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Gonzalez de Alba C, Moghari MH, Browne LP, Friesen RM, Fonseca B, Malone LJ. Feasibility of gray-blood late gadolinium enhancement evaluation in young patients with congenital and acquired heart disease. Front Cardiovasc Med 2023; 10:1269412. [PMID: 37915741 PMCID: PMC10616296 DOI: 10.3389/fcvm.2023.1269412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Accepted: 09/26/2023] [Indexed: 11/03/2023] Open
Abstract
Background Late gadolinium enhancement (LGE) sequences have become common in pediatric cardiovascular magnetic resonance (CMR) to assess for myocardial fibrosis. Bright-blood late gadolinium enhancement (BB-LGE) by conventional phase-sensitive inversion recovery (PSIR) is commonly utilized, but similar inversion time (TI) value of fibrosis and left ventricular (LV) blood pool can make subendocardial areas difficult to assess. A gray-blood LGE (GB-LGE) technique has been described, targeting nulling of the LV blood pool and demonstrating improvement in ischemic scar detection over BB-LGE in adult patients. We sought to evaluate the feasibility of the GB-LGE technique in a young population with congenital and acquired heart disease and compare its ability to detect subendocardial scar to conventional BB-LGE. Methods Seventy-six consecutive patients referred for clinical CMR underwent both BB-LGE and GB-LGE on 1.5 T and 3 T scanners. Conventional PSIR sequences were obtained with TI to null the myocardium (BB-LGE) in short-axis and horizontal long-axis stacks. Same PSIR stacks were immediately repeated with TI to null the blood pool (GB-LGE). Both sequences were reviewed separately a week apart by two readers, blinded to the initial clinical interpretation. Studies were analyzed for overall image quality, confidence in scar detection, confidence in detection of LGE, LGE class, inter- and intra-observer agreement for the presence of scar, and intraclass correlation coefficient (ICC) for total scar burden. Results Overall confidence in myocardial scar detection by BB-LGE or GB-LGE as well as grading of image quality were not statistically different [(p = 1 and p = 1) and (p = 0.53, p = 0.18), respectively]. There was very good inter-observer agreement for the presence of scar on BB-LGE (K = 0.88, 95% CI 0.77-0.99) and GB-LGE (K = 0.84, 95% CI 0.7-0.96), as well as excellent intra-observer agreement for both readers (K = 0.93, 95% CI 0.87-0.99; and K = 0.81, 95% CI 0.69-0.95). Interclass correlation coefficient for total scar burden was excellent for BB-LGE (ICC = 0.98, 95% CI 0.96-0.99) and GB-LGE (ICC = 0.94, 95% CI 0.91-0.97). Conclusions The GB-LGE technique is feasible in the pediatric population with congenital and acquired heart disease. It can detect subendocardial/ischemic scar similar to conventional bright-blood PSIR sequences in the pediatric population.
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Affiliation(s)
- Cesar Gonzalez de Alba
- Division of Cardiology, Heart Institute, Children’s Hospital Colorado, University of Colorado, Aurora, CO, United States
| | - Mehdi H. Moghari
- Department of Radiology, University of Colorado, Aurora, CO, United States
- Department of Radiology, Children’s Hospital Colorado, Aurora, CO, United States
| | - Lorna P. Browne
- Department of Radiology, University of Colorado, Aurora, CO, United States
- Department of Radiology, Children’s Hospital Colorado, Aurora, CO, United States
| | - Richard M. Friesen
- Division of Cardiology, Heart Institute, Children’s Hospital Colorado, University of Colorado, Aurora, CO, United States
| | - Brian Fonseca
- Division of Cardiology, Heart Institute, Children’s Hospital Colorado, University of Colorado, Aurora, CO, United States
| | - LaDonna J. Malone
- Department of Radiology, University of Colorado, Aurora, CO, United States
- Department of Radiology, Children’s Hospital Colorado, Aurora, CO, United States
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Rusin CG, Acosta SI, Brady KM, Vu E, Scahill C, Fonseca B, Barrett C, Simsic J, Yates AR, Klepczynski B, Gaynor WJ, Penny DJ. Automated prediction of cardiorespiratory deterioration in patients with single-ventricle parallel circulation: A multicenter validation study. JTCVS Open 2023; 15:406-411. [PMID: 37808061 PMCID: PMC10556807 DOI: 10.1016/j.xjon.2023.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 04/13/2023] [Accepted: 05/02/2023] [Indexed: 10/10/2023]
Abstract
Objectives Patients with single-ventricle physiology have a significant risk of cardiorespiratory deterioration between their first- and second-stage palliation surgeries. Detection of deterioration episodes may allow for early intervention and improved outcomes. Methods A prospective study was executed at Nationwide Children's Hospital, Children's Hospital of Philadelphia, and Children's Hospital Colorado to collect physiologic data of subjects with single ventricle physiology during all hospitalizations between neonatal palliation and II surgeries using the Sickbay software platform (Medical Informatics Corp). Timing of cardiorespiratory deterioration events was captured via chart review. The predictive algorithm previously developed and validated at Texas Children's Hospital was applied to these data without retraining. Standard metrics such as receiver operating curve area, positive and negative likelihood ratio, and alert rates were calculated to establish clinical performance of the predictive algorithm. Results Our cohort consisted of 58 subjects admitted to the cardiac intensive care unit and stepdown units of participating centers over 14 months. Approximately 28,991 hours of high-resolution physiologic waveform and vital sign data were collected using the Sickbay. A total of 30 cardiorespiratory deterioration events were observed. the risk index metric generated by our algorithm was found to be both sensitive and specific for detecting impending events one to two hours in advance of overt extremis (receiver operating curve = 0.927). Conclusions Our algorithm can provide a 1- to 2-hour advanced warning for 53.6% of all cardiorespiratory deterioration events in children with single ventricle physiology during their initial postop course as well as interstage hospitalizations after stage I palliation with only 2.5 alarms being generated per patient per day.
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Affiliation(s)
- Craig G. Rusin
- Department of Pediatrics—Cardiology, Baylor College of Medicine, Texas Children's Hospital, Houston, Tex
| | - Sebastian I. Acosta
- Department of Pediatrics—Cardiology, Baylor College of Medicine, Texas Children's Hospital, Houston, Tex
| | - Kennith M. Brady
- Department of Anesthesiology, Northwestern University, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill
| | - Eric Vu
- Department of Anesthesiology, Northwestern University, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill
| | - Carly Scahill
- Department of Pediatrics—Cardiology, Children's Hospital Colorado, Aurora, Colo
| | - Brian Fonseca
- Department of Pediatrics—Cardiology, Children's Hospital Colorado, Aurora, Colo
| | - Cindy Barrett
- Department of Pediatrics—Cardiology, Children's Hospital Colorado, Aurora, Colo
| | - Janet Simsic
- Department of Pediatrics—Cardiology, Nationwide Children's Hospital, Columbus, Ohio
| | - Andrew R. Yates
- Department of Pediatrics—Cardiology, Nationwide Children's Hospital, Columbus, Ohio
| | - Brenna Klepczynski
- Department of Cardiovascular Surgery, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - William J. Gaynor
- Department of Cardiovascular Surgery, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Daniel J. Penny
- Department of Pediatrics—Cardiology, Baylor College of Medicine, Texas Children's Hospital, Houston, Tex
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Stone ML, Albertz ML, Galambos C, Twite MD, Campbell DN, Di Maria M, Fonseca B, Miyamoto SD, Ing RJ. Multi-Disciplinary Management and Surgical Resection of Intracardiac Fibromas Causing Bilateral Ventricular Outflow Tract Obstructions in an Infant. Semin Cardiothorac Vasc Anesth 2022; 26:315-322. [PMID: 36006828 DOI: 10.1177/10892532221123693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Cardiac tumors remain rare in children with benign pathologies predominating. Indications for surgical management often result from compromised ventricular chamber size, biventricular outflow tract obstruction, impaired ventricular function, or the presence of medically refractory dysrhythmias. We present a case of a six-month-old infant with two intracardiac fibromas originating in the interventricular septum. The fibromas were causing significant biventricular outflow obstruction. The patient successfully underwent tumor resection on cardiopulmonary bypass The literature on pediatric cardiac tumors is reviewed. Multi-disciplinary medical planning is necessary for successful anesthetic and surgical treatment of this high-risk patient population.
