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Ferrero P, Constantine A, Chessa M, Dimopoulos K. Pulmonary arterial hypertension related to congenital heart disease with a left-to-right shunt: phenotypic spectrum and approach to management. Front Cardiovasc Med 2024; 11:1360555. [PMID: 38784170 PMCID: PMC11111857 DOI: 10.3389/fcvm.2024.1360555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Accepted: 04/30/2024] [Indexed: 05/25/2024] Open
Abstract
Patients with pulmonary hypertension associated with a left-right shunt include a wide spectrum of pathophysiological substrates, ranging from those characterized by pulmonary over-circulation to those with advanced pulmonary vascular disease. The former group may benefit from shunt repair in carefully selected cases but, when advanced pulmonary vascular disease has developed, defect closure should be avoided, and pulmonary vasodilators may be used to improve effort tolerance and hemodynamics. There is a paucity of evidence, however, to support decision-making in the care of these patients. We discuss the principles of management in patients with pulmonary hypertension and a predominant left-right shunt. The recommendations and statements made in this paper are based on pathophysiological considerations and expert opinion.
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Affiliation(s)
- Paolo Ferrero
- ACHD Unit, IRCCS-Policlinico San Donato, Milan, Italy
| | - Andrew Constantine
- Adult Congenital Heart Disease Unit, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Massimo Chessa
- ACHD Unit, IRCCS-Policlinico San Donato, Milan, Italy
- Vita Salute San Raffaele University, Milan, Italy
| | - Konstantinos Dimopoulos
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Royal Brompton Hospital, London, United Kingdom
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
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2
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Wang X, Zhu Z, Lu Z, Wang W, Wang X. Pulmonary flow-study can predict in-hospital prognosis of unifocalization and corrective repair of pulmonary atresia/ventricular septal defect with major aortopulmonary collateral arteries. Heliyon 2024; 10:e27109. [PMID: 38444466 PMCID: PMC10912514 DOI: 10.1016/j.heliyon.2024.e27109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 02/15/2024] [Accepted: 02/23/2024] [Indexed: 03/07/2024] Open
Abstract
Objectives With the development of perioperative treatment, the results of the unifocalization and corrective repair of pulmonary atresia/ventricular septal defect with major aortopulmonary collateral arteries have been significantly improved. However, the in-hospital recovery is quite different individually. Therefore, it is essential to find prognostic indicators to avoid unsatisfactory recovery. Design This was a case-control study. Setting The study was conducted in the national center for cardiovascular diseases in China. Participants Pediatric patients between 2014 and 2022. Interventions None. Measurements & main results A total of 19 patients were included. The possible prognostic indicators included were commonly used clinical data. Unsatisfactory postoperative recovery was defined as mechanical ventilation≥ 7 days and/or in-hospital death. Satisfactory postoperative recovery was defined as mechanical ventilation<7 days and survival at discharge. We separated patients into two groups and compared the peri-operative data through univariable analysis. There were 8 patients in unsatisfactory recovery group (including 1 death) and 11 patients in satisfactory recovery group. Among all the possible prognostic indicators, through univariable analysis, pulmonary arterial pressure in pulmonary flow study was statistically different (p = 0.027 < 0.05). The ROC curve showed that the area under curve and cut-off values in predicting satisfactory recovery were 0.841 and 22 mmHg; the corresponding sensitivity and specificity were 100% and 72.7%. There was no statistical difference between the two groups in ventricular septal fenestration and pulmonary hypertension targeting drugs. Conclusion A pulmonary arterial pressure <22 mmHg in pulmonary flow study may avoid unsatisfactory in-hospital recovery after unifocalization and corrective repair of pulmonary atresia/ventricular septal defect with major aortopulmonary collateral arteries.
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Affiliation(s)
| | | | - Zhongyuan Lu
- Department of Pediatric Intensive Care Unit, National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, People's Republic of China
| | - Wenlong Wang
- Department of Pediatric Intensive Care Unit, National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, People's Republic of China
| | - Xu Wang
- Department of Pediatric Intensive Care Unit, National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, People's Republic of China
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Yasuhara J, Watanabe K, Watanabe A, Shirasu T, Matsuzaki Y, Watanabe H, Takagi H, Sumitomo N, Kuno T. Pulmonary vasodilator therapies in pulmonary arterial hypertension associated with CHD: a systematic review and network meta-analysis. Cardiol Young 2023; 33:2297-2311. [PMID: 36721907 DOI: 10.1017/s1047951123000124] [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: 02/02/2023]
Abstract
The optimal treatment strategy using pulmonary vasodilators in pulmonary arterial hypertension associated with CHD (PAH-CHD) remains controversial. We aimed to compare the efficacy and safety of pulmonary vasodilators in PAH-CHD. PubMed and EMBASE databases were searched through May 2022 and a network meta-analysis was conducted. The primary outcomes were mean difference of changes in 6-minute walk distance, NYHA functional class, and N-terminal pro-brain natriuretic peptide. The secondary outcomes included pulmonary vascular resistance, mean pulmonary arterial pressure, and resting oxygen saturation. We identified 14 studies, yielding 807 patients with PAH-CHD. Bosentan and sildenafil were associated with a significant increase in 6-minute walk distance from baseline compared with placebo (MD 48.92 m, 95% CI 0.32 to 97.55 and MD 59.70 m, 95% CI 0.88 to 118.53, respectively). Bosentan, sildenafil, and combination of bosentan and sildenafil were associated with significant improvement in NYHA functional class compared with placebo (MD -0.33, 95% CI -0.51 to -0.14, MD -0.58, 95% CI -0.75 to -0.22 and MD -0.62, 95% CI -0.92 to -0.31, respectively). Bosentan and sildenafil were also associated with significant improvements in secondary outcomes. These findings were largely confirmed in the subgroup analysis. Various adverse events were reported; however, serious adverse event rates were relatively low (4.8-8.7%), including right heart failure, acute kidney injury, respiratory failure, hypotension, and discontinuation of pulmonary vasodilators. In conclusion, bosentan and sildenafil were the most effective in improving prognostic risk factor such as 6-minute walk distance and NYHA class. Overall, pulmonary vasodilators were well tolerated in PAH-CHD.
