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Dammassa V, Colombo CNJ, Erba M, Ciarrocchi F, Pagani M, Price S, Mojoli F, Tavazzi G. Echocardiographic assessment of right ventricular performance in COVID-19 related acute respiratory distress syndrome: the importance of systo-diastolic interaction. Ultrasound J 2024; 16:26. [PMID: 38713303 PMCID: PMC11076422 DOI: 10.1186/s13089-024-00366-5] [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: 08/17/2023] [Accepted: 02/20/2024] [Indexed: 05/08/2024] Open
Abstract
BACKGROUND The cardiac manifestations of COVID-19 have been described in patients with acute respiratory distress syndrome (ARDS) admitted to intensive care unit (ICU). The presence and impact of right ventricular (RV) diastolic function and performance has not been studied in this population yet. We describe the prevalence of RV diastolic dysfunction, assessed by the pulmonary valve pre-ejection A wave (PV A wave), and the RV systo-diastolic interaction, using the RV total isovolumic time (t-IVT), in COVID-19 ARDS. RESULTS Prospective observational study enrolling patients with moderate to severe COVID-19 ARDS admitted to ICU who underwent a transthoracic echocardiogram within 24 h of ICU admission and at least a second one during the ICU stay. Respiratory, hemodynamic and biochemistry parameters were collected. 163 patients (age 61.0 ± 9.3 years, 72% males) were enrolled. 36 patients (22.1%) had RV dysfunction, 45 (27.1%) LV systolic dysfunction. 73 patients (44.7%) had PV A wave. The RV t-IVT correlated with TAPSE at ICU admission (p < 0.002; r - 0.61), presence of PV A wave (p < 0.001; r 0.78), peak inspiratory pressure (PIP) (p < 0.001; r 0.42), PEEP (p < 0.001; r 0.68), dynamic driving pressure (DDP) (p < 0.001; r 0.58), and PaO2/FiO2 ratio (p < 0.01; r - 0.35). The presence of PV A wave was associated with higher PIP (p < 0.001; r 0.45), higher PEEP (p < 0.001; r 0.56), higher DDP (p < 0.01, r 0.51), and lower PaO2/FiO2 ratio (p < 0.001; r - 0.49). CONCLUSIONS RV t-IVT and the presence of PV A wave are non-invasive means to describe a significant RV diastolic dysfunction and may be consider descriptive signs of RV performance in COVID-19 ARDS.
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Affiliation(s)
- Valentino Dammassa
- Department of Experimental Medicine, University of Pavia, Pavia, Italy
- Adult Intensive Care Unit, Royal Brompton Hospital, London, UK
| | - Costanza Natalia Julia Colombo
- Department of Experimental Medicine, University of Pavia, Pavia, Italy
- Anesthesia and Intensive Care, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Massimo Erba
- Anesthesia and Intensive Care, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Fabio Ciarrocchi
- Anesthesia and Intensive Care, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Michele Pagani
- Anesthesia and Intensive Care, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Susanna Price
- Adult Intensive Care Unit, Royal Brompton Hospital, London, UK
- National Heart and Lung Institute, Imperial College, London, UK
| | - Francesco Mojoli
- Anesthesia and Intensive Care, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, Unit of Anesthesia and Intensive Care, University of Pavia, Pavia, Italy
| | - Guido Tavazzi
- Anesthesia and Intensive Care, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, Unit of Anesthesia and Intensive Care, University of Pavia, Pavia, Italy.
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Avesani M, Jalal Z, Friedberg MK, Villemain O, Venet M, Di Salvo G, Thambo JB, Iriart X. Adverse remodelling in tetralogy of Fallot: From risk factors to imaging analysis and future perspectives. Hellenic J Cardiol 2024; 75:48-59. [PMID: 37495104 DOI: 10.1016/j.hjc.2023.07.008] [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: 02/20/2023] [Revised: 05/29/2023] [Accepted: 07/21/2023] [Indexed: 07/28/2023] Open
Abstract
Although contemporary outcomes of initial surgical repair of tetralogy of Fallot (TOF) are excellent, the survival of adult patients remains significantly lower than that of the normal population due to the high incidence of heart failure, ventricular arrhythmias, and sudden cardiac death. The underlying mechanisms are only partially understood but involve an adverse biventricular response, so-called remodelling, to key stressors such as right ventricular (RV) pressure-and/or volume-overload, myocardial fibrosis, and electro-mechanical dyssynchrony. In this review, we explore risk factors and mechanisms of biventricular remodelling, from histological to electro-mechanical aspects, and the role of imaging in their assessment. We discuss unsolved challenges and future directions to better understand and treat the long-term sequelae of this complex congenital heart disease.
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Affiliation(s)
- Martina Avesani
- Paediatric and Congenital Cardiology Department, M3C National Reference Centre, Bordeaux University Hospital, Bordeaux, France; IHU Liryc, Electrophysiology and Heart Modelling Institute, Bordeaux University Foundation, Pessac, France; Paediatric Cardiology Unit, Department of Woman's and Child's Health, University-Hospital of Padova, University of Padua, Padua, Italy
| | - Zakaria Jalal
- Paediatric and Congenital Cardiology Department, M3C National Reference Centre, Bordeaux University Hospital, Bordeaux, France; IHU Liryc, Electrophysiology and Heart Modelling Institute, Bordeaux University Foundation, Pessac, France
| | - Mark K Friedberg
- Labatt Family Heart Center, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Olivier Villemain
- Labatt Family Heart Center, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Maeyls Venet
- Labatt Family Heart Center, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Giovanni Di Salvo
- Paediatric Cardiology Unit, Department of Woman's and Child's Health, University-Hospital of Padova, University of Padua, Padua, Italy
| | - Jean-Benoît Thambo
- Paediatric and Congenital Cardiology Department, M3C National Reference Centre, Bordeaux University Hospital, Bordeaux, France; IHU Liryc, Electrophysiology and Heart Modelling Institute, Bordeaux University Foundation, Pessac, France
| | - Xavier Iriart
- Paediatric and Congenital Cardiology Department, M3C National Reference Centre, Bordeaux University Hospital, Bordeaux, France; IHU Liryc, Electrophysiology and Heart Modelling Institute, Bordeaux University Foundation, Pessac, France.
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Takahashi K. Usefulness of End-Diastolic Forward Flow in Patients With Repaired Tetralogy of Fallot. Circ J 2023; 88:81-82. [PMID: 38057081 DOI: 10.1253/circj.cj-23-0754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2023]
Affiliation(s)
- Ken Takahashi
- Department of Pediatrics, Juntendo University Urayasu Hospital
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Ghonim S, Babu-Narayan SV. Use of Cardiovascular Magnetic Resonance for Risk Stratification in Repaired Tetralogy of Fallot. CJC PEDIATRIC AND CONGENITAL HEART DISEASE 2023; 2:393-403. [PMID: 38161667 PMCID: PMC10755838 DOI: 10.1016/j.cjcpc.2023.08.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 08/30/2023] [Indexed: 01/03/2024]
Abstract
The risk of premature death in adult patients with repaired tetralogy of Fallot is real and not inconsiderable. From the third decade of life, the incidence of malignant ventricular arrhythmia (VA) is known to exponentially rise. Progressive adverse mechanoelectrical modelling because of years of volume and/or pressure overload from residual pulmonary valve dysfunction and ventricular scar creates the perfect catalyst for VA. Although potentially lifesaving, implantable cardiac defibrillators are associated with substantial psychological and physical morbidity. Better selection of patients most at risk of VA, so that implantable cardiac defibrillators are not inflicted on patients who will never need them, is therefore crucial and has inspired research on this topic for several decades. Cardiovascular magnetic resonance (CMR) enables noninvasive, radiation-free clinical assessment of anatomy and function, making it ideal for the lifelong surveillance of patients with congenital heart disease. Gold standard measurements of ventricular volumes and systolic function can be derived from CMR. Tissue characterization using CMR can identify a VA substrate and provides insight into myocardial disease. We detail risk factors for VA identified using currently available CMR techniques. We also discuss emerging and advanced CMR techniques that have not all yet translated into routine clinical practice. We review how CMR-defined predictors of VA in repaired tetralogy of Fallot can be incorporated into risk scores with other clinical factors to improve the accuracy of risk prediction and to allow for pragmatic clinical application. Finally, we discuss what the future may hold.
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Affiliation(s)
- Sarah Ghonim
- Adult Congenital Disease Unit, Royal Brompton Hospital, London, United Kingdom
- Cardiovascular Magnetic Resonance Unit, Royal Brompton Hospital, London, United Kingdom
- National Heart Lung Institute, Imperial College London, London, United Kingdom
| | - Sonya V. Babu-Narayan
- Adult Congenital Disease Unit, Royal Brompton Hospital, London, United Kingdom
- Cardiovascular Magnetic Resonance Unit, Royal Brompton Hospital, London, United Kingdom
- National Heart Lung Institute, Imperial College London, London, United Kingdom
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Sperotto F, Gearhart A, Hoskote A, Alexander PMA, Barreto JA, Habet V, Valencia E, Thiagarajan RR. Cardiac arrest and cardiopulmonary resuscitation in pediatric patients with cardiac disease: a narrative review. Eur J Pediatr 2023; 182:4289-4308. [PMID: 37336847 PMCID: PMC10909121 DOI: 10.1007/s00431-023-05055-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 05/27/2023] [Accepted: 06/02/2023] [Indexed: 06/21/2023]
Abstract
Children with cardiac disease are at a higher risk of cardiac arrest as compared to healthy children. Delivering adequate cardiopulmonary resuscitation (CPR) can be challenging due to anatomic characteristics, risk profiles, and physiologies. We aimed to review the physiological aspects of resuscitation in different cardiac physiologies, summarize the current recommendations, provide un update of current literature, and highlight knowledge gaps to guide research efforts. We specifically reviewed current knowledge on resuscitation strategies for high-risk categories of patients including patients with single-ventricle physiology, right-sided lesions, right ventricle restrictive physiology, left-sided lesions, myocarditis, cardiomyopathy, pulmonary arterial hypertension, and arrhythmias. Cardiac arrest occurs in about 1% of hospitalized children with cardiac disease, and in 5% of those admitted to an intensive care unit. Mortality after cardiac arrest in this population remains high, ranging from 30 to 65%. The neurologic outcome varies widely among studies, with a favorable neurologic outcome at discharge observed in 64%-95% of the survivors. Risk factors for cardiac arrest and associated mortality include younger age, lower weight, prematurity, genetic syndrome, single-ventricle physiology, arrhythmias, pulmonary arterial hypertension, comorbidities, mechanical ventilation preceding cardiac arrest, surgical complexity, higher vasoactive-inotropic score, and factors related to resources and institutional characteristics. Recent data suggest that Extracorporeal membrane oxygenation CPR (ECPR) may be a valid strategy in centers with expertise. Overall, knowledge on resuscitation strategies based on physiology remains limited, with a crucial need for further research in this field. Collaborative and interprofessional studies are highly needed to improve care and outcomes for this high-risk population. What is Known: • Children with cardiac disease are at high risk of cardiac arrest, and cardiopulmonary resuscitation may be challenging due to unique characteristics and different physiologies. • Mortality after cardiac arrest remains high and neurologic outcomes suboptimal. What is New: • We reviewed the unique resuscitation challenges, current knowledge, and recommendations for different cardiac physiologies. • We highlighted knowledge gaps to guide research efforts aimed to improve care and outcomes in this high-risk population.
