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Raga L, Heydarian H, Winlaw D, Zang H, Cnota JF, Ollberding NJ, Hill GD. Precision in Norwood Shunt Sizing: Single Ventricle Reconstruction Trial Public Dataset Analysis. Ann Thorac Surg 2024; 118:459-467. [PMID: 38513984 DOI: 10.1016/j.athoracsur.2024.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 02/01/2024] [Accepted: 03/04/2024] [Indexed: 03/23/2024]
Abstract
BACKGROUND Morbidity and mortality after the Norwood procedure remains high. Shunt size selection is not standardized and the impact of shunt size on outcomes is poorly understood. The Single Ventricle Reconstruction trial randomized infants to modified Blalock-Taussig-Thomas shunt (MBTTS) or right ventricle-to-pulmonary artery shunt at the Norwood procedure. We assessed shunt size distribution and its association with postoperative outcomes. METHODS We included 544 patients, excluding 5 with ambiguous shunt crossover data. Normalized shunt diameter 1 and 2 were calculated as shunt diameter divided by patient's weight and body surface area, respectively. The primary outcome was 30-day mortality after Norwood. Secondary outcomes were intensive care and total length of stay, and survival to Glenn procedure. Logistic and ordinal regression models evaluated the association of normalized shunt diameter with outcomes. RESULTS Thirty-day mortality after Norwood was 11.4% (n = 62), survival to Glenn procedure was 72.6% (n = 395), median length of stay was 14.0 (interquartile range, 9.0-27.7) days and 24.0 (interquartile range, 16.0-41.0) days in the intensive care and total, respectively. Normalized shunt diameters exhibited variation in both shunt types but were not associated with 30-day mortality. Right ventricle-to-pulmonary artery shunt size was not associated with secondary outcomes. However, a MBTTS diameter ≥1.5 mm/kg predicted longer Norwood (odds ratio, 4.89; 95% CI, 1.41-16.90) and intensive care (odds ratio, 4.11; 95% CI, 1.25-13.49]) duration. CONCLUSIONS Shunt size selection was variable. Right ventricle-to-pulmonary artery shunt had a wider size range seen with favorable outcomes compared with MBTTS. A MBTTS either too large or too small is associated with worse postoperative outcomes. Refining shunt sizing practices can improve surgical outcomes after the Norwood procedure.
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Affiliation(s)
- Luisa Raga
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Haleh Heydarian
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - David Winlaw
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Huaiyu Zang
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - James F Cnota
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Nicholas J Ollberding
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio; Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Garick D Hill
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio.
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Kim AY, Woo W, Saxena A, Tanidir IC, Yao A, Kurniawati Y, Thakur V, Shin YR, Shin JI, Jung JW, Barron DJ. Treatment of hypoplastic left heart syndrome: a systematic review and meta-analysis of randomised controlled trials. Cardiol Young 2024; 34:659-666. [PMID: 37724575 DOI: 10.1017/s1047951123002986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/21/2023]
Abstract
BACKGROUND This meta-analysis aimed to consolidate existing data from randomised controlled trials on hypoplastic left heart syndrome. METHODS Hypoplastic left heart syndrome specific randomised controlled trials published between January 2005 and September 2021 in MEDLINE, EMBASE, and Cochrane databases were included. Regardless of clinical outcomes, we included all randomised controlled trials about hypoplastic left heart syndrome and categorised them according to their results. Two reviewers independently assessed for eligibility, relevance, and data extraction. The primary outcome was mortality after Norwood surgery. Study quality and heterogeneity were assessed. A random-effects model was used for analysis. RESULTS Of the 33 included randomised controlled trials, 21 compared right ventricle-to-pulmonary artery shunt and modified Blalock-Taussig-Thomas shunt during the Norwood procedure, and 12 regarded medication, surgical strategy, cardiopulmonary bypass tactics, and ICU management. Survival rates up to 1 year were superior in the right ventricle-to-pulmonary artery shunt group; this difference began to disappear at 3 years and remained unchanged until 6 years. The right ventricle-to-pulmonary artery shunt group had a significantly higher reintervention rate from the interstage to the 6-year follow-up period. Right ventricular function was better in the modified Blalock-Taussig-Thomas shunt group 1-3 years after the Norwood procedure, but its superiority diminished in the 6-year follow-up. Randomised controlled trials regarding medical treatment, surgical strategy during cardiopulmonary bypass, and ICU management yielded insignificant results. CONCLUSIONS Although right ventricle-to-pulmonary artery shunt appeared to be superior in the early period, the two shunts applied during the Norwood procedure demonstrated comparable long-term prognosis despite high reintervention rates in right ventricle-to-pulmonary artery shunt due to pulmonary artery stenosis. For medical/perioperative management of hypoplastic left heart syndrome, further randomised controlled trials are needed to deliver specific evidence-based recommendations.
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Affiliation(s)
- A Y Kim
- Division of Pediatric Cardiology, Department of Pediatrics, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| | - W Woo
- Department of Thoracic and Cardiovascular Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - A Saxena
- Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India
| | - I C Tanidir
- Department of Pediatric Cardiology, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
| | - A Yao
- Department of Health Service Promotion, University of Tokyo, Japan
| | - Y Kurniawati
- Department of Pediatric Cardiology, National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
| | - V Thakur
- Department of Pediatrics, Labatt Family Heart Center, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Y R Shin
- Department of Cardiovascular Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - J I Shin
- Department of Pediatrics, Labatt Family Heart Center, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
- Severance Underwood Meta-research Center, Institute of Convergence Science, Yonsei University, Seoul, South Korea
| | - J W Jung
- Division of Pediatric Cardiology, Department of Pediatrics, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| | - D J Barron
- Division of Cardiovascular Surgery, Department of Surgery, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
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Schuermans A, Van den Eynde J, Jacquemyn X, Van De Bruaene A, Lewandowski AJ, Kutty S, Geva T, Budts W, Gewillig M, Roest AAW. Preterm Birth Is Associated With Adverse Cardiac Remodeling and Worse Outcomes in Patients With a Functional Single Right Ventricle. J Pediatr 2022; 255:198-206.e4. [PMID: 36470462 DOI: 10.1016/j.jpeds.2022.11.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 11/04/2022] [Accepted: 11/30/2022] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To assess the effects of preterm birth on cardiac structure and function and transplant-free survival in patients with hypoplastic left heart syndrome and associated anomalies throughout the staged palliation process. STUDY DESIGN Data from the Single Ventricle Reconstruction trial were used to assess the impact of prematurity on echocardiographic measures at birth, Norwood, Stage II, and 14 months in 549 patients with a single functional right ventricle. Medical history was recorded once a year using medical records or telephone interviews. Cox regression models were applied to analyze transplant-free survival to age 6 years. Causal mediation analysis was performed to estimate the mediating effect of birth weight within this relationship. RESULTS Of the 549 participants, 64 (11.7%) were born preterm. Preterm-born participants had lower indexed right ventricle end-diastolic volumes at birth but higher volumes than term-born participants by age 14 months. Preterm-born participants had an increased risk of death or heart transplantation from birth to age 6 years, with an almost linear increase in the observed risk as gestational age decreased below 37 weeks. Of the total effect of preterm birth on transplant-free survival, 27.3% (95% CI 2.5-59.0%) was mediated through birth weight. CONCLUSIONS Preterm birth is associated with adverse right ventricle remodeling and worse transplant-free survival throughout the palliation process, in part independently of low birth weight. Further investigation into this vulnerable group may allow development of strategies that mitigate the impact of prematurity on outcomes in patients with hypoplastic left heart syndrome.
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Affiliation(s)
- Art Schuermans
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium; Oxford Cardiovascular Clinical Research Facility, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Jef Van den Eynde
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium; Helen B. Taussig Heart Center, The Johns Hopkins Hospital and School of Medicine, Baltimore, MD
| | - Xander Jacquemyn
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Alexander Van De Bruaene
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium; Congenital and Structural Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Adam J Lewandowski
- Oxford Cardiovascular Clinical Research Facility, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Shelby Kutty
- Helen B. Taussig Heart Center, The Johns Hopkins Hospital and School of Medicine, Baltimore, MD
| | - Tal Geva
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Werner Budts
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium; Congenital and Structural Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Marc Gewillig
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium; Pediatric Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Arno A W Roest
- Department of Pediatric Cardiology, Leiden University Medical Center, Leiden, The Netherlands.
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Kumar KR, Flair A, Thompson EJ, Zimmerman KO, Andersen ND, Hill KD, Hornik CP. Association Between Digoxin Use and Cardiac Function in Infants With Single-Ventricle Congenital Heart Disease During the Interstage Period. Pediatr Crit Care Med 2022; 23:453-463. [PMID: 35404313 PMCID: PMC9203926 DOI: 10.1097/pcc.0000000000002946] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To examine the association between digoxin use and cardiac function assessed by echocardiographic indices in infants with single-ventricle (SV) congenital heart disease (CHD) during the interstage period. DESIGN Retrospective cohort study. SETTING Fifteen North American hospitals. PATIENTS Infants discharged home following stage 1 palliation (S1P) and prior to stage 2 palliation (S2P). Infants with no post-S1P and pre-S2P echocardiograms were excluded. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 373 eligible infants who met inclusion criteria, 140 (37.5%) were discharged home on digoxin. In multivariable linear and logistic regressions, we found that compared with infants discharged home without digoxin, those discharged with digoxin had a smaller increase in end-systolic volume (β = -8.17 [95% CI, -15.59 to -0.74]; p = 0.03) and area (β = -1.27 [-2.45 to -0.09]; p = 0.04), as well as a smaller decrease in ejection fraction (β = 3.38 [0.47-6.29]; p = 0.02) and fractional area change (β = 2.27 [0.14-4.41]; p = 0.04) during the interstage period. CONCLUSIONS Digoxin may partially mitigate the expected decrease in cardiac function during the interstage period through its positive inotropic effects. Prospective clinical trials are needed to establish the pharmacokinetics, safety, and efficacy of digoxin use in SV CHD.
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Affiliation(s)
- Karan R. Kumar
- Duke Clinical Research Institute, Durham, North Carolina
- Department of Pediatrics, Duke University, Durham, North Carolina
| | - Antonina Flair
- Duke Clinical Research Institute, Durham, North Carolina
| | - Elizabeth J. Thompson
- Duke Clinical Research Institute, Durham, North Carolina
- Department of Pediatrics, Duke University, Durham, North Carolina
| | - Kanecia O. Zimmerman
- Duke Clinical Research Institute, Durham, North Carolina
- Department of Pediatrics, Duke University, Durham, North Carolina
| | | | - Kevin D. Hill
- Duke Clinical Research Institute, Durham, North Carolina
- Department of Pediatrics, Duke University, Durham, North Carolina
| | - Christoph P. Hornik
- Duke Clinical Research Institute, Durham, North Carolina
- Department of Pediatrics, Duke University, Durham, North Carolina
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5
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Surgical Strategies in Single Ventricle Management of Neonates and Infants. Can J Cardiol 2022; 38:909-920. [PMID: 35513174 DOI: 10.1016/j.cjca.2022.04.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 04/25/2022] [Accepted: 04/26/2022] [Indexed: 12/17/2022] Open
Abstract
No area of congenital heart disease has undergone greater change and innovation than Single Ventricle management over the past 20 years. Surgical and catheter lab interventions have transformed outcomes such that in some subgroups more than 80% of these patients can survive into adulthood. Driven by parallel development in diagnostic imaging and cardiac intensive care, surgical management is focused on the neonatal period as the key time to creating a balanced circulation and limiting pulmonary blood-flow. Different configurations of the circulation including new types of surgical shunts and the role of 'hybrid' circulations provide greater options and better physiology. This overview will focus on these changes in surgical management and timing but also look at the exciting areas of regenerative therapies to improve ventricular function, and the concept of ventricular rehabilitation to achieve biventricular circulations in certain groups of patients. The importance of early (neonatal) intervention and multidisciplinary approach to management is emphasised, as well as looking beyond simply survival but also improving neurodevelopmental outcomes.
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Batsis M, Kochilas L, Chin AJ, Kelleman M, Ferguson E, Oster ME. Association of Digoxin With Preserved Echocardiographic Indices in the Interstage Period: A Possible Mechanism to Explain Improved Survival? J Am Heart Assoc 2021; 10:e021443. [PMID: 34854311 PMCID: PMC9075357 DOI: 10.1161/jaha.121.021443] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Background For patients with hypoplastic left heart syndrome, digoxin has been associated with reduced interstage mortality after the Norwood operation, but the mechanism of this benefit remains unclear. Preservation of right ventricular (RV) echocardiographic indices has been associated with better outcomes in hypoplastic left heart syndrome. Therefore, we sought to determine whether digoxin use is associated with preservation of the RV indices in the interstage period. Methods and Results We conducted a retrospective cohort study of prospectively collected data using the public use data set from the Pediatric Heart Network Single Ventricle Reconstruction trial, conducted in 15 North American centers between 2005 and 2008. We included all patients who survived the interstage period and had echocardiographic data post‐Norwood and pre‐Glenn operations. We used multivariable linear regression to compare changes in RV parameters, adjusting for relevant covariates. Of 289 patients, 94 received digoxin at discharge post‐Norwood. There were no significant differences in baseline clinical characteristics or post‐Norwood echocardiographic RV indices (RV end‐diastolic volume indexed, RV end‐systolic volume indexed, ejection fraction) in the digoxin versus no‐digoxin groups. At the end of the interstage period and after adjustment for relevant covariates, patients on digoxin had better preserved RV indices compared with those not on digoxin for the ΔRV end‐diastolic volume (11 versus 15 mL, P=0.026) and the ΔRV end‐systolic volume (6 versus 9 mL, P=0.009) with the indexed ΔRV end‐systolic volume (11 versus 20 mL/BSA1.3, P=0.034). The change in the RV ejection fraction during the interstage period between the 2 groups did not meet statistical significance (−2 versus −5, P=0.056); however, the trend continued to be favorable for the digoxin group. Conclusions Digoxin use during the interstage period is associated with better preservation of the RV volume and tricuspid valve measurements leading to less adverse remodeling of the single ventricle. These findings suggest a possible mechanism of action explaining digoxin’s survival benefit during the interstage period.