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Affiliation(s)
- Matthew L Stone
- 129263University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO, USA
| | - Megan L Albertz
- University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO, USA
| | - Csaba Galambos
- University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO, USA
| | - Mark D Twite
- University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO, USA
| | - David N Campbell
- 129263University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO, USA
| | - Michael Di Maria
- University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO, USA
| | - Brian Fonseca
- University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO, USA
| | - Shelley D Miyamoto
- University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO, USA
| | - Richard J Ing
- University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO, USA
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Fujiwara T, Berhane H, Scott MB, Englund EK, Schäfer M, Fonseca B, Berthusen A, Robinson JD, Rigsby CK, Browne LP, Markl M, Barker AJ. Segmentation of the Aorta and Pulmonary Arteries Based on 4D Flow MRI in the Pediatric Setting Using Fully Automated Multi-Site, Multi-Vendor, and Multi-Label Dense U-Net. J Magn Reson Imaging 2021; 55:1666-1680. [PMID: 34792835 DOI: 10.1002/jmri.27995] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 11/04/2021] [Accepted: 11/05/2021] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Automated segmentation using convolutional neural networks (CNNs) have been developed using four-dimensional (4D) flow magnetic resonance imaging (MRI). To broaden usability for congenital heart disease (CHD), training with multi-institution data is necessary. However, the performance impact of heterogeneous multi-site and multi-vendor data on CNNs is unclear. PURPOSE To investigate multi-site CNN segmentation of 4D flow MRI for pediatric blood flow measurement. STUDY TYPE Retrospective. POPULATION A total of 174 subjects across two sites (female: 46%; N = 38 healthy controls, N = 136 CHD patients). Participants from site 1 (N = 100), site 2 (N = 74), and both sites (N = 174) were divided into subgroups to conduct 10-fold cross validation (10% for testing, 90% for training). FIELD STRENGTH/SEQUENCE 3 T/1.5 T; retrospectively gated gradient recalled echo-based 4D flow MRI. ASSESSMENT Accuracy of the 3D CNN segmentations trained on data from single site (single-site CNNs) and data across both sites (multi-site CNN) were evaluated by geometrical similarity (Dice score, human segmentation as ground truth) and net flow quantification at the ascending aorta (Qs), main pulmonary artery (Qp), and their balance (Qp/Qs), between human observers, single-site and multi-site CNNs. STATISTICAL TESTS Kruskal-Wallis test, Wilcoxon rank-sum test, and Bland-Altman analysis. A P-value <0.05 was considered statistically significant. RESULTS No difference existed between single-site and multi-site CNNs for geometrical similarity in the aorta by Dice score (site 1: 0.916 vs. 0.915, P = 0.55; site 2: 0.906 vs. 0.904, P = 0.69) and for the pulmonary arteries (site 1: 0.894 vs. 0.895, P = 0.64; site 2: 0.870 vs. 0.869, P = 0.96). Qs site-1 medians were 51.0-51.3 mL/cycle (P = 0.81) and site-2 medians were 66.7-69.4 mL/cycle (P = 0.84). Qp site-1 medians were 46.8-48.0 mL/cycle (P = 0.97) and site-2 medians were 76.0-77.4 mL/cycle (P = 0.98). Qp/Qs site-1 medians were 0.87-0.88 (P = 0.97) and site-2 medians were 1.01-1.03 (P = 0.43). Bland-Altman analysis for flow quantification found equivalent performance. DATA CONCLUSION Multi-site CNN-based segmentation and blood flow measurement are feasible for pediatric 4D flow MRI and maintain performance of single-site CNNs. LEVEL OF EVIDENCE 3 TECHNICAL EFFICACY: Stage 2.
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Affiliation(s)
- Takashi Fujiwara
- Department of Radiology, Section of Pediatric Radiology, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Haben Berhane
- Department of Biomedical Engineering, Northwestern University, Chicago, Illinois, USA
| | - Michael B Scott
- Department of Biomedical Engineering, Northwestern University, Chicago, Illinois, USA.,Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Erin K Englund
- Department of Radiology, Section of Pediatric Radiology, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Michal Schäfer
- Division of Cardiology, Heart Institute, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Brian Fonseca
- Department of Pediatrics, Section of Pediatric Cardiology, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Alexander Berthusen
- Department of Radiology, Section of Pediatric Radiology, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Joshua D Robinson
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA.,Division of Pediatric Cardiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA.,Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Cynthia K Rigsby
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA.,Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA.,Department of Medical Imaging, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Lorna P Browne
- Department of Radiology, Section of Pediatric Radiology, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Michael Markl
- Department of Biomedical Engineering, Northwestern University, Chicago, Illinois, USA.,Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Alex J Barker
- Department of Radiology, Section of Pediatric Radiology, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.,Department of Bioengineering, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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Schulick N, Lin Y, Fonseca B, Campbell DN, L Stone M. Surgical management of a collateral arch channel and aortic coarctation. J Card Surg 2021; 37:445-448. [PMID: 34766377 DOI: 10.1111/jocs.16135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 11/01/2021] [Accepted: 11/02/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND The atretic connection between the left fourth and sixth aortic arches is a rare congenital cardiac anomaly with controversial debates on its origin. This anatomy has been previously reported with additional cardiac anomalies of maldevelopment. AIMS We present the successful surgical management of a 3-month-old female with Cornelia de Lange syndrome and coarctation of the aorta in the setting of this unique collateral channel. MATERIALS & METHODS We review the beneficial utility and novelty of three-dimensional computed tomography angiography for this anatomic lesion while also discussing the importance of multidisciplinary preoperative planning in the coordinated management of this arch anomaly and potential concomitant comorbid conditions. RESULTS The presented surgical case demonstrates the successful reconstruction of the aortic arch by coarctectomy with extended end-to-end anastomosis by a left posterolateral thoracotomy in a patient with a collateral arch channel and a hemodynamically significant aortic coarctation. CONCLUSION Atretic connection between the left fourth and sixth aortic arches remains a rare congenital anomaly and may occur in the setting of an aortic coarctation. Unclear arch anatomy and indeterminant proximal aortic sizing on echocardiogram should prompt cross-sectional imaging with computed tomography angiography to guide surgical technique selection for aortic arch reconstruction when a collateral arch channel or unique branching pattern is suspected.
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Affiliation(s)
- Nicole Schulick
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Yihan Lin
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Brian Fonseca
- Division of Pediatric Cardiology, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, Colorado, USA
| | - David N Campbell
- Division of Pediatric Cardiothoracic Surgery, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Matthew L Stone
- Division of Pediatric Cardiothoracic Surgery, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, Colorado, USA
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Jain SS, Steele JM, Fonseca B, Huang S, Shah S, Maskatia SA, Buddhe S, Misra N, Ramachandran P, Gaur L, Eshtehardi P, Anwar S, Kaushik N, Han F, Chaudhuri NR, Grosse-Wortmann L. COVID-19 Vaccination-Associated Myocarditis in Adolescents. Pediatrics 2021; 148:peds.2021-053427. [PMID: 34389692 DOI: 10.1542/peds.2021-053427] [Citation(s) in RCA: 83] [Impact Index Per Article: 27.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/10/2021] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVES In this study, we aimed to characterize the clinical presentation, short-term prognosis, and myocardial tissue changes as noted on cardiovascular magnetic resonance (CMR) or cardiac MRI in pediatric patients with coronavirus disease 2019 vaccination-associated myocarditis (C-VAM). METHODS In this retrospective multicenter study across 16 US hospitals, patients <21 years of age with a diagnosis of C-VAM were included and compared with a cohort with multisystem inflammatory syndrome in children. Younger children with C-VAM were compared with older adolescents. RESULTS Sixty-three patients with a mean age of 15.6 years were included; 92% were male. All had received a messenger RNA vaccine and, except for one, presented after the second dose. Four patients had significant dysrhythmia; 14% had mild left ventricular dysfunction on echocardiography, which resolved on discharge; 88% met the diagnostic CMR Lake Louise criteria for myocarditis. Myocardial injury as evidenced by late gadolinium enhancement on CMR was more prevalent in comparison with multisystem inflammatory syndrome in children. None of the patients required inotropic, mechanical, or circulatory support. There were no deaths. Follow-up data obtained in 86% of patients at a mean of 35 days revealed resolution of symptoms, arrhythmias, and ventricular dysfunction. CONCLUSIONS Clinical characteristics and early outcomes are similar between the different pediatric age groups in C-VAM. The hospital course is mild, with quick clinical recovery and excellent short-term outcomes. Myocardial injury and edema are noted on CMR. Close follow-up and further studies are needed to understand the long-term implications and mechanism of these myocardial tissue changes.
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Affiliation(s)
- Supriya S Jain
- New York Medical College and Maria Fareri Children's Hospital at Westchester Medical Center, Valhalla, New York
| | | | | | - Sihong Huang
- College of Human Medicine, Michigan State University and Helen DeVos Children's Hospital, Spectrum Health, Grand Rapids, Michigan
| | - Sanket Shah
- Children's Mercy Hospital, Kansas City, Missouri
| | - Shiraz A Maskatia
- School of Medicine, Stanford University and Lucile Packard Children's Hospital, Palo Alto, California
| | - Sujatha Buddhe
- Seattle Children's Hospital and University of Washington, Seattle, Washington
| | - Nilanjana Misra
- Cohen Children's Medical Center of New York, Northwell Health, Queens, New York
| | | | - Lasya Gaur
- School of Medicine, John Hopkins University, Baltimore, Maryland
| | - Parham Eshtehardi
- Northside Heart and Vascular Institute, Northside Hospital, Atlanta, Georgia
| | - Shafkat Anwar
- University of California, San Francisco, San Francisco, California
| | - Neeru Kaushik
- University of California, San Francisco Benioff Children's Hospitals, Oakland, California
| | - Frank Han
- College of Medicine, University of Illinois, Peoria, Illinois
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Aly D, Lutterbach J, Stone M, Fonseca B. ENDOCARDITIS PRECIPITATED RUPTURE SINUS OF VALSALVA ANEURYSM COEXISTING WITH A VENTRICULAR SEPTAL DEFECT AND BICUSPID AORTIC VALVE. J Am Coll Cardiol 2020. [DOI: 10.1016/s0735-1097(20)33647-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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8
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Schäfer M, Browne LP, Truong U, Jaggers JJ, Mitchell MB, Malone L, Morgan G, Chatfield K, McLennan D, Turbendian H, Vargas D, Fonseca B, DiMaria M, Shah A, Ivy MP, Barker AJ, Hunter KS, Wilson N, Ivy DD, Campbell DN. Aortic stiffness in adolescent Turner and Marfan syndrome patients. Eur J Cardiothorac Surg 2019; 54:926-932. [PMID: 29684119 DOI: 10.1093/ejcts/ezy168] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 03/25/2018] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVES Turner syndrome (TS) and Marfan syndrome (MFS) are partially characterized by aortopathies with a risk of developing severe aortic dilation, stiffness and consequent dissection and aneurysm formation. The incidence of a bicuspid aortic valve (BAV) is also increased in TS. We investigated aortic stiffness in teenage TS and MFS patients and evaluated to what degree stiffness in TS patients is augmented by the presence of a BAV. METHODS Fifty-seven patients with TS (n = 37) and MFS (n = 20), as well as 22 controls with similar age and size distribution underwent evaluation of thoracic aortic stiffness using phase-contrast magnetic resonance imaging. Calculated stiffness indices including pulse wave velocity (PWV), distensibility and relative area change (RAC) were collected to characterize the ascending aorta and descending aorta. PWV was also determined to evaluate global aortic arch stiffness. RESULTS Patients with TS had reduced distensibility (0.43 vs 0.58%/mmHg, P < 0.05) and RAC (21 vs 29%, P < 0.01) in the ascending aorta when compared with normal controls. Similarly, patients with MFS had reduced ascending aortic distensibility (0.39 vs 0.58%/mmHg, P < 0.05) and RAC (22 vs 29%, P < 0.05). There were no differences in measured PWV in the ascending aorta. Patients with TS had significantly elevated PWV measured in the aortic arch when compared with controls (2.7 vs 1.9 m/s, P < 0.05). Patients with MFS had more prominent elevation in aortic arch PWV (4.2 vs 1.9 m/s, P < 0.01). The descending aortas had decreased distensibility (0.36 vs 0.55%/mmHg, P < 0.05) and RAC (18 vs 25%, P < 0.01) only in MFS patients. Additionally, 18 TS patients with a BAV were compared with 19 TS patients with a trileaflet aortic valve, without significant differences observed in any of the considered stiffness indices. CONCLUSIONS TS and MFS teenage patients display evidence of increased aortic stiffness. In TS patients, this is focused in the ascending aorta and is independent of the presence of a BAV. MFS patients display a generalized reduction in compliance of the entire aorta.