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Affiliation(s)
- Francesca Sperotto
- Department of Cardiology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, MA, USA.
| | - Addison Gearhart
- Department of Cardiology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Aparna Hoskote
- Cardiac Intensive Care Unit, Heart and Lung Directorate, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - Peta M A Alexander
- Department of Cardiology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Jessica A Barreto
- Department of Cardiology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Victoria Habet
- Department of Cardiology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Eleonore Valencia
- Department of Cardiology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Ravi R Thiagarajan
- Department of Cardiology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, MA, USA
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Huang Y, Cai X, Zhong L, Xie W, Lou Q, Ma J, Chen J, Zhuang J, Wen S, Zhao J. End-diastolic forward flow in repaired tetralogy of Fallot: Mid-term outcomes from a single center. Front Cardiovasc Med 2023; 9:1068752. [PMID: 36698943 PMCID: PMC9868297 DOI: 10.3389/fcvm.2022.1068752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 12/15/2022] [Indexed: 01/11/2023] Open
Abstract
Background Pulmonary arterial end-diastolic forward flow (EDFF) following repaired tetralogy of Fallot (rTOF) is recognized as right ventricular (RV) restrictive physiology, which is closely related to poor prognosis. This study sought to review mid-term experience and investigate the risk factors of EDFF in the rTOF patients. Methods From September 2016 to January 2019, 100 patients (age < 18 years old) who underwent complete tetralogy of Fallot (TOF) repair were enrolled and were divided into EDFF group (n = 52) and non-EDFF group (n = 48) based on the presence of postoperative EDFF. Elastic net analysis was performed for variable selection. Univariate and multivariate logistic analyses were used to analyze the correlation between risk factors and EDFF. Results End-diastolic forward flow group had lower systolic blood pressure (P = 0.037), diastolic blood pressure (P = 0.027), and higher vasoactive-inotrope score within 24 h after surgery (P = 0.022) than non-EDFF group. Transannular patch (TAP) was an independent predictor of postoperative EDFF [P = 0.029, OR: 2.585 (1.102∼6.061)]. Patients were followed up for a median of 2.6 years [interquartile range (IQR) 1.6] after the first TOF repair. During follow-up, the prevalence of the EDFF was lower in those with pulmonary valve (PV) reconstructions than that in those undergoing patch enlargement without PV reconstructions in the primary TOF repair (P < 0.001). Conclusion End-diastolic forward flow was associated with TAP. Patients with EDFF might have a transient hemodynamic instability in the early postoperative period. PV reconstructions in the TOF repair might reduce the incidence of EDFF in the mid-term follow-up.
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Affiliation(s)
- Ying Huang
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Xiaowei Cai
- Department of Thoracic and Cardiovascular Surgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Lishan Zhong
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Wen Xie
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Qi Lou
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Jianrui Ma
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Jimei Chen
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Jian Zhuang
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Shusheng Wen
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Junfei Zhao
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
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7
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Outcome of humanitarian patients with late complete repair of tetralogy of Fallot: A 13-year long single-center experience. INTERNATIONAL JOURNAL OF CARDIOLOGY CONGENITAL HEART DISEASE 2022. [DOI: 10.1016/j.ijcchd.2022.100414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Bhende VV, Sharma TS, Trivedi BY, Kumar A, Parmar DM, Nerurkar P, Shah PM, Fumakiya NJ, Majmudar HP, Pathan SR. Evaluation of right ventricular performance in patients with postoperative congenital heart disease using Doppler tissue imaging and cardiopulmonary bypass indices: A prospective cohort study. Health Sci Rep 2022; 5:e909. [PMID: 36320652 PMCID: PMC9617649 DOI: 10.1002/hsr2.909] [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: 05/06/2022] [Revised: 09/15/2022] [Accepted: 10/17/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND AND AIMS Postoperative cardiac outcomes after intracardiac repair (ICR) are determined by numerous factors whereas right ventricle (RV) dysfunction is considered essential for them, as only few studies attempted to evaluate it postsurgically. RV's function is supposed to be the strong prognostic factor for patients diagnosed with congenital heart defects; therefore, assessing it is the main objective of the study. METHODS This is a prospective single-centered cohort study performed on 50 pediatric patients with congenital heart disease (CHD) who underwent ICR between January 2019 and January 2022. All patients underwent echocardiographic assessment of RV function via tricuspid annular plane systolic excursion (TAPSE) and fractional area change (FAC) at 1, 24, and 48 h. After surgery, where pre- and postoperative RV pressure, cardiopulmonary bypass (CPB), and aortic cross-clamp (ACC) time were assessed. Similarly ventilation intensive care unit (ICU) and hospital stay times and mediastinal drainage were also monitored. RESULTS The mean ± standard deviation for pre- and postoperative RV pressure was 49.1 ± 16.12 and 42.7 ± 2.9 mmHg, respectively, whereas that for pre- and postoperative pulmonary artery pressure was 30.4 ± 2.6 and 24.2 ± 12.9 mmHg, with p value of <0.002 and <0.001, respectively. The mean ± standard deviation of CPB and ACC times was 120.92 ± 74.17 and 78.44 ± 50.5 min accordingly, while those for mean ± standard deviation of ventilation time, mediastinum chest drainage, ICU and hospital stays were 30.36 ± 54.04, 43.78 ± 46.7 min, 5.9 ± 4.01 h, were 30.36 ± 54.0, 43.78 ± 46.7 min, 5.9 ± 4.01 and 10.3 ± 4.83 h, respectively. CONCLUSIONS RV dysfunction plays the important role in longer recovery and intraoperative time, while its effect is mostly transient. The use of TAPSE and FAC methods is valuable in the evaluation of postoperative outcomes, and the former proved to be more effective.
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Affiliation(s)
- Vishal V. Bhende
- Department of Pediatric Cardiac Surgery, Bhanubhai and Madhuben Patel Cardiac Centre, Shree Krishna HospitalBhaikaka UniversityGujaratIndia
| | - Tanishq S. Sharma
- Department of Pediatric Cardiac Surgery, Bhanubhai and Madhuben Patel Cardiac Centre, Shree Krishna HospitalBhaikaka UniversityGujaratIndia
| | - Bhadra Y. Trivedi
- Department of Pediatric Cardiology, Bhanubhai and Madhuben Patel Cardiac Centre, Shree Krishna HospitalBhaikaka UniversityGujaratIndia
| | - Amit Kumar
- Department of Pediatric Cardiac Intensive Care, Bhanubhai and Madhuben Patel Cardiac Centre, Shree Krishna HospitalBhaikaka UniversityGujaratIndia
| | - Dushyant M. Parmar
- Department of Perfusion Technology, Bhanubhai and Madhuben Patel Cardiac Centre, Shree Krishna HospitalBhaikaka UniversityGujaratIndia
| | - Paresh Nerurkar
- Department of Perfusion Technology, Bhanubhai and Madhuben Patel Cardiac Centre, Shree Krishna HospitalBhaikaka UniversityGujaratIndia
| | - Prachi M. Shah
- Department of Perfusion Technology, Bhanubhai and Madhuben Patel Cardiac Centre, Shree Krishna HospitalBhaikaka UniversityGujaratIndia
| | - Naresh J. Fumakiya
- Department of Echocardiography, Bhanubhai and Madhuben Patel Cardiac Centre, Shree Krishna HospitalBhaikaka UniversityGujaratIndia
| | - Hardil P. Majmudar
- Department of Pediatric Cardiac Surgery, Bhanubhai and Madhuben Patel Cardiac Centre, Shree Krishna HospitalBhaikaka UniversityGujaratIndia
| | - Sohilkhan R. Pathan
- Clinical Research Coordinator, Central Research Services (Crs), Bhanubhai and Madhuben Patel Cardiac Centre, Shree Krishna HospitalBhaikaka UniversityGujaratIndia
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Ekhomu O, Faerber JA, Wang Y, Huang J, Mai AD, DiLorenzo MP, Bhatt SM, Avitabile CM, Mercer-Rosa L. Right atrial function early after tetralogy of Fallot repair. THE INTERNATIONAL JOURNAL OF CARDIOVASCULAR IMAGING 2022; 38:1961-1972. [PMID: 37726603 DOI: 10.1007/s10554-022-02595-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Accepted: 03/10/2022] [Indexed: 11/28/2022]
Abstract
Diastolic dysfunction after repair for Tetralogy of Fallot (TOF) is associated with adverse long-term outcomes. Right atrial (RA) mechanics as a proxy of right ventricular (RV) diastolic function in the early post-operative period after surgical repair for TOF has not been reported. We sought to evaluate RA and RV strain prior to hospital discharge after TOF repair and to identify important patient factors associated with strain using a machine learning method. Single center retrospective cohort study of TOF patients undergoing surgical repair, with analysis of RA and RV strain from pre-and post-operative echocardiograms. RA function was assessed by the peak RA strain, systolic RA strain rate, early diastolic RA strain rate and RA emptying fraction. RV systolic function was measured by global longitudinal strain. Pre- and post-operative values were compared using Wilcoxon rank sum test. Gradient boosted machine (GBM) models were used to identify the most important predictors of post-operative strain. In total, 153 patients were enrolled, median age at TOF repair 3.5 months (25th-75th percentile: 2.2- 5.2), mostly male (67%), and White (64.1%). From pre-to post-operative period, there was significant worsening in all RA parameters and in RV strain. GBM models identified patient, anatomic, and surgical factors that were strong predictors of post-operative RA and RV strain. These factors included pulmonary valve and branch pulmonary artery Z scores, birth weight, gestational age and age at surgery, pre-operative RV fractional area change and oxygen saturation, type of outflow tract repair, duration of cardiopulmonary bypass, and early post-operative partial arterial pressure of oxygen. There is significant worsening in RA and RV strain early after TOF repair, indicating early alteration in diastolic and systolic function after surgery. Several patient and operative factors influence post-operative RV function. Most of the factors described are not readily modifiable, however they may inform pre-operative risk-stratification. The clinical application of RA strain and the prognostic implication of these early changes merit further study.
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Affiliation(s)
- Omonigho Ekhomu
- Division of Cardiology, Rush University Children's Hospital, Chicago, IL, USA
| | - Jennifer A Faerber
- Department of Biomedical and Health Informatics, Data Science and Biostatistics Unit, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Yan Wang
- Division of Cardiology, Echocardiography Laboratory, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jing Huang
- Department of Biomedical and Health Informatics, Data Science and Biostatistics Unit, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Anh Duc Mai
- Division of Cardiology, Echocardiography Laboratory, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Michael P DiLorenzo
- Division of Cardiology, Department of Pediatrics, New York-Presbyterian/Morgan Stanley Children's Hospital, Columbia University Medical Center, New York, NY, USA
| | - Shivani M Bhatt
- Division of Cardiology, Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Catherine M Avitabile
- Division of Cardiology, Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Laura Mercer-Rosa
- Division of Cardiology, Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
- Division of Cardiology, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA.
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Fogel MA, Anwar S, Broberg C, Browne L, Chung T, Johnson T, Muthurangu V, Taylor M, Valsangiacomo-Buechel E, Wilhelm C. Society for Cardiovascular Magnetic Resonance/European Society of Cardiovascular Imaging/American Society of Echocardiography/Society for Pediatric Radiology/North American Society for Cardiovascular Imaging Guidelines for the use of cardiovascular magnetic resonance in pediatric congenital and acquired heart disease : Endorsed by The American Heart Association. J Cardiovasc Magn Reson 2022; 24:37. [PMID: 35725473 PMCID: PMC9210755 DOI: 10.1186/s12968-022-00843-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 01/12/2022] [Indexed: 11/16/2022] Open
Abstract
Cardiovascular magnetic resonance (CMR) has been utilized in the management and care of pediatric patients for nearly 40 years. It has evolved to become an invaluable tool in the assessment of the littlest of hearts for diagnosis, pre-interventional management and follow-up care. Although mentioned in a number of consensus and guidelines documents, an up-to-date, large, stand-alone guidance work for the use of CMR in pediatric congenital 36 and acquired 35 heart disease endorsed by numerous Societies involved in the care of these children is lacking. This guidelines document outlines the use of CMR in this patient population for a significant number of heart lesions in this age group and although admittedly, is not an exhaustive treatment, it does deal with an expansive list of many common clinical issues encountered in daily practice.
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Affiliation(s)
- Mark A Fogel
- Departments of Pediatrics (Cardiology) and Radiology, The Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. .,Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| | - Shaftkat Anwar
- Department of Pediatrics (Cardiology) and Radiology, The University of California-San Francisco School of Medicine, San Francisco, USA
| | - Craig Broberg
- Division of Cardiovascular Medicine, Oregon Health and Sciences University, Portland, USA
| | - Lorna Browne
- Department of Radiology, University of Colorado, Denver, USA
| | - Taylor Chung
- Department of Radiology and Biomedical Imaging, The University of California-San Francisco School of Medicine, San Francisco, USA
| | - Tiffanie Johnson
- Department of Pediatrics (Cardiology), Indiana University School of Medicine, Indianapolis, USA
| | - Vivek Muthurangu
- Department of Pediatrics (Cardiology), University College London, London, UK
| | - Michael Taylor
- Department of Pediatrics (Cardiology), University of Cincinnati School of Medicine, Cincinnati, USA
| | | | - Carolyn Wilhelm
- Department of Pediatrics (Cardiology), University Hospitals-Cleveland, Cleaveland, USA
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11
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Novo G, Almeida A, Nobile D, Morreale P, Fattouch K, Lisi DD, Manno G, Lancellotti P, Pinto FJ. RIGHT VENTRICLE FUNCTION IN PATIENTS WITH ANTERIOR MYOCARDIAL INFARCTION: ARE WE SURE IT IS NOT INVOLVED? Curr Probl Cardiol 2022; 47:101277. [PMID: 35661811 DOI: 10.1016/j.cpcardiol.2022.101277] [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: 05/29/2022] [Accepted: 05/30/2022] [Indexed: 11/28/2022]
Abstract
The right and left ventricle of heart are intimately connected by anatomical and functional links. Hence, acute changes in cardiac geometry and function can modify the performance and physiology of both sides of the heart, influencing each other. After a brief overview of the anatomy and related imaging techniques for the study of right ventricular function, we report a review on the interesting correlation of acute anterior myocardial infarction and right ventricular function, very often underestimated.