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Affiliation(s)
- Jun Yasuhara
- Center for Cardiovascular Research, The Abigail Wexner Research and The Heart Center, Nationwide Children's Hospital, Columbus, OH, USA
| | - Kae Watanabe
- Division of Pediatric Cardiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Atsuyuki Watanabe
- Division of Hospital Medicine, University of Tsukuba Hospital, Tsukuba, Ibaraki, Japan
| | - Takuro Shirasu
- Department of Surgery and Division of Vascular and Endovascular Surgery, School of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Yuichi Matsuzaki
- Division of Cardiac Surgery, McGill University, Montréal, Québec, Canada
| | - Hirofumi Watanabe
- Department of Regenerative Medicine and Cell Biology, Medical University of South Carolina, Charleston, SC, USA
| | - Hisato Takagi
- Division of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan
| | - Naokata Sumitomo
- Department of Pediatric Cardiology, Saitama Medical University International Medical Center, Saitama, Japan
| | - Toshiki Kuno
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY, USA
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4
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Ishida H, Maeda J, Uchida K, Yamagishi H. Unique Pulmonary Hypertensive Vascular Diseases Associated with Heart and Lung Developmental Defects. J Cardiovasc Dev Dis 2023; 10:333. [PMID: 37623346 PMCID: PMC10455332 DOI: 10.3390/jcdd10080333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 07/10/2023] [Accepted: 08/01/2023] [Indexed: 08/26/2023] Open
Abstract
Although pediatric pulmonary hypertension (PH) shares features and mechanisms with adult PH, there are also some significant differences between the two conditions. Segmental PH is a unique pediatric subtype of PH with unclear and/or multifactorial pathophysiological mechanisms, and is often associated with complex congenital heart disease (CHD), pulmonary atresia with ventricular septal defect, and aortopulmonary collateral arteries. Some cases of complex CHD, associated with a single ventricle after Fontan operation, show pathological changes in the small peripheral pulmonary arteries and pulmonary vascular resistance similar to those observed in pulmonary arterial hypertension (PAH). This condition is termed as the pediatric pulmonary hypertensive vascular disease (PPHVD). Recent advances in genetics have identified the genes responsible for PAH associated with developmental defects of the heart and lungs, such as TBX4 and SOX17. Targeted therapies for PAH have been developed; however, their effects on PH associated with developmental heart and lung defects remain to be established. Real-world data analyses on the anatomy, pathophysiology, genetics, and molecular biology of unique PPHVD cases associated with developmental defects of the heart and lungs, using nationwide and/or international registries, should be conducted in order to improve the treatments and prognosis of patients with these types of pediatric PH.
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Affiliation(s)
- Hidekazu Ishida
- Department of Pediatrics, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita 565-0871, Osaka, Japan;
| | - Jun Maeda
- Department of Cardiology, Tokyo Metropolitan Children’s Medical Center, 2-8-29 Musashidai, Fuchu 183-8561, Tokyo, Japan;
| | - Keiko Uchida
- Department of Pediatrics, Keio University of Medicine, 35 Shinanomachi, Shinjuku-ku 160-8582, Tokyo, Japan;
- Keio University Health Center, 4-1-1 Hiyoshi, Kohoku-ku, Yokohama 223-8521, Kanagawa, Japan
| | - Hiroyuki Yamagishi
- Department of Pediatrics, Keio University of Medicine, 35 Shinanomachi, Shinjuku-ku 160-8582, Tokyo, Japan;
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Humbert M, Kovacs G, Hoeper MM, Badagliacca R, Berger RMF, Brida M, Carlsen J, Coats AJS, Escribano-Subias P, Ferrari P, Ferreira DS, Ghofrani HA, Giannakoulas G, Kiely DG, Mayer E, Meszaros G, Nagavci B, Olsson KM, Pepke-Zaba J, Quint JK, Rådegran G, Simonneau G, Sitbon O, Tonia T, Toshner M, Vachiery JL, Vonk Noordegraaf A, Delcroix M, Rosenkranz S. 2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Respir J 2023; 61:13993003.00879-2022. [PMID: 36028254 DOI: 10.1183/13993003.00879-2022] [Citation(s) in RCA: 398] [Impact Index Per Article: 398.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Marc Humbert
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France, Service de Pneumologie et Soins Intensifs Respiratoires, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Assistance Publique Hôpitaux de Paris, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France
| | - Gabor Kovacs
- University Clinic of Internal Medicine, Division of Pulmonology, Medical University of Graz, Graz, Austria
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Marius M Hoeper
- Respiratory Medicine, Hannover Medical School, Hanover, Germany
- Biomedical Research in End-stage and Obstructive Lung Disease (BREATH), member of the German Centre of Lung Research (DZL), Hanover, Germany
| | - Roberto Badagliacca
- Dipartimento di Scienze Cliniche Internistiche, Anestesiologiche e Cardiovascolari, Sapienza Università di Roma, Roma, Italy
- Dipartimento Cardio-Toraco-Vascolare e Chirurgia dei Trapianti d'Organo, Policlinico Umberto I, Roma, Italy
| | - Rolf M F Berger
- Center for Congenital Heart Diseases, Beatrix Children's Hospital, Dept of Paediatric Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Margarita Brida
- Department of Sports and Rehabilitation Medicine, Medical Faculty University of Rijeka, Rijeka, Croatia
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton and Harefield Hospitals, Guys and St Thomas's NHS Trust, London, UK
| | - Jørn Carlsen
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Andrew J S Coats
- Faculty of Medicine, University of Warwick, Coventry, UK
- Faculty of Medicine, Monash University, Melbourne, Australia
| | - Pilar Escribano-Subias
- Pulmonary Hypertension Unit, Cardiology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
- CIBER-CV (Centro de Investigaciones Biomédicas En Red de enfermedades CardioVasculares), Instituto de Salud Carlos III, Madrid, Spain
- Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - Pisana Ferrari
- ESC Patient Forum, Sophia Antipolis, France
- AIPI, Associazione Italiana Ipertensione Polmonare, Bologna, Italy
| | - Diogenes S Ferreira
- Alergia e Imunologia, Hospital de Clinicas, Universidade Federal do Parana, Curitiba, Brazil
| | - Hossein Ardeschir Ghofrani
- Department of Internal Medicine, University Hospital Giessen, Justus-Liebig University, Giessen, Germany
- Department of Pneumology, Kerckhoff Klinik, Bad Nauheim, Germany
- Department of Medicine, Imperial College London, London, UK
| | - George Giannakoulas
- Cardiology Department, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - David G Kiely
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
- Sheffield Pulmonary Vascular Disease Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Insigneo Institute, University of Sheffield, Sheffield, UK
| | - Eckhard Mayer
- Thoracic Surgery, Kerckhoff Clinic, Bad Nauheim, Germany
| | - Gergely Meszaros
- ESC Patient Forum, Sophia Antipolis, France
- European Lung Foundation (ELF), Sheffield, UK
| | - Blin Nagavci
- Institute for Evidence in Medicine, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Karen M Olsson
- Clinic of Respiratory Medicine, Hannover Medical School, member of the German Center of Lung Research (DZL), Hannover, Germany
| | - Joanna Pepke-Zaba
- Pulmonary Vascular Diseases Unit, Royal Papworth Hospital, Cambridge, UK
| | | | - Göran Rådegran
- Department of Cardiology, Clinical Sciences Lund, Faculty of Medicine, Lund, Sweden
- The Haemodynamic Lab, The Section for Heart Failure and Valvular Disease, VO. Heart and Lung Medicine, Skåne University Hospital, Lund, Sweden
| | - Gerald Simonneau
- Faculté Médecine, Université Paris Saclay, Le Kremlin-Bicêtre, France
- Centre de Référence de l'Hypertension Pulmonaire, Hopital Marie-Lannelongue, Le Plessis-Robinson, France
| | - Olivier Sitbon
- INSERM UMR_S 999, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France