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Affiliation(s)
- Michal Schäfer
- Division of Cardiology, Department of Pediatrics, Heart Institute, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
| | - Lorna P Browne
- Department of Radiology, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
| | - Uyen Truong
- Division of Cardiology, Department of Pediatrics, Heart Institute, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
| | - James J Jaggers
- Division of Congenital Heart Surgery, Department of Surgery, Heart Institute, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
| | - Max B Mitchell
- Division of Congenital Heart Surgery, Department of Surgery, Heart Institute, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
| | - Ladonna Malone
- Department of Radiology, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
| | - Gareth Morgan
- Division of Cardiology, Department of Pediatrics, Heart Institute, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
| | - Kathryn Chatfield
- Division of Cardiology, Department of Pediatrics, Heart Institute, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
| | - Daniel McLennan
- Division of Cardiology, Department of Pediatrics, Heart Institute, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
| | - Harma Turbendian
- Division of Congenital Heart Surgery, Department of Surgery, Heart Institute, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
| | - Danial Vargas
- Department of Radiology, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
| | - Brian Fonseca
- Division of Cardiology, Department of Pediatrics, Heart Institute, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
| | - Michael DiMaria
- Division of Cardiology, Department of Pediatrics, Heart Institute, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
| | - Anar Shah
- Division of Cardiology, Department of Pediatrics, Heart Institute, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
| | - Margaret P Ivy
- Division of Cardiology, Department of Pediatrics, Heart Institute, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
| | - Alex J Barker
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Kendall S Hunter
- Division of Cardiology, Department of Pediatrics, Heart Institute, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
| | - Neil Wilson
- Division of Cardiology, Department of Pediatrics, Heart Institute, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
| | - D Dunbar Ivy
- Division of Cardiology, Department of Pediatrics, Heart Institute, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
| | - David N Campbell
- Division of Congenital Heart Surgery, Department of Surgery, Heart Institute, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
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9
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Schäfer M, Ivy DD, Abman SH, Stenmark K, Browne LP, Barker AJ, Mitchell MB, Morgan GJ, Wilson N, Shah A, Kollengode M, Naresh N, Fonseca B, DiMaria M, Buckner JK, Hunter KS, Kheyfets V, Fenster BE, Truong U. Differences in pulmonary arterial flow hemodynamics between children and adults with pulmonary arterial hypertension as assessed by 4D-flow CMR studies. Am J Physiol Heart Circ Physiol 2019; 316:H1091-H1104. [PMID: 30822118 PMCID: PMC7327229 DOI: 10.1152/ajpheart.00802.2018] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Despite different developmental and pathological processes affecting lung vascular remodeling in both patient populations, differences in 4D MRI findings between children and adults with PAH have not been studied. The purpose of this study was to compare flow hemodynamic state, including flow-mediated shear forces, between pediatric and adult patients with PAH matched by severity of pulmonary vascular resistance index (PVRi). Adults (n = 10) and children (n = 10) with PAH matched by pulmonary vascular resistance index (PVRi) and healthy adult (n = 10) and pediatric (n = 10) subjects underwent comprehensive 4D-flow MRI to assess peak systolic wall shear stress (WSSmax) measured in the main (MPA), right (RPA), and left pulmonary arteries (LPA), viscous energy loss (EL) along the MPA-RPA and MPA-LPA tract, and qualitative analysis of secondary flow hemodynamics. WSSmax was decreased in all pulmonary vessels in children with PAH when compared with the same age group (all P < 0.05). Similarly, WSSmax was decreased in all pulmonary vessels in adult PAH patients when compared with healthy adult subjects (all P < 0.01). Average EL was increased in adult patients with PAH when compared with the same age group along both MPA-RPA (P = 0.020) and MPA-LPA (P = 0.025) tracts. There were no differences in EL indices between adults and pediatric patients. Children and adult patients with PAH have decreased shear hemodynamic forces. However, pathological flow hemodynamic formations appear to be more consistent in adult patients, whereas flow hemodynamic abnormalities appear to be more variable in children with PAH for comparable severity of PVRi. NEW & NOTEWORTHY Both children and adult patients with PAH have decreased shear hemodynamic forces inside the pulmonary arteries associated with the degree of vessel dilation and stiffness. These differences also exist between healthy normotensive children and adults. However, pathological flow hemodynamic formations appear to more uniform in adult patients, whereas in children with PAH flow, hemodynamic abnormalities appear to be more variable. Pathological flow formations appear not to have a major effect on viscous energy loss associated with the flow conduction through proximal pulmonary arteries.
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Affiliation(s)
- Michal Schäfer
- Division of Pediatric Cardiology, Heart Institute, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
| | - D Dunbar Ivy
- Division of Pediatric Cardiology, Heart Institute, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
| | - Steven H Abman
- Division of Pulmonology, Breathing Institute, University of Colorado Denver Anschutz Medical Campus , Aurora, Colorado
| | - Kurt Stenmark
- Developmental Lung Biology and Cardiovascular Pulmonary Research Laboratories, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
| | - Lorna P Browne
- Department of Radiology, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
| | - Alex J Barker
- Department of Radiology, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
| | - Max B Mitchell
- Department of Surgery, Pediatric Heart Surgery, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
| | - Gareth J Morgan
- Division of Pediatric Cardiology, Heart Institute, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
| | - Neil Wilson
- Division of Pediatric Cardiology, Heart Institute, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
| | - Anar Shah
- Division of Pediatric Cardiology, Heart Institute, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
| | - Madhukar Kollengode
- Division of Pediatric Cardiology, Heart Institute, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
| | - Nivedita Naresh
- Department of Radiology, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
| | - Brian Fonseca
- Division of Pediatric Cardiology, Heart Institute, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
| | - Michael DiMaria
- Division of Pediatric Cardiology, Heart Institute, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
| | - J Kern Buckner
- Division of Cardiology, National Jewish Health , Denver, Colorado
| | - Kendall S Hunter
- Division of Pediatric Cardiology, Heart Institute, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
| | - Vitaly Kheyfets
- Department of Bioengineering, University of Colorado Denver , Aurora, Colorado
| | - Brett E Fenster
- Division of Cardiology, National Jewish Health , Denver, Colorado
| | - Uyen Truong
- Division of Pediatric Cardiology, Heart Institute, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
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Schäfer M, Browne LP, Morgan GJ, Barker AJ, Fonseca B, Ivy DD, Mitchell MB. Reduced proximal aortic compliance and elevated wall shear stress after early repair of tetralogy of Fallot. J Thorac Cardiovasc Surg 2018; 156:2239-2249. [DOI: 10.1016/j.jtcvs.2018.08.081] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 08/23/2018] [Accepted: 08/31/2018] [Indexed: 02/05/2023]
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Schäfer M, Wilson N, Ivy DD, Ing R, Abman S, Browne LP, Morgan G, Ross M, McLennan D, Barker AJ, Fonseca B, Di Maria M, Hunter KS, Truong U. Noninvasive wave intensity analysis predicts functional worsening in children with pulmonary arterial hypertension. Am J Physiol Heart Circ Physiol 2018; 315:H968-H977. [PMID: 30004811 DOI: 10.1152/ajpheart.00227.2018] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The purpose of the present study was to characterize pulmonary vascular stiffness using wave intensity analysis (WIA) in children with pulmonary arterial hypertension (PAH), compare the WIA indexes with catheterization- and MRI-derived hemodynamics, and assess the prognostic ability of WIA-derived biomarkers to predict the functional worsening. WIA was performed in children with PAH ( n = 40) and healthy control subjects ( n = 15) from phase-contrast MRI-derived flow and area waveforms in the main pulmonary artery (MPA). From comprehensive WIA spectra, we collected and compared with healthy control subjects forward compression waves (FCW), backward compression waves (BCW), forward decompression waves (FDW), and wave propagation speed ( c-MPA). There was no difference in the magnitude of FCW between PAH and control groups (88 vs. 108 mm5·s-1·ml-1, P = 0.239). The magnitude of BCW was increased in patients with PAH (32 vs. 5 mm5·s-1·ml-1, P < 0.001). There was no difference in magnitude of indexed FDW (32 vs. 28 mm5·s-1·ml-1, P = 0.856). c-MPA was increased in patients with PAH (3.2 vs. 1.6 m/s, P < 0.001). BCW and FCW correlated with mean pulmonary arterial pressure, right ventricular volumes, and ejection fraction. Elevated indexed BCW [heart rate (HR) = 2.91, confidence interval (CI): 1.18-7.55, P = 0.019], reduced indexed FDW (HR = 0.34, CI: 0.11-0.90, P = 0.030), and increased c-MPA (HR = 3.67, CI: 1.47-10.20, P = 0.004) were strongly associated with functional worsening of disease severity. Our results suggest that noninvasively derived biomarkers of pulmonary vascular resistance and stiffness may be helpful for determining prognosis and monitoring disease progression in children with PAH. NEW & NOTEWORTHY Wave intensity analysis (WIA) studies are lacking in children with pulmonary arterial hypertension (PAH) partially because WIA, which is necessary to assess vascular stiffness, requires an invasive pressure-derived waveform along with simultaneous flow measurements. We analyzed vascular stiffness using WIA in children with PAH who underwent phase-contrast MRI and observed significant differences in WIA indexes between patients with PAH and control subjects. Furthermore, WIA indexes were predictive of functional worsening and were associated with standard catheterization measures.