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Affiliation(s)
- Giuseppina Novo
- Cardiology Unit, Department of Excellence of Sciences for Health Promotion and Mothernal-Child Care, Internal Medicine and Specialities (ProMISE), University of Palermo, University Hospital Paolo Giaccone, Palermo, Italy.
| | - Ana Almeida
- Centro Cardiovascular da Universidade de Lisboa - CCUL, CAML, Faculdade de Medicina, Universidade de Lisboa, Portugal; Serviço de Cardiologia, Hospital Universitário de Santa Maria, CHULN, Portugal
| | - Domenico Nobile
- Cardiology Unit, Department of Excellence of Sciences for Health Promotion and Mothernal-Child Care, Internal Medicine and Specialities (ProMISE), University of Palermo, University Hospital Paolo Giaccone, Palermo, Italy
| | - Pierluigi Morreale
- Cardiology Unit, Department of Excellence of Sciences for Health Promotion and Mothernal-Child Care, Internal Medicine and Specialities (ProMISE), University of Palermo, University Hospital Paolo Giaccone, Palermo, Italy
| | - Khalil Fattouch
- Maria Eleonora Hospital, Department of Cardiac Surgery, GVM Care & Research, Palermo, Italy
| | - Daniela Di Lisi
- Cardiology Unit, Department of Excellence of Sciences for Health Promotion and Mothernal-Child Care, Internal Medicine and Specialities (ProMISE), University of Palermo, University Hospital Paolo Giaccone, Palermo, Italy
| | - Girolamo Manno
- Cardiology Unit, Department of Excellence of Sciences for Health Promotion and Mothernal-Child Care, Internal Medicine and Specialities (ProMISE), University of Palermo, University Hospital Paolo Giaccone, Palermo, Italy
| | - Patrizio Lancellotti
- Department of Cardiology, Groupe Interdisciplinaire de Genoproteomique Appliquee Cardiovascular Sciences, University of Liège, Liège, Belgium
| | - Fausto J Pinto
- Centro Cardiovascular da Universidade de Lisboa - CCUL, CAML, Faculdade de Medicina, Universidade de Lisboa, Portugal; Serviço de Cardiologia, Hospital Universitário de Santa Maria, CHULN, Portugal
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12
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Fogel MA, Anwar S, Broberg C, Browne L, Chung T, Johnson T, Muthurangu V, Taylor M, Valsangiacomo-Buechel E, Wilhelm C. Society for Cardiovascular Magnetic Resonance/European Society of Cardiovascular Imaging/American Society of Echocardiography/Society for Pediatric Radiology/North American Society for Cardiovascular Imaging Guidelines for the Use of Cardiac Magnetic Resonance in Pediatric Congenital and Acquired Heart Disease: Endorsed by The American Heart Association. Circ Cardiovasc Imaging 2022; 15:e014415. [PMID: 35727874 PMCID: PMC9213089 DOI: 10.1161/circimaging.122.014415] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Cardiovascular magnetic resonance has been utilized in the management and care of pediatric patients for nearly 40 years. It has evolved to become an invaluable tool in the assessment of the littlest of hearts for diagnosis, pre-interventional management and follow-up care. Although mentioned in a number of consensus and guidelines documents, an up-to-date, large, stand-alone guidance work for the use of cardiovascular magnetic resonance in pediatric congenital 36 and acquired 35 heart disease endorsed by numerous Societies involved in the care of these children is lacking. This guidelines document outlines the use of cardiovascular magnetic resonance in this patient population for a significant number of heart lesions in this age group and although admittedly, is not an exhaustive treatment, it does deal with an expansive list of many common clinical issues encountered in daily practice.
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Affiliation(s)
- Mark A Fogel
- Departments of Pediatrics (Cardiology) and Radiology, The Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA, (M.A.F.).,Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA, (M.A.F.)
| | - Shaftkat Anwar
- Department of Pediatrics (Cardiology) and Radiology, The University of California-San Francisco School of Medicine, San Francisco, USA, (S.A.)
| | - Craig Broberg
- Division of Cardiovascular Medicine, Oregon Health and Sciences University, Portland, USA, (C.B.)
| | - Lorna Browne
- Department of Radiology, University of Colorado, Denver, USA, (L.B.)
| | - Taylor Chung
- Department of Radiology and Biomedical Imaging, The University of California-San Francisco School of Medicine, San Francisco, USA, (T.C.)
| | - Tiffanie Johnson
- Department of Pediatrics (Cardiology), Indiana University School of Medicine, Indianapolis, USA, (T.J.)
| | - Vivek Muthurangu
- Department of Pediatrics (Cardiology), University College London, London, UK, (V.M.)
| | - Michael Taylor
- Department of Pediatrics (Cardiology), University of Cincinnati School of Medicine, Cincinnati, USA, (M.T.)
| | | | - Carolyn Wilhelm
- Department of Pediatrics (Cardiology), University Hospitals-Cleveland, Cleaveland, USA (C.W.)
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13
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Abstract
INTRODUCTION In patients with right ventricular diastolic dysfunction after complete repair of tetralogy of Fallot, some employ the use of beta-blockade. The theoretical benefit of this therapy is felt to be one of the two: 1) reduction in heart rate with subsequent increase in diastolic filling time and stroke volume; 2) halting or reversal of right ventricular remodelling. This study aimed to characterise the use of beta-blockade in paediatric admissions with complete repair of tetralogy of Fallot and characterise the effects of beta-blockade on admission characteristics. METHODS Admissions from 2004 to 2015 in the Pediatric Health Information System database with complete repair of tetralogy of Fallot were identified. Characteristics between admissions with and without beta-blockade were compared by univariate analysis. Next, regression analyses were conducted to determine the independent association of beta-blockade on length of admission, billed charges, cardiac arrest, and inpatient mortality while controlling for demographic variables and comorbidities. RESULTS A total of 3594 admissions were included in the final analyses. Of these, 371 employed beta-blockade. Admissions with beta-blockade were more likely to have heart failure and tachyarrhythmias. These admissions also tended to be longer by univariate analysis. Regression analyses demonstrated that beta-blockade was independently associated with a 2.8-day increase in length of stay and no statistically significant change in billed charges, cardiac arrest, or inpatient mortality. CONCLUSIONS Beta-blockade after complete repair of tetralogy of Fallot is associated with a longer length of stay but did not statistically significantly impact billed charges, cardiac arrest, or inpatient mortality.
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14
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Van den Eynde J, Derdeyn E, Schuermans A, Shivaram P, Budts W, Danford DA, Kutty S. End-Diastolic Forward Flow and Restrictive Physiology in Repaired Tetralogy of Fallot: A Systematic Review and Meta-Analysis. J Am Heart Assoc 2022; 11:e024036. [PMID: 35301867 PMCID: PMC9075485 DOI: 10.1161/jaha.121.024036] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background Pulmonary arterial end‐diastolic forward flow (EDFF) following repaired tetralogy of Fallot has been thought to represent right ventricular (RV) restrictive physiology, but is not fully understood. This systematic review and meta‐analysis sought to clarify its physiological and clinical correlates, and to define a framework for understanding EDFF and RV restrictive physiology. Methods and Results PubMed/MEDLINE, Embase, Scopus, and reference lists of relevant articles were searched for observational studies published before March 2021. Random‐effects meta‐analysis was performed to identify factors associated with EDFF. Forty‐two individual studies published between 1995 and 2021, including a total of 2651 participants (1132 with EDFF; 1519 with no EDFF), met eligibility criteria. The pooled estimated prevalence of EDFF among patients with repaired tetralogy of Fallot was 46.5% (95% CI, 41.6%–51.3%). Among patients with EDFF, the use of a transannular patch was significantly more common, and their stay in the intensive care unit was longer. EDFF was associated with greater RV indexed volumes and mass, as well as smaller E‐wave velocity at the tricuspid valve. Finally, pulmonary regurgitation fraction was greater in patients with EDFF, and moderate to severe pulmonary regurgitation was more common in this population. Conclusions EDFF is associated with dilated, hypertrophied RVs and longstanding pulmonary regurgitation. Although several studies have defined RV restrictive physiology as the presence of EDFF, our study found no clear indicators of poor RV compliance in patients with EDFF, suggesting that EDFF may have multiple causes and might not be the precise equivalent of RV restrictive physiology.
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Affiliation(s)
- Jef Van den Eynde
- Helen B. Taussig Heart Center The Johns Hopkins Hospital and School of Medicine Baltimore MD.,Department of Cardiovascular Diseases University Hospitals Leuven and Department of Cardiovascular SciencesKU Leuven Leuven Belgium
| | - Emilie Derdeyn
- Faculty of Medicine and Health Sciences University of Antwerp Antwerp Belgium
| | - Art Schuermans
- Department of Cardiovascular Diseases University Hospitals Leuven and Department of Cardiovascular SciencesKU Leuven Leuven Belgium.,Division of Cardiovascular Medicine Radcliffe Department of Medicine Oxford Cardiovascular Clinical Research Facility University of Oxford United Kingdom
| | - Pushpa Shivaram
- Division of Pediatric Cardiology Augusta University Augusta GA
| | - Werner Budts
- Department of Cardiovascular Diseases University Hospitals Leuven and Department of Cardiovascular SciencesKU Leuven Leuven Belgium.,Congenital and Structural Cardiology UZ Leuven Leuven Belgium
| | - David A Danford
- Helen B. Taussig Heart Center The Johns Hopkins Hospital and School of Medicine Baltimore MD
| | - Shelby Kutty
- Helen B. Taussig Heart Center The Johns Hopkins Hospital and School of Medicine Baltimore MD
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15
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Soliman-Aboumarie H, Pastore MC, Galiatsou E, Gargani L, Pugliese NR, Mandoli GE, Valente S, Hurtado-Doce A, Lees N, Cameli M. Echocardiography in the intensive care unit: An essential tool for diagnosis, monitoring and guiding clinical decision-making. Physiol Int 2021. [PMID: 34825894 DOI: 10.1556/1647.2021.00055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Accepted: 10/22/2021] [Indexed: 11/19/2022]
Abstract
In the last years, new trends on patient diagnosis for admission in cardiac intensive care unit (CICU) have been observed, shifting from acute myocardial infarction or acute heart failure to non-cardiac diseases such as sepsis, acute respiratory failure or acute kidney injury. Moreover, thanks to the advances in scientific knowledge and higher availability, there has been increasing use of positive pressure mechanical ventilation which has its implications on the heart. Therefore, there is a growing need for Cardiac intensivists to quickly, noninvasively and repeatedly evaluate various hemodynamic conditions and the response to therapy. Transthoracic critical care echocardiography (CCE) currently represents an essential tool in CICU, as it is used to evaluate biventricular function and complications following acute coronary syndromes, identify the mechanisms of circulatory failure, acute valvular pathologies, tailoring and titrating intravenous treatment or mechanical circulatory support. This could be completed with trans-esophageal echocardiography (TOE), advanced echocardiography and lung ultrasound to provide a thorough evaluation and monitoring of CICU patients. However, CCE could sometimes be challenging as the acquisition of good-quality images is limited by mechanical ventilation, suboptimal patient position or recent surgery with drains on the chest. Moreover, there are some technical caveats that one should bear in mind while performing CCE in order to optimize its use and avoid misleading findings. The aim of this review is to highlight the key role of CCE, providing an updated overview of its main applications and possible pitfalls in order to facilitate its use in CICU for clinical decision-making.