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Affiliation(s)
- Maria Batsis
- Sibley Heart Center Cardiology Children's Healthcare of Atlanta Atlanta GA.,Department of Pediatrics Emory University School of Medicine Atlanta GA
| | - Lazaros Kochilas
- Sibley Heart Center Cardiology Children's Healthcare of Atlanta Atlanta GA.,Department of Pediatrics Emory University School of Medicine Atlanta GA
| | - Alvin J Chin
- Department of Pediatrics Perelman School of Medicine University of Pennsylvania Philadelphia PA
| | - Michael Kelleman
- Department of Pediatrics Emory University School of Medicine Atlanta GA
| | - Eric Ferguson
- Sibley Heart Center Cardiology Children's Healthcare of Atlanta Atlanta GA.,Department of Pediatrics Emory University School of Medicine Atlanta GA
| | - Matthew E Oster
- Sibley Heart Center Cardiology Children's Healthcare of Atlanta Atlanta GA.,Department of Pediatrics Emory University School of Medicine Atlanta GA
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7
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Czosek RJ, Anderson JB, Baskar S, Khoury PR, Jayaram N, Spar DS. Predictors and outcomes of heart block during surgical stage I palliation of patients with a single ventricle: A report from the NPC-QIC. Heart Rhythm 2021; 18:1876-1883. [PMID: 34029735 PMCID: PMC8607956 DOI: 10.1016/j.hrthm.2021.05.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 05/12/2021] [Accepted: 05/16/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Mortality in cohorts with a single ventricle remains high with multiple associated factors. The effect of heart block during stage I palliation remains unclear. OBJECTIVE The purpose of this study was to study patient and surgical risks of heart block and its effect on 12-month transplant-free survival in patients with a single ventricle. METHODS Patient, surgical, outcome data and heart block status (transient and permanent) were obtained from the National Pediatric Cardiology Quality Improvement Collaborative single ventricle database. Bivariate analysis was performed comparing patients with and without heart block, and multivariate modeling was used to identify variables associated with block. One-year outcomes were analyzed to identify variables associated with lower 12-month transplant-free survival. RESULTS In total, 1423 patients were identified, of whom 28 (2%) developed heart block (second degree or complete) during their surgical admission. Associated risk factors for block included heterotaxy syndrome (odds ratio [OR] 6.4) and atrial flutter/fibrillation (OR 3.8). Patients with heart block had lower 12-month survival, though only in patients with complete heart block as opposed to second degree block. At 12 months of age, 43% (12/28) of patients with heart block died and were more likely to experience mortality at 12 months than patients without block (OR 4.9; 95% confidence interval 1.4-17.5; P = .01). CONCLUSION Although rare, complete heart block after stage I palliation represents an additional risk of poor outcomes in this high-risk patient population. Heterotaxy syndrome was the most significant risk factor for the development of heart block after stage I palliation. The role of transient block in outcomes and potential rescue with long-term pacing remains unknown and requires additional study.
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Affiliation(s)
- Richard J Czosek
- Division of Cardiology, Department of Pediatrics, Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio.
| | - Jeffrey B Anderson
- Division of Cardiology, Department of Pediatrics, Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Shankar Baskar
- Division of Cardiology, Department of Pediatrics, Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Philip R Khoury
- Division of Cardiology, Department of Pediatrics, Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Natalie Jayaram
- Division of Cardiology, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, Missouri
| | - David S Spar
- Division of Cardiology, Department of Pediatrics, Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Bhatla P, Kumar TS, Makadia L, Winston B, Bull C, Nielsen JC, Williams D, Chakravarti S, Ohye RG, Mosca RS. Periscopic technique in Norwood operation is associated with better preservation of early ventricular function. JTCVS Tech 2021; 8:116-123. [PMID: 34401829 PMCID: PMC8350951 DOI: 10.1016/j.xjtc.2021.05.014] [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: 07/31/2020] [Accepted: 05/13/2021] [Indexed: 11/16/2022] Open
Abstract
Objective Although the right ventricle (RV) to pulmonary artery conduit in stage 1 Norwood operation results in improved interstage survival, the long-term effects of the ventriculotomy used in the traditional technique remain a concern. The periscopic technique (PT) of RV to pulmonary artery conduit placement has been described as an alternative technique to minimize RV injury. A retrospective study was performed to compare the effects of traditional technique and PT on ventricular function following Norwood operation. Methods A retrospective study of all patients who underwent Norwood operation from 2012 to 2019 was performed. Patients with baseline RV dysfunction and significant tricuspid valve regurgitation were excluded. Prestage 2 echocardiograms were reviewed by a blinded experienced imager for quantification of RV function (sinus and infundibular RV fractional area change) as well as for regional conduit site wall dysfunction (normal or abnormal, including hypokinesia, akinesia, or dyskinesia). Wilcoxon rank-sum tests were used to assess differences in RV infundibular and RV sinus ejection fraction and the Fisher exact test was used to assess differences in regional wall dysfunction. Results Twenty-two patients met inclusion criteria. Eight underwent traditional technique and 14 underwent PT. Median infundibular RV fractional area change was 49% and 37% (P = .02) and sinus RV fractional area change was 50% and 41% for PT and traditional technique (P = .007) respectively. Similarly qualitative regional RV wall function was better preserved in PT (P = .002). Conclusions The PT for RV to pulmonary artery conduit in Norwood operation results in better preservation of early RV global and regional systolic function. Whether or not this benefit translates to improved clinical outcome still needs to be studied.
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Affiliation(s)
- Puneet Bhatla
- Division of Pediatric Cardiology, New York University Langone Medical Center, New York, NY.,Department of Radiology, New York University Langone Medical Center, New York, NY
| | - Tk Susheel Kumar
- Department of Cardiac Surgery, New York University Langone Medical Center, New York, NY
| | - Luv Makadia
- Department of Pediatrics, New York University Langone Medical Center, New York, NY
| | - Brandon Winston
- Department of Cardiac Surgery, New York University Langone Medical Center, New York, NY
| | - Catherine Bull
- Department of Cardiac Surgery, New York University Langone Medical Center, New York, NY
| | - James C Nielsen
- Division of Pediatric Cardiology, New York University Langone Medical Center, New York, NY
| | - David Williams
- Department of Cardiac Surgery, New York University Langone Medical Center, New York, NY
| | - Sujata Chakravarti
- Division of Pediatric Cardiology, New York University Langone Medical Center, New York, NY
| | - Richard G Ohye
- Department of Cardiac Surgery, Mott Children's Hospital, Ann Arbor, Mich
| | - Ralph S Mosca
- Department of Cardiac Surgery, New York University Langone Medical Center, New York, NY
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9
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Sinha R, Altin HF, McCracken C, Well A, Rosenblum J, Kanter K, Kogon B, Alsoufi B. Effect of Atrioventricular Valve Repair on Multistage Palliation Results of Single-Ventricle Defects. Ann Thorac Surg 2021; 111:662-670. [DOI: 10.1016/j.athoracsur.2020.03.126] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 03/17/2020] [Accepted: 03/30/2020] [Indexed: 11/30/2022]
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10
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Carrillo SA, Texter KM, Phelps C, Tan Y, McConnell PI, Galantowicz M. Tricuspid Valve and Right Ventricular Function Throughout the Hybrid Palliation Strategy for Hypoplastic Left Heart Syndrome and Variants. World J Pediatr Congenit Heart Surg 2020; 12:9-16. [PMID: 32783502 DOI: 10.1177/2150135120947692] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Tricuspid valve (TV) and right ventricular (RV) function are major determinants of morbidity and mortality in patients with hypoplastic left heart syndrome (HLHS). We sought to retrospectively evaluate these parameters throughout the hybrid palliation strategy. METHODS From 2002 to 2018, 203 patients with HLHS and variants presented for hybrid stage I (HS1). Echocardiographic evaluation of tricuspid regurgitation (TR) and RV function was assessed at multiple time points. Clinical outcomes including tricuspid valvuloplasty, transplantation, and death were reviewed. RESULTS The most prevalent HLHS subtype was aortic atresia/mitral atresia. The presence of significant TR and/or RV dysfunction was 14.78% and 9.36%, respectively, at the time of initial HS1. There were 185 survivors following HS1 (91.13%, n = 185/203), while 147 patients underwent comprehensive stage II or bidirectional Glenn shunt (72.41%, n = 147/203). Tricuspid valvuloplasty was undertaken in nine patients (4.86%, n = 9/185). Ultimately, 100 patients underwent the Fontan procedure. The odds of development of significant TR and/or RV dysfunction were not statistically different throughout the stages of palliation (TR: odds ratio [OR] = 0.14-0.25, P = .5260; RV dysfunction: OR = 0.02-0.13, P = .3992). However, the risk of death and/or transplant was 2.5- to 3.8-fold when either were present alone or in combination (TR: OR = 2.58, P = .0356; RV dysfunction: OR = 3.84, P = .0262). Transplant-free survival at 15 years was 44.8%. CONCLUSION Following hybrid palliation for HLHS, the majority of survivors have normal RV and TV functions. Tricuspid valvuloplasty was required in few patients. Once significant TR and/or RV dysfunction ensues, there is a two- to three-fold risk of death and/or transplant.
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Affiliation(s)
- Sergio A Carrillo
- Department of Cardiothoracic Surgery, The Ohio State University School of Medicine, 2650Nationwide Children's Hospital, Columbus, OH, USA
| | - Karen M Texter
- Division of Cardiology, The Ohio State University School of Medicine, 2650Nationwide Children's Hospital, Columbus, OH, USA
| | - Christina Phelps
- Division of Cardiology, The Ohio State University School of Medicine, 2650Nationwide Children's Hospital, Columbus, OH, USA
| | - Yubo Tan
- Center for Biostatistics, The Ohio State University School of Medicine, 2650Nationwide Children's Hospital, Columbus, OH, USA
| | - Patrick I McConnell
- Department of Cardiothoracic Surgery, The Ohio State University School of Medicine, 2650Nationwide Children's Hospital, Columbus, OH, USA
| | - Mark Galantowicz
- Department of Cardiothoracic Surgery, The Ohio State University School of Medicine, 2650Nationwide Children's Hospital, Columbus, OH, USA
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11
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Frommelt PC, Hu C, Trachtenberg F, Baffa JM, Boruta RJ, Chowdhury S, Cnota JF, Dragulescu A, Levine JC, Lu J, Mercer-Rosa L, Miller TA, Shah A, Slesnick TC, Stapleton G, Stelter J, Wong P, Newburger JW. Impact of Initial Shunt Type on Echocardiographic Indices in Children After Single Right Ventricle Palliations. Circ Cardiovasc Imaging 2019; 12:e007865. [PMID: 30755054 DOI: 10.1161/circimaging.118.007865] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Heart size and function in children with single right ventricle (RV) anomalies may be influenced by shunt type at the Norwood procedure. We sought to identify shunt-related differences during early childhood after staged surgical palliations using echocardiography. Methods We compared echocardiographic indices of RV, neoaortic, and tricuspid valve size and function at 14 months, pre-Fontan, and 6 years in 241 subjects randomized to a Norwood procedure using either the modified Blalock-Taussig shunt or RV-to-pulmonary-artery shunt. Results At 6 years, the shunt groups did not differ significantly in any measure except for increased indexed neoaortic area in the modified Blalock-Taussig shunt. RV ejection fraction improved between pre-Fontan and 6 years in the RV-to-pulmonary artery shunt group but was stable in the modified Blalock-Taussig shunt group. For the entire cohort, RV diastolic and systolic size and functional indices were improved at 6 years compared with earlier measurements, and indexed tricuspid and neoaortic annular area decreased from 14 months to 6 years. The prevalence of ≥moderate tricuspid and neoaortic regurgitation was uncommon and did not vary by group or time period. Diminished RV ejection fraction at the 14-month study was predictive of late death/transplant; the hazard of late death/transplant when RV ejection fraction was <40% was tripled (hazard ratio, 3.18; 95% CI, 1.41-7.17). Conclusions By 6 years after staged palliation, shunt type has not impacted RV size and function, and RV and valvar size and function show beneficial remodeling. Poor RV systolic function at 14 months predicts worse late survival independent of the initial shunt type. Clinical Trial Registration URL: https://www.clinicaltrials.gov . Unique identifier: NCT00115934.
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Affiliation(s)
- Peter C Frommelt
- Department of Pediatrics, Division of Pediatric Cardiology, Children's Hospital of Wisconsin, Milwaukee (P.C.F., J.S.).,Department of Pediatrics, Division of Pediatric Cardiology, Medical College of Wisconsin, Milwaukee (P.C.F., J.S.)
| | - Chenwei Hu
- Department of Pediatrics, Division of Pediatric Cardiology, New England Research Institutes, Waterford, MA (C.H., F.T.)
| | - Felicia Trachtenberg
- Department of Pediatrics, Division of Pediatric Cardiology, New England Research Institutes, Waterford, MA (C.H., F.T.)
| | - Jeanne Marie Baffa
- Department of Pediatrics, Division of Pediatric Cardiology, The Nemours Cardiac Center, Wilmington, DE (J.M.B.)
| | - Richard J Boruta
- Department of Pediatrics, Division of Pediatric Cardiology, Duke University Hospital, Durham, NC (R.J.B.)
| | - Shahryar Chowdhury
- Department of Pediatrics, Division of Pediatric Cardiology, Medical University of South Carolina, Charleston (S.C.)
| | - James F Cnota
- Department of Pediatrics, Division of Pediatric Cardiology, Cincinnati Children's Hospital and Medical Center, OH (J.F.C.)
| | - Andreea Dragulescu
- Department of Pediatrics, Division of Pediatric Cardiology, Hospital of Sick Children, Toronto, Canada (A.D.)
| | - Jami C Levine
- Department of Pediatrics, Division of Pediatric Cardiology, Boston Children's Hospital, Harvard Medical School, MA (J.C.L., J.W.N.)
| | - Jimmy Lu
- Department of Pediatrics, Division of Pediatric Cardiology, University of Michigan Medical School, Ann Arbor (J.L.)
| | - Laura Mercer-Rosa
- Department of Pediatrics, Division of Pediatric Cardiology, Children's Hospital of Philadelphia, University of Pennsylvania Medical School (L.M.-R.)
| | - Thomas A Miller
- Department of Pediatrics, Division of Pediatric Cardiology, Primary Children's Medical Center, University of Utah, Salt Lake City (T.A.M.)
| | - Amee Shah
- Department of Pediatrics, Division of Pediatric Cardiology, Morgan Stanley Children's Hospital of New York-Presbyterian (A.S.).,Department of Pediatrics, Division of Pediatric Cardiology, Columbia College of Physicians and Surgeons, New York, NY (A.S.)
| | - Timothy C Slesnick
- Department of Pediatrics, Division of Pediatric Cardiology, Children's Healthcare of Atlanta, Emory University, Atlanta, GA (T.C.S.)
| | - Gary Stapleton
- Department of Pediatrics, Division of Pediatric Cardiology, John Hopkins All Children's Health Institute, Baltimore, MD (G.S.)
| | - Jessica Stelter
- Department of Pediatrics, Division of Pediatric Cardiology, Children's Hospital of Wisconsin, Milwaukee (P.C.F., J.S.).,Department of Pediatrics, Division of Pediatric Cardiology, Medical College of Wisconsin, Milwaukee (P.C.F., J.S.)
| | - Pierre Wong
- Department of Pediatrics, Division of Pediatric Cardiology, Children's Hospital Los Angeles, CA (P.W.)
| | - Jane W Newburger
- Department of Pediatrics, Division of Pediatric Cardiology, Boston Children's Hospital, Harvard Medical School, MA (J.C.L., J.W.N.)
