric and Adolescent Clinic, Fürth, Germany
| | - Sören Lukassen
- Institute of Human Genetics, Friedrich-Alexander Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Arif B Ekici
- Institute of Human Genetics, Friedrich-Alexander Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Andreas Mackensen
- Department of Internal Medicine 5, Haematology and Oncology, Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Simon Völkl
- Department of Internal Medicine 5, Haematology and Oncology, Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Sven Dittrich
- Department of Pediatric Cardiology, Friedrich-Alexander Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
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Kreutzer C, Klinger DA, Chiostri B, Sendoya S, Daneri ML, Gutierrez A, Fraire RA, Torres SF. Lymphatic Decompression Concomitant With Fontan/Kreutzer Procedure: Early Experience. World J Pediatr Congenit Heart Surg 2021; 11:284-292. [PMID: 32294012 DOI: 10.1177/2150135120905656] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To present a strategy for identifying patients at risk of lymphatic failure in the setting of planned Fontan/Kreutzer completion, allowing a tailored surgical approach. METHODS Since January 2017, clinical evaluation before performance of the Fontan/Kreutzer procedure included T2-weighted magnetic resonance imaging (MRI) lymphangiography. Thoracic lymphatic abnormalities were categorized using a scale of I to IV according to progression of severity. Patients with severe lymphatic abnormalities (types III and IV) underwent Fontan/Kreutzer with lymphatic decompression via connection of the left jugular-subclavian junction containing the thoracic duct to the systemic atrium (group A). RESULTS Thirteen patients were enrolled. Magnetic resonance imaging showed type I abnormalities in four cases (30.7%), II in four (30.7%), III in two (15.3%), and IV in three (23.3%). Patients in types III and IV underwent a Fontan/Kreutzer with lymphatic decompression (group A, n = 5), while patients in types I and II underwent a fenestrated extracardiac Fontan/Kreutzer procedure without lymphatic decompression (group B, n = 8). Preoperatively, there were no differences in age, weight, ventricular dominance (right vs left), superior vena cava pressure, incidence of chylothorax after previous superior cavopulmonary anastomosis (Glenn), or need for concomitant procedures at Fontan/Kreutzer completion. There were no differences in procedural times between the groups, nor were there differences in mortalities and Fontan/Kreutzer takedowns. There were no statistically significant differences in early and late morbidity between the two groups with the exception of total volume of effusions output postoperatively. At median follow-up of 18 months (range, 4-28 months), all patients in group A are in New York Heart Association class 1 with no differences between groups in arterial oxygen saturation. CONCLUSIONS Lymphatic decompression during Fontan/Kreutzer procedure was successfully performed in patients identified by MRI as predisposed to lymphatic failure. A larger cohort of patients and longer follow-up are required to determine the efficacy of this approach in preventing early- and long-term Fontan/Kreutzer failure.