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Affiliation(s)
- Hatem Soliman-Aboumarie
- 1 Department of Anesthetics and Critical Care, Harefield Hospital, Royal Brompton and Harefield Hospitals, Guy's and St Thomas NHS Foundation Trust, London , United Kingdom
- 4 School of Cardiovascular Sciences and Medicine, King's College, London , United Kingdom
| | - Maria Concetta Pastore
- 2 Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Eftychia Galiatsou
- 1 Department of Anesthetics and Critical Care, Harefield Hospital, Royal Brompton and Harefield Hospitals, Guy's and St Thomas NHS Foundation Trust, London , United Kingdom
| | - Luna Gargani
- 3 Institute of Clinical Physiology, National Research Council, Pisa, Italy
| | | | - Giulia Elena Mandoli
- 2 Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Serafina Valente
- 2 Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Ana Hurtado-Doce
- 1 Department of Anesthetics and Critical Care, Harefield Hospital, Royal Brompton and Harefield Hospitals, Guy's and St Thomas NHS Foundation Trust, London , United Kingdom
| | - Nicholas Lees
- 1 Department of Anesthetics and Critical Care, Harefield Hospital, Royal Brompton and Harefield Hospitals, Guy's and St Thomas NHS Foundation Trust, London , United Kingdom
| | - Matteo Cameli
- 2 Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
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16
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Kabbani MS, Jijeh A, Diraneyya OM, Basakran FA, Bin Sabbar NS, Fatima A, AlEraij SM, Alshahrani WA, Ardah HI, Shaath GA. Does interatrial communication affect post-operative course of children undergoing tetralogy of Fallot repair? Single centre retrospective cohort study: propensity score matching. Cardiol Young 2021; 32:1-6. [PMID: 34738885 DOI: 10.1017/s1047951121004431] [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] [Indexed: 11/06/2022]
Abstract
INTRODUCTION During tetralogy of Fallot repair, leaving or even create an interatrial communication may facilitate post-operative course particularly with right ventricle restrictive physiology. The aim of our study is to assess the influence of atrial communication on post-operative course of tetralogy of Fallot repair. METHODS Retrospectively, we studied all children who had tetralogy of Fallot repair (2003-2018). We divided them into two groups: tetralogy of Fallot repair with interatrial communication (TOFASD) group and tetralogy of Fallot repair with intact atrial septum (TOFIAS) group. We performed propensity match score for specific pre- or intra-operative variables and compared groups for post-operative outcome variables. Secondarily, we looked for right ventricle restrictive physiology incidence and influence of early repair performed before 3 months of age on post-operative course. RESULTS One hundred and sixty children underwent tetralogy of Fallot repair including (93) cases of TOFIAS (58%) and (67) cases of TOFASD (42%). With propensity matching score, 52 patients from each group were compared. Post-operative course was indifferent in term of positive pressure ventilation time, vasoactive inotropic score, creatinine and lactic acid levels, duration and amount of chest drainage and length of intensive care unit and hospital stay. Right ventricle restrictive physiology occurred in 38% of patients with no effects on outcome. 12/104 patients (12%) with early repair needed longer pressure ventilation time (p = 0.003) and intensive care unit stay (p = 0.02). CONCLUSION Leaving interatrial communication in tetralogy of Fallot repair did not affect post-operative course. As well, right ventricle restrictive physiology did not affect post-operative course. Infants undergoing early tetralogy of Fallot repair may require longer duration of positive pressure ventilation time and intensive care unit stay.
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Affiliation(s)
- Mohamed S Kabbani
- Cardiac Science Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
- King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Abdulraouf Jijeh
- Cardiac Science Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Obayda M Diraneyya
- Cardiac Science Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Fatimah A Basakran
- King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Najla S Bin Sabbar
- King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Anis Fatima
- Cardiac Science Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Sheikah M AlEraij
- Department of Family Medicine, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Wafa A Alshahrani
- King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Husam I Ardah
- King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- Department of Biostatistics and Bioinformatics, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Ghassan A Shaath
- Cardiac Science Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
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17
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Umeta Y, Iino T, Miura K, Kudo K, Tamura Y, Sato W, Seki K, Iino K, Watanabe H. Clinical implications of antegrade diastolic pulmonary artery flow in adults. J Cardiol 2021; 78:542-549. [PMID: 34393003 DOI: 10.1016/j.jjcc.2021.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 06/29/2021] [Accepted: 07/12/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND End-diastolic opening of the pulmonary valve and subsequent antegrade diastolic pulmonary artery flow (ADPAF) reflect restrictive right ventricular (RV) physiology in children. However, this has attracted little attention in adults. PURPOSE To clarify the clinical implications of ADPAF in adults. METHODS AND RESULTS The study population consisted of 23,049 consecutive adult patients who underwent echocardiography in our hospital between 2008 and 2015. ADPAF was found in 17 patients (0.07%). The simultaneous recording of RV and pulmonary artery pressures revealed marked elevation of RV diastolic pressure, which exceeded pulmonary artery pressure at the time of atrial contraction. These results suggested that ADPAF implies RV restriction. Based on the level of tricuspid annular plane systolic excursion (TAPSE), we classified these patients into two groups: reduced RV function (R-RVF) group (12 patients with TAPSE <17 mm) and preserved RV function (P-RVF) group (5 patients with TAPSE ≥17 mm). In the R-RVF group, four patients died, one patient underwent left ventricular assist device implantation, and two patients underwent unplanned hospitalization for heart failure during follow-up. The R-RVF group had poorer prognosis and higher mortality rate compared with the P-RVF group. CONCLUSIONS ADPAF reflects RV restriction in adults. ADPAF suggests a less favorable prognosis in patients with R-RVF.
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Affiliation(s)
- Yuri Umeta
- Department of Cardiovascular Medicine, Akita University Graduate School of Medicine, Akita, Japan
| | - Takako Iino
- Department of Cardiovascular Medicine, Akita University Graduate School of Medicine, Akita, Japan
| | - Ken Miura
- Department of Cardiovascular Medicine, Akita University Graduate School of Medicine, Akita, Japan
| | - Kodai Kudo
- Department of Cardiovascular Medicine, Akita University Graduate School of Medicine, Akita, Japan
| | - Yoshikazu Tamura
- Department of Cardiovascular Medicine, Akita University Graduate School of Medicine, Akita, Japan
| | - Wakana Sato
- Department of Cardiovascular Medicine, Akita University Graduate School of Medicine, Akita, Japan
| | - Katsuhito Seki
- Department of Cardiovascular Medicine, Akita University Graduate School of Medicine, Akita, Japan
| | - Kenji Iino
- Department of Cardiovascular Medicine, Akita University Graduate School of Medicine, Akita, Japan
| | - Hiroyuki Watanabe
- Department of Cardiovascular Medicine, Akita University Graduate School of Medicine, Akita, Japan.
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18
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Bassareo PP, Deidda M, Calcaterra G, Marras AR, Marras M, Saba L. Right ventricular diastolic function in post-surgical Tetralogy of Fallot patients: A pilot study to make a comparison between echocardiography and cardiac MRI. INTERNATIONAL JOURNAL OF CARDIOLOGY CONGENITAL HEART DISEASE 2021. [DOI: 10.1016/j.ijcchd.2021.100135] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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19
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Faerber JA, Huang J, Zhang X, Song L, DeCost G, Mascio CE, Ravishankar C, O'Byrne ML, Naim MY, Kawut SM, Goldmuntz E, Mercer-Rosa L. Identifying Risk Factors for Complicated Post-operative Course in Tetralogy of Fallot Using a Machine Learning Approach. Front Cardiovasc Med 2021; 8:685855. [PMID: 34368247 PMCID: PMC8339319 DOI: 10.3389/fcvm.2021.685855] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 06/21/2021] [Indexed: 11/15/2022] Open
Abstract
Introduction: Tetralogy of Fallot (TOF) repair is associated with excellent operative survival. However, a subset of patients experiences post-operative complications, which can significantly alter the early and late post-operative course. We utilized a machine learning approach to identify risk factors for post-operative complications after TOF repair. Methods: We conducted a single-center prospective cohort study of children <2 years of age with TOF undergoing surgical repair. The outcome was occurrence of post-operative cardiac complications, measured between TOF repair and hospital discharge or death. Predictors included patient, operative, and echocardiographic variables, including pre-operative right ventricular strain and fractional area change as measures of right ventricular function. Gradient-boosted quantile regression models (GBM) determined predictors of post-operative complications. Cross-validated GBMs were implemented with and without a filtering stage non-parametric regression model to select a subset of clinically meaningful predictors. Sensitivity analysis with gradient-boosted Poisson regression models was used to examine if the same predictors were identified in the subset of patients with at least one complication. Results: Of the 162 subjects enrolled between March 2012 and May 2018, 43 (26.5%) had at least one post-operative cardiac complication. The most frequent complications were arrhythmia requiring treatment (N = 22, 13.6%), cardiac catheterization (N = 17, 10.5%), and extracorporeal membrane oxygenation (ECMO) (N = 11, 6.8%). Fifty-six variables were used in the machine learning analysis, of which there were 21 predictors that were already identified from the first-stage regression. Duration of cardiopulmonary bypass (CPB) was the highest ranked predictor in all models. Other predictors included gestational age, pre-operative right ventricular (RV) global longitudinal strain, pulmonary valve Z-score, and immediate post-operative arterial oxygen level. Sensitivity analysis identified similar predictors, confirming the robustness of these findings across models. Conclusions: Cardiac complications after TOF repair are prevalent in a quarter of patients. A prolonged surgery remains an important predictor of post-operative complications; however, other perioperative factors are likewise important, including pre-operative right ventricular remodeling. This study identifies potential opportunities to optimize the surgical repair for TOF to diminish post-operative complications and secure improved clinical outcomes. Efforts toward optimizing pre-operative ventricular remodeling might mitigate post-operative complications and help reduce future morbidity.
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Affiliation(s)
- Jennifer A Faerber
- Data Science and Biostatistics Unit, Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Jing Huang
- Department of Biostatistics, Epidemiology & Informatics, University of Pennsylvania, Philadelphia, PA, United States.,Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Xuemei Zhang
- Data Science and Biostatistics Unit, Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Lihai Song
- Data Science and Biostatistics Unit, Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Grace DeCost
- School of Public Health, Brown University, Providence, RI, United States
| | - Christopher E Mascio
- Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Chitra Ravishankar
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Michael L O'Byrne
- Data Science and Biostatistics Unit, Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA, United States.,Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States.,Leonard Davis Institute and Center for Cardiovascular Outcomes, Quality, and Evaluative Research, University of Pennsylvania, Philadelphia, PA, United States
| | - Maryam Y Naim
- Departments of Anesthesiology, Critical Care Medicine and Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Steven M Kawut
- Departments of Medicine and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Elizabeth Goldmuntz
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Laura Mercer-Rosa
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
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20
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Abstract
Introduction: Advancements in surgery and management have resulted in a growing population of aging adults with tetralogy of Fallot (TOF). As a result, there has been a parallel growth in late complications associated with the sequelae from the underlying cardiac anomalies as well as the surgical and other interventional treatments.Areas covered: Here, we review challenges related to an aging population of patients with TOF, particularly late complications, and highlight advances in management and key areas for future research. Pulmonary regurgitation, heart failure, arrhythmias, and aortic complications are some of these late complications. There is also a growing incidence of acquired cardiovascular disease, obesity, and diabetes associated with aging. Management of these late complications and acquired comorbidities continues to evolve as research provides insights into long-term outcomes from medical therapies and surgical interventions.Expert opinion: The management of an aging TOF population will continue to transform with advances in imaging technologies to identify subclinical disease and valve replacement technologies that will prevent and mitigate disease progression. In the coming years, we speculate that there will be more data to support the use of novel heart failure therapies in TOF and consensus guidelines on the management of refractory arrhythmias and aortic complications.