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12
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Kim AS, Witzenburg CM, Conaway M, Vergales JE, Holmes JW, L'Ecuyer TJ, Dean PN. Trajectory of right ventricular indices is an early predictor of outcomes in hypoplastic left heart syndrome. CONGENIT HEART DIS 2019; 14:1185-1192. [PMID: 31393088 DOI: 10.1111/chd.12834] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 06/28/2019] [Accepted: 07/17/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Children with hypoplastic left heart syndrome (HLHS) have risk for mortality and/or transplantation. Previous studies have associated right ventricular (RV) indices in a single echocardiogram with survival, but none have related serial measurements to outcomes. This study sought to determine whether the trajectory of RV indices in the first year of life was associated with transplant-free survival to stage 3 palliation (S3P). METHODS HLHS patients at a single center who underwent stage 1 palliation (S1P) between 2000 and 2015 were reviewed. Echocardiographic indices of RV size and function were obtained before and following S1P and stage 2 palliation (S2P). The association between these indices and transplant-free survival to S3P was examined. RESULTS There were 61 patients enrolled in the study with 51 undergoing S2P, 20 S3P, and 18 awaiting S3P. In the stage 1 perioperative period, indexed RV end-systolic area increased in patients who died or needed transplant following S2P, and changed little in those surviving to S3P (3.37 vs -0.04 cm2 /m2 , P = .017). Increased indexed RV end-systolic area was associated with worse transplant-free survival. (OR = 0.815, P = .042). In the interstage period, indexed RV end-diastolic area increased less in those surviving to S3P (3.6 vs 9.2, P = .03). CONCLUSION Change in indexed RV end-systolic area through the stage 1 perioperative period was associated with transplant-free survival to S3P. Neither the prestage nor poststage 1 indexed RV end-systolic area was associated with transplant-free survival to S3P. Patients with death or transplant before S3P had a greater increase in indexed RV end-diastolic area during the interstage period. This suggests earlier serial changes in RV size which may provide prognostic information beyond RV indices in a single study.
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Affiliation(s)
- Andrew S Kim
- Division of Cardiology, Department of Pediatrics, University of Virginia, Charlottesville, Virginia
| | - Colleen M Witzenburg
- Department of Biomedical Engineering, University of Virginia, Charlottesville, Virginia
| | - Mark Conaway
- Division of Translational Research and Applied Statistics, Department of Public Health Sciences, University of Virginia, Charlottesville, Virginia
| | - Jeffrey E Vergales
- Division of Cardiology, Department of Pediatrics, University of Virginia, Charlottesville, Virginia
| | - Jeffrey W Holmes
- Department of Biomedical Engineering, University of Virginia, Charlottesville, Virginia.,Department of Medicine, University of Virginia, Charlottesville, Virginia
| | - Thomas J L'Ecuyer
- Division of Cardiology, Department of Pediatrics, University of Virginia, Charlottesville, Virginia
| | - Peter N Dean
- Division of Cardiology, Department of Pediatrics, University of Virginia, Charlottesville, Virginia
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13
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Slieker MG, Meza JM, Devlin PJ, Burch PT, Karamlou T, DeCampli WM, McCrindle BW, Williams WG, Morgan CT, Fleishman CE, Mertens L. Pre-intervention morphologic and functional echocardiographic characteristics of neonates with critical left heart obstruction: a Congenital Heart Surgeons Society (CHSS) inception cohort study. Eur Heart J Cardiovasc Imaging 2019; 20:658-667. [PMID: 30339206 DOI: 10.1093/ehjci/jey141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 08/16/2018] [Accepted: 09/11/2018] [Indexed: 11/14/2022] Open
Abstract
AIMS The aims of this study were to provide a detailed descriptive analysis of pre-intervention morphologic and functional echocardiographic parameters in a large, unselected, multicentre cohort of neonates diagnosed with critical left heart obstruction and to compare echocardiographic features between the different subtypes of left-sided lesions. METHODS AND RESULTS Pre-intervention echocardiograms for 651 patients from 19 Congenital Heart Surgeons' Society (CHSS) institutions were reviewed in a core lab according to a standardized protocol including >150 morphologic and functional variables. The four most common subtypes of lesions were: aortic atresia (AA)/mitral atresia (MA) (29% of patients), AA/mitral stenosis (MS) (20%), aortic stenosis (AS)/MS (26%), and isolated AS (iAS) (18%). Only 17% of patients with AS/MS had an apex-forming left ventricle, compared with 0% of those with AA/MA and AA/MS (P < 0.0001). Aortic arch hypoplasia and coarctation were common across all four groups, while those with AA/MA and AA/MS had the smallest ascending aorta diameters. Flow in the ascending aorta was retrograde in 43% and 10% of the patients with AS/MS and iAS, respectively. The right ventricle was apex forming in 100% of patients with AA/MA and AA/MS, 96% with AS/MS and 70% with iAS (P < 0.0001). Moderate to severe tricuspid regurgitation was present in 13% of all patients. CONCLUSION This large multi-institutional study generates insight into the distribution of the functional and morphologic spectrum in patients with critical left-sided heart disease and identifies differences in these functional and morphologic characteristics between the main anatomic subtypes of critical left heart obstruction.
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Affiliation(s)
- Martijn G Slieker
- Department of Pediatrics, Division of Cardiology, The Hospital for Sick Children, 555 University Ave, Toronto, ON, Canada
| | - James M Meza
- Congenital Heart Surgeons' Society Data Center, 555 University Ave, Toronto, ON, Canada
| | - Paul J Devlin
- Congenital Heart Surgeons' Society Data Center, 555 University Ave, Toronto, ON, Canada
| | - Phillip T Burch
- Department of Surgery, Section of Pediatric Cardiothoracic Surgery, University of Utah, 100 North Medical Drive, Salt Lake City, UT, USA
| | - Tara Karamlou
- Department of Surgery, Phoenix Children's Hospital, 1919 East Thomas Road, Phoenix, AZ, USA
| | - William M DeCampli
- The Heart Center, Arnold Palmer Hospital for Children, 92 W. Miller Street, Orlando, FL, USA
| | - Brian W McCrindle
- Department of Pediatrics, Division of Cardiology, The Hospital for Sick Children, 555 University Ave, Toronto, ON, Canada.,Congenital Heart Surgeons' Society Data Center, 555 University Ave, Toronto, ON, Canada
| | - William G Williams
- Congenital Heart Surgeons' Society Data Center, 555 University Ave, Toronto, ON, Canada
| | - Conall T Morgan
- Department of Pediatrics, Division of Cardiology, The Hospital for Sick Children, 555 University Ave, Toronto, ON, Canada
| | - Craig E Fleishman
- The Heart Center, Arnold Palmer Hospital for Children, 92 W. Miller Street, Orlando, FL, USA
| | - Luc Mertens
- Department of Pediatrics, Division of Cardiology, The Hospital for Sick Children, 555 University Ave, Toronto, ON, Canada
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14
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Neo-aortic insufficiency late after staged reconstruction for hypoplastic left heart syndrome: impact of differences in initial palliative procedures. Heart Vessels 2019; 34:1456-1463. [PMID: 30915524 DOI: 10.1007/s00380-019-01376-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 03/08/2019] [Indexed: 10/27/2022]
Abstract
The neo-aortic insufficiency in patients with hypoplastic left heart syndrome is an important sequela. We assessed the risks of the neo-aortic valve deterioration by the difference of initial palliations: Group I underwent primary Norwood (Nw) with systemic-to-pulmonary artery shunt (SPS), Group II underwent bilateral pulmonary artery banding (bPAB) and subsequent Nw with SPS (bPAB-Nw/SPS), Group III underwent bPAB and subsequent Nw with bidirectional Glenn (BDG) procedure (bPAB-Nw/BDG). The neo-aortic valve z score changes over time did not reach statistical significance in all groups (p = 0.43 for Group I, 0.20 for Group II, and 0.30 for Group III). The degree of neo-aortic valve insufficiency did not change significantly over time during this period except for Group III (p = 0.34 for Group I, 0.20 for Group II, and 0.02 for Group III). On the other hand, dimensions of the neo-aortic annulus and degrees of neo-aortic insufficiency did not differ significantly among the 3 groups at any pre-determined time. The presence or absence of incision into the sino-tubular junction at Nw did not affect the late neo-aortic valve z score or insufficiency. These data indicate that the difference of initial palliative procedures does not affect late neo-aortic valve insufficiency in Nw survivors. Because valve failure may develop in longer follow-up, further observation should be conducted.
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15
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Kutty S, Danford DA. Shunts and the Single Right Ventricle. Circ Cardiovasc Imaging 2019; 12:e008711. [DOI: 10.1161/circimaging.118.008711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Shelby Kutty
- The Helen B. Taussig Heart Center, Johns Hopkins Hospital and School of Medicine, Baltimore, MD (S.K.)
| | - David A. Danford
- Division of Pediatric Cardiology, University of Nebraska College of Medicine and Children’s Hospital and Medical Center, Omaha, NE (D.A.D.)
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16
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Hormaza VM, Conaway M, Schneider DS, Vergales JE. The effect of right ventricular function on survival and morbidity following stage 2 palliation: An analysis of the single ventricle reconstruction trial public data set. CONGENIT HEART DIS 2018; 14:274-279. [PMID: 30506893 DOI: 10.1111/chd.12722] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 09/24/2018] [Accepted: 10/20/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Limited information is known on how right ventricular function affects outcomes after stage 2 palliation. We evaluated the impact of different right ventricular indices prior to stage 2 palliation on morbidity and mortality. DESIGN Retrospective study design. SETTING Pediatric Heart Network Single Ventricle Reconstruction Trial Public Data Set. PATIENT Any variant of stage 1 palliation and all anatomic hypoplastic left heart syndrome variants in the trial were evaluated. Echocardiograms prior to stage 2 palliation were analyzed and compared between those who failed and those who survived. INTERVENTION None. OUTCOME MEASURES Mortality was defined as death, listed for transplant, or transplanted after stage 2 palliation. Morbidity was evaluated as hospital length of stay and duration of intubation. RESULTS A total of 283 patients met criteria for analysis. Of those, only 18 patients failed stage 2. Right ventricular fractional area change was less in those who failed (30% vs 34%, P = .039) and right ventricular indexed end-diastolic volume and end-systolic volume were larger in those who failed (142.74 mL/ BSA1.3 vs 111.29 mL/BSA1.3 , P = .023, 88.45 mL/ BSA1.3 vs 62.75 mL/ BSA1.3 , P = .025, respectively). Larger right ventricular indexed end-diastolic and systolic volumes were associated with failure (OR 1.17 [1.01-1.35] P = .021, OR 1.25 [1.03-1.52] P = .021, respectively). Every 10% increase in RV ejection fraction had a 63% decrease in length of stay and a 68% decrease in duration of intubation (P = .014, and P = .039, respectively). CONCLUSION Patients with decreased right ventricular fractional area change and larger right ventricular indexed end-diastolic and systolic volumes were more likely to fail stage 2 palliation. Those with preserved right ventricular function had a shorter hospital length of stay and duration of intubation. Echocardiographic measurements of right ventricular indices during the interstage period can be utilized to determine the prognosis following stage 2 palliation.
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Affiliation(s)
- Vanessa Marie Hormaza
- Division of Cardiology, Department of Pediatrics, University of Virginia, Charlottesville, Virginia
| | - Mark Conaway
- Division of Translational Research and Statistics, Department of Public Health Sciences, University of Virginia, Charlottesville, Virginia
| | - Daniel Scott Schneider
- Division of Cardiology, Department of Pediatrics, University of Virginia, Charlottesville, Virginia
| | - Jeffrey Eric Vergales
- Division of Cardiology, Department of Pediatrics, University of Virginia, Charlottesville, Virginia
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17
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Mercer-Rosa L, Goldberg DJ. Prognostic Value of Serial Echocardiography in Hypoplastic Left Heart Syndrome: Smaller Hearts, Better Results. Circ Cardiovasc Imaging 2018; 11:e008006. [PMID: 30012828 DOI: 10.1161/circimaging.118.008006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Laura Mercer-Rosa
- Assistant Professor of Pediatrics, Perelman School of Medicine, University of Pennsylvania Children's Hospital of Philadelphia (L.M.-R., D.J.G.).
| | - David J Goldberg
- Assistant Professor of Pediatrics, Perelman School of Medicine, University of Pennsylvania Children's Hospital of Philadelphia (L.M.-R., D.J.G.)
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18
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Cohen MS, Dagincourt N, Zak V, Baffa JM, Bartz P, Dragulescu A, Dudlani G, Henderson H, Krawczeski CD, Lai WW, Levine JC, Lewis AB, McCandless RT, Ohye RG, Owens ST, Schwartz SM, Slesnick TC, Taylor CL, Frommelt PC. The Impact of the Left Ventricle on Right Ventricular Function and Clinical Outcomes in Infants with Single-Right Ventricle Anomalies up to 14 Months of Age. J Am Soc Echocardiogr 2018; 31:1151-1157. [PMID: 29980396 DOI: 10.1016/j.echo.2018.05.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Indexed: 12/26/2022]
Abstract
BACKGROUND Children with single-right ventricle anomalies such as hypoplastic left heart syndrome (HLHS) have left ventricles of variable size and function. The impact of the left ventricle on the performance of the right ventricle and on survival remains unclear. The aim of this study was to identify whether left ventricular (LV) size and function influence right ventricular (RV) function and clinical outcome after staged palliation for single-right ventricle anomalies. METHODS In the Single Ventricle Reconstruction trial, echocardiography-derived measures of LV size and function were compared with measures of RV systolic and diastolic function, tricuspid regurgitation, and outcomes (death and/or heart transplantation) at baseline (preoperatively), early after Norwood palliation, before stage 2 palliation, and at 14 months of age. RESULTS Of the 522 subjects who met the study inclusion criteria, 381 (73%) had measurable left ventricles. The HLHS subtype of aortic atresia/mitral atresia was significantly less likely to have a measurable left ventricle (41%) compared with the other HLHS subtypes: aortic stenosis/mitral stenosis (100%), aortic atresia/mitral stenosis (96%), and those without HLHS (83%). RV end-diastolic and end-systolic volumes were significantly larger, while diastolic indices suggested better diastolic properties in those subjects with no left ventricles compared with those with measurable left ventricles. However, RV ejection fraction was not different on the basis of LV size and function after staged palliation. Moreover, there was no difference in transplantation-free survival to Norwood discharge, through the interstage period, or at 14 months of age between those subjects who had measurable left ventricles compared with those who did not. CONCLUSIONS LV size varies by anatomic subtype in infants with single-right ventricle anomalies. Although indices of RV size and diastolic function were influenced by the presence of a left ventricle, there was no difference in RV systolic function or transplantation-free survival on the basis of LV measures.
