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Maller VV, Johnson JN, Boston U, Knott-Craig C. Transseptal coronary artery-a pictorial review. Pediatr Radiol 2024:10.1007/s00247-024-05911-x. [PMID: 38637337 DOI: 10.1007/s00247-024-05911-x] [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: 11/21/2023] [Revised: 03/08/2024] [Accepted: 03/15/2024] [Indexed: 04/20/2024]
Abstract
A transseptal coronary artery course, also known as a transconal course, is an anomalous course of the left main coronary artery (LMCA) or the left anterior descending artery (LAD) through the conal septal myocardium. The conal septal myocardium is the posterior wall of the right ventricular outflow tract (RVOT), acting as a dividing myocardial wall between the subaortic and subpulmonary outflow tracts. The initial segment of a transseptal coronary artery has an extraconal course between the aorta and the RVOT cranial to the true intramyocardial segment. The transseptal coronary artery then emerges out of the conal septal myocardium at the epicardial surface on the lateral aspect of the RVOT. Many consider the transseptal coronary artery to be a benign entity. However, there are few case reports of severe cardiac symptoms such as myocardial ischemia, arrhythmia, and even sudden cardiac deaths due to potential coronary artery compression in the systolic phase. In this article, we seek to describe the imaging findings of transseptal coronary artery course on coronary computed tomography angiography (CTA), discuss their clinical analysis, and briefly discuss the management of these lesions.
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Affiliation(s)
- Vijetha V Maller
- Department of Radiology, LeBonheur Children's Hospital, University of Tennessee Health Science Center, 848 Adams Avenue, Radiology G216, Memphis, TN, USA.
| | - Jason N Johnson
- Division of Pediatric Cardiology, Pediatrics, Heart institute, LeBonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Umar Boston
- Division of Pediatric Cardiothoracic Surgery, Department of Surgery, Heart Institute, LeBonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Christopher Knott-Craig
- Division of Pediatric Cardiothoracic Surgery, Department of Surgery, Heart Institute, LeBonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN, USA
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Philip RR, Sentilles C, Johnson JN, Merlocco A, Ramakrishnan K, Ryan KA, Boston U, Sathanandam S. Lessons from the Pandemic: Role of Percutaneous ECMO and Balloon Atrial Septostomy in Multi-System Inflammatory Syndrome in Children. J Clin Med 2024; 13:2168. [PMID: 38673441 PMCID: PMC11050248 DOI: 10.3390/jcm13082168] [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: 02/22/2024] [Revised: 03/27/2024] [Accepted: 04/04/2024] [Indexed: 04/28/2024] Open
Abstract
Multi-system inflammatory syndrome in children (MIS-C) in the setting of COVID-19 can be associated with severe cardiopulmonary dysfunction. This clinical deterioration may sometimes necessitate veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support. We describe an algorithmic approach including the role of balloon atrial septostomy in this cohort. This is the first reported series of percutaneous VA-ECMO in pediatric patients with MIS-C for better outcomes. The lessons from this approach can be replicated in other pediatric clinical conditions and adds to the armament of multiple pediatric specialties.
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Affiliation(s)
- Ranjit R. Philip
- Division of Pediatric Cardiology, Department of Pediatrics, University of Tennessee Health Science Center, 50 N Dunlap St., Memphis, TN 38103, USA; (J.N.J.); (A.M.); (K.A.R.); (S.S.)
- The Heart Institute, Le Bonheur Children’s Hospital, 51 N Dunlap St., Memphis, TN 38103, USA; (K.R.); (U.B.)
| | - Claire Sentilles
- Division of General Pediatrics, Department of Pediatrics, University of Tennessee Health Science Center, 50 N Dunlap St., Memphis, TN 38103, USA;
| | - Jason N. Johnson
- Division of Pediatric Cardiology, Department of Pediatrics, University of Tennessee Health Science Center, 50 N Dunlap St., Memphis, TN 38103, USA; (J.N.J.); (A.M.); (K.A.R.); (S.S.)
- The Heart Institute, Le Bonheur Children’s Hospital, 51 N Dunlap St., Memphis, TN 38103, USA; (K.R.); (U.B.)
| | - Anthony Merlocco
- Division of Pediatric Cardiology, Department of Pediatrics, University of Tennessee Health Science Center, 50 N Dunlap St., Memphis, TN 38103, USA; (J.N.J.); (A.M.); (K.A.R.); (S.S.)