- Faculté Médecine, Université Paris Saclay, Le Kremlin-Bicêtre, France
- Service de Pneumologie et Soins Intensifs Respiratoires, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Assistance Publique Hôpitaux de Paris, Le Kremlin-Bicêtre, France
| | - Thomy Tonia
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Mark Toshner
- Dept of Medicine, Heart Lung Research Institute, University of Cambridge, Royal Papworth NHS Trust, Cambridge, UK
| | - Jean-Luc Vachiery
- Department of Cardiology, Pulmonary Vascular Diseases and Heart Failure Clinic, HUB Hôpital Erasme, Brussels, Belgium
| | | | - Marion Delcroix
- Clinical Department of Respiratory Diseases, Centre of Pulmonary Vascular Diseases, University Hospitals of Leuven, Leuven, Belgium
- The two chairpersons (M. Delcroix and S. Rosenkranz) contributed equally to the document and are joint corresponding authors
| | - Stephan Rosenkranz
- Clinic III for Internal Medicine (Department of Cardiology, Pulmonology and Intensive Care Medicine), and Cologne Cardiovascular Research Center (CCRC), Heart Center at the University Hospital Cologne, Köln, Germany
- The two chairpersons (M. Delcroix and S. Rosenkranz) contributed equally to the document and are joint corresponding authors
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Humbert M, Kovacs G, Hoeper MM, Badagliacca R, Berger RMF, Brida M, Carlsen J, Coats AJS, Escribano-Subias P, Ferrari P, Ferreira DS, Ghofrani HA, Giannakoulas G, Kiely DG, Mayer E, Meszaros G, Nagavci B, Olsson KM, Pepke-Zaba J, Quint JK, Rådegran G, Simonneau G, Sitbon O, Tonia T, Toshner M, Vachiery JL, Vonk Noordegraaf A, Delcroix M, Rosenkranz S. 2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Heart J 2022; 43:3618-3731. [PMID: 36017548 DOI: 10.1093/eurheartj/ehac237] [Citation(s) in RCA: 949] [Impact Index Per Article: 474.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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Interventionelle Behandlungsverfahren der pulmonalen Hypertension im Kindesalter. Monatsschr Kinderheilkd 2022. [DOI: 10.1007/s00112-022-01583-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
ZusammenfassungDie pulmonale Hypertension (PH) ist eine progressive Gefäßerkrankung und führt über eine Widerstands- und/oder Druckerhöhung im kleinen Kreislauf zu einem fortschreitenden Rechtsherzversagen. Auch wenn mithilfe aktueller medikamentöser Therapien eine deutliche Verbesserung der Lebensqualität und des Überlebens der Betroffenen erreicht werden konnte, bleibt die PH eine zumeist nichtheilbare Erkrankung, die im fortgeschrittenen Stadium eine Lungentransplantation notwendig macht. Interventionelle Verfahren, wie die Anlage eines interatrialen Shunts (z. B. durch atriale Septostomie oder den Atrial Flow Regulator) oder eines Reversed Potts Shunt, verbessern die RV-Funktion und die ventrikuläre Interaktion durch Schaffung einer prä- oder posttrikuspidalen „Eisenmenger-Physiologie“ und stellen eine Überbrückung oder sogar Alternative zur Lungentransplantation dar. Bei Patienten mit segmentaler PH oder chronisch thrombembolischer pulmonaler Hypertension (CTEPH) stellt die Ballonangioplastie eine bereits etablierte Intervention zur Verbesserung der pulmonalen Perfusion und damit rechtsventrikulären (RV-)Funktion dar. Dagegen ist die pulmonalarterielle Denervation ein neuartiges Verfahren, mit dem Ziel, die neurohumorale Dysregulation bei PH positiv zu beeinflussen. Der individuelle Einsatz solcher Interventionen, additiv zu den bereits etablierten medikamentösen Therapien, erweitert die Behandlungsmöglichkeiten und kann die Prognose betroffener Patienten noch weiter verbessern.
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Raja J, Menon S, Ramanan S, Baruah SD, Gopalakrishnan A, Dharan B. Outcomes of repair of anomalous origin of pulmonary artery branch from aorta ascendens with autologous tissue: a rare condition revisited. Cardiol Young 2022; 33:1-4. [PMID: 35791259 DOI: 10.1017/s1047951122001998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Anomalous origin of pulmonary artery branch from ascending aorta (APA) in the presence of two separate semilunar valves is an uncommon entity necessitating early diagnosis and surgery to prevent development of irreversible pulmonary vascular disease. We evaluated our experience with the technique and outcome of 11 patients with this condition. METHODS Between January 2000 and December 2019, 11 patients were diagnosed with APA. Echocardiographic data were collected from the records, including the site of origin of the anomalous pulmonary artery, additional defects, pulmonary artery pressures, and biventricular function. Intraoperative charts were reviewed for the details of the surgical procedure and cardiopulmonary bypass. Post-operative data included survival, ventilatory support, and duration of hospital stay. After discharge, children were reviewed at 1 month, 3 months, 6 months, and then at yearly intervals. RESULTS Of the 11 patients, females were more than males (7:4) with a median age of 6 months (15 days-28 years) and median weight of 5.7 kg (1.8-40 kg). Nine patients underwent direct re-implantation of anomalous pulmonary artery branch to main pulmonary artery. The survival rate was 88.8% in our series. On follow-up, no re-operations or re-interventions were required and all surgically corrected patients were in stable clinical condition. CONCLUSION Early- and midterm outcomes of children who underwent surgery for APA is convincing. Early direct re-implantation of the anomalous branch pulmonary artery to main pulmonary artery without any graft material is the optimal surgical strategy for these patients.
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Affiliation(s)
- Javid Raja
- Pediatric Cardiac Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Sabarinath Menon
- Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
| | - Sowmya Ramanan
- Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
| | - Sudip Dutta Baruah
- Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
| | - Arun Gopalakrishnan
- Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
| | - Baiju Dharan
- Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
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Bonnet D, Szezepanski I, Delacourt C, Malkezadeh-Milani S, Lévy M. Multifactorial pulmonary hypertension in infantile scimitar syndrome. Arch Cardiovasc Dis 2022; 115:142-150. [DOI: 10.1016/j.acvd.2022.01.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 01/17/2022] [Accepted: 01/18/2022] [Indexed: 11/29/2022]
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Alex A, Ayyappan A, Valakkada J, Kramadhari H, Sasikumar D, Menon S. Major Aortopulmonary Collateral Arteries. Radiol Cardiothorac Imaging 2022; 4:e210157. [PMID: 35782757 PMCID: PMC8893210 DOI: 10.1148/ryct.210157] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 10/23/2021] [Accepted: 11/29/2021] [Indexed: 06/15/2023]
Abstract
Major aortopulmonary collateral arteries (MAPCAs) are congenital vessels that arise from the aorta or its first-order branches and are distally connected to the pulmonary arterial vasculature, thereby providing pulmonary blood flow. MAPCAs are commonly associated with several congenital heart diseases that have compromised pulmonary circulation due to severe stenosis involving pulmonary valves or arteries or due to pulmonary atresia. Embryologically, MAPCAs are presumed to be persistent segmental arteries. MAPCAs can be imaged with CT and MRI, and such imaging findings are important for surgeons and interventionists. The management options for MAPCAs include unifocalization, surgical ligation, and endovascular interventions, such as coil embolization. This review highlights the role of reporting certain critical features of MAPCAs at CT and MRI, which will help to facilitate management decisions for systemic-to-pulmonary collateral vessels observed in patients with congenital heart disease. Keywords: Pediatrics, CT Angiography, Image Postprocessing, Interventional-Vascular, MR Angiography, Embolization, Stents, Cardiac, Vascular, Aorta © RSNA, 2022.