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Affiliation(s)
- Meryl S Cohen
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
| | | | - Victor Zak
- New England Research Institutes, Boston, Massachusetts
| | - Jeanne Marie Baffa
- Division of Cardiology, A.I. DuPont Hospital for Children, Wilmington, Delaware
| | - Peter Bartz
- Division of Cardiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Andreea Dragulescu
- Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Gul Dudlani
- Division of Cardiology, Johns Hopkins All Children's Heart Institute, St. Petersburg, Florida
| | - Heather Henderson
- Division of Pediatric Cardiology, Duke University Medical Center, Raleigh, North Carolina
| | | | - Wyman W Lai
- Division of Cardiology, Morgan Stanley Children's Hospital, New York, New York
| | - Jami C Levine
- Department of Cardiology, Children's Hospital, Boston, Boston, Massachusetts
| | - Alan B Lewis
- Division of Cardiology, Children's Hospital Los Angeles, Los Angeles, California
| | | | - Richard G Ohye
- Division of Cardiac Surgery, University of Michigan Health System, Ann Arbor, Michigan
| | - Sonal T Owens
- Division of Pediatric Cardiology, University of Michigan Health System, Ann Arbor, Michigan
| | - Steven M Schwartz
- Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Ontario, Canada
| | | | - Carolyn L Taylor
- Division of Pediatric Cardiology, Medical University of South Carolina, Charleston, South Carolina
| | - Peter C Frommelt
- Division of Cardiology, Medical College of Wisconsin, Milwaukee, Wisconsin
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19
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Son JS, James A, Fan CPS, Mertens L, McCrindle BW, Manlhiot C, Friedberg MK. Prognostic Value of Serial Echocardiography in Hypoplastic Left Heart Syndrome. Circ Cardiovasc Imaging 2018; 11:e006983. [DOI: 10.1161/circimaging.117.006983] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 05/17/2018] [Indexed: 11/16/2022]
Affiliation(s)
- Jae Sung Son
- Division of Pediatric Cardiology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea (J.S.S.)
| | - Adam James
- Division of Cardiology, Labatt Family Heart Centre, Hospital for Sick Children and University of Toronto, ON, Canada (A.J., C.-P.S.F., L.M., B.W.M., C.M., M.K.F.)
| | - Chun-Po Steve Fan
- Division of Cardiology, Labatt Family Heart Centre, Hospital for Sick Children and University of Toronto, ON, Canada (A.J., C.-P.S.F., L.M., B.W.M., C.M., M.K.F.)
| | - Luc Mertens
- Division of Cardiology, Labatt Family Heart Centre, Hospital for Sick Children and University of Toronto, ON, Canada (A.J., C.-P.S.F., L.M., B.W.M., C.M., M.K.F.)
| | - Brian W. McCrindle
- Division of Cardiology, Labatt Family Heart Centre, Hospital for Sick Children and University of Toronto, ON, Canada (A.J., C.-P.S.F., L.M., B.W.M., C.M., M.K.F.)
| | - Cedric Manlhiot
- Division of Cardiology, Labatt Family Heart Centre, Hospital for Sick Children and University of Toronto, ON, Canada (A.J., C.-P.S.F., L.M., B.W.M., C.M., M.K.F.)
| | - Mark K. Friedberg
- Division of Cardiology, Labatt Family Heart Centre, Hospital for Sick Children and University of Toronto, ON, Canada (A.J., C.-P.S.F., L.M., B.W.M., C.M., M.K.F.)
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20
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Jean-St-Michel E, Meza JM, Maguire J, Coles J, McCrindle BW. Survival to Stage II with Ventricular Dysfunction: Secondary Analysis of the Single Ventricle Reconstruction Trial. Pediatr Cardiol 2018. [PMID: 29520465 DOI: 10.1007/s00246-018-1845-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Ventricular dysfunction affects survival in patients with single right ventricle (RV), and remains one of the primary indications for heart transplantation. Since it is challenging to predict the capacity of patients with ventricular dysfunction to proceed to the stage II procedure, we sought to identify factors that would be associated with death or heart transplantation without achieving stage II for single RV patients with ventricular dysfunction after Norwood procedure. The Single Ventricle Reconstruction (SVR) trial public-use database was used. Patients with a RV ejection fraction less than 44% or a RV fractional area of change less than 35% on the post-Norwood echocardiogram were included. Parametric risk hazard analysis was used to identify risk factors for death or transplantation without achieving stage II. Of 365 patients with ventricular function measurements on the post-Norwood echocardiogram, 123 (34%) patients had RV dysfunction. The transplantation-free survival was significantly lower for those with ventricular dysfunction compared to those with normal function (log rank Chi-square = 4.23, p = 0.04). Furthermore, having a Blalock-Taussig (BT) shunt, a large RV, a post-Norwood infectious complication, and a surgeon who performs five or less Norwood per year were independent risk factors for death or transplantation without achieving stage II. The predicted 6-month transplantation-free survival for patients with all four identified risk factors was 1% (70% CI 0-13%). Early heart transplantation referral might be considered for post-Norwood patients with BT shunt and RV dysfunction, especially if other high-risk features are present.
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Affiliation(s)
- Emilie Jean-St-Michel
- Division of Cardiology, The Labatt Family Heart Centre, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.
| | - James M Meza
- Division of Cardiovascular Surgery, The Labatt Family Heart Centre, Department of Surgery, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Jonathon Maguire
- Li Ka Shing Knowledge Institute of St. Michael's hospital, Department of Pediatrics, St. Michael's Hospital, University of Toronto, 30 Bond St, Toronto, ON, M5B1W8, Canada
| | - John Coles
- Division of Cardiovascular Surgery, The Labatt Family Heart Centre, Department of Surgery, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Brian W McCrindle
- Division of Cardiology, The Labatt Family Heart Centre, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
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21
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Alsoufi B, Sinha R, McCracken C, Figueroa J, Altin F, Kanter K. Outcomes and risk factors associated with tricuspid valve repair in children with hypoplastic left heart syndrome†. Eur J Cardiothorac Surg 2018; 54:993-1000. [DOI: 10.1093/ejcts/ezy198] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2017] [Accepted: 04/19/2018] [Indexed: 11/15/2022] Open
Affiliation(s)
- Bahaaldin Alsoufi
- Division of Cardiothoracic Surgery, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Raina Sinha
- Division of Cardiothoracic Surgery, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Courtney McCracken
- Division of Cardiothoracic Surgery, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Janet Figueroa
- Division of Cardiothoracic Surgery, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Firat Altin
- Division of Cardiothoracic Surgery, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Kirk Kanter
- Division of Cardiothoracic Surgery, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
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Mahle WT, Hu C, Trachtenberg F, Menteer J, Kindel SJ, Dipchand AI, Richmond ME, Daly KP, Henderson HT, Lin KY, McCulloch M, Lal AK, Schumacher KR, Jacobs JP, Atz AM, Villa CR, Burns KM, Newburger JW. Heart failure after the Norwood procedure: An analysis of the Single Ventricle Reconstruction Trial. J Heart Lung Transplant 2018; 37:879-885. [PMID: 29571602 DOI: 10.1016/j.healun.2018.02.009] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 02/13/2018] [Accepted: 02/14/2018] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Heart failure results in significant morbidity and mortality in young children with hypoplastic left heart syndrome (HLHS) after the Norwood procedure. METHODS We studied subjects enrolled in the prospective Single Ventricle Reconstruction (SVR) Trial who survived to hospital discharge after a Norwood operation and were followed up to age 6 years. The primary outcome was heart failure, defined as heart transplant listing after Norwood hospitalization, death attributable to heart failure, or symptomatic heart failure (New York Heart Association [NYHA] Class IV). Multivariate modeling was undertaken using Cox regression methodology to determine variables associated with heart failure. RESULTS Of the 461 subjects discharged home following a Norwood procedure, 66 (14.3%) met the criteria for heart failure. Among these, 15 died from heart failure, 39 were listed for transplant (22 had a transplant, 12 died after listing, and 5 were alive and not yet transplanted), and 12 had NYHA Class IV heart failure but were never listed. The median age at heart failure identification was 1.28 (interquartile range 0.30 to 4.69) years. Factors associated with early heart failure included post-Norwood lower fractional area change, need for extracorporeal membrane oxygenation, non-Hispanic ethnicity, Norwood perfusion type, and total support time (p < 0.05). CONCLUSIONS By 6 years of age, heart failure developed in nearly 15% of children after the Norwood procedure. Although transplant listing was common, many patients died from heart failure before receiving a transplant or without being listed. Shunt type did not impact the risk of developing heart failure.
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Affiliation(s)
- William T Mahle
- Children's Healthcare of Atlanta and Department of Pediatrics, Division of Cardiology Emory University Atlanta, GA (W.T.M).
| | - Chenwei Hu
- New England Research Institutes, Watertown, MA (F.T., C.H.)
| | | | - JonDavid Menteer
- Children's Hospital Los Angeles and Department of Pediatrics, Division of Cardiology University of Southern California, Los Angeles, CA (J.M.)
| | - Steven J Kindel
- Children's Hospital of Wisconsin, Milwaukee and Department of Pediatrics, Division of Cardiology University of Wisconsin Milwaukee, WI (S.J.K.)
| | - Anne I Dipchand
- The Hospital for Sick Children and Department of Pediatrics, Division of Cardiology University of Toronto, Toronto, Ontario (A.I.D.)
| | - Marc E Richmond
- Morgan Stanley Children's Hospital of New York Presbyterian Columbia University Medical Center and Department of Pediatrics, Division of Cardiology Columbia University, New York, NY (M.E.R.)
| | - Kevin P Daly
- Boston Children's Hospital and Department of Pediatrics Cardiology Harvard School of Medicine, Boston, MA (K.PD., J.W.N.)
| | - Heather T Henderson
- Duke University Hospital and Department of Pediatrics, Division of Cardiology Duke University, Durham, NC (H.T.H.)
| | - Kimberly Y Lin
- Children's Hospital of Philadelphia and Department of Pediatrics, Division of Cardiology University of Pennsylvania, Philadelphia, PA (K.L.)
| | - Michael McCulloch
- Alfred I. DuPont Hospital for Children and Department of Pediatrics, Division of Cardiology Thomas Jefferson University, Wilmington, DE (M.M.)
| | - Ashwin K Lal
- Primary Children's Medical Center and Department of Pediatrics, Division of Cardiology University of Utah, Salt Lake City, UT (A.K.L.)
| | - Kurt R Schumacher
- University of Michigan Health System and Department of Pediatrics, Division of Cardiology University of Michigan, Ann Arbor, MI (K.S.)
| | - Jeffrey P Jacobs
- Johns Hopkins All Children's Heart Institute and Department of Surgery, Division of Cardiothoracic Surgery, St. Petersburg, FL (J.P.J.)
| | - Andrew M Atz
- Department of Pediatrics, Division of Cardiology Medical University of South Carolina, Charleston, SC (A.M.A.)
| | - Chet R Villa
- Cincinnati Children's Hospital Medical Center and Department of Pediatrics, Division of Cardiology University of Cincinnati, Cincinnati, OH (C.R.V.)
| | - Kristin M Burns
- National Heart, Lung, and Blood Institute, Bethesda, MD (K.M.B.)
| | - Jane W Newburger
- Boston Children's Hospital and Department of Pediatrics Cardiology Harvard School of Medicine, Boston, MA (K.PD., J.W.N.)
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23
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Beke DM. Norwood Procedure for Palliation of Hypoplastic Left Heart Syndrome: Right Ventricle to Pulmonary Artery Conduit vs Modified Blalock-Taussig Shunt. Crit Care Nurse 2018; 36:42-51. [PMID: 27908945 DOI: 10.4037/ccn2016861] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Patients with hypoplastic left heart syndrome undergo a series of operations to separate the pulmonary and systemic circulations. The first of at least 3 operations occurs in the newborn period, with a stage I palliation. The goal of stage I palliation is to provide pulmonary blood flow and create an unobstructed systemic outflow tract. Advances in surgical techniques and intraoperative and postoperative care have helped decrease morbidity and mortality for patients with hypoplastic left heart syndrome who have the stage I Norwood operation, but the patients continue to be at increased risk for hemodynamic collapse and adverse outcomes. This article discusses risk factors, surgical approach, postoperative nursing and medical management strategies, differences between and outcomes for the Norwood operation with the right ventricle to pulmonary artery conduit and the Norwood operation with a modified Blalock-Taussig shunt.
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Affiliation(s)
- Dorothy M Beke
- Dorothy M. Beke is a clinical nurse specialist in the cardiac intensive care unit at Boston Children's Hospital, Boston, Massachusetts. She is the unit's mechanical circulatory support clinical resource, the cardiovascular program bereavement coordinator, and a nurse practitioner in the cardiology preoperative clinic.
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24
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Cao JY, Phan K, Ayer J, Celermajer DS, Winlaw DS. Long term survival of hypoplastic left heart syndrome infants: Meta-analysis comparing outcomes from the modified Blalock-Taussig shunt and the right ventricle to pulmonary artery shunt. Int J Cardiol 2018; 254:107-116. [PMID: 29407078 DOI: 10.1016/j.ijcard.2017.10.040] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Revised: 10/09/2017] [Accepted: 10/12/2017] [Indexed: 12/29/2022]
Abstract
BACKGROUND Stage 1 palliation of hypoplastic left heart syndrome (HLHS) involves the Norwood procedure combined with a modified Blalock-Taussig shunt (mBTS) or right ventricle to pulmonary artery shunt (RVPAS). Short-term survival has been described previously, whereas longer-term outcomes remain a subject of debate. This meta-analysis aimed to describe the short and long-term survival outcomes of these two shunts, and explore factors that might influence survival. METHODS Medline, Cochrane Libraries and EMBASE were systematically searched, and 32 studies were included for statistical synthesis, comprising 1348 mBTS and 1258 RVPAS patients. RESULTS While early in-hospital survival was superior in the RVPAS group (RR=1.5, p<0.05, 95% CI: 1.21-1.85), this difference was lost from 2years post-stage 1 palliation (RR=0.91, p>0.05, 95% CI: 0.79-1.04), and maintained unchanged up to 6years. This shift in survival was also reflected in inter-stage survival, with superior RVPAS outcomes between stage 1 and 2 (RR=1.62, p<0.05, 95% CI: 1.39-1.88), and equivalent outcomes between stage 2 and 3. Potential contributors to this included a significantly higher rate of pulmonary artery stenosis in the RVPAS group and an increased requirement for shunt re-intervention in this group prior to stage 2. CONCLUSIONS Despite early advantages, RVPAS and mBTS for palliation of hypoplastic left heart syndrome produced comparable long-term survival. The RVPAS patients experienced more pulmonary artery stenosis and requirement for shunt re-intervention. The impact of shunt type on quality and survival with a Fontan is yet to be assessed.