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Affiliation(s)
- Jennifer P Woo
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, California, USA
| | - Doff B McElhinney
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, California, USA
| | - George K Lui
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, California, USA
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21
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Toh N, Akagi T, Kasahara S, Ito H. Evolution of echocardiography in adult congenital heart disease: from pulsed-wave Doppler to fusion imaging. J Echocardiogr 2021; 19:205-211. [PMID: 34047950 DOI: 10.1007/s12574-021-00533-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 05/19/2021] [Accepted: 05/24/2021] [Indexed: 01/04/2023]
Abstract
The number of patients with adult congenital heart disease (ACHD) has been dramatically increasing and adults with congenital heart disease now outnumber children with congenital heart disease. However, patients with ACHD are still at increased risk of morbidity and mortality due to residua and sequelae. Although echocardiography is an indispensable imaging modality in the comprehensive assessment of ACHD, accurate echocardiographic assessment of ACHD is challenging especially for physicians or sonographers who are not familiar with ACHD because of its complex morphology, physiology, and hemodynamics. A recently developed fusion imaging technology can provide synchronized display of real-time echocardiographic images and multiplanar reconstruction images of computed tomography or magnetic resonance imaging corresponding to the image plane of real-time echocardiography. We have reported the clinical utility of this fusion imaging technology for the precise evaluation of complex ACHD. On the other hand, conventional echocardiographic technology also plays an important role in assessing unique ACHD pathophysiology. For example, restrictive right ventricular physiology is a common finding after tetralogy of Fallot or pulmonary stenosis repair and can be evaluated by conventional pulsed-wave Doppler. In this review, we discuss the clinical usefulness of modern and conventional echocardiographic technologies for the evaluation of ACHD by presenting a case series.
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Affiliation(s)
- Norihisa Toh
- Department of Cardiovascular Medicine, Adult Congenital Heart Disease Center, Okayama University Hospital, 2-5-1, Shikata-Cho, Kita-ku, Okayama City, Okayama, 700-8558, Japan.
| | - Teiji Akagi
- Department of Cardiovascular Medicine, Adult Congenital Heart Disease Center, Okayama University Hospital, 2-5-1, Shikata-Cho, Kita-ku, Okayama City, Okayama, 700-8558, Japan
| | - Shingo Kasahara
- Department of Cardiovascular Surgery, Adult Congenital Heart Disease Center, Okayama University Hospital, Okayama, Japan
| | - Hiroshi Ito
- Department of Cardiovascular Medicine, Adult Congenital Heart Disease Center, Okayama University Hospital, 2-5-1, Shikata-Cho, Kita-ku, Okayama City, Okayama, 700-8558, Japan
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Vaikunth SS, Lui GK. Heart failure with reduced and preserved ejection fraction in adult congenital heart disease. Heart Fail Rev 2021; 25:569-581. [PMID: 31873841 DOI: 10.1007/s10741-019-09904-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Heart failure with reduced ejection fraction (HFrEF) is common in patients with adult congenital heart disease. Many of the most common congenital defects have a high prevalence of HFrEF, including left-sided obstructive lesions (aortic stenosis, coarctation of the aorta, Shone complex), tetralogy of Fallot, Ebstein anomaly, lesions in which there is a systemic right ventricle, and lesions palliated with a Fontan circulation. However, heart failure with preserved ejection fraction (HFpEF) is also prevalent in all these lesions. Comprehensive evaluation includes physical exam, biomarkers, echocardiography and advanced imaging, exercise stress testing, and, in some cases, invasive hemodynamics. Guideline-directed medical therapy for HFrEF can be applied to left-sided lesions and may be considered on an individual basis for systemic right ventricle and single-ventricle patients. Medical therapy is limited for HFpEF. However, in both HFrEF and HFpEF, ventricular dyssynchrony and arrhythmias play an important role, and medications for rhythm control, ablation, and cardiac resynchronization therapy should be considered. Finally, aggressive management of cardiovascular risk factors and comorbidities, including, but not limited to, hypertension, obesity, diabetes, dyslipidemia, and obstructive sleep apnea, cannot be overemphasized.
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Affiliation(s)
- Sumeet S Vaikunth
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto, CA, USA.
| | - George K Lui
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto, CA, USA.,Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, CA, USA
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Subramani S, Sharma A, Arora L, Hanada S, Krishnan S, Ramakrishna H. Perioperative Right Ventricular Dysfunction: Analysis of Outcomes. J Cardiothorac Vasc Anesth 2021; 36:309-320. [PMID: 33593648 DOI: 10.1053/j.jvca.2021.01.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 01/15/2021] [Indexed: 11/11/2022]
Abstract
Right ventricular dysfunction (RVD) is a well-known prognostic factor for adverse outcomes in cardiovascular medicine. The right ventricle (RV) in medically managed heart failure patients and in surgical patients perioperatively generally is overshadowed by left ventricular disease. However, with advancement of various diagnostic tools and better understanding of its functional anatomy, the role of the RV is emerging in many clinical conditions. The failure of one ventricle has significant effect on the function of the other ventricle and it is predominantly due to ventricular interdependence.1 The etiology of RVD is multifactorial and irrespective of etiology. RVD has been associated with significant increases in morbidity and mortality in various clinical scenarios.2,3 The primary objective of this comprehensive review is to analyze various etiology-related outcomes of RVD in the perioperative population.
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Affiliation(s)
- Sudhakar Subramani
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Archit Sharma
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Lovkesh Arora
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Satoshi Hanada
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Sundar Krishnan
- Department of Anesthesia, Duke University School of Medicine, Durham, NC
| | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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Sakata T, Mogi K, Sakurai M, Tani K, Hashimoto M, Shiko Y, Kawasaki Y, Matsumiya G, Takahara Y. Impact of tricuspid annuloplasty on postoperative changes in the right ventricular systolic and diastolic function: A retrospective cohort study. J Card Surg 2020; 35:1464-1470. [DOI: 10.1111/jocs.14611] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Tomoki Sakata
- Division of Cardiovascular Surgery Funabashi Municipal Medical Center Heart and Vascular Institute Funabashi Japan
- Department of Cardiovascular Surgery Chiba University Hospital Chiba Japan
| | - Kenji Mogi
- Division of Cardiovascular Surgery Funabashi Municipal Medical Center Heart and Vascular Institute Funabashi Japan
| | - Manabu Sakurai
- Division of Cardiovascular Surgery Funabashi Municipal Medical Center Heart and Vascular Institute Funabashi Japan
| | - Kengo Tani
- Division of Cardiovascular Surgery Funabashi Municipal Medical Center Heart and Vascular Institute Funabashi Japan
| | - Masafumi Hashimoto
- Division of Cardiovascular Surgery Funabashi Municipal Medical Center Heart and Vascular Institute Funabashi Japan
| | - Yuki Shiko
- Biostatistics Section, Clinical Research Center Chiba University Hospital Chiba Japan
| | - Yohei Kawasaki
- Biostatistics Section, Clinical Research Center Chiba University Hospital Chiba Japan
| | - Goro Matsumiya
- Department of Cardiovascular Surgery Chiba University Hospital Chiba Japan
| | - Yoshiharu Takahara
- Division of Cardiovascular Surgery Funabashi Municipal Medical Center Heart and Vascular Institute Funabashi Japan
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Egbe AC, Pellikka PA, Miranda WR, Bonnichsen C, Reddy YNV, Borlaug BA, Connolly HM. Echocardiographic predictors of severe right ventricular diastolic dysfunction in tetralogy of Fallot: Relations to patient outcomes. Int J Cardiol 2020; 306:49-55. [PMID: 32145939 PMCID: PMC7297267 DOI: 10.1016/j.ijcard.2020.02.067] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 01/08/2020] [Accepted: 02/26/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Previous studies have described echocardiographic indices of right ventricular (RV) diastolic function in patients with tetralogy of Fallot (TOF) but these indices have not been validated against invasive hemodynamic data. The purpose of this study was to determine echocardiographic predictors of severe RV diastolic dysfunction, and the impact of severe RV diastolic dysfunction on transplant-free survival. METHODS Cohort study of TOF patients that underwent non-simultaneous cardiac catheterization and echocardiogram at Mayo Clinic. Based on prior studies we selected these indices for assessment: tricuspid E/A, E/e', deceleration time, pulmonary artery forward flow, dilated inferior vena cava (IVC), and hepatic vein diastolic flow reversal (HVDFR). RV diastolic function classes (normal, mild/moderate and severe dysfunction) were created using arbitrary cut-off points of the median values of right ventricular end-diastolic pressure (RVEDP) and right atrial pressure (RAP) for the cohort. RESULTS Among 173 patients (age 40 ± 13 years), 68 patients were classified as normal (RVEDP≤14 and RAP≤10), 37 as mild/moderate dysfunction (either RVEDP>14 or RAP>10), and 69 as severe dysfunction (RVEDP>14 and RAP>10). Of the indices assessed, dilated IVC had the best sensitivity of 95% (area under the curve [AUC] 0.689) while HVDFR had the best specificity of 69% (AUC 0.648) for detecting severe RV diastolic dysfunction. Severe RV diastolic dysfunction was an independent risk factor for death/transplant (hazard ratio 2.83, p = 0.009). CONCLUSION Severe RV diastolic dysfunction, as defined by invasive hemodynamic indices, was associated with poor prognosis. Echocardiographic indices can identify these high risk patients, and hence improve risk stratification in clinical practice.
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Affiliation(s)
- Alexander C Egbe
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, MN 55905, United States of America.
| | - Patricia A Pellikka
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, MN 55905, United States of America
| | - William R Miranda
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, MN 55905, United States of America
| | - Crystal Bonnichsen
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, MN 55905, United States of America
| | - Yogesh N V Reddy
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, MN 55905, United States of America
| | - Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, MN 55905, United States of America
| | - Heidi M Connolly
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, MN 55905, United States of America
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Egbe AC, Vojjini R, Banala K, Najam M, Khalil F, Osman K, Badawy M, Anderson JH, Taggart NW. Determinants and Prognostic Implications of Left-Heart Filling Pressures in Tetralogy of Fallot. Can J Cardiol 2020; 36:1491-1498. [PMID: 32247704 DOI: 10.1016/j.cjca.2019.10.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 09/15/2019] [Accepted: 10/30/2019] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Elevated pulmonary artery wedge pressure (PAWP) is the hallmark of left-heart failure and is responsible for heart failure symptoms and mortality. Although PAWP typically correlates with right atrial pressure (RAP), it is primarily dependent on left-heart myocardial properties and volume status. As right-heart disease can occur in the absence of left-heart disease in patients with tetralogy of Fallot (TOF), we hypothesized that RAP was the primary determinant of PAWP in this population. METHODS A cohort study of adults with TOF that underwent right-heart catheterization at Mayo Clinic Rochester (1990 to 2017) to determine the relationship among RAP, PAWP, and mortality. RESULTS Among 213 patients (male 105; age 37 ± 14 years), the mean PAWP was 14 ± 5 mm Hg, and RAP was 11 ± 5 mm Hg. RAP was the strongest predictor of PAWP (β = 0.68, standard error = 0.06, P < 0.001), independent of left-heart disease and atherosclerotic cardiovascular risk factors. The patients with high PAWP also had normal tissue Doppler velocities, suggesting normal left-ventricular myocardial properties. PAWP was an independent predictor of death/transplant (hazard ration [HR] 1.11, 95% confidence interval [CI], 1.03-1.20, P = 0.004). However, when RAP was incorporated into the regression model, RAP (and not PAWP) became the independent predictor of outcomes (HR 1.14, 95% CI, 1.06-1.22, P = 0.001). CONCLUSIONS The current study showed that RAP was the primary determinant of PAWP and accounts, to some extent, for the mortality in patients with TOF and high PAWP. The data provide new insight in the pathophysiology of disease progression for symptomatic patients with TOF.
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Affiliation(s)
- Alexander C Egbe
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.
| | - Rahul Vojjini
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Keerthana Banala
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Maria Najam
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Fouad Khalil
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Karim Osman
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Mohamed Badawy
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Jason H Anderson
- Division of Pediatric Cardiology, Mayo Clinic, Rochester, Minnesota
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Egbe AC, Vojjini R, Badawy M, Jain V, Bonnichsen CR, Reddy YNV, Obokata M, Borlaug BA. Heightened Dependence of Left-Heart Filling Pressures on Right-Heart Failure in Congenital Heart Disease. Can J Cardiol 2020; 37:131-139. [PMID: 32492403 DOI: 10.1016/j.cjca.2020.02.084] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 02/18/2020] [Accepted: 02/20/2020] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Pulmonary artery wedge pressure (PAWP) is often elevated in patients with right-sided congenital heart disease (CHD), raising the possibility of coexisting left-heart disease, but pressure-volume relationships in the left and right sides of the heart influence one another through interdependence, which may be amplified in patients with CHD. METHODS We hypothesized that increases in PAWP in patients with CHD would be more strongly related to ventricular interdependence compared with patients who have isolated left-heart disease such as heart failure with preserved ejection fraction (HFpEF). Ventricular interdependence was assessed by the relationship between PAWP and right-atrial pressure (RAP), RAP/PAWP ratio, and the left-ventricular (LV) eccentricity index. RESULTS PAWP was elevated (≥15 mm Hg) in 49% of patients with CHD (n = 449). There was a very strong correlation between RAP and PAWP in CHD (r = 0.81, P < 0.001) that greatly exceeded the respective correlation in HFpEF (n = 160; r = 0.58, P < 0.001; P < 0.001 between groups). RAP/PAWP ratio and LV eccentricity index were higher in CHD than HFpEF (1.26 ± 0.18 vs 1.05 ± 0.14, P = 0.007) and (0.80 ± 0.21 vs 0.59 ± 0.19, P < 0.001), respectively. RAP (but not PAWP) was an independent predictor of death/transplant (hazard ratio 1.86 per 5 mm Hg, 95% confidence interval, 1.39-2.45, P = 0.002). CONCLUSIONS Left-heart filling pressures are commonly elevated in right-sided CHD, but this is related predominantly to right-heart failure and enhanced ventricular interdependence rather than left-heart disease. These data provide new insight into the basis of abnormal left-heart hemodynamics in patients with CHD and reinforce the importance of therapeutic interventions targeted to the right heart.