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Anoop A, Valakkada J, Sasikumar D, Menon S. Repercussions of a giant major aortopulmonary collateral aneurysm adjacent to vertebral artery origin. Ann Pediatr Cardiol 2022; 15:94-96. [PMID: 35847387 PMCID: PMC9280106 DOI: 10.4103/apc.apc_161_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 08/30/2021] [Accepted: 09/05/2021] [Indexed: 11/08/2022] Open
Abstract
An aneurysm of major aortopulmonary collateral in an adult with congenital cyanotic heart disease was detected incidentally following a hemoptysis episode. The location and size of the aneurysm needed special concern during treatment to avoid aneurysm-related complications and thromboembolism secondary to intervention.
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Affiliation(s)
- Ayyappan Anoop
- Department of Imaging Sciences and Interventional Radiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Jineesh Valakkada
- Department of Imaging Sciences and Interventional Radiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India,Address for correspondence: Dr. Jineesh Valakkada, Department of Imaging sciences and Interventional Radiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India. E-mail:
| | - Deepa Sasikumar
- Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Sabarinath Menon
- Department of Cardiovascular and Thoracic Surgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
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Khugaev GA, Shmalts AA. [Morphological assessment of pulmonary vessels in pulmonary arterial hypertension associated with congenital heart disease]. Arkh Patol 2021; 83:49-57. [PMID: 34609805 DOI: 10.17116/patol20218305149] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Pulmonary vascular remodeling is the key structural alteration in pulmonary arterial hypertension associated with congenital heart disease (CHD). Changes in the pulmonary vessels in CHD generally occur in the inner and middle coats. This review considers the pathology of these changes and highlights some issues of a stereological approach to the morphometry of pulmonary vasculature. It also touches upon the issues of the morphology of pulmonary vessels in post-capillary and segmental pulmonary hypertension.
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Affiliation(s)
- G A Khugaev
- A.N. Bakulev National Medical Research Center for Cardiovascular Surgery of the Ministry of Health of Russia, Moscow, Russia
| | - A A Shmalts
- A.N. Bakulev National Medical Research Center for Cardiovascular Surgery of the Ministry of Health of Russia, Moscow, Russia.,Russian Medical Academy of Continuing Professional Education of the Ministry of Health of Russia, Moscow, Russia
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13
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Shmalts AA, Gorbachevsky SV. Evidence base for specific pulmonary vasodilators in adults with congenital heart disease. TERAPEVT ARKH 2021; 93:1106-1116. [DOI: 10.26442/00403660.2021.09.201022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Accepted: 10/10/2021] [Indexed: 11/22/2022]
Abstract
After reviewing the current definitions and classification of pulmonary hypertension (PH) associated with congenital heart disease (CHD), based on an analysis of 59 clinical trials (of which 14 are randomized controlled trials) drugs registered in the Russian Federation, the evidence base for PH therapy in adults with CHD is provided. The presence of a randomized controlled trial of bosentan BREATHE-5 and uncontrolled trials of other drugs became the basis for a higher class and level of evidence of bosentan (IB) compared to other drugs (IIaC) for Eisenmenger syndrome in the current European (ERS/ESC 2015) and updated Russian (2020) guidelines. According to the updated European (ESC 2020) guidelines for congenital heart disease in adults, in Eisenmenger patients with reduced exercise capacity (6MWT distance 450 m), a treatment strategy with initial endothelin receptor antagonist monotherapy should be considered followed by combination therapy if patients fail to improve (IIaB), in low- and intermediate-risk patients with repaired simple lesions and pre-capillary PH, initial oral combination therapy or sequential combination therapy is recommended and high-risk patients should be treated with initial combination therapy including parenteral prostanoids (IA) and endothelin receptor antagonists and phosphodiesterase 5 inhibitors may be considered in selected patients with elevated pulmonary pressure/resistance in the absence of elevated ventricular end diastolic pressure (IIbC). Only three (bosentan, macitentan and selexipag) out of seven specific pulmonary vasodilators registered in the Russian Federation have indications for pulmonary arterial hypertension associated with congenital heart disease and Eisenmenger syndrome or pulmonary arterial hypertension associated with corrected simple congenital heart disease in the instructions for use.
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Baumgartner H, De Backer J, Babu-Narayan SV, Budts W, Chessa M, Diller GP, Iung B, Kluin J, Lang IM, Meijboom F, Moons P, Mulder BJ, Oechslin E, Roos-Hesselink JW, Schwerzmann M, Sondergaard L, Zeppenfeld K, Ernst S, Ladouceur M, Aboyans V, Alexander D, Christodorescu R, Corrado D, D’Alto M, de Groot N, Delgado V, Di Salvo G, Dos Subira L, Eicken A, Fitzsimons D, Frogoudaki AA, Gatzoulis M, Heymans S, Hörer J, Houyel L, Jondeau G, Katus HA, Landmesser U, Lewis BS, Lyon A, Mueller CE, Mylotte D, Petersen SE, Petronio AS, Roffi M, Rosenhek R, Shlyakhto E, Simpson IA, Sousa-Uva M, Torp-Pedersen CT, Touyz RM, Van De Bruaene A. Guía ESC 2020 para el tratamiento de las cardiopatías congénitas del adulto. Rev Esp Cardiol 2021. [DOI: 10.1016/j.recesp.2020.10.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Windsor J, Mukundan C, Stopak J, Ramakrishna H. Analysis of the 2020 European Society of Cardiology (ESC) Guidelines for the Management of Adults With Congenital Heart Disease (ACHD). J Cardiothorac Vasc Anesth 2021; 36:2738-2757. [PMID: 33985885 DOI: 10.1053/j.jvca.2021.04.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Accepted: 04/04/2021] [Indexed: 01/02/2023]
Abstract
Adult congenital heart disease (ACHD) continues to rapidly increase worldwide. With an estimated 1.5 million adults with ACHD in the USA alone, there is a growing need for better education in the management of these complex patients and multiple knowledge gaps exist. This manuscript comprehensively reviewed the recent (2020) updated European Society of Cardiology Guidelines for the management of ACHD created by the Task Force for the management of adult congenital heart disease of the European Society of Cardiology, with perioperative implications for the adult cardiac anesthesiologist and intensivist who may be called upon to manage these complex patients.
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Affiliation(s)
- Jimmy Windsor
- Clinical Associate Professor of Anesthesia, University of Iowa Carver College of Medicine Department of Anesthesia, Division of Pediatric Anesthesia, 200 Hawkins Drive, Iowa City, Iowa, 52242
| | - Chaitra Mukundan
- Clinical Assistant Professor of Anesthesia, University of Iowa Carver College of Medicine Department of Anesthesia, Division of Pediatric Anesthesia, 200 Hawkins Drive, Iowa City, Iowa, 52242
| | - Joshua Stopak
- Clinical Assistant Professor of Anesthesia, University of Iowa Carver College of Medicine Department of Anesthesia, Division of Pediatric Anesthesia, 200 Hawkins Drive, Iowa City, Iowa, 52242
| | - Harish Ramakrishna
- Professor of Anesthesiology, Mayo Clinic School of Medicine, Department of Anesthesiology and Perioperative Medicine, Division of Cardiovascular and Thoracic Anesthesiology, 200 First Street SW, Rochester, MN 55905.