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Affiliation(s)
- Jacob Y Cao
- Sydney Medical School, University of Sydney, Sydney, Australia
| | - Kevin Phan
- Sydney Medical School, University of Sydney, Sydney, Australia; NeuroSpine Surgery Research Group (NSURG), Prince of Wales Private Hospital, Sydney, Australia
| | - Julian Ayer
- Sydney Medical School, University of Sydney, Sydney, Australia; The Heart Centre for Children, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - David S Celermajer
- Sydney Medical School, University of Sydney, Sydney, Australia; Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - David S Winlaw
- Sydney Medical School, University of Sydney, Sydney, Australia; The Heart Centre for Children, The Children's Hospital at Westmead, Sydney, NSW, Australia.
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25
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Interstage evaluation of homograft-valved right ventricle to pulmonary artery conduits for palliation of hypoplastic left heart syndrome. J Thorac Cardiovasc Surg 2017; 155:1747-1755.e1. [PMID: 29223842 DOI: 10.1016/j.jtcvs.2017.11.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 10/18/2017] [Accepted: 11/01/2017] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Palliation of hypoplastic left heart syndrome with a standard nonvalved right ventricle to pulmonary artery conduit results in an inefficient circulation in part due to diastolic regurgitation. A composite right ventricle pulmonary artery conduit with a homograft valve has a hypothetical advantage of reducing regurgitation, but may differ in the propensity for stenosis because of valve remodeling. METHODS This retrospective cohort study included 130 patients with hypoplastic left heart syndrome who underwent a modified stage 1 procedure with a right ventricle to pulmonary artery conduit from 2002 to 2015. A composite valved conduit (cryopreserved homograft valve anastomosed to a polytetrafluoroethylene tube) was placed in 100 patients (47 aortic, 32 pulmonary, 13 femoral/saphenous vein, 8 unknown), and a nonvalved conduit was used in 30 patients. Echocardiographic functional parameters were evaluated before and after stage 1 palliation and before the bidirectional Glenn procedure, and interstage interventions were assessed. RESULTS On competing risk analysis, survival over time was better in the valved conduit group (P = .040), but this difference was no longer significant after adjustment for surgical era. There was no significant difference between groups in the cumulative incidence of bidirectional Glenn completion (P = .15). Patients with a valved conduit underwent more interventions for conduit obstruction in the interstage period, but this difference did not reach significance (P = .16). There were no differences between groups in echocardiographic parameters of right ventricle function at baseline or pre-Glenn. CONCLUSIONS In this cohort of patients with hypoplastic left heart syndrome, inclusion of a valved right ventricle to pulmonary artery conduit was not associated with any difference in survival on adjusted analysis and did not confer an identifiable benefit on right ventricle function.
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26
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Abstract
The aim of this study was to describe serial changes in echocardiographic Doppler pulmonary vein flow (PVF) patterns in infants with single right ventricle (RV) anomalies enrolled in the Single Ventricle Reconstruction trial. Measurement of PVF peak systolic (S) and diastolic (D) velocities, velocity time integrals (VTI), S/D peak velocity and VTI ratios, and frequency of atrial reversal (Ar) waves were made at three postoperative time points in 261 infants: early post-Norwood, pre-stage II surgery, and 14 months. Indices were compared over time, between initial shunt type [modified Blalock-Taussig shunt (MBTS) and right ventricle-to-pulmonary artery shunt (RVPAS)] and in relation to clinical outcomes. S velocities and VTI increased over time while D wave was stable, resulting in increasing S/D peak velocity and VTI ratios, with a median post-Norwood S/D VTI ratio of 1.14 versus 1.38 at pre-stage II and 1.89 at 14 months (P < 0.0001 between intervals). MBTS subjects had significantly higher S/D peak velocity and VTI ratios compared to RVPAS at the post-Norwood and pre-stage II time points (P < 0.0001) but not by 14 months. PVF patterns did not correlate with survival or hospitalization course at 1 year. PVF patterns after Norwood palliation differ from normal infants by having a dominant systolic pattern throughout infancy. PVF differences based upon shunt type resolve by 14 months and did not correlate with clinical outcomes. This study describes normative values and variations in PVF for infants with a single RV from shunt-dependent pulmonary blood flow to cavopulmonary blood flow.
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27
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Tadphale SD, Tang X, ElHassan NO, Beam B, Prodhan P. Cavopulmonary Anastomosis During Same Hospitalization as Stage 1 Norwood/Hybrid Palliative Surgery. Ann Thorac Surg 2017; 103:1285-1291. [PMID: 28274521 DOI: 10.1016/j.athoracsur.2017.01.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 11/27/2016] [Accepted: 01/03/2017] [Indexed: 12/23/2022]
Abstract
BACKGROUND Limited literature has examined characteristics of infants with hypoplastic left heart syndrome (HLHS) who remain hospitalized during the interstage period. We described their epidemiologic characteristics, in-hospital outcomes, and identified risk factors that predict the need for superior cavopulmonary anastomosis (SCPA) during the same hospitalization. METHODS This retrospective multicenter database analysis included infants with HLHS who underwent stage 1 palliation from 2004 through 2013. RESULTS Among 5374 infants with HLHS, 314 (5.8%) underwent SCPA during the same hospitalization as stage 1 palliation. They had a higher incidence of baseline comorbidities, complications, and interventions than infants who were discharged. Despite an overall increase in need for SCPA in the same hospitalization across different eras, there was no significant statistical difference in mortality in the two groups in the same era. Septicemia, necrotizing enterocolitis, modified Blalock-Taussig shunt, cardiac catheterization, cardiopulmonary resuscitation, extracorporeal membrane oxygenation, gastrostomy tube, and antiarrhythmic agents were independently associated with increased odds of undergoing SCPA during the same hospitalization. Patients undergoing right ventricle to pulmonary artery shunt were less likely to remain hospitalized until stage 2 palliation. Nonsurvivors in the SCPA group had greater need for interventions and worse intensive care unit outcomes. CONCLUSIONS Infants with HLHS who remain hospitalized after stage 1 until their stage 2 palliation differ significantly from infants who were discharged. Several clinical characteristics, comorbidities, and need for interventions are associated with the likelihood for undergoing stage 2 palliation during the same hospitalization. Timely identification and intervention of adjustable causes of heart failure may improve outcomes.
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Affiliation(s)
- Sachin D Tadphale
- Pediatric Cardiology, Department of Pediatrics, University of Tennessee Health Science Center, Le Bonheur Children's Hospital, Memphis, Tennessee; Pediatric Critical Care, Department of Pediatrics, University of Tennessee Health Science Center, Le Bonheur Children's Hospital, Memphis, Tennessee.
| | - Xinyu Tang
- Department of Biostatistics, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, Arkansas
| | - Nahed O ElHassan
- Department of Neonatology, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, Arkansas
| | - Brandon Beam
- Department of Pediatric Cardiology, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, Arkansas
| | - Parthak Prodhan
- Department of Pediatric Cardiology, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, Arkansas; Department of Pediatric Critical Care, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, Arkansas
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28
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Ruotsalainen HK, Bellsham-Revell HR, Bell AJ, Pihkala JI, Ojala TH, Simpson JM. Right ventricular systolic function in hypoplastic left heart syndrome: A comparison of manual and automated software to measure fractional area change. Echocardiography 2017; 34:587-593. [PMID: 28191731 DOI: 10.1111/echo.13470] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Quantitative echocardiographic assessment of right ventricular function is important in children with hypoplastic left heart syndrome (HLHS). The aim of this study was to examine the repeatability of different echocardiographic techniques, both manual and automated, to measure fractional area change (FAC) in patients with HLHS and to correlate these measurements with magnetic resonance imaging (MRI)-derived ejection fraction (EF). METHODS Fifty-one children with HLHS underwent transthoracic echocardiography and cardiac MRI under the same general anesthetic as part of routine inter-stage assessment. FAC was measured from the apical four-chamber view using three different techniques: velocity vector imaging (VVI) (Syngo USWP 3.0; Siemens Healthineers), QLAB (Q-lab R 10.0; Philips Healthcare), and manual endocardial contour tracing (Xcelera, Philips Healthcare). Intra- and inter-observer variability was calculated using intra-class correlation coefficient (ICC). FAC was correlated with MRI EF calculated using a single standard method. RESULTS Fractional area change had a good correlation with MRI-derived EF with an R value for VVI, QLAB, and manual methods of .7, .6, and .4, respectively. Intra- and inter-observer variability for FAC was good for automated echocardiographic methods (ICC>.85) but worse for manual method particularly inter-observer variability of FAC and end-systolic area. Both automated techniques tended to produce higher FAC values compared with manual measurements (P<.001). CONCLUSION Automation improves the repeatability of FAC in HLHS. There are some differences between automated software in terms of correlation with MRI-derived EF. Measurement bias and wide limits of agreement mean that the same echocardiographic technique should be used during the follow-up of individual patients.
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Affiliation(s)
- Hanna K Ruotsalainen
- Department of Pediatric Cardiology, Children's Hospital, University Hospital of Helsinki and University of Helsinki, Helsinki, Finland.,Department of Pediatrics, Kuopio University Hospital, Kuopio, Finland
| | - Hannah R Bellsham-Revell
- Department of Congenital Heart Disease, Evelina London Children's Hospital, London, United Kingdom
| | - Aaron J Bell
- Department of Congenital Heart Disease, Evelina London Children's Hospital, London, United Kingdom
| | - Jaana I Pihkala
- Department of Pediatric Cardiology, Children's Hospital, University Hospital of Helsinki and University of Helsinki, Helsinki, Finland
| | - Tiina H Ojala
- Department of Pediatric Cardiology, Children's Hospital, University Hospital of Helsinki and University of Helsinki, Helsinki, Finland
| | - John M Simpson
- Department of Congenital Heart Disease, Evelina London Children's Hospital, London, United Kingdom
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29
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Horriat NL, Deatsman SL, Stelter J, Frommelt PC, Hill GD. Variable Myocardial Response to Load Stresses in Infants with Single Left Ventricular Anatomy: Influence of Initial Physiology and Surgical Palliative Strategy. Pediatr Cardiol 2016; 37:1569-1574. [PMID: 27554256 DOI: 10.1007/s00246-016-1471-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Accepted: 08/16/2016] [Indexed: 10/21/2022]
Abstract
Initial surgical strategies in neonates with single left ventricular (LV) anatomy vary based on adequacy of pulmonary and systemic blood flow. Differing myocardial responses to these strategies, as reflected in indices of systolic function, ventricular size, and mass have not been well defined. We sought to evaluate single LV myocardial response to varied physiology and initial palliation and determine whether the response is consistent and predictable. Infants with single LV physiology were divided based on neonatal palliation: no palliation/PA band (NO); BT shunt only (BT); or Norwood procedure (NP). Echo measures were obtained at presentation, early post-bidirectional Glenn (BDG), late post-BDG follow-up, and post-Fontan procedure. Measures included ejection fraction, LV mass indexed to height2.7 and end diastolic volume indexed to body surface area, and mass/volume ratio. The cohort included 38 children (13 NO, 13 BT, 12 NP). Ejection fraction was similar but depressed in all groups at all stages. LV mass was higher in the NP group than the BT group at early post-BDG (p = 0.03) and higher than both BT and NO groups (p < 0.01) at late post-BDG, but the difference was resolved by post-Fontan follow-up. The NP group had the most remarkable remodeling in LV size from BDG to Fontan, suggesting that volume unloading is most valuable in this subgroup. Ventricular remodeling can be identified by echocardiography in children with single LV physiology, despite variable initial surgical palliative strategies. Importantly, these initial surgical strategies do not result in significant differences after Fontan palliation during early childhood.
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Affiliation(s)
- Narges L Horriat
- Department of Pediatrics, Division of Cardiology, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226, USA
| | - Sara L Deatsman
- Department of Obstetrics and Gynecology, University of Florida, PO Box 100294, Gainesville, FL, 32610, USA
| | - Jessica Stelter
- Department of Pediatrics, Division of Cardiology, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226, USA
| | - Peter C Frommelt
- Department of Pediatrics, Division of Cardiology, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226, USA
| | - Garick D Hill
- Department of Pediatrics, Division of Cardiology, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226, USA. .,Children's Hospital of Wisconsin, 9000 W. Wisconsin Ave., Milwaukee, WI, 53226, USA.
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30
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Wong J, Lamata P, Rathod RH, Bertaud S, Dedieu N, Bellsham-Revell H, Pushparajah K, Razavi R, Hussain T, Schaeffter T, Powell AJ, Geva T, Greil GF. Right ventricular morphology and function following stage I palliation with a modified Blalock-Taussig shunt versus a right ventricle-to-pulmonary artery conduit. Eur J Cardiothorac Surg 2016; 51:50-57. [PMID: 27422888 PMCID: PMC5226069 DOI: 10.1093/ejcts/ezw227] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Revised: 05/17/2016] [Accepted: 05/28/2016] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVES The Norwood procedure for hypoplastic left heart syndrome (HLHS) is performed either via a right ventricle-to-pulmonary artery (RVPA) conduit or a modified Blalock–Taussig (MBT) shunt. Cardiac magnetic resonance (CMR) data was used to assess the effects of the RVPA conduit on ventricular shape and function through a computational analysis of anatomy and assessment of indices of strain. METHODS A retrospective analysis of 93 CMR scans of subjects with HLHS was performed (59 with MBT shunt, 34 with RVPA conduit), incorporating data at varying stages of surgery from two congenital centres. Longitudinal and short-axis cine images were used to create a computational cardiac atlas and assess global strain. RESULTS Those receiving an RVPA conduit had significant differences (P< 0.0001) in the shape of the RV corresponding to increased ventricular dilatation (P = 0.001) and increased sphericity (P = 0.006). Differences were evident only following completion of stage II surgery. Despite preserved ejection fraction in both groups, functional strain in the RVPA conduit group compared with that in the MBT shunt group was reduced across multiple ventricular axes, including a reduced systolic longitudinal strain rate (P< 0.0001), reduced diastolic longitudinal strain rate (P = 0.0001) and reduced midventricular systolic circumferential strain (P < 0.0001). CONCLUSIONS Computational modelling analysis reveals differences in ventricular remodelling in patients with HLHS undergoing an RVPA conduit insertion with focal scarring and volume loading leading to decreased functional markers of strain. The need for continued surveillance is warranted, as deleterious effects may not become apparent until later years.