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Affiliation(s)
- Michal Schäfer
- Division of Cardiology, Heart Institute, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus , Aurora, Colorado
| | - Neil Wilson
- Division of Cardiology, Heart Institute, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus , Aurora, Colorado
| | - D Dunbar Ivy
- Division of Cardiology, Heart Institute, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus , Aurora, Colorado
| | - Richard Ing
- Division of Pediatric Cardiac Anesthesiology, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus , Aurora, Colorado
| | - Steven Abman
- Division of Pulmonology, Breathing Institute, University of Colorado Anschutz Medical Campus , Aurora, Colorado
| | - Lorna P Browne
- Department of Radiology, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus , Aurora, Colorado
| | - Gareth Morgan
- Division of Cardiology, Heart Institute, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus , Aurora, Colorado
| | - Michael Ross
- Division of Cardiology, Heart Institute, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus , Aurora, Colorado
| | - Daniel McLennan
- Division of Cardiology, Heart Institute, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus , Aurora, Colorado
| | - Alex J Barker
- Department of Radiology, Feinberg School of Medicine, Northwestern University , Chicago, Illinois
| | - Brian Fonseca
- Division of Cardiology, Heart Institute, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus , Aurora, Colorado
| | - Michael Di Maria
- Division of Cardiology, Heart Institute, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus , Aurora, Colorado
| | - Kendall S Hunter
- Division of Cardiology, Heart Institute, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus , Aurora, Colorado
| | - Uyen Truong
- Division of Cardiology, Heart Institute, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus , Aurora, Colorado
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Zablah JE, Ross M, Wilson N, Fonseca B, Mitchell MB. Kawashima by Fenestrated Hemi-Fontan for Palliation Following Prior Stage I Norwood Operation. World J Pediatr Congenit Heart Surg 2018; 9:451-453. [DOI: 10.1177/2150135118769326] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Single ventricle patients with interrupted inferior vena cava (IVC) and azygos continuation to the superior vena cava (SVC) are typically palliated with a bidirectional cavopulmonary shunt (BCPS), known as the Kawashima operation in this setting. Because the volume of venous blood directed to the pulmonary arteries is substantially greater in the presence of interrupted IVC, Kawashima procedures are commonly delayed to older age compared to other single ventricle patients undergoing BCPS. We report two young infant single ventricle patients with interrupted IVC and azygos continuation to the SVC who underwent stage I Norwood procedures for initial palliation. In both cases, a fenestrated hemi-Fontan procedure achieved successful Kawashima circulations.
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Affiliation(s)
- Jenny E. Zablah
- Interventional Cardiology, Children’s Hospital of Colorado, Heart Institute, Aurora, CO, USA
| | - Michael Ross
- Interventional Cardiology, Children’s Hospital of Colorado, Heart Institute, Aurora, CO, USA
| | - Neil Wilson
- Interventional Cardiology, Children’s Hospital of Colorado, Heart Institute, Aurora, CO, USA
| | - Brian Fonseca
- Children’s Hospital of Colorado, Heart Institute, Aurora, CO, USA
| | - Max B. Mitchell
- Pediatric Cardiothoracic Surgery, Children’s Hospital of Colorado, Heart Institute, Aurora, CO, USA
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13
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Schäfer M, Truong U, Ivy DD, Fonseca B, Malone L, DiMaria M, Barker AJ, Vargas D, Hunter KS, Jone PN, Browne LP. Children with kawasaki disease present elevated stiffness of great arteries: Phase-contrast MRI study. J Magn Reson Imaging 2018; 48:1228-1236. [PMID: 29707843 DOI: 10.1002/jmri.26167] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 04/11/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Patients with diagnosed Kawasaki disease (KD) are known to develop extracardiac vascular lesions and are prone to accelerated stiffening of medium-size arteries. PURPOSE To noninvasively evaluate great vessel (central aorta and main pulmonary artery (MPA)) stiffness using phase-contrast MRI (PC-MRI). STUDY TYPE Retrospective review. SUBJECTS Thirty-three patients with previously diagnosed KD and 15 control subjects underwent PC-MRI evaluation. FIELD STRENGTH/SEQUENCE A free-breathing PC-MRI sequence was applied with Cartesian encoding and retrospective sorting using a 1.5 or 3.0T system. ASSESSMENT We evaluated regionally specific vessel stiffness using pulse-wave velocity (PWV) and relative area change (RAC) at the ascending aorta, descending aorta, and MPA. STATISTICAL TESTS Hemodynamics among patients with KD and controls were compared using Student's t-test, Wilcoxon Rank-sum, and χ2 . Additional group-specific comparisons were performed using Kruskal-Wallis or one-way analysis of variance (ANOVA). RESULTS Patients with KD showed elevated PWV in both ascending (5.0 ± 1.2 vs. 2.4 ± 0.5, P < 0.001) and descending aorta (4.4 ± 2.1 vs. 2.8 ± 0.8, P < 0.001). RAC was correspondingly reduced in both segments (both P < 0.01). PWV measured in MPA was increased in KD patients (2.2 ± 0.5 vs. 1.5 ± 0.6, P = 0.045) while the RAC was reduced (34 ± 6 vs. 47 ± 3, P = 0.045). There were no associations between considered vessel stiffness indices and respective ventricular size and function, functional indices, and no correlations were observed with KD severity markers. DATA CONCLUSION Patients with KD have elevated great vessel stiffness measured at the chronic stage of the disease. Accelerated stiffness process does not appear to affect biventricular function in youth Level of Evidence: 1 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2018;47:1228-1236.
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Affiliation(s)
- Michal Schäfer
- Division of Cardiology, Heart Institute, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Denver, Colorado, USA.,Department of Bioengineering, College of Engineering and Applied Sciences, University of Colorado Denver, Anschutz Medical Campus, Denver, Colorado, USA
| | - Uyen Truong
- Division of Cardiology, Heart Institute, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Denver, Colorado, USA
| | - D Dunbar Ivy
- Division of Cardiology, Heart Institute, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Denver, Colorado, USA
| | - Brian Fonseca
- Division of Cardiology, Heart Institute, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Denver, Colorado, USA
| | - Ladonna Malone
- Department of Radiology, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Denver, Colorado, USA
| | - Michael DiMaria
- Division of Cardiology, Heart Institute, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Denver, Colorado, USA
| | - Alex J Barker
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Daniel Vargas
- Department of Radiology, University of Colorado Hospital, University of Colorado Denver, Anschutz Medical Campus, Denver, Colorado, USA
| | - Kendall S Hunter
- Division of Cardiology, Heart Institute, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Denver, Colorado, USA.,Department of Bioengineering, College of Engineering and Applied Sciences, University of Colorado Denver, Anschutz Medical Campus, Denver, Colorado, USA
| | - Pei-Ni Jone
- Division of Cardiology, Heart Institute, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Denver, Colorado, USA
| | - Lorna P Browne
- Department of Radiology, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Denver, Colorado, USA
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14
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Jone PN, Gould R, Barrett C, Younoszai AK, Fonseca B. Data-Driven Quality Improvement Project to Increase the Value of the Congenital Echocardiographic Report. Pediatr Cardiol 2018; 39:726-730. [PMID: 29350246 DOI: 10.1007/s00246-018-1812-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 01/04/2018] [Indexed: 10/18/2022]
Abstract
Echocardiography is the primary diagnostic modality for congenital heart disease patients. The written report is used to communicate with the care team and organization is often divided into the body with detailed findings and the conclusions with important findings summarized. Strategies to increase workflow efficiency include batch writing of reports after performance of multiple echocardiograms and the use of report templates which may contribute to discrepancies within report leading to potential downstream medical errors. The aim of this project was to measure the rate of inconsistencies in the echocardiogram reports and through an iterative series of process improvement decrease this rate while maintaining sonographer efficiency and diagnostic accuracy. The discrepancy rate, diagnostic error rate, and sonographer productivity were collected one-year prior and during the iterative quality improvement process. The primary outcome and discrepancies in reports were determined by two reviewers: an experienced pediatric echocardiographic cardiologist and a senior sonographer. Minor discrepancies were defined as contradictions between the body and the conclusion of the report that were unlikely to affect patient care. Major discrepancies were defined as discrepancies between the body and the conclusion that had significant potential to affect patient care. Sonographer productivity was measured as studies per sonographer per month. Our primary intervention was to initiate a quarterly QI meeting and to decrease the batch writing of preliminary echocardiogram reports. No major discrepancies were identified pre- or post-intervention. The minor discrepancies decreased from 40.7 to 6%. Sonographer productivity was not significantly changed with a slight increase from 100 studies/sonographer/month during the baseline to 101 studies/sonographer/month during the intervention. There was no change in major or minor diagnostic error rate. Our quality improvement intervention increased the value of our reports by significantly decreasing minor discrepancies without negatively impacting sonographer productivity or diagnostic accuracy.