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Abstract
The number of rTOF patients who survive into adulthood is steadily rising, with currently more than 90% reaching the third decade of life. However, rTOF patients are not cured, but rather have a lifelong increased risk for cardiac and non-cardiac complications. Heart failure is recognized as a significant complication. Its occurrence is strongly associated with adverse outcome. Unfortunately, conventional concepts of heart failure may not be directly applicable in this patient group. This article presents a review of the current knowledge on HF in rTOF patients, including incidence and prevalence, the most common mechanisms of heart failure, i.e., valvular pathologies, shunt lesions, left atrial hypertension, primary left heart and right heart failure, arrhythmias, and coronary artery disease. In addition, we will review information regarding extracardiac complications, risk factors for the development of heart failure, clinical impact and prognosis, and assessment possibilities, particularly of the right ventricle, as well as management strategies. We explore potential future concepts that may stimulate further research into this field.
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Wang Z, Guo B, Wang X, Xiao Y, Lv Z, Liang Y, Jin M. Long-term outcomes of percutaneous closure of patent ductus arteriosus associated with unilateral absence of a pulmonary artery. J Card Surg 2021; 36:2029-2034. [PMID: 33738816 DOI: 10.1111/jocs.15495] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 02/26/2021] [Accepted: 03/04/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE This study aimed to evaluate the long-term outcomes of patients with patent ductus arteriosus (PDA) associated with unilateral absence of a pulmonary artery (UAPA). METHODS Patients diagnosed with PDA associated with UAPA between January 2005 and June 2019 were retrospectively enrolled in this study. Demographic and clinical characteristics, treatments, and follow-up information were evaluated. RESULTS A total of 11 patients were diagnosed with PDA associated with UAPA. Percutaneous closure was successfully conducted in nine patients. The mean diameters of the PDA measured by aortogram and occluders were 5.3 ± 1.8 mm and 11.5 ± 3.9 mm, respectively. The median pulmonary systemic flow ratio (Qp:Qs) in five patients was 1.41, and the median total lung resistance was 12 Wood Units. The mean systolic pulmonary artery (PA) pressure was 68.3 ± 19.1 mmHg. In five patients with pre- and postprocedure catheter data, the systolic pulmonary arterial pressure decreased significantly after closure (from 77.0 ± 20.2 to 58.8 ± 17.5 mmHg; p = .024), as did the mean pulmonary arterial pressure (from 58.2 ± 14.6 to 39.0 ± 14.1 mmHg; p = .18). The PA pressure and heart size gradually decreased to normal levels in eight patients, and their quality of life was significantly improved. The ratio of lung to systemic circulation pressure was less than 0.75. CONCLUSIONS In appropriate patients with PDA associated with UAPA, transcatheter closure of PDA has the potential to improve PA hypertension. A ratio of lung to systemic circulation pressure less than 0.75 may be an important reference index for predicting whether PA pressure can be reduced to a normal level after occlusion.
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Affiliation(s)
- Zhiyuan Wang
- Department of Pediatric Heart Center, Beijing Pediatric Heart Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Baojing Guo
- Department of Pediatric Heart Center, Beijing Pediatric Heart Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xiaofang Wang
- Department of Pediatric Heart Center, Beijing Pediatric Heart Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yanyan Xiao
- Department of Pediatric Heart Center, Beijing Pediatric Heart Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Zhenyu Lv
- Department of Pediatric Heart Center, Beijing Pediatric Heart Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yongmei Liang
- Department of Pediatric Heart Center, Beijing Pediatric Heart Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Mei Jin
- Department of Pediatric Heart Center, Beijing Pediatric Heart Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
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Sadiq AM, Sadiq AM. A case of computed tomography diagnosis of truncus arteriosus type IV. Oxf Med Case Reports 2021; 2021:omaa144. [PMID: 33614054 PMCID: PMC7885140 DOI: 10.1093/omcr/omaa144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 11/20/2020] [Accepted: 12/12/2020] [Indexed: 11/12/2022] Open
Abstract
Persistent truncus arteriosus is a rare congenital heart disease with four variants, and the last being the rarest. The prognosis without surgical intervention is poor. In such cases, an echocardiography is not sufficient hence computed tomography (CT) imaging is required. We report a 26-year-old female with difficulty in breathing since childhood with cyanosis. Her echocardiography showed a ventricular septal defect (VSD) and the CT showed a single arterial trunk overriding the interventricular septum with a VSD, and the descending aorta giving rise to the pulmonary arteries suggestive of pseudo truncus, known as truncus arteriosus type IV.
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Affiliation(s)
- Abid M Sadiq
- Department of Internal Medicine, Kilimanjaro Christian Medical Centre, Moshi, Tanzania.,Department of Internal Medicine, Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Adnan M Sadiq
- Department of Radiology, Kilimanjaro Christian Medical Centre, Moshi, Tanzania.,Department of Radiology, Kilimanjaro Christian Medical University College, Moshi, Tanzania
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Baumgartner H, De Backer J, Babu-Narayan SV, Budts W, Chessa M, Diller GP, Lung B, Kluin J, Lang IM, Meijboom F, Moons P, Mulder BJM, Oechslin E, Roos-Hesselink JW, Schwerzmann M, Sondergaard L, Zeppenfeld K. 2020 ESC Guidelines for the management of adult congenital heart disease. Eur Heart J 2021; 42:563-645. [PMID: 32860028 DOI: 10.1093/eurheartj/ehaa554] [Citation(s) in RCA: 817] [Impact Index Per Article: 272.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
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Meinel K, Koestenberger M, Sallmon H, Hansmann G, Pieles GE. Echocardiography for the Assessment of Pulmonary Hypertension and Congenital Heart Disease in the Young. Diagnostics (Basel) 2020; 11:diagnostics11010049. [PMID: 33396225 PMCID: PMC7823322 DOI: 10.3390/diagnostics11010049] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Revised: 12/21/2020] [Accepted: 12/22/2020] [Indexed: 12/18/2022] Open
Abstract
While invasive assessment of hemodynamics and testing of acute vasoreactivity in the catheterization laboratory is the gold standard for diagnosing pulmonary hypertension (PH) and pulmonary vascular disease (PVD) in children, transthoracic echocardiography (TTE) serves as the initial diagnostic tool. International guidelines suggest several key echocardiographic variables and indices for the screening studies when PH is suspected. However, due to the complex anatomy and special physiological considerations, these may not apply to patients with congenital heart disease (CHD). Misinterpretation of TTE variables can lead to delayed diagnosis and therapy, with fatal consequences, or–on the other hand-unnecessary invasive diagnostic procedures that have relevant risks, especially in the pediatric age group. We herein provide an overview of the echocardiographic workup of children and adolescents with PH with a special focus on children with CHD, such as ventricular/atrial septal defects, tetralogy of Fallot or univentricular physiology. In addition, we address the use of echocardiography as a tool to assess eligibility for exercise and sports, a major determinant of quality of life and outcome in patients with PH associated with CHD.
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Affiliation(s)
- Katharina Meinel
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University Graz, 8036 Graz, Austria; (K.M.); (M.K.)
- European Pediatric Pulmonary Vascular Disease Network, 13125 Berlin, Germany; (H.S.); (G.H.)
| | - Martin Koestenberger
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University Graz, 8036 Graz, Austria; (K.M.); (M.K.)