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Affiliation(s)
- James Wong
- Department of Imaging Sciences, Kings College London, St Thomas' Hospital, London, UK
| | - Pablo Lamata
- Department of Imaging Sciences, Kings College London, St Thomas' Hospital, London, UK
| | - Rahul H Rathod
- Boston Children's Hospital, Harvard Medical School, Boston, USA
| | - Sophie Bertaud
- Department of Imaging Sciences, Kings College London, St Thomas' Hospital, London, UK
| | - Nathalie Dedieu
- Department of Imaging Sciences, Kings College London, St Thomas' Hospital, London, UK
| | | | - Kuberan Pushparajah
- Department of Imaging Sciences, Kings College London, St Thomas' Hospital, London, UK
| | - Reza Razavi
- Department of Imaging Sciences, Kings College London, St Thomas' Hospital, London, UK
| | - Tarique Hussain
- Department of Imaging Sciences, Kings College London, St Thomas' Hospital, London, UK
| | - Tobias Schaeffter
- Department of Imaging Sciences, Kings College London, St Thomas' Hospital, London, UK
| | - Andrew J Powell
- Boston Children's Hospital, Harvard Medical School, Boston, USA
| | - Tal Geva
- Boston Children's Hospital, Harvard Medical School, Boston, USA
| | - Gerald F Greil
- Department of Imaging Sciences, Kings College London, St Thomas' Hospital, London, UK
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31
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Plummer ST, Hornik CP, Baker H, Fleming GA, Foerster S, Ferguson ME, Glatz AC, Hirsch R, Jacobs JP, Lee KJ, Lewis AB, Li JS, Martin M, Porras D, Radtke WAK, Rhodes JF, Vincent JA, Zampi JD, Hill KD. Maladaptive aortic properties after the Norwood procedure: An angiographic analysis of the Pediatric Heart Network Single Ventricle Reconstruction Trial. J Thorac Cardiovasc Surg 2016; 152:471-479.e3. [PMID: 27167022 DOI: 10.1016/j.jtcvs.2016.03.091] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Revised: 03/07/2016] [Accepted: 03/13/2016] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Aortic arch reconstruction in children with single ventricle lesions may predispose to circulatory inefficiency and maladaptive physiology leading to increased myocardial workload. We sought to describe neoaortic anatomy and physiology, risk factors for abnormalities, and impact on right ventricular function in patients with single right ventricle lesions after arch reconstruction. METHODS Prestage II aortic angiograms from the Pediatric Heart Network Single Ventricle Reconstruction trial were analyzed to define arch geometry (Romanesque [normal], crenel [elongated], or gothic [angular]), indexed neoaortic dimensions, and distensibility. Comparisons were made with 50 single-ventricle controls without prior arch reconstruction. Factors associated with ascending neoaortic dilation, reduced distensibility, and decreased ventricular function on the 14-month echocardiogram were evaluated using univariate and multivariable logistic regression. RESULTS Interpretable angiograms were available for 326 of 389 subjects (84%). Compared with controls, study subjects more often demonstrated abnormal arch geometry (67% vs 22%, P < .01) and had increased ascending neoaortic dilation (Z score 3.8 ± 2.2 vs 2.6 ± 2.0, P < .01) and reduced distensibility index (2.2 ± 1.9 vs 8.0 ± 3.8, P < .01). Adjusted odds of neoaortic dilation were increased in subjects with gothic arch geometry (odds ratio [OR], 3.2 vs crenel geometry, P < .01) and a right ventricle-pulmonary artery shunt (OR, 3.4 vs Blalock-Taussig shunt, P < .01) but were decreased in subjects with aortic atresia (OR, 0.7 vs stenosis, P < .01) and those with recoarctation (OR, 0.3 vs no recoarctation, P = .04). No demographic, anatomic, or surgical factors predicted reduced distensibility. Neither dilation nor distensibility predicted reduced right ventricular function. CONCLUSIONS After Norwood surgery, the reconstructed neoaorta demonstrates abnormal anatomy and physiology. Further study is needed to evaluate the longer-term impact of these features.
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Affiliation(s)
| | | | | | | | | | - M Eric Ferguson
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Ga
| | | | - Russel Hirsch
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jeffrey P Jacobs
- Johns Hopkins Children's Heart Surgery, All Children's Hospital and Florida Hospital for Children, St Petersburg, Tampa, and Orlando, Fla
| | - Kyong-Jin Lee
- Hospital for Sick Children, Toronto, Ontario, Canada
| | - Alan B Lewis
- Children's Hospital Los Angeles, Los Angeles, Calif
| | | | - Mary Martin
- University of Utah School of Medicine, Salt Lake City, Utah
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32
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Grotenhuis HB, Ruijsink B, Chetan D, Dragulescu A, Friedberg MK, Kotani Y, Caldarone CA, Honjo O, Mertens LL. Impact of Norwood versus hybrid palliation on cardiac size and function in hypoplastic left heart syndrome. Heart 2016; 102:966-74. [PMID: 26908097 DOI: 10.1136/heartjnl-2015-308787] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Accepted: 01/20/2016] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE The hybrid approach for hypoplastic left heart syndrome (HLHS) could theoretically result in better preservation of right ventricular (RV) function then the Norwood procedure. The aim of this study was to compare echocardiographic indices of RV size and function in patients after Norwood and hybrid throughout all stages of palliation. METHODS 76 HLHS patients (42 Norwood, 34 hybrid) were retrospectively studied. Echocardiography was obtained before stage I, before and after stage II, and before and after Fontan. Median follow-up was 4.9 years (range 1.1-8.5). RESULTS Baseline characteristics before stage I were similar. Hybrid patients demonstrated a significant decrease in RV fractional area change (FAC) between baseline and pre-stage II (36±9% vs 27±6%; p<0.01); Norwood patients remained stable (32±10% vs 32±7%; p=0.21). At pre-stage II, moderate/severe tricuspid valve (TV) regurgitation was found in nine Norwood (33%) and four hybrid (18%) patients (p=0.19). After stage II, the difference in FAC became insignificant (29±7% vs 25±8%, p=0.08) and moderate/severe TV regurgitation (TR) was found in 13 Norwood (48%) and four hybrid patients (19%) (p=0.18). At pre-Fontan, RV FAC was similar after Norwood and hybrid (34±5% vs 33±6%, p=0.69), which remained unchanged after Fontan. After Fontan, one Norwood and one hybrid patient had moderate TR. RV and TV size were similar for both groups at each time point. CONCLUSIONS Patients after Norwood and hybrid procedures had equivalent indices of RV size, and systolic and diastolic function throughout all stages of palliation. Small differences in individual RV and TV indices are likely to be explained by differences in physiology or surgical timing rather than by intrinsic differences in myocardial and valve function.
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Affiliation(s)
- Heynric B Grotenhuis
- The Labatt Family Heart Center, The Hospital for Sick Children, The University of Toronto, Toronto, Ontario, Canada
| | - Bram Ruijsink
- The Labatt Family Heart Center, The Hospital for Sick Children, The University of Toronto, Toronto, Ontario, Canada
| | - Devin Chetan
- Division of Cardiovascular Surgery, The Hospital for Sick Children, The University of Toronto, Toronto, Ontario, Canada
| | - Andreea Dragulescu
- The Labatt Family Heart Center, The Hospital for Sick Children, The University of Toronto, Toronto, Ontario, Canada
| | - Mark K Friedberg
- The Labatt Family Heart Center, The Hospital for Sick Children, The University of Toronto, Toronto, Ontario, Canada
| | - Yasuhiro Kotani
- Division of Cardiovascular Surgery, The Hospital for Sick Children, The University of Toronto, Toronto, Ontario, Canada
| | - Christopher A Caldarone
- Division of Cardiovascular Surgery, The Hospital for Sick Children, The University of Toronto, Toronto, Ontario, Canada
| | - Osami Honjo
- Division of Cardiovascular Surgery, The Hospital for Sick Children, The University of Toronto, Toronto, Ontario, Canada
| | - Luc L Mertens
- The Labatt Family Heart Center, The Hospital for Sick Children, The University of Toronto, Toronto, Ontario, Canada
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Kulkarni A, Neugebauer R, Lo Y, Gao Q, Lamour JM, Weinstein S, Hsu DT. Outcomes and risk factors for listing for heart transplantation after the Norwood procedure: An analysis of the Single Ventricle Reconstruction Trial. J Heart Lung Transplant 2015; 35:306-311. [PMID: 26632030 DOI: 10.1016/j.healun.2015.10.033] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 10/14/2015] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Infants with hypoplastic left heart syndrome after palliation have the worst survival among heart transplant recipients. Heart transplantation is often reserved for use in patients with sub-optimal results after palliative surgery. This study characterized outcomes after listing in infants with a single ventricle who had undergone the Norwood procedure and identified predictors of the decision to list for heart transplantation. METHODS The public-use database from the multicenter, prospective randomized Single Ventricle Reconstruction trial was used to identify patients who were listed for heart transplantation. Outcomes on the waiting list and after transplantation were determined. Risk factors were compared between those who were listed and those who survived without listing. RESULTS Among 555 patients, 33 patients (5.9%) were listed and 18 underwent heart transplantation. Mortality was 39% while waiting for a heart and was 33% after heart transplantation. Overall, 1-year survival after listing (including death after transplantation) was 48%. Factors associated with listing were a lower right ventricular fractional area change at birth, non-hypoplastic left heart syndrome diagnosis, and a more complicated post-Norwood course, defined as a higher need for extracorporeal membrane oxygenation, longer intensive care unit stay, more complications, and a higher number of discharge medications. CONCLUSIONS Worse right ventricular function, non-hypoplastic left heart syndrome diagnosis, and complex intensive care unit stay were significant risk factors for listing for heart transplantation after the Norwood procedure. Heart transplantation as a rescue procedure after the Norwood procedure in the first year of life carries a significant risk of mortality.
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Affiliation(s)
- Aparna Kulkarni
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York.
| | | | - Yungtai Lo
- Department of Biostatistics, Albert Einstein College of Medicine, Bronx, New York
| | - Qi Gao
- Department of Biostatistics, Albert Einstein College of Medicine, Bronx, New York
| | - Jacqueline M Lamour
- Department of Pediatrics, Albert Einstein College of Medicine/Children's Hospital at Montefiore, Bronx, New York
| | - Samuel Weinstein
- Department of Pediatrics, Albert Einstein College of Medicine/Children's Hospital at Montefiore, Bronx, New York
| | - Daphne T Hsu
- Department of Pediatrics, Albert Einstein College of Medicine/Children's Hospital at Montefiore, Bronx, New York
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Abstract
PURPOSE OF REVIEW Much data exist concerning Norwood discharge mortality. Less is known about late survival. Examining the available data in light of the Single Ventricle Reconstruction trial is insightful as focus shifts toward long-term survival. RECENT FINDINGS Data from 2000 to 2001 demonstrated approximately 40-50% 10-year survival, 30-40% or less between 10 and 15 years. The shape of the curves was characteristic; the majority of deaths within the first year, followed by a late constant phase. Publications from 2001 to 2005 suggested that various combinations of technical and perioperative modifications allowed hospital discharge survivals as high as 90-94%. As results matured (2005-2010) a consistent message was that, although the shape of the newer curves was similar (highest hazard in the first 1 year), higher hospital survival shifted the later phase to yield better long-term survival (70-85% between 5 and 10 years). Some emphasized right ventricle-based shunts as a 'cause' of improving results. Since 2010, the Single Ventricle Reconstruction trial has matured and has increasingly shifted opinion away from the right ventricle shunt as a 'cause' of improved results. The survival of the right ventricle shunt group is slightly higher at 3 years, but the 1-year statistical significance has been lost and the two groups converge. As the Single Ventricle Reconstruction study was based on the interaction between randomized shunt and survival, the secondary and other endpoint analyses must be cautiously considered. SUMMARY The current English-language literature suggests a 60-80% 5-10 year survival expectation. The shape of the survival curve remains; the highest hazard remains the first year before a later, stable phase is reached. Rather than a 'magic bullet' theory surrounding one technique or practice, centers have differentially adopted various combinations to optimize Norwood survival. Optimizing interstage I survival is a challenge to further increase the percentage of patients reaching the late, stable phase.
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Survival and right ventricular performance for matched children after stage-1 Norwood: Modified Blalock-Taussig shunt versus right-ventricle-to-pulmonary-artery conduit. J Thorac Cardiovasc Surg 2015; 150:1440-50, 1452.e1-8; discussion 1450-2. [PMID: 26254760 DOI: 10.1016/j.jtcvs.2015.06.069] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Revised: 06/04/2015] [Accepted: 06/06/2015] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Early survival advantages after Norwood with right-ventricle-(RV)-to-pulmonary-artery conduit (NW-RVPA) over Norwood-operation with a Blalock-Taussig shunt (NW-BT) are offset by concerns regarding delayed RV dysfunction. We compared trends in survival, RV dysfunction, and tricuspid valve regurgitation (TR) between NW-RVPA and NW-BT for propensity-matched neonates with critical left ventricular outflow tract obstruction (LVOTO). METHODS In an inception cohort (2005-2014; 21 institutions), 454 neonates with critical LVOTO underwent Norwood stage 1. Propensity-score matching paired 169 NW-RVPA patients with 169 NW-BT patients. End-states were compared between NW-RVPA and NW-BT using competing-risks, multiphase, parametric, hazard analysis. Post-Norwood echocardiogram reports (n = 2993) were used to grade RV dysfunction and TR. Time-related prevalence of ≥moderate RV dysfunction and TR were characterized using nonlinear mixed-model regression, and compared between groups via multiphase, parametric models. RESULTS Overall 6-year survival was better after NW-RVPA (70%) versus NW-BT (55%; P < .001). Additionally, transplant-free survival during this time was better after NW-RVPA (64%) versus NW-BT (53%; P = .004). Overall prevalence of ≥moderate RV dysfunction reached 11% within 3 months post-Norwood. During this time, RV dysfunction after NW-BT was 16% versus 6% after NW-RVPA (P = .02), and coincided temporally with an increased early hazard for death. For survivors, late RV dysfunction was <5% and was not different between groups (P = .36). Overall prevalence of ≥moderate TR reached 13% at 2 years post-Norwood and was increased after NW-BT (16%) versus NW-RVPA (11%; P = .003). Late TR was similar between groups. CONCLUSIONS Among propensity-score-matched neonates with critical LVOTO, NW-RVPA offers superior 6-year survival with no greater prevalence of RV dysfunction or TR than conventional NW-BT operations.