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Affiliation(s)
- Pei-Ni Jone
- Pediatric Cardiology, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 East 16th Avenue, B100, Aurora, CO, 80045, USA.
| | - Ruthanne Gould
- Pediatric Cardiology, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 East 16th Avenue, B100, Aurora, CO, 80045, USA
| | - Cindy Barrett
- Pediatric Cardiology, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 East 16th Avenue, B100, Aurora, CO, 80045, USA
| | - Adel K Younoszai
- Pediatric Cardiology, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 East 16th Avenue, B100, Aurora, CO, 80045, USA
| | - Brian Fonseca
- Pediatric Cardiology, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 East 16th Avenue, B100, Aurora, CO, 80045, USA
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15
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Schäfer M, Collins KK, Browne LP, Ivy DD, Abman S, Friesen R, Frank B, Fonseca B, DiMaria M, Hunter KS, Truong U, von Alvensleben JC. Effect of electrical dyssynchrony on left and right ventricular mechanics in children with pulmonary arterial hypertension. J Heart Lung Transplant 2018; 37:870-878. [PMID: 29496397 DOI: 10.1016/j.healun.2018.01.1308] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Revised: 12/12/2017] [Accepted: 01/31/2018] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Electrical and right ventricular (RV) mechanical dyssynchrony has been previously described in pediatric pulmonary arterial hypertension (PAH), but less is known about the relationship between electrical dyssynchrony and biventricular function. In this study we applied cardiac magnetic resonance (CMR) imaging to evaluate biventricular size and function with a focus on left ventricular (LV) strain mechanics in pediatric PAH patients with and without electrical dyssynchrony. METHODS Fifty-six children with PAH and comprehensive CMR evaluation were stratified based on QRS duration z-score, with electrical dyssynchrony defined as z-score ≥2. Comprehensive biventricular volumetric, dyssynchrony, and strain analysis was performed. RESULTS Nineteen PAH patients had or developed electrical dyssynchrony. Patients with electrical dyssynchrony had significantly reduced RV ejection fraction (35% vs 50%, p = 0.003) and greater end-diastolic (168 vs 112 ml/m2, p = 0.041) and end-systolic (119 vs 57, ml/m2, p = 0.026) volumes. Patients with electrical dyssynchrony had reduced RV longitudinal strain (-14% vs -19%, p = 0.007), LV circumferential strain measured at the free wall (-19% vs -22%, p = 0.047), and the LV longitudinal strain in the septal region (-10% vs -15%, p = 0.0268). LV mechanical intraventricular dyssynchrony was reduced in patients with electrical dyssynchrony at the LV free wall (43 vs 19 ms, p = 0.019). CONCLUSIONS The electrical dyssynchrony is associated with the reduced LV strain, enlarged RV volumes, and reduced biventricular function in children with PAH. CMR assessment of biventricular mechanical function with respect to QRS duration may help to detect pathophysiologic processes associated with progressed PAH.
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Affiliation(s)
- Michal Schäfer
- Division of Cardiology, Heart Institute, Children's Hospital Colorado, Anschutz Medical Campus, University of Colorado Denver, Aurora, Colorado.
| | - Kathryn K Collins
- Division of Cardiology, Heart Institute, Children's Hospital Colorado, Anschutz Medical Campus, University of Colorado Denver, Aurora, Colorado
| | - Lorna P Browne
- Department of Radiology, Breathing Institute, Children's Hospital Colorado, Anschutz Medical Campus, University of Colorado Denver, Aurora, Colorado
| | - D Dunbar Ivy
- Division of Cardiology, Heart Institute, Children's Hospital Colorado, Anschutz Medical Campus, University of Colorado Denver, Aurora, Colorado
| | - Steven Abman
- Division of Pulmonology, Breathing Institute, Children's Hospital Colorado, Anschutz Medical Campus, University of Colorado Denver, Aurora, Colorado
| | - Richard Friesen
- Division of Cardiology, Heart Institute, Children's Hospital Colorado, Anschutz Medical Campus, University of Colorado Denver, Aurora, Colorado
| | - Benjamin Frank
- Division of Cardiology, Heart Institute, Children's Hospital Colorado, Anschutz Medical Campus, University of Colorado Denver, Aurora, Colorado
| | - Brian Fonseca
- Division of Cardiology, Heart Institute, Children's Hospital Colorado, Anschutz Medical Campus, University of Colorado Denver, Aurora, Colorado
| | - Michael DiMaria
- Division of Cardiology, Heart Institute, Children's Hospital Colorado, Anschutz Medical Campus, University of Colorado Denver, Aurora, Colorado
| | - Kendall S Hunter
- Division of Cardiology, Heart Institute, Children's Hospital Colorado, Anschutz Medical Campus, University of Colorado Denver, Aurora, Colorado
| | - Uyen Truong
- Division of Cardiology, Heart Institute, Children's Hospital Colorado, Anschutz Medical Campus, University of Colorado Denver, Aurora, Colorado
| | - Johannes C von Alvensleben
- Division of Cardiology, Heart Institute, Children's Hospital Colorado, Anschutz Medical Campus, University of Colorado Denver, Aurora, Colorado
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16
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Friesen RM, Schäfer M, Jone PN, Appiawiah N, Vargas D, Fonseca B, DiMaria MV, Truong U, Malone L, Browne LP. Myocardial Perfusion Reserve Index in Children With Kawasaki Disease. J Magn Reson Imaging 2017; 48:132-139. [PMID: 29232024 DOI: 10.1002/jmri.25922] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Accepted: 11/30/2017] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Coronary artery lesions in patients with Kawasaki disease (KD) can impair myocardial perfusion, yet evaluation of perfusion defects by cardiac magnetic resonance (MR) in children is often qualitative. PURPOSE In this study we aimed to use a quantitative method of myocardial perfusion using stress cardiac MR-derived myocardial perfusion reserve index (MPRI) in children with KD and compare MPRI with ventricular mechanical performance evaluated by cardiac MR strain analysis. STUDY TYPE This study was a retrospective review. SUBJECTS Twenty-one children with a diagnosis of KD who underwent stress perfusion cardiac MR were compared with nine controls. FIELD STRENGTH/SEQUENCE First-pass perfusion imaging using a T1 -weighted gradient echo sequence was performed at rest and stress after administration of adenosine with 1.5T or 3T magnets. ASSESSMENT The MPRI was calculated as the ratio of maximum slope of myocardial enhancement during stress compared to rest and was evaluated with the American Heart Association 17 segment model. STATISTICAL TESTS Demographic and clinical characteristics among KD patients and controls were compared using Student's t-test for normally distributed continuous variables, Wilcoxon-rank sum test for nonnormally distributed variables, and χ2 for categorical variables. RESULTS There was a significant decrease in MPRI in Segment 7 (1.53 vs. 2.23, P = 0.0058) in KD patients compared with controls. The reduction in MPRI in Segment 12 approached statistical significance (1.58 vs. 2.31, P = 0.0636). Three patients who underwent serial studies had decreased MPRI longitudinally. No differences were seen in circumferential or radial strain. DATA CONCLUSION MPRI shows impaired myocardial perfusion in patients with KD. MPRI can change over time, suggestive of progressive coronary artery changes, which may precede fibrosis and mechanical decline. MPRI can assess segmental and global perfusion defects in patients with KD and should be a part of routine cardiac MR evaluation in KD. LEVEL OF EVIDENCE 3 Technical Efficacy Stage 3 J. Magn. Reson. Imaging 2017.
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Affiliation(s)
- Richard M Friesen
- Department of Critical Care Medicine, Seattle Children's Hospital, University of Washington, Seattle, Washington, USA.,Division of Cardiology, Heart Institute, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Denver, Colorado, USA
| | - Michal Schäfer
- Division of Cardiology, Heart Institute, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Denver, Colorado, USA.,Department of Bioengineering, College of Engineering and Applied Sciences, University of Colorado Denver, Anschutz Medical Campus, Denver, Colorado, USA
| | - Pei-Ni Jone
- Division of Cardiology, Heart Institute, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Denver, Colorado, USA
| | - Nana Appiawiah
- Department of Radiology, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Denver, Colorado, USA
| | - Daniel Vargas
- Department of Radiology, University of Colorado Denver, Anschutz Medical Campus, Denver, Colorado, USA
| | - Brian Fonseca
- Division of Cardiology, Heart Institute, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Denver, Colorado, USA
| | - Michael V DiMaria
- Division of Cardiology, Heart Institute, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Denver, Colorado, USA
| | - Uyen Truong
- Division of Cardiology, Heart Institute, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Denver, Colorado, USA
| | - LaDonna Malone
- Department of Radiology, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Denver, Colorado, USA
| | - Lorna P Browne
- Department of Radiology, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Denver, Colorado, USA
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Midão L, Maia J, Almada M, Fonseca B, Gonçalves D, Braga J, Teixeira N, Correia-da-Silva G. Cannabis sativa tetrahydrocannabinol (THC) impact on placental endocrine function. Porto Biomed J 2017; 2:185-186. [DOI: 10.1016/j.pbj.2017.07.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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18
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Malone L, Fonseca B, Fagan T, Gralla J, Wilson N, Vargas D, DiMaria M, Truong U, Browne LP. Erratum to: Preprocedural Risk Assessment Prior to PPVI with CMR and Cardiac CT. Pediatr Cardiol 2017; 38:1315. [PMID: 28589406 DOI: 10.1007/s00246-017-1643-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Ladonna Malone
- Department of Radiology, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Brian Fonseca
- Department of Cardiology, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Thomas Fagan
- University of Tennessee Health Sciences Center, Aurora, Colorado, USA
| | - Jane Gralla
- Department of Pediatrics, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Neil Wilson
- Department of Cardiology, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Daniel Vargas
- Department of Radiology, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Micheal DiMaria
- Department of Cardiology, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Uyen Truong
- Department of Cardiology, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Lorna P Browne
- Department of Radiology, Children's Hospital Colorado, Aurora, Colorado, USA.