- European Pediatric Pulmonary Vascular Disease Network, 13125 Berlin, Germany; (H.S.); (G.H.)
| | - Hannes Sallmon
- European Pediatric Pulmonary Vascular Disease Network, 13125 Berlin, Germany; (H.S.); (G.H.)
- Department of Pediatric Cardiology, Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany
- Department of Congenital Heart Disease/Pediatric Cardiology, Deutsches Herzzentrum Berlin (DHZB), 13353 Berlin, Germany
| | - Georg Hansmann
- European Pediatric Pulmonary Vascular Disease Network, 13125 Berlin, Germany; (H.S.); (G.H.)
- Department of Pediatric Cardiology and Critical Care, Hannover Medical School, 30625 Hannover, Germany
| | - Guido E. Pieles
- European Pediatric Pulmonary Vascular Disease Network, 13125 Berlin, Germany; (H.S.); (G.H.)
- National Institute for Health Research (NIHR) Cardiovascular Biomedical Research Centre, Congenital Heart Unit, Bristol Royal Hospital for Children and Bristol Heart Institute, Bristol BS2 8HW, UK
- Institute of Sport Exercise and Health (ISEH), University College London, London W1T 7HA, UK
- Correspondence:
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Pulmonary Arterial Hypertension Associated with Congenital Heart Disease in Adults over the Age of 40 Years. J Clin Med 2020; 9:jcm9124071. [PMID: 33348628 PMCID: PMC7766787 DOI: 10.3390/jcm9124071] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 12/07/2020] [Accepted: 12/16/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Pulmonary arterial hypertension associated with adult congenital heart disease (PAH-ACHD) leads to significant mortality at a young age. Risk factors for a negative outcome in older adults are lacking. METHODS PAH-ACHD patients ≥ 40 years of age under active follow-up between January 2005 and December 2018 were included. Demographic data, as well as medical/surgical history, were retrieved from hospital records. The primary end-point was all-cause mortality. RESULTS In total, 65 patients (67.7% female, mean age 45.19 ± 6.75 years) were included. Out of these, 46 (70.8%) had a shunt lesion, 12 (18.5%) had PAH associated with complex congenital heart defects, and 7 (10.8%) had segmental pulmonary hypertension due to major aorto-pulmonary collaterals. Down syndrome was present in 13 patients (20.0%). During a median follow-up of 4.2 years (IQR 1.2-7.5), 16 patients (24.6%) died. On univariate analysis, NT-proBNP (log), creatinine, and a previous history of ventricular arrhythmias were predictors of all-cause mortality. Upon multivariate analysis, NT-proBNP (log) (HR: 4.1, 95% CI: 1.2-14.4, p = 0.029) and creatinine (HR: 16.3, 95% CI: 2.2-118.7, p = 0.006) remained as independent predictors of all-cause mortality. CONCLUSIONS PAH-ACHD patients over the age of 40 years are burdened with significant mortality, of which NT-proBNP and creatinine are independent predictors.
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Condliffe R. Pulmonary arterial hypertension associated with congenital heart disease: classification and pathophysiology. JOURNAL OF CONGENITAL CARDIOLOGY 2020. [DOI: 10.1186/s40949-020-00040-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
AbstractWhile the development of pulmonary arterial hypertension is not uncommon in adult congenital heart disease patients, other forms of pulmonary hypertension (PH) may also be present. A good understanding of PH classification is therefore vital for clinicians managing adult patients with congenital heart disease. This paper reviews both the general classification of PH and more detailed approaches to classifying pulmonary arterial hypertension in association with congenital heart disease.
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Nashat H, Favoccia C, Constantine A, Dimopoulos K. The investigation and diagnosis of pulmonary hypertension in adults with congenital heart disease. JOURNAL OF CONGENITAL CARDIOLOGY 2020. [DOI: 10.1186/s40949-020-00050-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
AbstractPulmonary hypertension is not uncommon in adult patients with congenital heart disease and can significantly affect their exercise capacity, quality of life and prognosis. Timely identification and management of pulmonary hypertension in these patients is important. Patients must be allocated to the correct diagnostic group and treatment decided upon, including offering pulmonary arterial hypertension therapies to those who are most likely to benefit.In this paper, we provide an overview of the diagnostic modalities that are used to investigate and diagnose pulmonary hypertension in modern adult congenital heart disease practice. Emphasis is placed on echocardiography, which is the modality of choice for raising the suspicion of PH, and cardiac catheterisation, which is fundamental in establishing the diagnosis. Other modalities, such as cardiac magnetic resonance imaging and computed tomography can provide complementary information on anatomy and physiology.Combining all this information into a clinical diagnosis and management plan requires clinical expertise and a multidisciplinary approach, especially when managing this rare and complex group of patients.
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Liew N, Rashid Z, Tulloh R. Strategies for the management of pulmonary arterial hypertension in patients with congenital heart disease. JOURNAL OF CONGENITAL CARDIOLOGY 2020. [DOI: 10.1186/s40949-020-00052-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Abstract
Background
Pulmonary hypertension (PH) is commonly seen in adults who have congenital heart disease (CHD). Therapy is available for pulmonary arterial hypertension (PAH) and has greatly benefitted many patients with PAH related to CHD (PAH-CHD) over the last 15 years, with evidence of improved quality of life and prognosis in those with Eisenmenger syndrome and repaired PAH-CHD.
In this review, we describe the standard management and advanced therapies for PAH, which are available in specialist PH centres around the UK and Ireland, and how these are used in PAH-CHD. Decisions around the choice of therapy are governed by commissioning and available evidence.
Conclusion
We explain the different pathways for action and the variety of medications now at our disposal to help this important group of patients.
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Hayashi T, Ono H, Kaneko Y. Association of Preoperative Mixed Venous Oxygen Saturation with Postoperative Segmental Pulmonary Hypertension in Pulmonary Atresia with Ventricular Septal Defect and Major Aortopulmonary Collaterals. Pediatr Cardiol 2020; 41:1689-1696. [PMID: 32710283 DOI: 10.1007/s00246-020-02428-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 07/21/2020] [Indexed: 11/25/2022]
Abstract
In patients with pulmonary atresia with ventricular septal defect and major aortopulmonary collateral arteries (PA/VSD/MAPCAs), segmental pulmonary hypertension is common; however, its pathophysiology remains to be elucidated. This study aimed to identify preoperative hemodynamic factors associated with segmental pulmonary hypertension after intracardiac repair in patients with PA/VSD/MAPCAs. This study included 12 patients with PA/VSD/MAPCAs who underwent unifocalization and intracardiac repair from 2009 at our institution. Hemodynamic measurements of preoperative and postoperative cardiac catheterization were collected. Patients were considered to have pulmonary hypertension if the mean pulmonary pressure measured postoperatively at any peripheral pulmonary artery was ≥ 20 mmHg. The data were compared between patients with and without postoperative segmental pulmonary hypertension; p value < 0.05 was considered statistically significant. Intracardiac repair was performed at the age of 2.1 years (range 0.5-28.2 years). Unifocalization was performed separately prior to intracardiac repair in two patients and concomitantly in 10 patients. Postoperative cardiac catheterization, performed 1.2 years (range 0.2-8.7 years) after intracardiac repair, revealed that five patients had segmental pulmonary hypertension. Patients with postoperative pulmonary hypertension had significantly lower preoperative mixed venous oxygen saturation than those without pulmonary hypertension (57% [55-63%] vs. 65% [53-75%], p < 0.05). No significant differences were found between the groups in terms of age at intracardiac repair, preoperative arterial oxygen saturation, and preoperative peripheral pulmonary arterial mean pressure. Lower preoperative mixed venous oxygen saturation was associated with segmental pulmonary hypertension after intracardiac repair in patients with PA/VSD/MAPCAs.