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Hill GD, Frommelt PC, Stelter J, Campbell MJ, Cohen MS, Kharouf R, Lai WW, Levine JC, Lu JC, Menon SC, Slesnick TC, Wong PC, Saudek DE. Impact of initial norwood shunt type on right ventricular deformation: the single ventricle reconstruction trial. J Am Soc Echocardiogr 2015; 28:517-21. [PMID: 25690998 PMCID: PMC4426007 DOI: 10.1016/j.echo.2015.01.018] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND The Single Ventricle Reconstruction trial demonstrated a transplantation-free survival advantage at 12-month follow-up for patients with right ventricle-pulmonary artery shunts (RVPAS) with the Norwood procedure compared with modified Blalock-Taussig shunts but similar survival and decreased global right ventricular (RV) function on longer term follow-up. The impact of the required ventriculotomy for the RVPAS remains unknown. The aim of this study was to compare echocardiography-derived RV deformation indices after stage 2 procedures in survivors with single RV anomalies enrolled in the Single Ventricle Reconstruction trial. METHODS Global and regional RV systolic longitudinal and circumferential strain and strain rate, ejection fraction, and short-axis percentage fractional area change were all derived by speckle-tracking echocardiography from protocol echocardiograms obtained at 14.3 ± 1.2 months. Student t tests or Wilcoxon rank sum tests were used to compare groups. RESULTS The cohort included 275 subjects (129 in the modified Blalock-Taussig shunt group and 146 in the RVPAS group). Longitudinal deformation could be quantified in 214 subjects (78%) and circumferential measures in 182 subjects (66%). RV ejection fraction and percentage fractional area change did not differ between groups. There were no significant differences between groups for global or regional longitudinal deformation. Circumferential indices showed abnormalities in deformation in the RVPAS group, with decreased global circumferential strain (P = .05), strain rate (P = .09), and anterior regional strain rate (P = .07) that approached statistical significance. CONCLUSIONS RV myocardial deformation at 14 months, after stage 2 procedures, was not significantly altered by the type of initial shunt placed. However, abnormal trends were appreciated in circumferential deformation for the RVPAS group in the area of ventriculotomy that may represent early myocardial dysfunction. These data provide a basis for longer term RV deformation assessment in survivors after Norwood procedures.
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Affiliation(s)
| | | | | | | | - Meryl S Cohen
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Rami Kharouf
- Alfred I. DuPont Hospital for Children, Wilmington, Delaware
| | - Wyman W Lai
- Columbia University Medical Center, New York, New York
| | | | - Jimmy C Lu
- University of Michigan, Ann Arbor, Michigan
| | | | | | - Pierre C Wong
- Children's Hospital Los Angeles, Los Angeles, California
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Ishigami S, Ohtsuki S, Tarui S, Ousaka D, Eitoku T, Kondo M, Okuyama M, Kobayashi J, Baba K, Arai S, Kawabata T, Yoshizumi K, Tateishi A, Kuroko Y, Iwasaki T, Sato S, Kasahara S, Sano S, Oh H. Intracoronary autologous cardiac progenitor cell transfer in patients with hypoplastic left heart syndrome: the TICAP prospective phase 1 controlled trial. Circ Res 2014; 116:653-64. [PMID: 25403163 DOI: 10.1161/circresaha.116.304671] [Citation(s) in RCA: 141] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
RATIONALE Hypoplastic left heart syndrome (HLHS) remains a lethal congenital cardiac defect. Recent studies have suggested that intracoronary administration of autologous cardiosphere-derived cells (CDCs) may improve ventricular function. OBJECTIVE The aim of this study was to test whether intracoronary delivery of CDCs is feasible and safe in patients with hypoplastic left heart syndrome. METHODS AND RESULTS Between January 5, 2011, and January 16, 2012, 14 patients (1.8±1.5 years) were prospectively assigned to receive intracoronary infusion of autologous CDCs 33.4±8.1 days after staged procedures (n=7), followed by 7 controls with standard palliation alone. The primary end point was to assess the safety, and the secondary end point included the preliminary efficacy to verify the right ventricular ejection fraction improvements between baseline and 3 months. Manufacturing and intracoronary delivery of CDCs were feasible, and no serious adverse events were reported within the 18-month follow-up. Patients treated with CDCs showed right ventricular ejection fraction improvement from baseline to 3-month follow-up (46.9%±4.6% to 52.1%±2.4%; P=0.008). Compared with controls at 18 months, cardiac MRI analysis of CDC-treated patients showed a higher right ventricular ejection fraction (31.5%±6.8% versus 40.4%±7.6%; P=0.049), improved somatic growth (P=0.0005), reduced heart failure status (P=0.003), and lower incidence of coil occlusion for collaterals (P=0.007). CONCLUSIONS Intracoronary infusion of autologous CDCs seems to be feasible and safe in children with hypoplastic left heart syndrome after staged surgery. Large phase 2 trials are warranted to examine the potential effects of cardiac function improvements and the long-term benefits of clinical outcomes. CLINICAL TRIAL REGISTRATION URL http://www.clinicaltrials.gov. Unique identifier: NCT01273857.
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Affiliation(s)
- Shuta Ishigami
- From the Departments of Cardiovascular Surgery (S.I., S.T., D.O., M.O., J.K., S.A., T.K., K.Y., A.T., Y.K., S.K., S.S.), Pediatrics (S.O., T.E., M.K., K.B.), Anesthesiology and Resuscitology (T.I.), and Radiology (S.S.), Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan; and Department of Regenerative Medicine, Center for Innovative Clinical Medicine, Okayama University Hospital (H.O.), Okayama, Japan
| | - Shinichi Ohtsuki
- From the Departments of Cardiovascular Surgery (S.I., S.T., D.O., M.O., J.K., S.A., T.K., K.Y., A.T., Y.K., S.K., S.S.), Pediatrics (S.O., T.E., M.K., K.B.), Anesthesiology and Resuscitology (T.I.), and Radiology (S.S.), Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan; and Department of Regenerative Medicine, Center for Innovative Clinical Medicine, Okayama University Hospital (H.O.), Okayama, Japan
| | - Suguru Tarui
- From the Departments of Cardiovascular Surgery (S.I., S.T., D.O., M.O., J.K., S.A., T.K., K.Y., A.T., Y.K., S.K., S.S.), Pediatrics (S.O., T.E., M.K., K.B.), Anesthesiology and Resuscitology (T.I.), and Radiology (S.S.), Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan; and Department of Regenerative Medicine, Center for Innovative Clinical Medicine, Okayama University Hospital (H.O.), Okayama, Japan
| | - Daiki Ousaka
- From the Departments of Cardiovascular Surgery (S.I., S.T., D.O., M.O., J.K., S.A., T.K., K.Y., A.T., Y.K., S.K., S.S.), Pediatrics (S.O., T.E., M.K., K.B.), Anesthesiology and Resuscitology (T.I.), and Radiology (S.S.), Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan; and Department of Regenerative Medicine, Center for Innovative Clinical Medicine, Okayama University Hospital (H.O.), Okayama, Japan
| | - Takahiro Eitoku
- From the Departments of Cardiovascular Surgery (S.I., S.T., D.O., M.O., J.K., S.A., T.K., K.Y., A.T., Y.K., S.K., S.S.), Pediatrics (S.O., T.E., M.K., K.B.), Anesthesiology and Resuscitology (T.I.), and Radiology (S.S.), Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan; and Department of Regenerative Medicine, Center for Innovative Clinical Medicine, Okayama University Hospital (H.O.), Okayama, Japan
| | - Maiko Kondo
- From the Departments of Cardiovascular Surgery (S.I., S.T., D.O., M.O., J.K., S.A., T.K., K.Y., A.T., Y.K., S.K., S.S.), Pediatrics (S.O., T.E., M.K., K.B.), Anesthesiology and Resuscitology (T.I.), and Radiology (S.S.), Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan; and Department of Regenerative Medicine, Center for Innovative Clinical Medicine, Okayama University Hospital (H.O.), Okayama, Japan
| | - Michihiro Okuyama
- From the Departments of Cardiovascular Surgery (S.I., S.T., D.O., M.O., J.K., S.A., T.K., K.Y., A.T., Y.K., S.K., S.S.), Pediatrics (S.O., T.E., M.K., K.B.), Anesthesiology and Resuscitology (T.I.), and Radiology (S.S.), Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan; and Department of Regenerative Medicine, Center for Innovative Clinical Medicine, Okayama University Hospital (H.O.), Okayama, Japan
| | - Junko Kobayashi
- From the Departments of Cardiovascular Surgery (S.I., S.T., D.O., M.O., J.K., S.A., T.K., K.Y., A.T., Y.K., S.K., S.S.), Pediatrics (S.O., T.E., M.K., K.B.), Anesthesiology and Resuscitology (T.I.), and Radiology (S.S.), Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan; and Department of Regenerative Medicine, Center for Innovative Clinical Medicine, Okayama University Hospital (H.O.), Okayama, Japan
| | - Kenji Baba
- From the Departments of Cardiovascular Surgery (S.I., S.T., D.O., M.O., J.K., S.A., T.K., K.Y., A.T., Y.K., S.K., S.S.), Pediatrics (S.O., T.E., M.K., K.B.), Anesthesiology and Resuscitology (T.I.), and Radiology (S.S.), Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan; and Department of Regenerative Medicine, Center for Innovative Clinical Medicine, Okayama University Hospital (H.O.), Okayama, Japan
| | - Sadahiko Arai
- From the Departments of Cardiovascular Surgery (S.I., S.T., D.O., M.O., J.K., S.A., T.K., K.Y., A.T., Y.K., S.K., S.S.), Pediatrics (S.O., T.E., M.K., K.B.), Anesthesiology and Resuscitology (T.I.), and Radiology (S.S.), Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan; and Department of Regenerative Medicine, Center for Innovative Clinical Medicine, Okayama University Hospital (H.O.), Okayama, Japan
| | - Takuya Kawabata
- From the Departments of Cardiovascular Surgery (S.I., S.T., D.O., M.O., J.K., S.A., T.K., K.Y., A.T., Y.K., S.K., S.S.), Pediatrics (S.O., T.E., M.K., K.B.), Anesthesiology and Resuscitology (T.I.), and Radiology (S.S.), Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan; and Department of Regenerative Medicine, Center for Innovative Clinical Medicine, Okayama University Hospital (H.O.), Okayama, Japan
| | - Ko Yoshizumi
- From the Departments of Cardiovascular Surgery (S.I., S.T., D.O., M.O., J.K., S.A., T.K., K.Y., A.T., Y.K., S.K., S.S.), Pediatrics (S.O., T.E., M.K., K.B.), Anesthesiology and Resuscitology (T.I.), and Radiology (S.S.), Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan; and Department of Regenerative Medicine, Center for Innovative Clinical Medicine, Okayama University Hospital (H.O.), Okayama, Japan
| | - Atsushi Tateishi
- From the Departments of Cardiovascular Surgery (S.I., S.T., D.O., M.O., J.K., S.A., T.K., K.Y., A.T., Y.K., S.K., S.S.), Pediatrics (S.O., T.E., M.K., K.B.), Anesthesiology and Resuscitology (T.I.), and Radiology (S.S.), Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan; and Department of Regenerative Medicine, Center for Innovative Clinical Medicine, Okayama University Hospital (H.O.), Okayama, Japan
| | - Yosuke Kuroko
- From the Departments of Cardiovascular Surgery (S.I., S.T., D.O., M.O., J.K., S.A., T.K., K.Y., A.T., Y.K., S.K., S.S.), Pediatrics (S.O., T.E., M.K., K.B.), Anesthesiology and Resuscitology (T.I.), and Radiology (S.S.), Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan; and Department of Regenerative Medicine, Center for Innovative Clinical Medicine, Okayama University Hospital (H.O.), Okayama, Japan
| | - Tatsuo Iwasaki
- From the Departments of Cardiovascular Surgery (S.I., S.T., D.O., M.O., J.K., S.A., T.K., K.Y., A.T., Y.K., S.K., S.S.), Pediatrics (S.O., T.E., M.K., K.B.), Anesthesiology and Resuscitology (T.I.), and Radiology (S.S.), Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan; and Department of Regenerative Medicine, Center for Innovative Clinical Medicine, Okayama University Hospital (H.O.), Okayama, Japan
| | - Shuhei Sato
- From the Departments of Cardiovascular Surgery (S.I., S.T., D.O., M.O., J.K., S.A., T.K., K.Y., A.T., Y.K., S.K., S.S.), Pediatrics (S.O., T.E., M.K., K.B.), Anesthesiology and Resuscitology (T.I.), and Radiology (S.S.), Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan; and Department of Regenerative Medicine, Center for Innovative Clinical Medicine, Okayama University Hospital (H.O.), Okayama, Japan
| | - Shingo Kasahara
- From the Departments of Cardiovascular Surgery (S.I., S.T., D.O., M.O., J.K., S.A., T.K., K.Y., A.T., Y.K., S.K., S.S.), Pediatrics (S.O., T.E., M.K., K.B.), Anesthesiology and Resuscitology (T.I.), and Radiology (S.S.), Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan; and Department of Regenerative Medicine, Center for Innovative Clinical Medicine, Okayama University Hospital (H.O.), Okayama, Japan
| | - Shunji Sano
- From the Departments of Cardiovascular Surgery (S.I., S.T., D.O., M.O., J.K., S.A., T.K., K.Y., A.T., Y.K., S.K., S.S.), Pediatrics (S.O., T.E., M.K., K.B.), Anesthesiology and Resuscitology (T.I.), and Radiology (S.S.), Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan; and Department of Regenerative Medicine, Center for Innovative Clinical Medicine, Okayama University Hospital (H.O.), Okayama, Japan
| | - Hidemasa Oh
- From the Departments of Cardiovascular Surgery (S.I., S.T., D.O., M.O., J.K., S.A., T.K., K.Y., A.T., Y.K., S.K., S.S.), Pediatrics (S.O., T.E., M.K., K.B.), Anesthesiology and Resuscitology (T.I.), and Radiology (S.S.), Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan; and Department of Regenerative Medicine, Center for Innovative Clinical Medicine, Okayama University Hospital (H.O.), Okayama, Japan.
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Impact of initial shunt type on cardiac size and function in children with single right ventricle anomalies before the Fontan procedure: the single ventricle reconstruction extension trial. J Am Coll Cardiol 2014; 64:2026-35. [PMID: 25440099 DOI: 10.1016/j.jacc.2014.08.033] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Revised: 07/06/2014] [Accepted: 08/13/2014] [Indexed: 11/20/2022]
Abstract
BACKGROUND In children with single right ventricular (RV) anomalies, changes in RV size and function may be influenced by shunt type chosen at the time of the Norwood procedure. OBJECTIVES The study sought to identify shunt-related differences in echocardiographic findings at 14 months and ≤6 months pre-Fontan in survivors of the Norwood procedure. METHODS We compared 2-dimensional and Doppler echocardiographic indices of RV size and function, neo-aortic and tricuspid valve annulus dimensions and function, and aortic size and patency at 14.1 ± 1.2 months and 33.6 ± 9.6 months in subjects randomized to a Norwood procedure using either the modified Blalock-Taussig shunt (MBTS) or right ventricle to pulmonary artery shunt (RVPAS). RESULTS Acceptable echocardiograms were available at both time points in 240 subjects (114 MBTS, 126 RVPAS). At 14 months, all indices were similar between shunt groups. From the 14-month to pre-Fontan echocardiogram, the MBTS group had stable indexed RV volumes and ejection fraction, while the RVPAS group had increased RV end-systolic volume (p = 0.004) and decreased right ventricular ejection fraction (RVEF) (p = 0.004). From 14 months to pre-Fontan, the treatment groups were similar with respect to decline in indexed neo-aortic valve area, >mild neo-aortic valve regurgitation (<5% at each time), indexed tricuspid valve area, and ≥moderate tricuspid valve regurgitation (<20% at each time). CONCLUSIONS Initial Norwood shunt type influences pre-Fontan RV remodeling during the second and third years of life in survivors with single RV anomalies, with greater RVEF deterioration after RVPAS. Encouragingly, other indices of RV function remain stable before Fontan regardless of shunt type. (Comparison of Two Types of Shunts in Infants with Single Ventricle Defect Undergoing Staged Reconstruction-Pediatric Heart Network; NCT00115934).