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Schäfer M, Ivy DD, Abman SH, Barker AJ, Browne LP, Fonseca B, Kheyfets V, Hunter KS, Truong U. Apparent Aortic Stiffness in Children With Pulmonary Arterial Hypertension: Existence of Vascular Interdependency? Circ Cardiovasc Imaging 2017; 10:CIRCIMAGING.116.005817. [PMID: 28193613 DOI: 10.1161/circimaging.116.005817] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Accepted: 12/15/2016] [Indexed: 01/08/2023]
Abstract
BACKGROUND Left ventricular dysfunction, mediated by ventricular interdependence, has been associated with negative outcomes in children with pulmonary arterial hypertension (PAH). Considering the dilation of the pulmonary arteries as a paramount sign of PAH, we hypothesized that the ascending aorta will present signs of apparent stiffness in children with PAH and that this effect may be because of mechanical interaction with the dilated main pulmonary artery (MPA). METHODS AND RESULTS Forty-two children with PAH and 26 age- and size-matched controls underwent comprehensive cardiac magnetic resonance evaluation. Assessment of aortic stiffness was evaluated by measuring pulse wave velocity, aortic strain, and distensibility. Children with PAH had significantly increased pulse wave velocity in the ascending aorta (3.4 versus 2.3 m/s for PAH and controls, respectively; P=0.001) and reduced aortic strain (23% versus 29%; P<0.0001) and distensibility (0.47 versus 0.64%/mm Hg; P=0.02). Indexed MPA diameter correlated with pulse wave velocity (P=0.04) and with aortic strain (P=0.02). The ratio of MPA to aortic size correlated with pulse wave velocity (P=0.0098), strain (P=0.0099), and distensibility (P=0.015). Furthermore, aortic relative area change was associated with left ventricular ejection fraction (P=0.045) and ventricular-vascular coupling ratio (P=0.042). CONCLUSIONS Pediatric PAH patients have increased apparent ascending aortic stiffness, which was strongly associated with the degree of MPA distension. We speculate that distension of the MPA may play a major role in limiting full aortic expansion during systole, which modulates left ventricular performance and impacts systemic hemodynamics in pediatric PAH.
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Affiliation(s)
- Michal Schäfer
- From the Division of Cardiology, Heart Institute, Children's Hospital Colorado (M.S., D.D.I., B.F., K.S.H., U.T.), Department of Bioengineering, College of Engineering and Applied Sciences (M.S., D.D.I., V.K., K.S.H., U.T.), Division of Pulmonology, Breathing Institute, Children's Hospital Colorado (S.H.A.), and Department of Radiology, Children's Hospital Colorado (L.P.B.), University of Colorado Denver/Anschutz Medical Campus; and Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, IL (A.J.B.).
| | - D Dunbar Ivy
- From the Division of Cardiology, Heart Institute, Children's Hospital Colorado (M.S., D.D.I., B.F., K.S.H., U.T.), Department of Bioengineering, College of Engineering and Applied Sciences (M.S., D.D.I., V.K., K.S.H., U.T.), Division of Pulmonology, Breathing Institute, Children's Hospital Colorado (S.H.A.), and Department of Radiology, Children's Hospital Colorado (L.P.B.), University of Colorado Denver/Anschutz Medical Campus; and Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, IL (A.J.B.)
| | - Steven H Abman
- From the Division of Cardiology, Heart Institute, Children's Hospital Colorado (M.S., D.D.I., B.F., K.S.H., U.T.), Department of Bioengineering, College of Engineering and Applied Sciences (M.S., D.D.I., V.K., K.S.H., U.T.), Division of Pulmonology, Breathing Institute, Children's Hospital Colorado (S.H.A.), and Department of Radiology, Children's Hospital Colorado (L.P.B.), University of Colorado Denver/Anschutz Medical Campus; and Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, IL (A.J.B.)
| | - Alex J Barker
- From the Division of Cardiology, Heart Institute, Children's Hospital Colorado (M.S., D.D.I., B.F., K.S.H., U.T.), Department of Bioengineering, College of Engineering and Applied Sciences (M.S., D.D.I., V.K., K.S.H., U.T.), Division of Pulmonology, Breathing Institute, Children's Hospital Colorado (S.H.A.), and Department of Radiology, Children's Hospital Colorado (L.P.B.), University of Colorado Denver/Anschutz Medical Campus; and Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, IL (A.J.B.)
| | - Lorna P Browne
- From the Division of Cardiology, Heart Institute, Children's Hospital Colorado (M.S., D.D.I., B.F., K.S.H., U.T.), Department of Bioengineering, College of Engineering and Applied Sciences (M.S., D.D.I., V.K., K.S.H., U.T.), Division of Pulmonology, Breathing Institute, Children's Hospital Colorado (S.H.A.), and Department of Radiology, Children's Hospital Colorado (L.P.B.), University of Colorado Denver/Anschutz Medical Campus; and Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, IL (A.J.B.)
| | - Brian Fonseca
- From the Division of Cardiology, Heart Institute, Children's Hospital Colorado (M.S., D.D.I., B.F., K.S.H., U.T.), Department of Bioengineering, College of Engineering and Applied Sciences (M.S., D.D.I., V.K., K.S.H., U.T.), Division of Pulmonology, Breathing Institute, Children's Hospital Colorado (S.H.A.), and Department of Radiology, Children's Hospital Colorado (L.P.B.), University of Colorado Denver/Anschutz Medical Campus; and Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, IL (A.J.B.)
| | - Vitaly Kheyfets
- From the Division of Cardiology, Heart Institute, Children's Hospital Colorado (M.S., D.D.I., B.F., K.S.H., U.T.), Department of Bioengineering, College of Engineering and Applied Sciences (M.S., D.D.I., V.K., K.S.H., U.T.), Division of Pulmonology, Breathing Institute, Children's Hospital Colorado (S.H.A.), and Department of Radiology, Children's Hospital Colorado (L.P.B.), University of Colorado Denver/Anschutz Medical Campus; and Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, IL (A.J.B.)
| | - Kendall S Hunter
- From the Division of Cardiology, Heart Institute, Children's Hospital Colorado (M.S., D.D.I., B.F., K.S.H., U.T.), Department of Bioengineering, College of Engineering and Applied Sciences (M.S., D.D.I., V.K., K.S.H., U.T.), Division of Pulmonology, Breathing Institute, Children's Hospital Colorado (S.H.A.), and Department of Radiology, Children's Hospital Colorado (L.P.B.), University of Colorado Denver/Anschutz Medical Campus; and Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, IL (A.J.B.)
| | - Uyen Truong
- From the Division of Cardiology, Heart Institute, Children's Hospital Colorado (M.S., D.D.I., B.F., K.S.H., U.T.), Department of Bioengineering, College of Engineering and Applied Sciences (M.S., D.D.I., V.K., K.S.H., U.T.), Division of Pulmonology, Breathing Institute, Children's Hospital Colorado (S.H.A.), and Department of Radiology, Children's Hospital Colorado (L.P.B.), University of Colorado Denver/Anschutz Medical Campus; and Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, IL (A.J.B.)
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Malone L, Fonseca B, Fagan T, Gralla J, Wilson N, Vargas D, DiMaria M, Truong U, Browne LP. Preprocedural Risk Assessment Prior to PPVI with CMR and Cardiac CT. Pediatr Cardiol 2017; 38:746-753. [PMID: 28210769 DOI: 10.1007/s00246-017-1574-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Accepted: 01/19/2017] [Indexed: 11/29/2022]
Abstract
Percutaneous pulmonary valve intervention (PPVI) is a less invasive and less costly approach to pulmonary valve replacement compared with the surgical alternative. Potential complications of PPVI include coronary compression and pulmonary arterial injury/rupture. The purpose of this study was to characterize the morphological risk factors for PPVI complication with cardiac MRI and cardiac CTA. A retrospective review of 88 PPVI procedures was performed. 44 patients had preprocedural cardiac MRIs or CTAs available for review. Multiple morphological variables on cardiac MRI and CTA were compared with known PPVI outcome and used to investigate associations of variables in determining coronary compression or right ventricular-pulmonary arterial conduit injury. The most significant risk factor for coronary artery compression was the proximity of the coronary arteries to the conduit. In all patients with coronary compression during PPVI, the coronary artery touched the conduit on the preprocedural CTA/MRI, whilst in patients without coronary compression the mean distance between the coronary artery and the conduit was 4.9 mm (range of 0.8-20 mm). Multivariable regression analysis demonstrated that exuberant conduit calcification was the most important variable for determining conduit injury. Position of the coronary artery directly contacting the conduit without any intervening fat may predict coronary artery compression during PPVI. Exuberant conduit calcification increases the risk of PPVI-associated conduit injury. Close attention to these factors is recommended prior to intervention in patients with pulmonary valve dysfunction.
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Affiliation(s)
- Ladonna Malone
- Department of Radiology, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Brian Fonseca
- Department of Cardiology, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Thomas Fagan
- University of Tennessee Health Sciences Center, Aurora, Colorado, USA
| | - Jane Gralla
- Department of Pediatrics, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Neil Wilson
- Department of Cardiology, Children's Hospital Colorado, Aurora, Colorado, USA
| | | | - Micheal DiMaria
- Department of Cardiology, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Uyen Truong
- Department of Cardiology, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Lorna P Browne
- Department of Radiology, Children's Hospital Colorado, Aurora, Colorado, USA.
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Goot BH, Patel S, Fonseca B. Rapid 3D imaging of the lower airway by MRI in patients with congenital heart disease: A retrospective comparison of delayed volume interpolated breath-hold examination (VIBE) to turbo spin echo (TSE). CONGENIT HEART DIS 2016; 12:84-90. [PMID: 27611348 DOI: 10.1111/chd.12408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Revised: 08/06/2016] [Accepted: 08/15/2016] [Indexed: 11/30/2022]
Abstract
OBJECTIVE When imaging the lower airway by MRI, the traditional technique turbo spin echo (TSE) results in high quality 2D images, however planning and acquisition times are lengthy. An alternative, delayed volume interpolated breath-holds examination (VIBE), is a 3D gradient echo technique that produces high spatial resolution imaging of the airway in one breath-hold. The objective of this study is to retrospectively evaluate the accuracy of lower airway measurements obtained by delayed VIBE when compared to TSE. DESIGN Patients with congenital heart disease who underwent a cardiac MRI (CMR) that included a delayed VIBE sequence from 5/2008 to 9/2013 were included. Standard TSE imaging was performed and delayed VIBE was acquired 5 min after gadolinium contrast administration. Airway measurements were made on both sequences by two observers in a blinded fashion to the other observer and other technique. Intraclass correlations (ICC) were calculated to assess for agreement between both techniques and the observers. RESULTS 29 studies met inclusion criteria with a mean patient age of 8.8 years (2 months to 63 years) and mean patient weight of 30.2 kg (3.5-110). All delayed VIBE and TSE sequences were found to be of diagnostic quality. Mean acquisition time was shorter for the delayed VIBE (13.1 seconds) than TSE (949.9 seconds). Overall there was very good agreement between the delayed VIBE and TSE measurements for both observers (ICC 0.78-0.94) with the exception of the distal right bronchus (ICC 0.67) The interobserver agreement was also excellent for both TSE (ICC 0.78-0.96) and VIBE (ICC 0.85-0.96). CONCLUSION Delayed VIBE is rapid and at least as accurate as the alternative TSE imaging for assessment of the lower airway by MRI across a wide spectrum of patients.
