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Ait Ali L, Martini N, Listo E, Valenti E, Sotelo J, Salvadori S, Passino C, Monteleone A, Stagnaro N, Trocchio G, Marrone C, Raimondi F, Catapano G, Festa P. Impact of 4D-Flow CMR Parameters on Functional Evaluation of Fontan Circulation. Pediatr Cardiol 2024; 45:998-1006. [PMID: 38519622 PMCID: PMC11056328 DOI: 10.1007/s00246-024-03446-4] [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: 12/18/2023] [Accepted: 02/06/2024] [Indexed: 03/25/2024]
Abstract
We sought to evaluate the potential clinical role of 4D-flow cardiac magnetic resonance (CMR)-derived energetics and flow parameters in a cohort of patients' post-Fontan palliation. In patients with Fontan circulation who underwent 4D-Flow CMR, streamlines distribution was evaluated, as well a 4D-flow CMR-derived energetics parameters as kinetic energy (KE) and energy loss (EL) normalized by volume. EL/KE index as a marker of flow efficiency was also calculated. Cardiopulmonary exercise test (CPET) was also performed in a subgroup of patients. The population study included 55 patients (mean age 22 ± 11 years). The analysis of the streamlines revealed a preferential distribution of the right superior vena cava flow for the right pulmonary artery (62.5 ± 35.4%) and a mild preferential flow for the left pulmonary artery (52.3 ± 40.6%) of the inferior vena cave-pulmonary arteries (IVC-PA) conduit. Patients with heart failure (HF) presented lower IVC/PA-conduit flow (0.75 ± 0.5 vs 1.3 ± 0.5 l/min/m2, p = 0.004) and a higher mean flow-jet angle of the IVC-PA conduit (39.2 ± 22.8 vs 15.2 ± 8.9, p < 0.001) than the remaining patients. EL/KE index correlates inversely with VO2/kg/min: R: - 0.45, p = 0.01 peak, minute ventilation (VE) R: - 0.466, p < 0.01, maximal voluntary ventilation: R:0.44, p = 0.001 and positively with the physiological dead space to the tidal volume ratio (VD/VT) peak: R: 0.58, p < 0.01. From our data, lower blood flow in IVC/PA conduit and eccentric flow was associated with HF whereas higher EL/KE index was associated with reduced functional capacity and impaired lung function. Larger studies are needed to confirm our results and to further improve the prognostic role of the 4D-Flow CMR in this challenging population.
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Affiliation(s)
- Lamia Ait Ali
- Institute of Clinical Physiology, National Research Council, Via Aurelia Sud, 54100, Massa, Pisa, Italy.
- Gabriele Monasterio Foundation, Pisa, Massa, Italy.
| | | | - Elisa Listo
- Azienda Ospedaliera ASL, 3-Ospedale Villascassi, Genoa, Italy
| | - Elisa Valenti
- Institute of Clinical Physiology, National Research Council, Via Aurelia Sud, 54100, Massa, Pisa, Italy
| | - Julio Sotelo
- Departamento de Informática, Universidad Técnica Federico Santa María, Santiago, Chile
| | - Stefano Salvadori
- Institute of Clinical Physiology, National Research Council, Via Aurelia Sud, 54100, Massa, Pisa, Italy
| | | | | | | | - Gianluca Trocchio
- ASST Ospedale Papa Giovanni XXIII, Piazza OMS, 1, 24127, Bergamo BG, Bergamo, Italy
| | | | - Francesca Raimondi
- ASST Ospedale Papa Giovanni XXIII, Piazza OMS, 1, 24127, Bergamo BG, Bergamo, Italy.