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Affiliation(s)
- Taiyu Hayashi
- Division of Cardiology, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, 1578535, Japan.
| | - Hiroshi Ono
- Division of Cardiology, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, 1578535, Japan
| | - Yukihiro Kaneko
- Division of Cardiovascular Surgery, National Center for Child Health and Development, Tokyo, Japan
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Segmental Pulmonary Hypertension in Children with Congenital Heart Disease. Medicina (B Aires) 2020; 56:medicina56100492. [PMID: 32987636 PMCID: PMC7598652 DOI: 10.3390/medicina56100492] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 09/21/2020] [Accepted: 09/22/2020] [Indexed: 11/17/2022] Open
Abstract
Segmental pulmonary hypertension is a complex condition in children that encompasses many congenital heart diseases including pulmonary atresia with ventricular septal defect, hemitruncus/truncus arteriosus with branch pulmonary artery stenosis, unilateral absent pulmonary artery, and several post-tricuspid shunt lesions. Multimodality imaging is required to confirm and assess pulmonary vascular disease in subjects with major aorto-pulmonary collaterals. We describe 3 children with complex congenital heart defects who have a variable degree of segmental pulmonary hypertension and discuss management strategies and the role of interventional and/or pulmonary hypertension targeted therapies.
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Papamichalis M, Xanthopoulos A, Papamichalis P, Skoularigis J, Triposkiadis F. Adult congenital heart disease with pulmonary arterial hypertension: mechanisms and management. Heart Fail Rev 2020; 25:773-794. [PMID: 31407139 DOI: 10.1007/s10741-019-09847-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Michail Papamichalis
- Department of Cardiology, Larissa University General Hospital, P.O. Box 1425, 411 10, Larissa, Greece
| | - Andrew Xanthopoulos
- Department of Cardiology, Larissa University General Hospital, P.O. Box 1425, 411 10, Larissa, Greece
| | | | - John Skoularigis
- Department of Cardiology, Larissa University General Hospital, P.O. Box 1425, 411 10, Larissa, Greece
| | - Filippos Triposkiadis
- Department of Cardiology, Larissa University General Hospital, P.O. Box 1425, 411 10, Larissa, Greece.
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Albinni S, Marx M, Lang IM. Focused Update on Pulmonary Hypertension in Children-Selected Topics of Interest for the Adult Cardiologist. MEDICINA (KAUNAS, LITHUANIA) 2020; 56:E420. [PMID: 32825190 PMCID: PMC7559541 DOI: 10.3390/medicina56090420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 08/13/2020] [Accepted: 08/16/2020] [Indexed: 11/16/2022]
Abstract
Pulmonary hypertensive vascular disease (PHVD), and pulmonary hypertension (PH), which is a broader term, are severe conditions associated with high morbidity and mortality at all ages. Treatment guidelines in childhood are widely adopted from adult data and experience, though big differences may exist regarding aetiology, concomitant conditions and presentation. Over the past few years, paediatric aspects have been incorporated into the common guidelines, which currently address both children and adults with pulmonary hypertension (PH). There are multiple facets of PH in the context of cardiac conditions in childhood. Apart from Eisenmenger syndrome (ES), the broad spectrum of congenital heart disease (CHD) comprises PH in failing Fontan physiology, as well as segmental PH. In this review we provide current data and novel aspects on the pathophysiological background and individual management concepts of these conditions. Moreover, we focus on paediatric left heart failure with PH and its challenging issues, including end stage treatment options, such as mechanical support and paediatric transplantation. PH in the context of rare congenital disorders, such as Scimitar Syndrome and sickle cell disease is discussed. Based on current data, we provide an overview on multiple underlying mechanisms of PH involved in these conditions, and different management strategies in children and adulthood. In addition, we summarize the paediatric aspects and the pros and cons of the recently updated definitions of PH. This review provides deeper insights into some challenging conditions of paediatric PH in order to improve current knowledge and care for children and young adults.
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Affiliation(s)
- Sulaima Albinni
- Paediatric Heart Centre Vienna, Department of Paediatrics and Adolescent Medicine, Medical University of Vienna, 1090 Wien, Austria;
| | - Manfred Marx
- Paediatric Heart Centre Vienna, Department of Paediatrics and Adolescent Medicine, Medical University of Vienna, 1090 Wien, Austria;
| | - Irene M. Lang
- AKH-Vienna, Department of Cardiology, Medical University of Vienna, 1090 Wien, Austria;
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Editorial commentary: Challenges in the diagnosis and management of pulmonary artery stenosis. Trends Cardiovasc Med 2020; 31:185-186. [PMID: 32122731 DOI: 10.1016/j.tcm.2020.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 02/11/2020] [Indexed: 11/21/2022]
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A single-centre, placebo-controlled, double-blind randomised cross-over study of nebulised iloprost in patients with Eisenmenger syndrome: A pilot study. Int J Cardiol 2020; 299:131-135. [PMID: 31371115 DOI: 10.1016/j.ijcard.2019.07.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 06/18/2019] [Accepted: 07/01/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND Pulmonary arterial hypertension (PAH), is a rare and progressive disease with a high morbidity and mortality. Prostanoid pulmonary vasodilators are the most effective treatment for idiopathic and connective tissue associated PAH. Nonetheless, data examining their safety and efficacy in patients with Eisenmenger syndrome the most severe form of PAH, that is, related to cyanotic congenital heart disease (CHD-PAH) remains limited. AIM To evaluate safety and the clinical efficacy of nebulised iloprost in patients with Eisenmenger syndrome who are on maximum background oral PAH therapy. METHODS This pilot study was a randomised, double-blind, placebo-controlled, cross-over study. Patients were randomised to receive nebulised placebo or iloprost for 12 weeks and were then crossed over, with a 7-14-day washout. The primary endpoint was a change in 6-minute walk distance (6MWD). RESULTS Sixteen patients (11 females, aged 47.3 ± 9.8 year) were recruited, twelve completed the study. All were in WHO-FC III, with a resting oxygen saturation of 84 [81-87] % and a median 6MWD of 290 [260-300] m. There was no significant difference in the primary endpoint between nebulised iloprost (0[-4-9]m) and placebo (10 [-15-51]m), p = 0.58. There were no safety concerns with nebulised iloprost. CONCLUSIONS Our pilot study provides preliminary evidence that the addition of nebulised iloprost to maximum oral PAH therapy did not improve the primary endpoint of 6MWD. Nebulised iloprost was well tolerated with no significant safety concerns in CHD-PAH.