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Affiliation(s)
- Christian Kreutzer
- Division of Pediatric Cardiovascular Surgery, Hospital Universitario Austral, Pilar, Buenos Aires, Argentina
| | - Daniel Alberto Klinger
- Division of Pediatric Cardiovascular Surgery, Hospital Universitario Austral, Pilar, Buenos Aires, Argentina
| | - Benjamin Chiostri
- Division of Pediatric Cardiovascular Surgery, Hospital Universitario Austral, Pilar, Buenos Aires, Argentina
| | - Santiago Sendoya
- Division of Pediatric Cardiology, Hospital Universitario Austral, Pilar, Buenos Aires, Argentina
| | - Mariana Lopez Daneri
- Division of Pediatric Cardiology, Hospital Universitario Austral, Pilar, Buenos Aires, Argentina
| | - Augusto Gutierrez
- Division of Pediatric Cardiology, Hospital Universitario Austral, Pilar, Buenos Aires, Argentina
| | - Rafael Alfredo Fraire
- Division of Pediatric Critical Care, Hospital Universitario Austral, Pilar, Buenos Aires, Argentina
| | - Silvio Fabio Torres
- Division of Pediatric Critical Care, Hospital Universitario Austral, Pilar, Buenos Aires, Argentina
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Bordonaro V, Ciancarella P, Ciliberti P, Curione D, Napolitano C, Santangelo TP, Natali GL, Rollo M, Guccione P, Pasquini L, Secinaro A. Dynamic contrast-enhanced magnetic resonance lymphangiography in pediatric patients with central lymphatic system disorders. LA RADIOLOGIA MEDICA 2021; 126:737-743. [PMID: 33394367 DOI: 10.1007/s11547-020-01309-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Accepted: 11/15/2020] [Indexed: 11/28/2022]
Abstract
Central conducting lymphatics (CCLs) disorders represent a broad spectrum of clinical entities ranging from self-limiting traumatic leaks treated by conservative strategies, to complex lymphatic circulation abnormalities that are progressive and unresponsive to currently available treatments. Dynamic contrast-enhanced magnetic resonance lymphangiography (DCMRL) performed by intranodal injection of gadolinium-based contrast material is a recently developed technique which allows a minimally invasive evaluation of the CCL abnormalities providing a dynamic assessment of lymph flow and its pathways. In our institution, DCMRL is performed after bilateral cannulation of inguinal lymph nodes, using a MR protocol which includes volumetric 3D T2-SPACE (sampling perfection with application-optimized contrasts using different flip-angle evolution) and free-breathing respiratory navigated sequence and TWIST (time-resolved angiography with Interleaved stochastic trajectories) MR angiography sequence, during intranodal injection of paramagnetic contrast medium. Although DCMRL applications in clinical practice are still improving, a minimally invasive assessment of lymphatic pathways is particularly important both in pediatric patients with primitive lymphatic system disorders and in children with complex congenital heart disease associated with CCL impairment.
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Affiliation(s)
- Veronica Bordonaro
- Department of Imaging, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.
| | - Paolo Ciancarella
- Department of Imaging, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Paolo Ciliberti
- Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Davide Curione
- Department of Imaging, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Carmela Napolitano
- Department of Imaging, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | | | - Gian Luigi Natali
- Department of Imaging, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Massimo Rollo
- Department of Imaging, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Paolo Guccione
- Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Luciano Pasquini
- Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Aurelio Secinaro
- Department of Imaging, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
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Alsaied T, Ashfaq A. From Other Journals: A Review of Recent Articles in Pediatric Cardiology. Pediatr Cardiol 2021; 42:469-473. [PMID: 33025027 PMCID: PMC7538048 DOI: 10.1007/s00246-020-02478-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 09/26/2020] [Indexed: 11/28/2022]
Abstract
In this review, we provide a brief description of recently published articles addressing topics relevant to pediatric cardiologists. Our hope is to provide a summary of the latest articles published recently in other journals in our field. The articles address (1) outcomes after anomalous aortic origin of the coronary artery repair which showed relief of ischemia in most patients with low mortality, (2) the role of lymphatic imaging to predict post-Fontan complications which showed that lymphatic imaging by MRI may have an added prognostic value, (3) European guidelines for participation in competitive sports in congenital heart disease patients using a systematic approach based on ventricular structure and function, pulmonary pressure, aortic root, arrhythmia, and cyanosis, (4) fenestrated atrial septal defect closure combined with medical therapy in patients with severe pulmonary hypertension which resulted in improved pulmonary pressure and offered hope for this population, (5) animal model study for pulmonary vein stenosis postsurgery showing activation of the mammalian target of rapamycin pathway and that application of rapamycin at the anastomosis location may prevent pulmonary vein stenosis, and (6) mitral valve replacement with the 15-mm mechanical valve describing a 20-year multicenter experience from the Netherland that showed that this "dime valve" may be a good option for small infants with mitral valve disease.
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Affiliation(s)
- Tarek Alsaied
- Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA. .,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
| | - Awais Ashfaq
- Heart Institute, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229 USA ,Heart Institute, Johns Hopkins All Children’s All Children’s Hospital, St. Petersburg, FL USA
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