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Robb C, Rajput MZ, Raptis D, Bhalla S. Don't skip a beat! Critical findings in imaging studies performed in adults with congenital heart disease. Curr Probl Diagn Radiol 2024; 53:297-307. [PMID: 38272749 DOI: 10.1067/j.cpradiol.2024.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 12/14/2023] [Accepted: 01/16/2024] [Indexed: 01/27/2024]
Abstract
With ongoing advances in both medical and surgical management, the population of adults with congenital heart disease (CHD) continues to grow each year and has surpassed the number of pediatric cases. These adult patients will present to adult emergency departments with increasing frequency. Adults with CHD are at increased risk of developing not only cardiovascular complications, such as aortic dissection and thromboemboli, but also abdominopelvic and neurologic processes at younger ages. These individuals are also more likely to develop less urgent but clinically significant complications including end-organ dysfunction, baffle leaks, or bleeding collateral vessels. Ultimately, imaging can play a critical role in determining the triage, diagnosis, and management of adult CHD patients. To accomplish this goal, radiologists must be able to distinguish acute and chronic complications of treated CHD from benign processes, including expected post-surgical changes or imaging artifacts. Radiologists also need to be familiar with the various long-term risks and complications associated with both treated and untreated forms of CHD, particularly those in adults with complex lesions.
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Affiliation(s)
- Caroline Robb
- Mallinckrodt Institute of Radiology, Washington University in St. Louis, 510 S. Kingshighway Boulevard, Campus Box 8131, St. Louis, MO 63110, USA
| | - M Zak Rajput
- Mallinckrodt Institute of Radiology, Washington University in St. Louis, 510 S. Kingshighway Boulevard, Campus Box 8131, St. Louis, MO 63110, USA.
| | - Demetrios Raptis
- Mallinckrodt Institute of Radiology, Washington University in St. Louis, 510 S. Kingshighway Boulevard, Campus Box 8131, St. Louis, MO 63110, USA
| | - Sanjeev Bhalla
- Mallinckrodt Institute of Radiology, Washington University in St. Louis, 510 S. Kingshighway Boulevard, Campus Box 8131, St. Louis, MO 63110, USA
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3
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Krishnamurthy R, Suman G, Chan SS, Kirsch J, Iyer RS, Bolen MA, Brown RKJ, El-Sherief AH, Galizia MS, Hanneman K, Hsu JY, de Rosen VL, Rajiah PS, Renapurkar RD, Russell RR, Samyn M, Shen J, Villines TC, Wall JJ, Rigsby CK, Abbara S. ACR Appropriateness Criteria® Congenital or Acquired Heart Disease. J Am Coll Radiol 2023; 20:S351-S381. [PMID: 38040460 DOI: 10.1016/j.jacr.2023.08.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 08/22/2023] [Indexed: 12/03/2023]
Abstract
Pediatric heart disease is a large and diverse field with an overall prevalence estimated at 6 to 13 per 1,000 live births. This document discusses appropriateness of advanced imaging for a broad range of variants. Diseases covered include tetralogy of Fallot, transposition of great arteries, congenital or acquired pediatric coronary artery abnormality, single ventricle, aortopathy, anomalous pulmonary venous return, aortopathy and aortic coarctation, with indications for advanced imaging spanning the entire natural history of the disease in children and adults, including initial diagnosis, treatment planning, treatment monitoring, and early detection of complications. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
| | - Garima Suman
- Research Author, Mayo Clinic, Rochester, Minnesota
| | | | - Jacobo Kirsch
- Panel Chair, Cleveland Clinic Florida, Weston, Florida
| | - Ramesh S Iyer
- Panel Chair, Seattle Children's Hospital, Seattle, Washington
| | | | - Richard K J Brown
- University of Utah, Department of Radiology and Imaging Sciences, Salt Lake City, Utah; Commission on Nuclear Medicine and Molecular Imaging
| | | | | | - Kate Hanneman
- Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Joe Y Hsu
- Kaiser Permanente, Los Angeles, California
| | | | | | | | - Raymond R Russell
- The Warren Alpert School of Medicine at Brown University, Providence, Rhode Island; American Society of Nuclear Cardiology
| | - Margaret Samyn
- Children's Hospital of Wisconsin, Milwaukee, Wisconsin; Society for Cardiovascular Magnetic Resonance
| | - Jody Shen
- Stanford University, Stanford, California
| | - Todd C Villines
- University of Virginia Health System, Charlottesville, Virginia; Society of Cardiovascular Computed Tomography
| | - Jessica J Wall
- University of Washington, Seattle, Washington; American College of Emergency Physicians
| | - Cynthia K Rigsby