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In Search of the Ideal Pulmonary Blood Source for the Norwood Procedure: A Meta-Analysis and Systematic Review. Ann Thorac Surg 2014; 98:142-50. [DOI: 10.1016/j.athoracsur.2014.02.078] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2013] [Revised: 02/23/2014] [Accepted: 02/25/2014] [Indexed: 11/17/2022]
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Abstract
Hypoplastic left heart syndrome, the most common complex congenital heart malformation, is characterized by underdeveloped left-sided heart structures. The Norwood procedure followed by two-staged operations has permitted the extended survival of many of these patients. Survival, however, remains suboptimal with most of the morbidity and mortality occurring during the Norwood procedure hospitalization. The modified Blalock-Taussig shunt has been implicated in contributing to the mortality risk due to decreased systemic diastolic blood pressure and coronary perfusion. Therefore, the right ventricle-to-pulmonary artery shunt was recently reevaluated as a lower-risk source of pulmonary blood flow in the Norwood procedure. The Pediatric Heart Network Single Ventricle Reconstruction trial, sponsored by the NIH National Heart, Lung and Blood Institute, evaluated the two types of shunts during the Norwood procedure. This randomized clinical trial has yielded important insight into the effects of shunt selection on morbidity, mortality, hemodynamics and overall current outcomes for hypoplastic left heart syndrome.
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Affiliation(s)
- Ming-Sing Si
- Department of Cardiac Surgery, Michigan Congenital Heart Center, C.S. Mott Children's Hospital, Room 11-735, 1540 E. Hospital Drive/SPC 4204, Ann Arbor, MI 48109-4204, USA
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Update on heart failure, heart transplant, congenital heart disease, and clinical cardiology. ACTA ACUST UNITED AC 2014; 66:290-7. [PMID: 24775619 DOI: 10.1016/j.rec.2012.10.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2012] [Accepted: 10/23/2012] [Indexed: 10/27/2022]
Abstract
In the year 2012, 3 scientific sections-heart failure and transplant, congenital heart disease, and clinical cardiology-are presented together in the same article. The most relevant development in the area of heart failure and transplantation is the 2012 publication of the European guidelines for heart failure. These describe new possibilities for some drugs (eplerenone and ivabradine); expand the criteria for resynchronization, ventricular assist, and peritoneal dialysis; and cover possibilities of percutaneous repair of the mitral valve (MitraClip(®)). The survival of children with hypoplastic left heart syndrome in congenital heart diseases has improved significantly. Instructions for percutaneous techniques and devices have been revised and modified for the treatment of atrial septal defects, ostium secundum, and ventricular septal defects. Hybrid procedures for addressing structural congenital heart defects have become more widespread. In the area of clinical cardiology studies have demonstrated that percutaneous prosthesis implantation has lower mortality than surgical implantation. Use of the CHA2DS2-VASc criteria and of new anticoagulants (dabigatran, rivaroxaban and apixaban) is also recommended. In addition, the development of new sequencing techniques has enabled the analysis of multiple genes.
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Fate of ventricular and valve performance following early bidirectional Glenn procedure after Norwood operation controlled for hypoplastic left heart syndome anatomic subtype. Pediatr Cardiol 2014; 35:332-43. [PMID: 24126954 DOI: 10.1007/s00246-013-0780-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Accepted: 08/14/2013] [Indexed: 10/26/2022]
Abstract
The Norwood operation (NO) with a right ventricle (RV)-to-pulmonary artery (PA) shunt (NRVPA) is reportedly associated with early hemodynamic advantage. Shunt strategy has been implicated in ventricular function. Outcomes after NRVPA compared with classic procedure as part of a strategy involving early bidirectional Glenn (BDG) procedure were analyzed with reference to RV, tricuspid, and neoaortic valve performance. Between January 2005 and December 2010, 128 neonates with hypoplastic left heart syndrome (HLHS) underwent NO. Controlled for aortic/mitral stenosis (AS-MS) subtype, 28 patients underwent NRVPA (group A), and 26 patients had classic procedure (group B). The patients with a non-HLHS single-ventricle anatomy and those who had undergone a hybrid approach for HLHS were excluded from the study. The mean age at NO was 6.8 ± 3.5 days in group A and 6.9 ± 3.6 days in group B. Transthoracic echocardiographic evaluation (TTE) after NO (TTE-1) at the midinterval between NO and BDG (TTE-2), before BDG (TTE-3), before Fontan (TTE-4), and at the last follow-up evaluation (TTE-5) was undertaken. Cardiac catheterization was used to assess hemodynamic parameters before the Glenn and Fontan procedures. The operative, interstage, and pre-Fontan survival rates for AS-MS after NO were respectively 88.1 % (90.3 % in group A vs. 84.7 % in group B; p = 0.08), 82.5 % (82.7 % in group A vs. 81.8 % in group B; p = 0.9), and 80.7 % (79.5 % in group A vs. 81.8 % in group B; p = 0.9). The median follow-up period was 39.6 months (interquartile range 2.7-4.9 months). The RV global function, mid- and longitudinal indexed dimensions, fractionated area change before BDG (TTE-1, TTE-2, TTE-3) and after BDG (TTE-4, TTE-5), and right ventricular end-diastolic pressure did not differ statistically between the groups (p > 0.05). No statistically significant difference in tricuspid or neoaortic intervention was found between the groups (p > 0.05). Controlled for the AS-MS HLHS subtype, shunt strategy showed no midterm survival or hemodynamic (ventricular or valve) impact. At midterm, the follow-up need for neoaortic or tricuspid valve surgical intervention was not affected by shunt selection. The structural ventricular adaptation after reversal of shunt physiology was irrespective of shunt strategy.
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Klitsie LM, Roest AAW, Blom NA, ten Harkel ADJ. Ventricular performance after surgery for a congenital heart defect as assessed using advanced echocardiography: from doppler flow to 3D echocardiography and speckle-tracking strain imaging. Pediatr Cardiol 2014; 35:3-15. [PMID: 24121730 DOI: 10.1007/s00246-013-0802-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2013] [Accepted: 09/14/2013] [Indexed: 02/01/2023]
Abstract
A varying degree of impairment of ventricular performance is observed over the long-term after surgery for a congenital heart defect (CHD). Impaired ventricular performance has been shown to be of prognostic value for increased risk of cardiovascular events in adult CHD patients. This emphasizes the importance of delineating the timing and cause of this postoperative impairment. Impairment of ventricular performance could develop over time as a consequence of residua, sequelae and complications of the CHD or surgical procedure. Yet, impaired ventricular performance has also been observed immediately after surgery and can persist and/or worsen over time. This postoperative impairment of ventricular performance is the focus of this review. This article provides an overview of echocardiographic techniques currently used to assess ventricular performance. Furthermore, we review current literature describing ventricular performance, as assessed using echocardiography, after correction of a CHD. In general, a decrease in ventricular performance is observed directly after surgery for CHD’s. Subsequent follow-up of ventricular performance is characterized by a varying degree of postoperative recovery. A consistent observation is the persistent impairment of right-ventricular performance after repair in several different subgroups of CHD patients ranging from ventricular septal defect repair to surgery for Tetralogy of Fallot.
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Marx GR, Shirali G, Levine JC, Guey LT, Cnota JF, Baffa JM, Border WL, Colan S, Ensing G, Friedberg MK, Goldberg DJ, Idriss SF, John JB, Lai WW, Lu M, Menon SC, Ohye RG, Saudek D, Wong PC, Pearson GD. Multicenter study comparing shunt type in the norwood procedure for single-ventricle lesions: three-dimensional echocardiographic analysis. Circ Cardiovasc Imaging 2013; 6:934-42. [PMID: 24097422 DOI: 10.1161/circimaging.113.000304] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The Pediatric Heart Network's Single Ventricle Reconstruction (SVR) trial randomized infants with single right ventricles (RVs) undergoing a Norwood procedure to a modified Blalock-Taussig or RV-to-pulmonary artery shunt. This report compares RV parameters in the 2 groups using 3-dimensional echocardiography. METHODS AND RESULTS Three-dimensional echocardiography studies were obtained at 10 of 15 SVR centers. Of the 549 subjects, 314 underwent 3-dimensional echocardiography studies at 1 to 4 time points (pre-Norwood, post-Norwood, pre-stage II, and 14 months) for a total of 757 3-dimensional echocardiography studies. Of these, 565 (75%) were acceptable for analysis. RV volume, mass, mass:volume ratio, ejection fraction, and severity of tricuspid regurgitation did not differ by shunt type. RV volumes and mass did not change after the Norwood, but increased from pre-Norwood to pre-stage II (end-diastolic volume [milliliters]/body surface area [BSA](1.3), end-systolic volume [milliliters]/BSA(1.3), and mass [grams]/BSA(1.3) mean difference [95% confidence interval]=25.0 [8.7-41.3], 19.3 [8.3-30.4], and 17.9 [7.3-28.5], then decreased by 14 months (end-diastolic volume/BSA(1.3), end-systolic volume/BSA(1.3), and mass/BSA(1.3) mean difference [95% confidence interval]=-24.4 [-35.0 to -13.7], -9.8 [-17.9 to -1.7], and -15.3 [-22.0 to -8.6]. Ejection fraction decreased from pre-Norwood to pre-stage II (mean difference [95% confidence interval]=-3.7 [-6.9 to -0.5]), but did not decrease further by 14 months. CONCLUSIONS We found no statistically significant differences between study groups in 3-dimensional echocardiography measures of RV size and function, or magnitude of tricuspid regurgitation. Volume unloading was seen after stage II, as expected, but ejection fraction did not improve. This study provides insights into the remodeling of the operated univentricular RV in infancy.
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Risk factors for prolonged length of stay after the stage 2 procedure in the single-ventricle reconstruction trial. J Thorac Cardiovasc Surg 2013; 147:1791-8, 1798.e1-4. [PMID: 24075564 DOI: 10.1016/j.jtcvs.2013.07.063] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Revised: 07/05/2013] [Accepted: 07/26/2013] [Indexed: 02/03/2023]
Abstract
BACKGROUND The single-ventricle reconstruction trial randomized patients with single right ventricle lesions to a modified Blalock-Taussig or right ventricle-to-pulmonary artery shunt at the Norwood. This analysis describes outcomes at the stage 2 procedure and factors associated with a longer hospital length of stay (LOS). METHODS We examined the association of shunt type with stage 2 hospital outcomes. Cox regression and bootstrapping were used to evaluate risk factors for longer LOS. We also examined characteristics associated with in-hospital death. RESULTS There were 393 subjects in the analytic cohort. Median stage 2 procedure hospital LOS (8 days; interquartile range [IQR], 6-14 days), hospital mortality (4.3%), transplantation (0.8%), median ventilator time (2 days; IQR, 1-3 days), median intensive care unit LOS (4 days; IQR, 3-7 days), number of additional cardiac procedures or complications, and serious adverse events did not differ by shunt type. Longer LOS was associated (R(2) = 0.26) with center, longer post-Norwood LOS (hazard ratio [HR], 1.93 per log day; P < .001), nonelective timing of the stage 2 procedure (HR, 1.78; P < .001), and pulmonary artery (PA) stenosis (HR, 1.56; P < .001). By univariate analysis, nonelective stage 2 (65% vs 32%; P = .009), moderate or greater atrioventricular valve (AVV) regurgitation (75% vs 24%; P < .001), and AVV repair (53% vs 9%; P < .001) were among the risk factors associated with in-hospital death. CONCLUSIONS Norwood LOS, PA stenoses, and nonelective stage 2 procedure, but not shunt type, are independently associated with longer LOS. Nonelective stage 2 procedure, moderate or greater AVV regurgitation, and need for AVV repair are among the risk factors for death.
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Frommelt PC, Gerstenberger E, Baffa J, Border WL, Bradley TJ, Colan S, Gorentz J, Heydarian H, John JB, Lai WW, Levine J, Lu JC, McCandless RT, Miller S, Nutting A, Ohye RG, Pearson GD, Wong PC, Cohen MS. Doppler flow patterns in the right ventricle-to-pulmonary artery shunt and neo-aorta in infants with single right ventricle anomalies: impact on outcome after initial staged palliations. J Am Soc Echocardiogr 2013; 26:521-9. [PMID: 23540728 PMCID: PMC4208752 DOI: 10.1016/j.echo.2013.02.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND A Pediatric Heart Network trial compared outcomes in infants with single right ventricle anomalies undergoing Norwood procedures randomized to modified Blalock-Taussig shunt (MBTS) or right ventricle-to-pulmonary artery shunt (RVPAS). Doppler patterns in the neo-aorta and RVPAS may characterize physiologic changes after staged palliations that affect outcomes and right ventricular (RV) function. METHODS Neo-aortic cardiac index (CI), retrograde fraction (RF) in the descending aorta and RVPAS conduit, RVPAS/neo-aortic systolic ejection time ratio, and systolic/diastolic (S/D) ratio were measured early after Norwood, before stage II palliation, and at 14 months. These parameters were compared with transplantation-free survival, length of hospital stay, and RV functional indices. RESULTS In 529 subjects (mean follow-up period, 3.0 ± 2.1 years), neo-aortic CI and descending aortic RF were significantly higher in the MBTS cohort after Norwood. The RVPAS RF averaged <25% at both interstage intervals. Higher pre-stage II descending aortic RF was correlated with lower RV ejection fraction (R = -0.24; P = .032) at 14 months for the MBTS cohort. Higher post-Norwood CI (5.6 vs 4.4 L/min/m(2), P = .04) and lower S/D ratio (1.40 vs 1.68, P = .01) were correlated with better interstage transplantation-free survival for the RVPAS cohort. No other Doppler flow patterns were correlated with outcomes. CONCLUSIONS After the Norwood procedure, infants tolerated significant descending aortic RF (MBTS) and conduit RF (RVPAS), with little correlation with clinical outcomes or RV function. Neo-aortic CI, ejection time, and S/D ratios also had limited correlations with outcomes or RV function, but higher post-Norwood neo-aortic CI and lower S/D ratio were correlated with better interstage survival in those with RVPAS.
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Actualización en insuficiencia cardiaca, trasplante cardiaco, cardiopatías congénitas y cardiología clínica. Rev Esp Cardiol 2013. [DOI: 10.1016/j.recesp.2012.10.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Implementing the Sano Modification in an Experimental Model of First-stage Palliation of Hypoplastic Left Heart Syndrome. ASAIO J 2013. [DOI: 10.1097/mat.0b013e3182768b7f] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
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