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Affiliation(s)
- Alexander C Egbe
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.
| | - Rahul Vojjini
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Mohamed Badawy
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Vaibhav Jain
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Yogesh N V Reddy
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Masaru Obokata
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Vandenheuvel M, Bouchez S, Wouters P, Mauermann E. Assessing Right Ventricular Function in the Perioperative Setting, Part II: What About Catheters? Anesthesiol Clin 2019; 37:697-712. [PMID: 31677686 DOI: 10.1016/j.anclin.2019.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
An-depth assessment of right ventricular function is important in a many perioperative settings. After exploring 2-dimensional echo-based evaluation, other proposed monitoring modalities are discussed. Pressure-based methods of right ventricular appraisal is discussed. Flow-based assessment is reviewed. An overview of the state of current right ventricular 3-dimensional echocardiography and its potential to construct clinical pressure-volume loops in conjunction with pressure measurements is provided. An overview of right ventricular assessment modalities that do not rely on 2-dimensional echocardiography is discussed. Tailored selection of monitoring modalities can be of great benefit for the perioperative physician. Integrating modalities offers optimal estimations of right ventricular function.
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Affiliation(s)
- Michael Vandenheuvel
- Department of Anesthesiology and Perioperative Medicine, Ghent University Hospital, C. Heymanslaan 10, Ghent 9000, Belgium
| | - Stefaan Bouchez
- Department of Anesthesiology and Perioperative Medicine, Ghent University Hospital, C. Heymanslaan 10, Ghent 9000, Belgium
| | - Patrick Wouters
- Department of Anesthesiology and Perioperative Medicine, Ghent University Hospital, C. Heymanslaan 10, Ghent 9000, Belgium
| | - Eckhard Mauermann
- Department of Anesthesiology and Perioperative Medicine, Ghent University Hospital, C. Heymanslaan 10, Ghent 9000, Belgium; Department for Anesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, Basel University Hospital, Spitalstrasse 21, Basel 4031, Switzerland.
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Tavazzi G, Bergsland N, Alcada J, Price S. Early signs of right ventricular systolic and diastolic dysfunction in acute severe respiratory failure: the importance of diastolic restrictive pattern. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2019; 9:649-656. [PMID: 31762290 PMCID: PMC7206565 DOI: 10.1177/2048872619883399] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND The incidence and pathophysiology of right ventricular failure in patients with severe respiratory insufficiency has been largely investigated. However, there is a lack of early signs suggesting right ventricular systolic and diastolic dysfunction prior to acute cor pulmonale development. METHODS We conducted a retrospective analytical cohort study of patients for acute respiratory distress syndrome undertaking an echocardiography during admission in the cardiothoracic intensive care unit. Patients were divided according to treatment: conventional protective ventilation (38 patients, 38%); interventional lung assist (23 patients, 23%); veno-venous extracorporeal membrane oxygenation (37 patients, 37%). Systolic and diastolic function was studied assessing, respectively: right ventricular systolic longitudinal function (tricuspid annular plane systolic excursion) and systolic contraction duration (tricuspid annular plane systolic excursion length); right ventricular diastolic filling time and right ventricular diastolic restrictive pattern (presence of pulmonary valve presystolic ejection wave). Correlation between the respiratory mechanics and systo-diastolic parameters were analysed. RESULTS In 98 patients studied, systolic dysfunction (tricuspid annular plane systolic excursion <16 mm) was present in 33.6% while diastolic restrictive pattern was present in 64%. A negative correlation was found between tricuspid annular plane systolic excursion and tricuspid annular plane systolic excursion length (P<0.0001; r -0.42). Tricuspid annular plane systolic excursion and tricuspid annular plane systolic excursion length correlated with right ventricular diastolic filling time (P<0.001; r -0.39). Pulmonary valve presystolic ejection wave was associated with tricuspid annular plane systolic excursion (P<0.0001), tricuspid annular plane systolic excursion length (P<0.0001), right ventricular diastolic filling time (P<0.0001), positive end-expiratory pressure (P<0.0001) and peak inspiratory pressure (P<0.0001). CONCLUSION Diastolic restrictive pattern is present in a remarkable percentage of patients with respiratory distress syndrome. Bedside echocardiography allows a mechanistic evaluation of systolic and diastolic interaction of the right ventricle.
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Affiliation(s)
- Guido Tavazzi
- Department of Clinical-Surgical, Diagnostic and Paediatric Sciences, University of Pavia, Italy.,Anesthesia and Intensive Care, Fondazione IRCCS Policlinico San Matteo, Italy
| | - Niels Bergsland
- Buffalo Neuroimaging Analysis Center, State University of New York, USA
| | - Joana Alcada
- Adult Intensive Care Unit, Royal Brompton Hospital, London, UK.,Inflammation, Repair and Development, Imperial College London, UK
| | - Susanna Price
- Adult Intensive Care Unit, Royal Brompton Hospital, London, UK
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Egbe AC, Bonnichsen C, Reddy YNV, Anderson JH, Borlaug BA. Pathophysiologic and Prognostic Implications of Right Atrial Hypertension in Adults With Tetralogy of Fallot. J Am Heart Assoc 2019; 8:e014148. [PMID: 31701796 PMCID: PMC6915294 DOI: 10.1161/jaha.119.014148] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Background Right atrial pressure (RAP), a composite metric of right ventricular diastolic function, volume status, and right heart compliance, is a predictor of mortality in patients with heart failure due to acquired heart disease. Because patients with tetralogy of Fallot (TOF) might have abnormal right atrial and ventricular mechanics caused by myocardial injury and remodeling, we hypothesized that RAP would be associated with disease severity and cardiovascular adverse events in this population. Methods and Results We performed a cohort study of adults with TOF who underwent right heart catheterization at the Mayo Clinic Rochester between 1990 and 2017. The objective was to determine the association between RAP and multiple domains of disease severity in TOF (percentage of predicted peak oxygen consumption, atrial or ventricular arrhythmia, and heart failure hospitalization), as well as cardiovascular adverse events, defined as sustained ventricular tachycardia, resuscitated or aborted sudden death, heart transplantation, or death. Among 225 patients (113 male; mean age: 39±14 years), mean RAP was 10.7±5.2 mm Hg and median was 10 mm Hg (interquartile range: 7–13 mm Hg). Increasing RAP was associated with atrial or ventricular arrhythmias (odds ratio: 5.01; 95% CI, 1.22–23.49; P<0.001), heart failure hospitalization (odds ratio: 1.47; 95% CI, 1.10–2.39; P=0.033) per 5 mm Hg, and worsening exercise capacity (peak oxygen consumption; R2=0.74, r=−0.86, P<0.001). RAP was a predictor of cardiovascular adverse events (hazard ratio: 1.28; 95% CI, 1.10–1.47; P=0.028) per 5 mm Hg. Conclusions In symptomatic patients with TOF, increasing RAP correlates with multiple domains of disease severity (risk stratification) and predicts future cardiovascular events (prognostication). These data have potential clinical implications in the target population of symptomatic TOF patients.
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Affiliation(s)
| | | | | | | | - Barry A Borlaug
- Department of Cardiovascular Medicine Mayo Clinic Rochester MN
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Histopathology of the right ventricular outflow tract and the relation to hemodynamics in patients with repaired tetralogy of Fallot. J Thorac Cardiovasc Surg 2019; 158:1173-1183.e5. [DOI: 10.1016/j.jtcvs.2019.03.118] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Revised: 03/20/2019] [Accepted: 03/30/2019] [Indexed: 11/22/2022]
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Forman J, Beech R, Slugantz L, Donnellan A. A Review of Tetralogy of Fallot and Postoperative Management. Crit Care Nurs Clin North Am 2019; 31:315-328. [PMID: 31351553 DOI: 10.1016/j.cnc.2019.05.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
This article discusses the anatomy and physiology of tetralogy of Fallot (TOF) and TOF variants. Indications for surgical repair, morbidity/mortalities, and surgical repair techniques are also reviewed. The article concludes with review of common postoperative complications and management strategies for arrhythmias, right ventricular dysfunction, low cardiac output, and residual defects.
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Affiliation(s)
- Johnna Forman
- Heinrich A. Werner Division of Pediatric Critical Care, University of Kentucky, Kentucky Children's Hospital, 800 Rose Street, MN 460, Lexington, KY 40536, USA.
| | - Rachel Beech
- Heinrich A. Werner Division of Pediatric Critical Care, University of Kentucky, Kentucky Children's Hospital, 800 Rose Street, MN 460, Lexington, KY 40536, USA
| | - Lucy Slugantz
- Pediatric Intensive Care Unit, University of Kentucky, Kentucky Children's Hospital, 800 Rose Street, MN 460, Lexington, KY 40536, USA
| | - Amy Donnellan
- Cardiac Intensive Care Unit, The Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 1002, Cincinnati, OH 45229, USA
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Nawrocki P, Wisniewski K, Schmidt C, Bruenen A, Debus V, Malec E, Januszewska K. Extubation on the operating table in patients with right ventricular pressure overload undergoing biventricular repair†. Eur J Cardiothorac Surg 2019; 56:904-910. [DOI: 10.1093/ejcts/ezz139] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 03/10/2019] [Accepted: 03/13/2019] [Indexed: 11/13/2022] Open
Abstract
Abstract
OBJECTIVES
Right ventricular pressure overload, which can result in restrictive right ventricular physiology, predicts slow recovery after biventricular repair of congenital heart defects. The goal of the study was to assess how extubation in the operating room influences the postoperative course in these patients.
METHODS
Between January 2013 and June 2017, a total of 65 children [median age 0.96 (0.13–9.47) years; median weight 8 (3.05–25.8) kg] with right ventricular pressure overload underwent an intracardiac correction. The most common malformations were tetralogy of Fallot (n = 34) and double outlet right ventricle with pulmonary stenosis (n = 11). The patients were divided into 2 groups: the first (n = 36) comprised late extubated (LE) and the second (n = 29), early extubated (EE) children, immediately after chest closure in the operating room. Preoperative, perioperative and postoperative records were analysed retrospectively.
RESULTS
Children who had EE had a lower heart rate (EE 124.2 vs LE 133.6 bpm; P = 0.03), higher arterial blood pressure (systolic: EE 87.9 ± 9.35 vs LE 81.4 ± 12.0 mmHg; P = 0.029; diastolic: EE 51.1 ± 6.5 vs LE 45.9 ± 6.64 mmHg; P = 0.003), lower central venous pressure (EE 8.6 ± 1.89 mmHg vs LE 9.9 ± 2.42 mmHg; P = 0.03), fewer pleural effusions in the first 6 postoperative days (EE 1.38 ml/kg/day vs LE 5.98 ml/kg/day; P = 0.009), shorter time of dopamine support ≥3 μg/kg (EE 7.29 ± 12.26 h vs LE 34.78 ± 38.05 h, P < 0.001), shorter stays in the intensive care unit (EE 2.7 ± 2.67 vs LE 5.0 ± 4.77 days, P = 0.001) and hospital (EE 11.8 ± 4.79 vs LE 15.5 ± 7.8 days; P = 0.022).
CONCLUSIONS
Extubation in the operating room of children with right ventricular pressure overload undergoing biventricular correction is feasible and safe and has a beneficial effect on the postoperative course.