- Specialty Chair, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Suhny Abbara
- Specialty Chair, University of Texas Southwestern Medical Center, Dallas, Texas
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Cevik J, Seth I, Rozen WM. Transforming breast reconstruction: the pioneering role of artificial intelligence in preoperative planning. Gland Surg 2023; 12:1271-1275. [PMID: 37842522 PMCID: PMC10570966 DOI: 10.21037/gs-23-265] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Accepted: 09/02/2023] [Indexed: 10/17/2023]
Abstract
Autologous breast reconstruction surgery is a vital part of the recovery process for patients with breast cancer. While various reconstructive options exist, the deep inferior epigastric artery perforator (DIEP) flap is often favoured for its ability to closely mimic natural breast tissue. However, the complex vascular anatomy associated with the deep inferior epigastric artery (DIEA) presents challenges for surgeons during DIEP flap execution. Preoperative imaging, such as computed tomography angiography (CTA), is commonly used to understand vascular architecture and aid in selecting appropriate perforators. Conventional reporting of CTA scans is a labour-intensive process that can be challenging and requires specific expertise. The integration of artificial intelligence (AI) and machine learning (ML) algorithms in medical imaging has the potential to address these challenges. AI can enhance CTA through improved data acquisition, image post-processing, and potentially interpretation. By automating the perforator selection process, AI applications can significantly reduce the time spent on preoperative imaging analysis and potentially improve accuracy and reliability. While AI shows promise in optimizing efficiency, accuracy, and reliability in breast reconstruction planning, challenges and ethical considerations need to be addressed. This article explores the challenges, opportunities, and future directions of using AI in the preoperative planning of autologous breast reconstruction.
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Affiliation(s)
- Jevan Cevik
- Department of Plastic and Reconstructive Surgery, Peninsula Health, Frankston, Victoria, Australia
- Peninsula Clinical School, Central Clinical School, Faculty of Medicine, Monash University, Frankston, Victoria, Australia
| | - Ishith Seth
- Department of Plastic and Reconstructive Surgery, Peninsula Health, Frankston, Victoria, Australia
- Peninsula Clinical School, Central Clinical School, Faculty of Medicine, Monash University, Frankston, Victoria, Australia
| | - Warren M. Rozen
- Department of Plastic and Reconstructive Surgery, Peninsula Health, Frankston, Victoria, Australia
- Peninsula Clinical School, Central Clinical School, Faculty of Medicine, Monash University, Frankston, Victoria, Australia
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Bissell MM, Raimondi F, Ait Ali L, Allen BD, Barker AJ, Bolger A, Burris N, Carhäll CJ, Collins JD, Ebbers T, Francois CJ, Frydrychowicz A, Garg P, Geiger J, Ha H, Hennemuth A, Hope MD, Hsiao A, Johnson K, Kozerke S, Ma LE, Markl M, Martins D, Messina M, Oechtering TH, van Ooij P, Rigsby C, Rodriguez-Palomares J, Roest AAW, Roldán-Alzate A, Schnell S, Sotelo J, Stuber M, Syed AB, Töger J, van der Geest R, Westenberg J, Zhong L, Zhong Y, Wieben O, Dyverfeldt P. 4D Flow cardiovascular magnetic resonance consensus statement: 2023 update. J Cardiovasc Magn Reson 2023; 25:40. [PMID: 37474977 PMCID: PMC10357639 DOI: 10.1186/s12968-023-00942-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 05/30/2023] [Indexed: 07/22/2023] Open
Abstract
Hemodynamic assessment is an integral part of the diagnosis and management of cardiovascular disease. Four-dimensional cardiovascular magnetic resonance flow imaging (4D Flow CMR) allows comprehensive and accurate assessment of flow in a single acquisition. This consensus paper is an update from the 2015 '4D Flow CMR Consensus Statement'. We elaborate on 4D Flow CMR sequence options and imaging considerations. The document aims to assist centers starting out with 4D Flow CMR of the heart and great vessels with advice on acquisition parameters, post-processing workflows and integration into clinical practice. Furthermore, we define minimum quality assurance and validation standards for clinical centers. We also address the challenges faced in quality assurance and validation in the research setting. We also include a checklist for recommended publication standards, specifically for 4D Flow CMR. Finally, we discuss the current limitations and the future of 4D Flow CMR. This updated consensus paper will further facilitate widespread adoption of 4D Flow CMR in the clinical workflow across the globe and aid consistently high-quality publication standards.