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Affiliation(s)
- Benjamin H Goot
- The Heart Institute, Department of Pediatrics, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Sonali Patel
- The Heart Institute, Department of Pediatrics, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Brian Fonseca
- The Heart Institute, Department of Pediatrics, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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Martinez-Aguila A, Fonseca B, Perez de Lara MJ, Pintor J. Effect of Melatonin and 5-Methoxycarbonylamino-N-Acetyltryptamine on the Intraocular Pressure of Normal and Glaucomatous Mice. ACTA ACUST UNITED AC 2016; 357:293-9. [DOI: 10.1124/jpet.115.231456] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Accepted: 03/02/2016] [Indexed: 01/02/2023]
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23
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Reeves JG, Montesa C, Fonseca B, Mitchell MB. Aortic Translocation for Repair of Transposition of the Great Arteries (S,D,L) With Ventricular Septal Defect and Pulmonic Stenosis. Ann Thorac Surg 2015; 101:357-9. [PMID: 26694279 DOI: 10.1016/j.athoracsur.2015.02.102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2015] [Revised: 02/10/2015] [Accepted: 02/18/2015] [Indexed: 10/22/2022]
Abstract
Biventricular repair for (S,D,L) transposition with ventricular septal defect, pulmonary stenosis, and superior-inferior ventricular malposition has not been described, to our knowledge. Herein we report biventricular repair of this complex lesion by aortic translocation.
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Affiliation(s)
- Justin G Reeves
- Department of Cardiovascular Surgery, School of Medicine, Children's Hospital Colorado and University of Colorado, Aurora, Colorado.
| | - Christine Montesa
- Department of Cardiothoracic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Brian Fonseca
- Department of Pediatrics, School of Medicine, The Heart Institute, Children's Hospital Colorado and University of Colorado, Aurora, Colorado
| | - Max B Mitchell
- Department of Cardiovascular Surgery, School of Medicine, The Heart Institute, Children's Hospital Colorado and University of Colorado, Aurora, Colorado
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Truong U, Patel S, Kheyfets V, Dunning J, Fonseca B, Barker AJ, Ivy D, Shandas R, Hunter K. Non-invasive determination by cardiovascular magnetic resonance of right ventricular-vascular coupling in children and adolescents with pulmonary hypertension. J Cardiovasc Magn Reson 2015; 17:81. [PMID: 26376972 PMCID: PMC4574020 DOI: 10.1186/s12968-015-0186-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Accepted: 08/21/2015] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Pediatric pulmonary hypertension (PH) remains a disease with high morbidity and mortality in children. Understanding ventricular-vascular coupling, a measure of how well matched the ventricular and vascular function are, may elucidate pathway leading to right heart failure. Ventricular vascular coupling ratio (VVCR), comprised of effective elastance (Ea, index of arterial load) and right ventricular maximal end-systolic elastance (Ees, index of contractility), is conventionally determined by catheterization. Here, we apply a non-invasive approach to determining VVCR in pediatric subjects with PH. METHODS This retrospective study included PH subjects who had a cardiovascular magnetic resonance (CMR) study within 14 days of cardiac catheterization. PH was defined as mean pulmonary artery pressure (mPAP) ≥ 25 mmHg on prior or current catheterization. A non-invasive measure of VVCR was derived from CMR-only (VVCRm) and compared to VVCR estimated by catheterization-derived single beat estimation (VVCRs). Indexed pulmonary vascular resistance (PVRi) and pulmonary vascular reactivity were determined during the catheterization procedure. Pearson correlation coefficients were calculated between PVRi and VVCRm. Receiver operating characteristic (ROC) curve analysis determined the diagnostic value of VVCRm in predicting vascular reactivity. RESULTS Seventeen subjects (3 months-23 years; mean 11.3 ± 7.4 years) were identified between January 2009-August 2013 for inclusion with equal gender distributions. Mean mPAP was 35 mmHg ± 15 and PVRi was 8.5 Woods unit x m2 ± 7.8. VVCRm (range 0.43-2.82) increased with increasing severity as defined by PVRi (p < 0.001), and was highly correlated with PVRi (r = 0.92, 95 % CI 0.79-0.97, p < 0.0001). Regression of VVCRm and PVRi demonstrated differing lines when separated by reactivity. VVCRm was significantly correlated with VVCRs (r = 0.79, CI 0.48-0.99, p <0.0001). ROC curve analysis showed high accuracy of VVCRm in determining vascular reactivity (VVCR = 0.85 had a sensitivity of 100 % and a specificity of 80 %) with an area under the curve of 0.89 (p = 0.008). CONCLUSION Measurement of VVCRm in pediatrics is feasible. Pulmonary vascular non-reactivity may be contribute to ventricular-vascular decoupling in severe PH. Therapeutic intervention to maintain a low vascular afterload in reactive patients may preserve right ventricular functional reserve and delay the onset of RV-PA decoupling. Use of VVCRm may have significant prognostic implication.
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Affiliation(s)
- Uyen Truong
- Division of Pediatric Cardiology, Children's Hospital Colorado, Aurora, CO, 80045, USA.
- Department for Pediatrics, Division of Cardiology, Children's Hospital Colorado, University of Colorado Anschultz Medical Center, 13123 E. 16th Avenue, B100, Aurora, CO, 80045, USA.
| | - Sonali Patel
- Division of Pediatric Cardiology, Children's Hospital Colorado, Aurora, CO, 80045, USA.
| | - Vitaly Kheyfets
- Department of Bioengineering, University of Colorado Denver Medical Campus, Aurora, CO, 80045, USA.
| | - Jamie Dunning
- Department of Bioengineering, University of Colorado Denver Medical Campus, Aurora, CO, 80045, USA.
| | - Brian Fonseca
- Division of Pediatric Cardiology, Children's Hospital Colorado, Aurora, CO, 80045, USA.
| | - Alex J Barker
- Department of Radiology, Northwestern University, Chicago, IL, USA.
| | - Dunbar Ivy
- Division of Pediatric Cardiology, Children's Hospital Colorado, Aurora, CO, 80045, USA.
| | - Robin Shandas
- Division of Pediatric Cardiology, Children's Hospital Colorado, Aurora, CO, 80045, USA.
- Department of Bioengineering, University of Colorado Denver Medical Campus, Aurora, CO, 80045, USA.
| | - Kendall Hunter
- Division of Pediatric Cardiology, Children's Hospital Colorado, Aurora, CO, 80045, USA.
- Department of Bioengineering, University of Colorado Denver Medical Campus, Aurora, CO, 80045, USA.
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Goot B, Patel S, Fonseca B. Rapid 3D imaging of the airway by MRI in patients with congenital heart disease: comparison of delayed volume interpolated breath hold examination (VIBE) technique to the turbo spin echo (TSE). J Cardiovasc Magn Reson 2014. [PMCID: PMC4043494 DOI: 10.1186/1532-429x-16-s1-p117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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26
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Truong U, Patel S, Fonseca B, Dunning J, Ivy D, Shandas R, Hunter K. Combined CMR and catheterization data in determining right ventricular-arterial coupling in children and adolescents with pulmonary arterial hypertension. J Cardiovasc Magn Reson 2014. [PMCID: PMC4044105 DOI: 10.1186/1532-429x-16-s1-o43] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Truong U, Fonseca B, Dunning J, Burgett S, Lanning C, Ivy DD, Shandas R, Hunter K, Barker AJ. Wall shear stress measured by phase contrast cardiovascular magnetic resonance in children and adolescents with pulmonary arterial hypertension. J Cardiovasc Magn Reson 2013; 15:81. [PMID: 24034144 PMCID: PMC3848825 DOI: 10.1186/1532-429x-15-81] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Accepted: 09/03/2013] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Pulmonary arterial hypertension (PAH) is a devastating disease with significant morbidity and mortality. At the macroscopic level, disease progression is observed as a complex interplay between mean pulmonary artery pressure, pulmonary vascular resistance, pulmonary vascular stiffness, arterial size, and flow. Wall shear stress (WSS) is known to mediate or be dependent on a number of these factors. Given that WSS is known to promote architectural vessel remodeling, it is imperative that the changes of this factor be quantified in the presence of PAH. METHODS In this study, we analyzed phase contrast imaging of the right pulmonary artery derived from cardiovascular magnetic resonance to quantify the local, temporal and circumferentially averaged WSS of a PAH population and a pediatric control population. In addition, information about flow and relative area change were derived. RESULTS Although the normotensive and PAH shear waveform exhibited a WSS profile which is uniform in magnitude and direction along the vessel circumference at systole, time-averaged WSS (2.2 ± 1.6 vs. 6.6 ± 3.4 dynes/cm(2), P = 0.018) and systolic WSS (8.2 ± 5.0 v. 20.0 ± 9.1 dynes/cm(2), P = 0.018) was significantly depressed in the PAH population as compared to the controls. BSA-indexed PA diameter was significantly larger in the PAH population (1.5 ± 0.4 vs. 0.7 ± 0.1 cm/m(2), P = 0.003). CONCLUSIONS In the presence of preserved flow rates through a large PAH pulmonary artery, WSS is significantly decreased. This may have implications for proximal pulmonary artery remodeling and cellular function in the progression of PAH.