- The Heart Institute, Le Bonheur Children’s Hospital, 51 N Dunlap St., Memphis, TN 38103, USA; (K.R.); (U.B.)
| | - Karthik Ramakrishnan
- The Heart Institute, Le Bonheur Children’s Hospital, 51 N Dunlap St., Memphis, TN 38103, USA; (K.R.); (U.B.)
- Division of Pediatric Cardiothoracic Surgery, Department of Surgery, University of Tennessee Health Science Center, 901 Madison Ave. Memphis, TN 38163, USA
| | - Kaitlin A. Ryan
- Division of Pediatric Cardiology, Department of Pediatrics, University of Tennessee Health Science Center, 50 N Dunlap St., Memphis, TN 38103, USA; (J.N.J.); (A.M.); (K.A.R.); (S.S.)
- The Heart Institute, Le Bonheur Children’s Hospital, 51 N Dunlap St., Memphis, TN 38103, USA; (K.R.); (U.B.)
| | - Umar Boston
- The Heart Institute, Le Bonheur Children’s Hospital, 51 N Dunlap St., Memphis, TN 38103, USA; (K.R.); (U.B.)
- Division of Pediatric Cardiothoracic Surgery, Department of Surgery, University of Tennessee Health Science Center, 901 Madison Ave. Memphis, TN 38163, USA
| | - Shyam Sathanandam
- Division of Pediatric Cardiology, Department of Pediatrics, University of Tennessee Health Science Center, 50 N Dunlap St., Memphis, TN 38103, USA; (J.N.J.); (A.M.); (K.A.R.); (S.S.)
- The Heart Institute, Le Bonheur Children’s Hospital, 51 N Dunlap St., Memphis, TN 38103, USA; (K.R.); (U.B.)
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Zuckermann A, Jacobs J, Shudo Y, Meyer D, Silvestry S, Leacche M, Sciortino C, Rodrigo M, Pham S, Takeda K, Copeland H, Vidic A, Kawabori M, Boston U, Bustamante-Munguira J, Esteve AE, Venkateswaran R, Schroder J, D'Alessandro D. Validating the 2014 Consensus Primary Graft Definition: An Analysis on the 1,056 Patients from the Multi-Center Guardian Registry. J Heart Lung Transplant 2023. [DOI: 10.1016/j.healun.2023.02.158] [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: 04/05/2023] Open
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Boston U, Zuckermann A, Stukov Y, Schroder J, Shudo Y, Bustamante-Munguira J, Leacche M, Silvestry S, Kawabori M, Takeda K, Jacobs J. Outcomes in Children and Young Adults with Congenital Heart Disease Undergoing Transplant: A Subgroup Analysis of the Guardian Heart Registry. J Heart Lung Transplant 2023. [DOI: 10.1016/j.healun.2023.02.613] [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: 04/05/2023] Open
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Buyukgoz C, Absi M, Martinez H, Street T, Siddique R, Boston U. Donor Heart Preservation Strategy Using a Cold Storage System for Pediatric Heart Transplantation. J Heart Lung Transplant 2023. [DOI: 10.1016/j.healun.2023.02.099] [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: 04/05/2023] Open
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Jacobs J, Boston U, Stukov Y, Schroder J, Bustamante-Munguira J, Zuckermann A. Pediatric Experience Using the Sherpapak Cardiac Transport System: A Subgroup Analysis of the Guardian Heart Registry. J Heart Lung Transplant 2023. [DOI: 10.1016/j.healun.2023.02.202] [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: 04/05/2023] Open
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Buyukgoz C, Sandhu H, Shah S, Rower K, Ramakrishnan K, Waller BR, Kiene A, Knott-Craig C, Boston U, Sathanandam S. Strategies and techniques for percutaneous Veno-Arterial ECMO cannulation and decannulation in children. Catheter Cardiovasc Interv 2023; 101:1088-1097. [PMID: 36994891 DOI: 10.1002/ccd.30649] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 03/01/2023] [Accepted: 03/10/2023] [Indexed: 03/31/2023]
Abstract