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Affiliation(s)
- Pawel Nawrocki
- Division of Pediatric Cardiac Surgery, Department of Cardiothoracic Surgery, University Hospital Münster, Münster, Germany
| | - Konrad Wisniewski
- Division of Pediatric Cardiac Surgery, Department of Cardiothoracic Surgery, University Hospital Münster, Münster, Germany
| | - Christoph Schmidt
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Andreas Bruenen
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Volker Debus
- Department of Pediatric Cardiology, University Hospital Münster, Münster, Germany
| | - Edward Malec
- Division of Pediatric Cardiac Surgery, Department of Cardiothoracic Surgery, University Hospital Münster, Münster, Germany
| | - Katarzyna Januszewska
- Division of Pediatric Cardiac Surgery, Department of Cardiothoracic Surgery, University Hospital Münster, Münster, Germany
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Consensus recommendations for echocardiography in adults with congenital heart defects from the International Society of Adult Congenital Heart Disease (ISACHD). Int J Cardiol 2018; 272:77-83. [PMID: 30017529 DOI: 10.1016/j.ijcard.2018.07.058] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 05/24/2018] [Accepted: 07/10/2018] [Indexed: 11/23/2022]
Abstract
The population of adults with congenital heart disease (ACHD) is increasing constantly due to medical, surgical and interventional successes and the input from advanced cardiovascular imaging. ACHD patients are at continuing risk of residua and sequelae related to their CHD contributing to significant morbidity and mortality. Consequently, lifelong expert surveillance is recommended for most patients. Healthcare providers are still working out how best to achieve this objective, how to train enough experts to provide high quality care, and how to organize the delivery of care. Echocardiography is crucial to clinical surveillance providing a comprehensive assessment of cardiac morphology, physiology, pathophysiology, and function. Thus it contributes significantly to the overall clinical management of ACHD patients. The International Society for Adult Congenital Heart Disease (ISACHD; www.isachd.org) is the leading organization of professionals worldwide dedicated to the pursuit of excellence in the care of ACHD patients. Recognizing the critical role of imaging in the diagnosis and management of ACHD, ISACHD established a task force to provide guidance on echocardiographic studies and reporting. The rationale is that standardization of echocardiographic imaging and reporting carries the potential to improve the overall quality of these exams around the world and facilitate collaborative multicenter research. The standardized ACHD protocols provided by the ISACHD task force (found in the appendices) include specific recommendations for data acquisition and reporting for each of the major adult congenital heart lesions. These protocols give a comprehensive and structured approach in the evaluation of ACHD patients and help to ensure excellent patient care.
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Kutty S, Valente AM, White MT, Hickey K, Danford DA, Powell AJ, Geva T. Usefulness of Pulmonary Arterial End-Diastolic Forward Flow Late After Tetralogy of Fallot Repair to Predict a "Restrictive" Right Ventricle. Am J Cardiol 2018; 121:1380-1386. [PMID: 29678339 DOI: 10.1016/j.amjcard.2018.02.025] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 01/25/2018] [Accepted: 02/06/2018] [Indexed: 10/17/2022]
Abstract
The functional significance of pulmonary arterial end-diastolic forward flow (EDFF) in patients with repaired tetralogy of Fallot (rTOF) is not fully understood, with conflicting reports regarding its associations with pulmonary regurgitation (PR), right ventricular (RV) size and function, and so-called restrictive RV physiology. To examine these associations, we retrospectively analyzed 399 patients with rTOF who had contemporaneous echocardiography (Echo) and cardiovascular magnetic resonance (CMR) studies. The median age at TOF repair was 0.7 years (0.21, 2.66), age at CMR was 19.8 years (13.0, 29.4), and interval between Echo and CMR was 48 days (0, 182). Doppler identified EDFF in 122 (31%) patients and CMR in 113 patients (28%). Compared with those without EDFF, patients with EDFF were younger, had greater PR, and higher RV end-diastolic volume, stroke volume, and ejection fraction. Markers of RV restriction such as right atrial size did not differ between groups. On multivariable regression, EDFF was associated with higher RV stroke volume and lower left ventricular end-diastolic volume. The association between Echo and CMR measurements of EDFF was modest (area under the receiver operating characteristic curve = 0.684, r = 0.374, p < 0.001). In conclusion, EDFF was common in this large cohort of patients with rTOF, but its presence and extent varied between Echo and CMR. EDFF was associated with greater PR and larger RV size, but not with markers of poor RV compliance such as right atrial enlargement. Mechanisms beyond RV noncompliance may contribute to the presence of EDFF.
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Friedberg MK. Imaging Right-Left Ventricular Interactions. JACC Cardiovasc Imaging 2018; 11:755-771. [DOI: 10.1016/j.jcmg.2018.01.028] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 12/22/2017] [Accepted: 01/25/2018] [Indexed: 11/25/2022]
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Öner T, Özdemir R, Güven B, Yılmazer MM, Doksöz Ö, Meşe T, Tavlı V. Evaluation of myocardial function in pediatric patients with transposition of great arteries after arterial switch operation. Anatol J Cardiol 2016; 16:55-61. [PMID: 26467364 PMCID: PMC5336706 DOI: 10.5152/akd.2015.5692] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVE An arterial switch operation converts the left ventricle (LV) into the systemic ventricle, replacing the right ventricle (RV), which is the systemic ventricle during the prenatal period. The procedure is performed in patients with arterial transposition and those in whom a coronary reimplantation procedure is performed. Therefore, the adaptation of LV and RV to the arterial switch operations is an interesting issue. This study aimed to evaluate systolic and diastolic functions in the LV and RV myocardium using echocardiography in pediatric patients with transposed great arteries after an arterial switch operation. METHODS This observational case control study included 28 patients and 20 gender-and age-matched healthy controls. A group study was performed using patients who were followed for at least 6 months after the operation and who visited the pediatric cardiology outpatient between October 2009 and May 2011. Systolic and diastolic parameters, LV and RV myocardial performance index (MPI) values, and left atrium (LA) volume index were assessed in both groups. RESULTS The LV MPI and tricuspid valve (TV) E/Ea ratio measured using pulsed-wave Doppler were higher in the patient group than in the control group. The TV E/A ratio and late velocity of lateral mitral annulus (Aa) and systolic velocity (Sa)-early diastolic velocity (Ea)-late velocity (Aa) of the septal mitral annulus and systolic velocity (Sa)-early diastolic velocity (Ea)-late velocity (Aa) of the lateral tricuspid annulus were lower in the patient group than in the control group. CONCLUSION Considering the present study's findings obtained during short-to mid-term follow-up, the RV tissue Doppler flows and the LV MPI were found impaired.
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Affiliation(s)
- Taliha Öner
- Department of Pediatric Cardiology, İzmir Dr. Behçet Uz Children Hospital; İzmir-Turkey.
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Defining and refining indications for transcatheter pulmonary valve replacement in patients with repaired tetralogy of Fallot: Contributions from anatomical and functional imaging. Int J Cardiol 2016; 221:916-25. [DOI: 10.1016/j.ijcard.2016.07.120] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Revised: 05/24/2016] [Accepted: 07/08/2016] [Indexed: 12/17/2022]
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Abstract
OBJECTIVES The objectives of this review are to discuss the mechanisms by which respiration impacts cardiovascular function and vice versa, with an emphasis on the impact of these interactions in pediatric cardiac critical care. DATA SOURCE A search of MEDLINE was conducted using PubMed. CONCLUSIONS In the presence of underlying cardiac and respiratory disease, the interplay between these two systems is significant and plays a pivotal role in the pathophysiology of acute and chronic phases of a wide spectrum of diseases. An understanding of these relationships is essential to optimizing the care of critically ill patients.
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Abstract
OBJECTIVES The objectives of this review are to discuss the anatomy, pathophysiology, surgical repair, and perioperative management strategies for tetralogy of Fallot and its variants. DATA SOURCE MEDLINE and PubMed. CONCLUSIONS Significant refinements have been made in the repair strategy for tetralogy of Fallot, based on improved understanding of postrepair physiology. Important considerations for timing and technique of surgery and perioperative management have been presented, and continued evolution is expected. Expanded use of the pulmonary valve reconstruction technique outlined herein, whatever the age of repair, may improve long-term outcome.
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Abstract
OBJECTIVES There has been a recent increase in our understanding of mechanisms whereby the two sides of the heart interact and modulate each other that may be particularly relevant to patients in the ICU. For this review, our objectives are to examine the function of the left ventricle, consider some of the ways in which the function of the right ventricle differs from that of the left, and examine the effects of the left ventricle on the function of the right and vice versa. DATA SOURCE MEDLINE and PubMed. CONCLUSIONS There are fundamental differences between the function of the left and right ventricles, which relate to a significant extent to differences in their respective arterial loads. Although traditionally it has been usual to consider the function of the left and right ventricle in isolation, it is now recognized that this approach is flawed and as a result there is an increasing appreciation of the continual cross talk between the two sides of the heart in both the normal and diseased states. A more rational approach to the use of standard therapies frequently used in the cardiac ICU will come from a better understanding of these important fundamental concepts, and novel therapeutic concepts are already emerging from new data regarding biventricular interactions.
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Shillcutt SK, Tavazzi G, Shapiro BP, Diaz-Gomez J. Pulmonic Regurgitation in the Adult Cardiac Surgery Patient. J Cardiothorac Vasc Anesth 2016; 31:215-228. [PMID: 27712967 DOI: 10.1053/j.jvca.2016.06.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Indexed: 11/11/2022]
Affiliation(s)
- Sasha K Shillcutt
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE.
| | - Guido Tavazzi
- Department of Anesthesia and Intensive Care, Emergency Medicine, University of Pavia Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | | | - Jose Diaz-Gomez
- Department of Critical Care Medicine, Anesthesiology, and Neurosurgery, Mayo Clinic, Jacksonville, FL
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Rathore KS, Agrawal SK, Kapoor A. Restrictive Physiology in Tetralogy of Fallot: Exercise and Arrhythmogenesis. Asian Cardiovasc Thorac Ann 2016; 14:279-83. [PMID: 16868099 DOI: 10.1177/021849230601400403] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The effect of right ventricular restrictive physiology on exercise capacity and arrhythmogenesis after correction of tetralogy of Fallot was assessed in 80 patients aged 7.9 ± 3.6 years. Right ventricular restrictive physiology was defined as the presence of an A wave across the pulmonary artery on 2-dimensional echocardiography. At the 6 month follow-up, 52 patients had restrictive physiology (group 1). A transannular patch was used in 36 patients in group 1 (62%) and in 19 (86%) of the 28 patients without restrictive physiology (group 2). Maximum heart rate attained (69% vs. 77%), maximum predicted heart rate (211 ± 12.6 vs. 226 ± 24.2 beats·min−1), and metabolic equivalents (7.6 ± 3.2 vs. 8.1 ± 2.6) were higher in group 2, but not significantly. The chronotropic index was similar in both groups. In group 1, 14% of patients presented with ventricular premature complexes at 6 months. No effect on exercise capacity and arrhythmogenesis could be attributed to restrictive physiology, but both groups had chronotropic incompetence compared to normal children.
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Affiliation(s)
- Kaushalendra S Rathore
- Department of Cardiovascular and Thoracic Surgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India.
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Shin YR, Jung JW, Kim NK, Choi JY, Kim YJ, Shin HJ, Park YH, Park HK. Factors associated with progression of right ventricular enlargement and dysfunction after repair of tetralogy of Fallot based on serial cardiac magnetic resonance imaging. Eur J Cardiothorac Surg 2016; 50:464-9. [DOI: 10.1093/ejcts/ezw049] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2015] [Accepted: 01/11/2016] [Indexed: 02/06/2023] Open
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Restrictive right ventricular performance assessed by cardiac magnetic resonance after balloon valvuloplasty of critical pulmonary valve stenosis. Cardiol Young 2016; 26:556-68. [PMID: 26095337 DOI: 10.1017/s1047951115000724] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Little data are published about right ventricular diastolic performance in patients with critical pulmonary valve stenosis after balloon pulmonary valvuloplasty thus far. METHODS A total of 44 patients with isolated critical pulmonary valve stenosis who had undergone balloon valvuloplasty with haemodynamic recordings were enrolled to the study; 33 patients who came for follow-up underwent further imaging by echocardiography after 6 months and their right ventricular functional parameters were compared with 33 control patients of the same age and sex. Out of 33 patients, 21 underwent cardiac MRI with late gadolinium enhancement to assess the presence of right ventricular fibrosis. RESULTS The right ventricular systolic pressure (p<0.0001) and right ventricular outflow tract gradient (p<0.0001) decreased acutely (p<0.0001) after balloon valvuloplasty. During follow-up, M-mode left ventricular end diastolic dimension (p<0.001) and end systolic dimension increased (p<0.001), whereas right ventricular end diastolic dimension decreased (p<0.001). Compared with controls, patients (n=33) had significantly reduced tricuspid annular Ea and higher E/Ea (p<0.001). Right ventricular systolic dysfunction was also suggested by reduced tricuspid annular systolic velocity (p<0.001). Late gadolinium enhancement was demonstrated in 13 out of 21 patients with restrictive physiology, which involves the anterior right ventricular outflow tract, anterior wall, and inferior wall. The right ventricular late gadolinium enhancement score correlated positively with age (r=0.7, p<0.001) and right ventricular mass index (r=0.52, p<0.001). CONCLUSION The persistence of right ventricular diastolic dysfunction after relief of chronic pressure overload of critical pulmonary valve stenosis suggests that a factor - other than increase in afterload - is involved in this physiology. Fibrosis is the most likely factor responsible for persistence of restrictive physiology as documented by late gadolinium enhancement.