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Affiliation(s)
- Uyen Truong
- Division of Pediatric Cardiology, Children’s Hospital Colorado, Aurora, CO 80045, USA
| | - Brian Fonseca
- Division of Pediatric Cardiology, Children’s Hospital Colorado, Aurora, CO 80045, USA
| | - Jamie Dunning
- Department for Bioengineering, University of Colorado, 13123 E. 16th Avenue B100, Aurora, CO 80045, USA
| | - Shawna Burgett
- Department for Bioengineering, University of Colorado, 13123 E. 16th Avenue B100, Aurora, CO 80045, USA
| | - Craig Lanning
- Department for Bioengineering, University of Colorado, 13123 E. 16th Avenue B100, Aurora, CO 80045, USA
| | - D Dunbar Ivy
- Division of Pediatric Cardiology, Children’s Hospital Colorado, Aurora, CO 80045, USA
| | - Robin Shandas
- Division of Pediatric Cardiology, Children’s Hospital Colorado, Aurora, CO 80045, USA
- Department for Bioengineering, University of Colorado, 13123 E. 16th Avenue B100, Aurora, CO 80045, USA
| | - Kendall Hunter
- Department for Bioengineering, University of Colorado, 13123 E. 16th Avenue B100, Aurora, CO 80045, USA
| | - Alex J Barker
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
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Fonseca B, Pazos M, Tavares T, Sanromán MA. Removal of hexavalent chromium of contaminated soil by coupling electrokinetic remediation and permeable reactive biobarriers. Environ Sci Pollut Res Int 2012; 19:1800-1808. [PMID: 22203400 DOI: 10.1007/s11356-011-0694-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/17/2011] [Accepted: 12/09/2011] [Indexed: 05/31/2023]
Abstract
PURPOSE In this study, a novel and ecological alternative have been developed to treat soils contaminated with hexavalent chromium coupling two well-known systems: electrokinetic remediation and permeable reactive biobarriers. The electric field promotes the electromigration of the hexavalent chromium oxyanions towards the anode. The biobarriers were placed before the anode electrode, in order to promote the reduction and retention of the chromium migrating in its direction. Thus, this technology provided a global treatment to soil removal without subsequent treatments of the contaminated effluents. METHODS The electrokinetic system was coupled with two different permeable reactive biobarriers composed by Arthrobacter viscosus bacteria, supported either in activated carbon or zeolite. An electric field of 10 V was applied and two different treatment times of 9 and 18 days were tested. RESULTS Removal values of 60% and 79% were obtained when electrokinetic treatment was coupled with zeolite and activated carbon biobarriers, respectively, for a test period of 18 day. The reduction of hexavalent chromium to trivalent chromium was around 45% for both systems. CONCLUSIONS In this work, two types of biobarriers were efficiently coupled to electrokinetic treatment to decontaminate soil with Cr(VI). Furthermore, the viability of the new coupling technology developed (electrokinetic + biobarriers) to treat low-permeability polluted soils was demonstrated.
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Affiliation(s)
- B Fonseca
- Institute for Biotechnology and Bioengineering, Centre of Biological Engineering, University of Minho, Braga, Portugal
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Fonseca B, Younoszai A, Landeck B. SIMPLE PRESENCE OF AORTIC HOLODIASTOLIC FLOW REVERSAL IN CONGENITAL HEART DISEASE DOES NOT PREDICT MODERATE AORTIC INSUFFICIENCY: NOVEL EVALUATION OF THE REVERSE TO FORWARD FLOW RATIO BY ECHO COMPARED TO MAGNETIC RESONANCE IMAGING. J Am Coll Cardiol 2012. [DOI: 10.1016/s0735-1097(12)60800-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Fonseca B, Teixeira A, Figueiredo H, Tavares T. Modelling of the Cr(VI) transport in typical soils of the North of Portugal. J Hazard Mater 2009; 167:756-762. [PMID: 19216027 DOI: 10.1016/j.jhazmat.2009.01.049] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2008] [Revised: 11/21/2008] [Accepted: 01/12/2009] [Indexed: 05/27/2023]
Abstract
Adsorption of hexavalent chromium [Cr(VI)] onto a loamy sand soil was studied using batch and steady flow tests with contaminant solutions at pH 2, 5 and 7. In all the cases the adsorption of Cr(VI) decreased with increasing pH. The hexavalent chromium speciation and its presence as different oxyanions, according to the solution pH, were the main variables affecting the adsorption process. The influence of the ratio soil/solution concentration was also studied in flow systems at pH 2. Chromium retention increased with the increasing of its concentration in the influent solution. A two-site adsorption model was fitted to the breakthrough curves of hexavalent chromium solutions in order to estimate the Freundlich (k(F)) and Langmuir (S(max)) adsorption parameters, using CXTFIT code. These values were compared to those determined by batch tests and it was concluded that batch tests tended to underestimate these parameters. Nevertheless, they followed the same trend as the parameters determined in opened system, even when the pH of the initial solution was modified.
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Affiliation(s)
- B Fonseca
- IBB-Institute for Biotechnology and Bioengineering, Centre of Biological Engineering, University of Minho, Braga, Portugal.
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Fonseca B, Ivy D, Lanning C. Magnetic resonance phase contrast imaging in children with pulmonary artery hypertension. J Cardiovasc Magn Reson 2009. [PMCID: PMC7860754 DOI: 10.1186/1532-429x-11-s1-p246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Quintelas C, Fonseca B, Silva B, Figueiredo H, Tavares T. Treatment of chromium(VI) solutions in a pilot-scale bioreactor through a biofilm of Arthrobacter viscosus supported on GAC. Bioresour Technol 2009; 100:220-226. [PMID: 18565747 DOI: 10.1016/j.biortech.2008.05.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2008] [Revised: 05/05/2008] [Accepted: 05/06/2008] [Indexed: 05/26/2023]
Abstract
The aim of this work is to evaluate the applicability of a biofilm to the removal of chromium in solution, at a pilot scale. The effect of the initial concentration of metal on the biosorption behavior of an Arthrobacter viscosus biofilm supported on granular activated carbon, in batch and column essays was also analyzed. Six isotherm equations have been tested in the present study. The best fit was obtained with the Freundlich model. It was observed that as the initial chromium concentration increases, the uptake increases too, but the removal percentage decreases, with values between 95.20% (C(0)=5mg/l) and 38.28% (C(0)=1000 mg/l). The batch adsorption studies were used to develop a pilot bioreactor able to remove chromium from aqueous solutions. Data obtained in a pilot-scale reactor showed an average removal percentage of 99.9%, during the first 30 days, for the initial concentration of 10mg/l and an average removal percentage of 72%, for the same period and for the initial concentration of 100mg/l. Uptake values of 11.35 mg/g and 14.55 mg/g were obtained, respectively, for the initial concentration of 10 and 100mg/l. The results obtained are very promising and encourage the utilization of this biofilm in environmental applications.
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Affiliation(s)
- C Quintelas
- IBB-Institute for Biotechnology and Bioengineering, Centre of Biological Engineering, University of Minho, Braga, Portugal.
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Roscioli T, Kennedy D, Cui J, Fonseca B, Watson GF, Pereira J, Xie YG, Mowat D. Pallister-Hall syndrome: Unreported skeletal features of aGLI3mutation. Am J Med Genet A 2005; 136A:390-4. [PMID: 16007608 DOI: 10.1002/ajmg.a.30818] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
We describe two patients with Pallister-Hall syndrome (PHS), both with evidence of a generalized skeletal dysplasia as typified by upper and lower acromesomelic limb shortening and the previously unreported fibular hypoplasia, radio-ulnar bowing, and proximal epiphyseal hypoplasia. Genomic DNA was only available for sequencing analysis in patient 2 and the mutation, c.3386_3387delTT was detected in exon 14 of the GL13 gene. It is also possible that the findings in patient 1 represent the phenotypic expression of a novel GLI3 mutation. This report further expands the PHS phenotype and raises the possibility of specific GLI3 mutations resulting in more severe skeletal features. It also suggests that PHS should be included in the differential diagnosis of antenatally ascertained acromesomelic limb shortening and bowing with fibular hypoplasia particularly in the presence of polysyndactyly.
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Affiliation(s)
- T Roscioli
- South Eastern Sydney Genetics Service, Sydney Children's Hospital, Sydney, Australia
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Abstract
We assessed the utility of the chest film as a screening tool for term and preterm neonates with suspected structural heart disease. Three independent observers, blinded to patient diagnosis, retrospectively evaluated the initial chest film for each of 128 consecutive neonates with suspected heart disease (gestational age, 23-42 weeks; birth weight, 500-4,621 g) who had undergone both chest radiography and echocardiography. These evaluations were subsequently compared with the results of the respective echocardiograms, read by board-certified pediatric cardiologists blinded to the chest film and chest film interpretation. Kappa statistics demonstrated moderate correlation (0.42-0.48) among different observers in their interpretation of the chest films but poor correlation (0.15-0.34) between chest radiography and echocardiography. The chest film had a low sensitivity for structural heart disease (26-59%), with a negative predictive value of 46-52%. Among neonates less than 2 kg or younger than 35 weeks of gestation, the chest film had still lower sensitivity for detecting heart disease. Despite agreement among observers in chest film interpretation, the chest film does not function as a screening test for neonates with suspected heart disease, particularly in small or premature neonates. In neonates with suspected heart disease, echocardiography should be considered, even in patients with chest films that do not suggest congenital heart disease.
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Affiliation(s)
- B Fonseca
- Department of Pediatrics, University of California, San Diego, UCSD Medical Center, 200 W. Arbor, CA 92103, USA
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Mella I, García de los Béos M, Tapia JC, Carrasco E, Fonseca B. [Weight-height development in juvenile diabetics]. Rev Chil Pediatr 1981; 52:204-12. [PMID: 7031789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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García de los Ríos M, Carrasco E, Padilla M, Fonseca B, López G. [Treatment of obesity with a liquid, relatively high protein diet (author's transl)]. Rev Med Chil 1980; 108:691-6. [PMID: 7221255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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