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Affiliation(s)
- Malenka M Bissell
- Department of Biomedical Imaging Science, Leeds Institute of Cardiovascular and Metabolic Medicine (LICAMM), LIGHT Laboratories, Clarendon Way, University of Leeds, Leeds, LS2 9NL, UK.
| | | | - Lamia Ait Ali
- Institute of Clinical Physiology CNR, Massa, Italy
- Foundation CNR Tuscany Region G. Monasterio, Massa, Italy
| | - Bradley D Allen
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Alex J Barker
- Department of Radiology, Children's Hospital Colorado, University of Colorado Anschutz Medical Center, Aurora, USA
| | - Ann Bolger
- Department of Medicine, University of California, San Francisco, CA, USA
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Nicholas Burris
- Department of Radiology, University of Michigan, Ann Arbor, USA
| | - Carl-Johan Carhäll
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
- Center for Medical Image Science and Visualization (CMIV), Linköping University, Linköping, Sweden
| | | | - Tino Ebbers
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
- Center for Medical Image Science and Visualization (CMIV), Linköping University, Linköping, Sweden
| | | | - Alex Frydrychowicz
- Department of Radiology and Nuclear Medicine, University Hospital Schleswig-Holstein, Campus Lübeck and Universität Zu Lübeck, Lübeck, Germany
| | - Pankaj Garg
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Julia Geiger
- Department of Diagnostic Imaging, University Children's Hospital, Zurich, Switzerland
- Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Hojin Ha
- Department of Mechanical and Biomedical Engineering, Kangwon National University, Chuncheon, South Korea
| | - Anja Hennemuth
- Institute of Computer-Assisted Cardiovascular Medicine, Charité - Universitätsmedizin, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site, Berlin, Germany
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Michael D Hope
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, USA
| | - Albert Hsiao
- Department of Radiology, University of California, San Diego, CA, USA
| | - Kevin Johnson
- Departments of Radiology and Medical Physics, University of Wisconsin, Madison, WI, USA
| | - Sebastian Kozerke
- Institute for Biomedical Engineering, University and ETH Zurich, Zurich, Switzerland
| | - Liliana E Ma
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Michael Markl
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Duarte Martins
- Department of Pediatric Cardiology, Hospital de Santa Cruz, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
| | - Marci Messina
- Department of Radiology, Northwestern Medicine, Chicago, IL, USA
| | - Thekla H Oechtering
- Department of Radiology and Nuclear Medicine, University Hospital Schleswig-Holstein, Campus Lübeck and Universität Zu Lübeck, Lübeck, Germany
- Departments of Radiology and Medical Physics, University of Wisconsin, Madison, WI, USA
| | - Pim van Ooij
- Department of Radiology & Nuclear Medicine, Amsterdam Cardiovascular Sciences, Amsterdam Movement Sciences, Amsterdam University Medical Centers, Location AMC, Amsterdam, The Netherlands
- Department of Pediatric Cardiology, Division of Pediatrics, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Cynthia Rigsby
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Department of Medical Imaging, Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Jose Rodriguez-Palomares
- Department of Cardiology, Hospital Universitari Vall d´Hebron,Vall d'Hebron Institut de Recerca (VHIR), Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red-CV, CIBER CV, Madrid, Spain
| | - Arno A W Roest
- Department of Pediatric Cardiology, Willem-Alexander's Children Hospital, Leiden University Medical Center and Center for Congenital Heart Defects Amsterdam-Leiden, Leiden, The Netherlands
| | | | - Susanne Schnell
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Department of Medical Physics, Institute of Physics, University of Greifswald, Greifswald, Germany
| | - Julio Sotelo
- School of Biomedical Engineering, Universidad de Valparaíso, Valparaíso, Chile
- Biomedical Imaging Center, Pontificia Universidad Catolica de Chile, Santiago, Chile
- Millennium Institute for Intelligent Healthcare Engineering - iHEALTH, Santiago, Chile
| | - Matthias Stuber
- Département de Radiologie Médicale, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Ali B Syed
- Department of Radiology, Stanford University, Stanford, CA, USA
| | - Johannes Töger
- Clinical Physiology, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| | - Rob van der Geest
- Division of Image Processing, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jos Westenberg