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Öner T, Özdemir R, Doksöz Ö, Yozgat Y, Karadeniz C, Demirpençe S, Yılmazer MM, Büyükinan M, Meşe T, Tavlı V. Cardiac Function in Newborns with Congenital Hypothyroidism: Association with Thyroid-Stimulating Hormone Levels. J Clin Res Pediatr Endocrinol 2015; 7:307-11. [PMID: 26777042 PMCID: PMC4805224 DOI: 10.4274/jcrpe.1969] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVE The aims of this study were to demonstrate ventricular function changes in patients with congenital hypothyroidism and to investigate whether there is an association between any such changes and thyroid-stimulating hormone (TSH) levels using M-mode and Doppler electrocardiography (ECG) and tissue Doppler imaging (TDI). METHODS Twenty-seven patients 5-30 days of age with congenital hypothyroidism who were scheduled to receive L-thyroxine treatment and 20 healthy newborns were included in this study. Twelve-lead ECG and M-mode TDI recordings of the patient and healthy groups were obtained. The patient group was divided into two subgroups according to TSH level (>100 uIU/mL or <100 uIU/mL), which were then compared on all parameters. RESULTS Decreases were observed in the ejection fraction (EF), shortening fraction (SF), and mitral lateral annulus, mitral septal annulus, and tricuspid lateral annulus systolic velocity (Sa) on TDI, whereas left ventricular end-systolic diameter (LVESd) and corrected QT interval (QTc) dispersion were significantly increased in the patient group compared with the control group. No significant differences between the groups were found in left ventricular end-diastolic diameter (LVEDd) or heart rate. When the two patient subgroups (TSH >100 uIU/mL and <100 uIU/mL) were compared, TDI septal annulus Sa wave length and heart rate were significantly lower in the TSH >100 group. CONCLUSION Impairment in left ventricular systolic function and increased risk of arrhythmia were observed in newborn infants with congenital hypothyroidism. TSH level was associated with heart rate and interventricular septum velocity.
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Affiliation(s)
- Taliha Öner
- Dr. Behçet Uz Children’s Hospital, Clinic of Pediatric Cardiology, İzmir, Turkey
| | - Rahmi Özdemir
- Dr. Behçet Uz Children's Hospital, Clinic of Pediatric Cardiology, İzmir, Turkey E-mail:
| | - Önder Doksöz
- Dr. Behçet Uz Children’s Hospital, Clinic of Pediatric Cardiology, İzmir, Turkey
| | - Yılmaz Yozgat
- Dr. Behçet Uz Children’s Hospital, Clinic of Pediatric Cardiology, İzmir, Turkey
| | - Cem Karadeniz
- Dr. Behçet Uz Children’s Hospital, Clinic of Pediatric Cardiology, İzmir, Turkey
| | - Savaş Demirpençe
- Dr. Behçet Uz Children’s Hospital, Clinic of Pediatric Cardiology, İzmir, Turkey
| | | | - Muammer Büyükinan
- Konya Training and Research Hospital, Clinic of Pediatric Endocrinology, Konya, Turkey
| | - Timur Meşe
- Dr. Behçet Uz Children’s Hospital, Clinic of Pediatric Cardiology, İzmir, Turkey
| | - Vedide Tavlı
- Dr. Behçet Uz Children’s Hospital, Clinic of Pediatric Cardiology, İzmir, Turkey
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Blanchart K, Buklas D, Labombarda F. Restrictive Physiology of Right Ventricle after Ross Procedure. Echocardiography 2015; 33:162-3. [PMID: 26387486 DOI: 10.1111/echo.13078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Kempny A, Diller GP, Alonso-Gonzalez R, Uebing A, Rafiq I, Li W, Swan L, Hooper J, Donovan J, Wort SJ, Gatzoulis MA, Dimopoulos K. Hypoalbuminaemia predicts outcome in adult patients with congenital heart disease. Heart 2015; 101:699-705. [PMID: 25736048 PMCID: PMC4413739 DOI: 10.1136/heartjnl-2014-306970] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Revised: 01/31/2015] [Accepted: 02/02/2015] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND In patients with acquired heart failure, hypoalbuminaemia is associated with increased risk of death. The prevalence of hypoproteinaemia and hypoalbuminaemia and their relation to outcome in adult patients with congenital heart disease (ACHD) remains, however, unknown. METHODS Data on patients with ACHD who underwent blood testing in our centre within the last 14 years were collected. The relation between laboratory, clinical or demographic parameters at baseline and mortality was assessed using Cox proportional hazards regression analysis. RESULTS A total of 2886 patients with ACHD were included. Mean age was 33.3 years (23.6-44.7) and 50.1% patients were men. Median plasma albumin concentration was 41.0 g/L (38.0-44.0), whereas hypoalbuminaemia (<35 g/L) was present in 13.9% of patients. The prevalence of hypoalbuminaemia was significantly higher in patients with great complexity ACHD (18.2%) compared with patients with moderate (11.3%) or simple ACHD lesions (12.1%, p<0.001). During a median follow-up of 5.7 years (3.3-9.6), 327 (11.3%) patients died. On univariable Cox regression analysis, hypoalbuminaemia was a strong predictor of outcome (HR 3.37, 95% CI 2.67 to 4.25, p<0.0001). On multivariable Cox regression, after adjusting for age, sodium and creatinine concentration, liver dysfunction, functional class and disease complexity, hypoalbuminaemia remained a significant predictor of death. CONCLUSIONS Hypoalbuminaemia is common in patients with ACHD and is associated with a threefold increased risk of risk of death. Hypoalbuminaemia, therefore, should be included in risk-stratification algorithms as it may assist management decisions and timing of interventions in the growing ACHD population.
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Affiliation(s)
- Aleksander Kempny
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton Hospital, London, UK
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital and National Heart and Lung Institute, Imperial College London, London, UK
- National Heart and Lung Institute, Imperial College School of Medicine, London, UK
- Department of Cardiology and Angiology, Adult Congenital and Valvular Heart Disease Center, University Hospital of Münster, Muenster, Germany
| | - Gerhard-Paul Diller
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton Hospital, London, UK
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital and National Heart and Lung Institute, Imperial College London, London, UK
- National Heart and Lung Institute, Imperial College School of Medicine, London, UK
- Department of Cardiology and Angiology, Adult Congenital and Valvular Heart Disease Center, University Hospital of Münster, Muenster, Germany
| | - Rafael Alonso-Gonzalez
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton Hospital, London, UK
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital and National Heart and Lung Institute, Imperial College London, London, UK
- National Heart and Lung Institute, Imperial College School of Medicine, London, UK
| | - Anselm Uebing
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton Hospital, London, UK
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital and National Heart and Lung Institute, Imperial College London, London, UK
- National Heart and Lung Institute, Imperial College School of Medicine, London, UK
| | - Isma Rafiq
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton Hospital, London, UK
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital and National Heart and Lung Institute, Imperial College London, London, UK
| | - Wei Li
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton Hospital, London, UK
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital and National Heart and Lung Institute, Imperial College London, London, UK
- National Heart and Lung Institute, Imperial College School of Medicine, London, UK
| | - Lorna Swan
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton Hospital, London, UK
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital and National Heart and Lung Institute, Imperial College London, London, UK
- National Heart and Lung Institute, Imperial College School of Medicine, London, UK
| | - James Hooper
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton Hospital, London, UK
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital and National Heart and Lung Institute, Imperial College London, London, UK
- National Heart and Lung Institute, Imperial College School of Medicine, London, UK
| | - Jackie Donovan
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton Hospital, London, UK
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital and National Heart and Lung Institute, Imperial College London, London, UK
- National Heart and Lung Institute, Imperial College School of Medicine, London, UK
| | - Stephen J Wort
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton Hospital, London, UK
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital and National Heart and Lung Institute, Imperial College London, London, UK
- National Heart and Lung Institute, Imperial College School of Medicine, London, UK
| | - Michael A Gatzoulis
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton Hospital, London, UK
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital and National Heart and Lung Institute, Imperial College London, London, UK
- National Heart and Lung Institute, Imperial College School of Medicine, London, UK
| | - Konstantinos Dimopoulos
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton Hospital, London, UK
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital and National Heart and Lung Institute, Imperial College London, London, UK
- National Heart and Lung Institute, Imperial College School of Medicine, London, UK
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Beg KA, Haq A, Amanullah M, Laique SN, Sadqani S, Aslam N, Rehmat AW, Hasan BS. Distinctive Hemodynamics in the Immediate Postoperative Period of Patients with a Longer Cardiac Intensive Care Stay Post-Tetralogy of Fallot Repair. CONGENIT HEART DIS 2015; 10:346-53. [PMID: 25864454 DOI: 10.1111/chd.12259] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/05/2015] [Indexed: 11/27/2022]
Abstract
OBJECTIVE After complete surgical repair the majority of tetralogy of Fallot (ToF), patients stay ≤2 days in the Cardiac Intensive Care Unit (CICU) while some may stay longer. We undertook this study to investigate the factors associated with shorter vs. longer length of stay in the CICU to help manage resources effectively. DESIGN Patients who underwent ToF repair at Aga Khan University, Pakistan, between July 2006 and December 2011 were studied in a case-control design. Clinical parameters were compared between short stay group (SSG) (≤2 days) and long stay group (LSG) (>2 days). Odds ratios were calculated, and regression was performed. RESULTS Ninety-eight patients (LSG 65, SSG 33) were included. Patients with lower preoperative saturation were 2.67 times more likely to be in the LSG group (P = .02). At 4 hours postoperatively, patients with a higher inotropic score (odds ratio [OR] = 3.03, confidence interval [CI] = 1.19-7.7, P = .02), higher central venous pressure (OR = 3.04, CI = 1.27-7.32, P = .013), and significant tachycardia at 4 hours (OR = 3.5, CI = 1.19-10.3. P = .02) were at risk for having a prolonged CICU stay. On multivariate analysis, significant postoperative tachycardia at 4 hours (z-score ≥3) was highly specific (sensitivity = 38.5%, specificity = 84.9%) for predicting the chances of being in the LSG. Other predictors included preop O(2) saturation ≤82.5% (sensitivity = 61.1%, specificity = 63.0%) and CVP ≥10 mm Hg at 4 hours (sensitivity = 55.4%, specificity = 71.9%). CONCLUSION Patients who end up staying longer in the CICU have features that are distinctive in the immediate postoperative period, and this can help clinicians in identifying patients who may need more support.
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Affiliation(s)
- Kisha A Beg
- Medical College, The Aga Khan University, Karachi, Pakistan
| | - Anwarul Haq
- Department of Pediatrics and Child Health, The Aga Khan University, Karachi, Pakistan
| | - Muneer Amanullah
- Section of Cardiothoracic Surgery, The Aga Khan University, Karachi, Pakistan
| | - Sobia N Laique
- Medical College, The Aga Khan University, Karachi, Pakistan
| | - Saleem Sadqani
- Department of Pediatrics and Child Health, The Aga Khan University, Karachi, Pakistan
| | - Nadeem Aslam
- Department of Pediatrics and Child Health, The Aga Khan University, Karachi, Pakistan
| | - Amina Wali Rehmat
- Cardiac Intensive Care Unit, The Aga Khan University, Karachi, Pakistan
| | - Babar S Hasan
- Department of Pediatrics and Child Health, The Aga Khan University, Karachi, Pakistan
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