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Favoccia C, Constantine AH, Wort SJ, Dimopoulos K. Eisenmenger syndrome and other types of pulmonary arterial hypertension related to adult congenital heart disease. Expert Rev Cardiovasc Ther 2019; 17:449-459. [DOI: 10.1080/14779072.2019.1623024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Carla Favoccia
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, National Heart and Lung Institute, Biomedical Research Unit, Royal Brompton Hospital, Imperial College, London, UK
| | - Andrew H Constantine
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, National Heart and Lung Institute, Biomedical Research Unit, Royal Brompton Hospital, Imperial College, London, UK
| | - Stephen J Wort
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, National Heart and Lung Institute, Biomedical Research Unit, Royal Brompton Hospital, Imperial College, London, UK
| | - Konstantinos Dimopoulos
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, National Heart and Lung Institute, Biomedical Research Unit, Royal Brompton Hospital, Imperial College, London, UK
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Montanaro C, Merola A, Kempny A, Alvarez-Alvarez B, Alonso-Gonzalez R, Swan L, Uebing A, Li W, Babu-Narayan SV, Gatzoulis MA, Dimopoulos K. The outcome of adults born with pulmonary atresia: High morbidity and mortality irrespective of repair. Int J Cardiol 2019; 280:61-66. [PMID: 30477927 DOI: 10.1016/j.ijcard.2018.11.011] [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] [Received: 04/08/2018] [Revised: 10/15/2018] [Accepted: 11/05/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To describe the characteristics and long-term outcome of a large adult cohort with pulmonary atresia. BACKGROUND Patients with pulmonary atresia (PA) are a heterogeneous population in terms of anatomy, physiology and surgical history, and their management during adulthood remains challenging. METHODS Data on all patients with PA followed in our center between January 2000 and March 2015 were recorded. Patients were classified into the following groups: PA with ventricular septal defect (PA-VSD, 1), PA with intact ventricular septum (PA-IVS, 2) and other miscellaneous PA (PA-other, 3). RESULTS Two-hundred twenty-seven patients with PA were identified, 66.1% female, mean age 25.5 ± 8.7 years. Over a median follow-up of 8.8 years, 49 (21.6%) patients had died: heart failure (n = 21, 42.8%) and sudden cardiac death (n = 8, 16.3%) were the main causes. There was no significant difference in mortality between the 3 Groups (p = 0.12) or between repaired and unrepaired patients in Group 1 (p = 0.16). Systemic ventricular dysfunction and resting oxygen saturations were the strongest predictors of mortality. Additionally, 116 (51%) patients were hospitalized, driven mainly by the need for invasive procedures, heart failure and arrhythmias. CONCLUSIONS Adult survivors with pulmonary atresia have a high morbidity and mortality irrespective of underlying cardiac anatomy and previous reparative or palliative surgery. We present herewith predictors of outcome in adult life that may assist with their tertiary adult congenital care.
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Affiliation(s)
- Claudia Montanaro
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton Hospital, London, UK
| | - Assunta Merola
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton Hospital, London, UK
| | - Aleksander Kempny
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton Hospital, London, UK; NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital and National Heart and Lung Institute, Imperial College London, UK
| | - Belen Alvarez-Alvarez
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton Hospital, London, UK
| | - Rafael Alonso-Gonzalez
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton Hospital, London, UK; NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital and National Heart and Lung Institute, Imperial College London, UK
| | - Lorna Swan
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton Hospital, London, UK; NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital and National Heart and Lung Institute, Imperial College London, UK
| | - Anselm Uebing
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton Hospital, London, UK; NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital and National Heart and Lung Institute, Imperial College London, UK
| | - Wei Li
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton Hospital, London, UK; NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital and National Heart and Lung Institute, Imperial College London, UK
| | - Sonya V Babu-Narayan
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton Hospital, London, UK; NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital and National Heart and Lung Institute, Imperial College London, UK
| | - Michael A Gatzoulis
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton Hospital, London, UK; NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital and National Heart and Lung Institute, Imperial College London, UK
| | - Konstantinos Dimopoulos
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton Hospital, London, UK; NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital and National Heart and Lung Institute, Imperial College London, UK.
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Rosenzweig EB, Abman SH, Adatia I, Beghetti M, Bonnet D, Haworth S, Ivy DD, Berger RMF. Paediatric pulmonary arterial hypertension: updates on definition, classification, diagnostics and management. Eur Respir J 2019; 53:1801916. [PMID: 30545978 PMCID: PMC6351335 DOI: 10.1183/13993003.01916-2018] [Citation(s) in RCA: 326] [Impact Index Per Article: 65.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Accepted: 10/09/2018] [Indexed: 12/16/2022]
Abstract
Paediatric pulmonary arterial hypertension (PAH) shares common features of adult disease, but is associated with several additional disorders and challenges that require unique approaches. This article discusses recent advances, ongoing challenges and distinct approaches for the care of children with PAH, as presented by the Paediatric Task Force of the 6th World Symposium on Pulmonary Hypertension. We provide updates of the current definition, epidemiology, classification, diagnostics and treatment of paediatric PAH, and identify critical knowledge gaps. Several features of paediatric PAH including the prominence of neonatal PAH, especially in pre-term infants with developmental lung diseases, and novel genetic causes of paediatric PAH are highlighted. The use of cardiac catheterisation as a diagnostic modality and haemodynamic definitions of PAH, including acute vasoreactivity, are addressed. Updates are provided on issues related to utility of the previous classification system to reflect paediatric-specific aetiologies and approaches to medical and interventional management of PAH, including the Potts shunt. Although a lack of clinical trial data for the use of PAH-targeted therapy persists, emerging data are improving the identification of appropriate targets for goal-oriented therapy in children. Such data will likely improve future clinical trial design to enhance outcomes in paediatric PAH.
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Affiliation(s)
- Erika B Rosenzweig
- Columbia University Medical Center, New York Presbyterian Hospital, New York, NY, USA
| | - Steven H Abman
- University of Colorado, Children's Hospital Colorado, Denver, CO, USA
| | - Ian Adatia
- Glenwood Children's Heart Clinic, Edmonton, AB, Canada
| | - Maurice Beghetti
- Pediatric Cardiology Unit and Centre Universitaire de Cardiologie et Chirurgie Cardiaque Pédiatrique, University Hospitals of Geneva and Lausanne, Lausanne, Switzerland
| | - Damien Bonnet
- Hôpital Necker Enfants Malades, AP-HP, Université Paris Descartes, Paris, France
| | | | - D Dunbar Ivy
- University of Colorado, Children's Hospital Colorado, Denver, CO, USA
| | - Rolf M F Berger
- Center for Congenital Heart Diseases, Pediatric Cardiology, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Dimopoulos K, Condliffe R, Tulloh RM, Clift P, Alonso-Gonzalez R, Bedair R, Chung NA, Coghlan G, Fitzsimmons S, Frigiola A, Howard LS, Jenkins P, Kenny D, Li W, MacDonald ST, McCabe C, Oliver JJ, Spence MS, Szantho GV, von Klemperer K, Wilson DG, Wort SJ. Echocardiographic Screening for Pulmonary Hypertension in Congenital Heart Disease. J Am Coll Cardiol 2018; 72:2778-2788. [DOI: 10.1016/j.jacc.2018.08.2201] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 07/26/2018] [Accepted: 08/14/2018] [Indexed: 01/08/2023]
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