- CardioVascular Imaging Group (CVIG), Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Liang Zhong
- National Heart Centre Singapore, Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
| | - Yumin Zhong
- Department of Radiology, School of Medicine, Shanghai Children's Medical Center Affiliated With Shanghai Jiao Tong University, Shanghai, People's Republic of China
| | - Oliver Wieben
- Departments of Radiology and Medical Physics, University of Wisconsin, Madison, WI, USA
| | - Petter Dyverfeldt
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
- Center for Medical Image Science and Visualization (CMIV), Linköping University, Linköping, Sweden
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Mastrodicasa D, Aquino GJ, Ordovas KG, Vargas D, Fleischmann D, Abbara S, Hanneman K. Radiology: Cardiothoracic Imaging Highlights 2022. Radiol Cardiothorac Imaging 2023; 5:e230042. [PMID: 37404783 PMCID: PMC10316293 DOI: 10.1148/ryct.230042] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 04/07/2023] [Accepted: 05/08/2023] [Indexed: 07/06/2023]
Abstract
Since its inaugural issue in 2019, Radiology: Cardiothoracic Imaging has disseminated the latest scientific advances and technical developments in cardiac, vascular, and thoracic imaging. In this review, we highlight select articles published in this journal between October 2021 and October 2022. The scope of the review encompasses various aspects of coronary artery and congenital heart diseases, vascular diseases, thoracic imaging, and health services research. Key highlights include changes in the revised Coronary Artery Disease Reporting and Data System 2.0, the value of coronary CT angiography in informing prognosis and guiding treatment decisions, cardiac MRI findings after COVID-19 vaccination or infection, high-risk features at CT angiography to identify patients with aortic dissection at risk for late adverse events, and CT-guided fiducial marker placement for preoperative planning for pulmonary nodules. Ongoing research and future directions include photon-counting CT and artificial intelligence applications in cardiovascular imaging. Keywords: Pediatrics, CT Angiography, CT-Perfusion, CT-Spectral Imaging, MR Angiography, PET/CT, Transcatheter Aortic Valve Implantation/Replacement (TAVI/TAVR), Cardiac, Pulmonary, Vascular, Aorta, Coronary Arteries © RSNA, 2023.
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Van De Bruaene A, Budts W. Collaterals in congenital heart disease: when and how to treat? Cardiovasc Diagn Ther 2023; 13:418-426. [PMID: 37583691 PMCID: PMC10423736 DOI: 10.21037/cdt-23-10] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 03/01/2023] [Indexed: 08/17/2023]
Abstract
The development of collateral circulation is not that rare in patients with congenital heart defects. These collaterals can affect cardiovascular hemodynamics and cause systemic arterial desaturation, which arises the question whether these should be closed. To date, few if any reports have been published on the therapeutic management of collaterals in adult patients with congenital heart disease in heart failure (HF). The focus of this article is to provide a pragmatic approach in the assessment of collateral circulation of the patient with HF. By considering the underlying hemodynamics and overall effects of the collateral circulation, we aim to provide a practical tool useful in clinical decision making. The paper highlights mainly the systemic venous to systemic venous collaterals, systemic venous to pulmonary venous (or pulmonary venous atrium) collaterals, and pulmonary arterio-venous malformations. Systemic venous anomalies are frequent and reported in 20% to 40% of patients who underwent Glenn or Fontan procedure. A reduction in effective pulmonary blood flow, coupled with increasing oxygen demands with growth, as well as a pressure difference between the higher pressure caval venous system and lower pressure atria (so called decompressing collaterals) are potential causes of collateral formation. Whether angiogenesis de novo or reappearance of embryological venous channels is responsible for collateral formation remains to be elucidated.
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Affiliation(s)
- Alexander Van De Bruaene
- Congenital and Structural Cardiology, University Hospitals Leuven, and Department of Cardiovascular Sciences, Catholic University Leuven, Leuven, Belgium
| | - Werner Budts
- Congenital and Structural Cardiology, University Hospitals Leuven, and Department of Cardiovascular Sciences, Catholic University Leuven, Leuven, Belgium
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