OBJECTIVES To describe the techniques used for percutaneous veno-arterial extracorporeal membrane oxygenation (VA-ECMO) cannulation and decannulation in children with the pediatric interventional cardiologist (PIC) as the primary operator, and present outcomes of this initial clinical experience. BACKGROUND Percutaneous VA-ECMO during cardiopulmonary resuscitation (CPR) has been successfully performed in adults, but currently, not much data exists on children. METHODS This is a single-center study including VA-ECMO cannulations performed by the PIC between 2019 and 2021. Efficacy was defined as the successful initiation of VA-ECMO without surgical cutdown. Safety was defined as the absence of additional procedures related to cannulation. RESULTS Twenty-three percutaneous VA-ECMO cannulations were performed by PIC on 20 children with 100% success. Fourteen (61%) were performed during ongoing CPR, and nine for cardiogenic shock. The Median age was 15 (0.15-18) years, and the median weight was 65 (3.3-180) kg. All arterial cannulations were via the femoral artery except in one, 8-week-old infant who was cannulated in the carotid artery. A distal perfusion cannula was placed in the ipsilateral limb in 17 (78%). The median time from initiating cannulation to ECMO flow was 35 (13-112) minutes. Two patients required arterial graft placement at the time of decannulation and one needed below-knee amputation. ECMO support was maintained for a median of 4 (0.3-38) days. Thirty-day survival was 74%. CONCLUSION Percutaneous VA-ECMO cannulations can be effectively performed, even during CPR with the Pediatric Interventional Cardiologist being the primary operator. This is an initial clinical experience. Future outcome studies compared with standard surgical cannulations are necessary to advocate routine percutaneous VA-ECMO in children.
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Affiliation(s)
- Cihangir Buyukgoz
- Division of Pediatric Cardiology, LeBonheur Children's Hospital, University of Tennessee, Memphis, Tennessee, USA
| | - Hitesh Sandhu
- Division of Pediatric Critical Care Medicine, LeBonheur Children's Hospital, University of Tennessee, Memphis, Tennessee, USA
| | - Samir Shah
- Division of Pediatric Critical Care Medicine, LeBonheur Children's Hospital, University of Tennessee, Memphis, Tennessee, USA
| | - Katy Rower
- Division of Pediatric Critical Care Medicine, LeBonheur Children's Hospital, University of Tennessee, Memphis, Tennessee, USA
| | - Karthik Ramakrishnan
- Division of Congenital Cardiac Surgery, LeBonheur Children's Hospital, University of Tennessee, Memphis, Tennessee, USA
| | - B Rush Waller
- Division of Pediatric Cardiology, LeBonheur Children's Hospital, University of Tennessee, Memphis, Tennessee, USA
| | - Ashley Kiene
- Division of Pediatric Cardiology, LeBonheur Children's Hospital, University of Tennessee, Memphis, Tennessee, USA
| | - Christopher Knott-Craig
- Division of Congenital Cardiac Surgery, LeBonheur Children's Hospital, University of Tennessee, Memphis, Tennessee, USA
| | - Umar Boston
- Division of Congenital Cardiac Surgery, LeBonheur Children's Hospital, University of Tennessee, Memphis, Tennessee, USA
| | - Shyam Sathanandam
- Division of Pediatric Cardiology, LeBonheur Children's Hospital, University of Tennessee, Memphis, Tennessee, USA
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Chakraborty A, Ramakrishnan K, Buyukgoz C, Tadphale S, Allen J, Absi M, Briceno-Medina M, Boston U, Knott-Craig CJ. Incidence of Acute Neurological Events in Neonates and Infants Undergoing Cardiac Surgery Using a High-Hematocrit/ High-Flow Bypass Strategy. World J Pediatr Congenit Heart Surg 2023; 14:375-379. [PMID: 36872647 DOI: 10.1177/21501351221143950] [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: 03/07/2023]
Abstract
Background: The incidence of new acute neurological injury occurring in neonates and infants during cardiac surgery utilizing cardiopulmonary bypass is reportedly 3% to 5%. In 2013, we adopted a high flow rate, and high hematocrit bypass strategy, and sought to assess the incidence of early neurological injuries associated with this strategy. Methods: Neonates and infants undergoing cardiopulmonary bypass between January 2013 and December 2019 (n = 714) comprise the study. Adverse neurological events (ANEs) were defined as any abnormality of pupils, delayed awakening, seizures, focal neurological deficits, concerns prompting neurological consultation, or any abnormality on neurological imaging in the postoperative period. Our bypass strategy included a high flow rate (150-200 mL/kg/min), without reduction of flow rates during cooling and maintaining a target hematocrit on bypass > 32% with a terminal hematocrit of > 42%. Results: Median weight at the time of the procedure was 4.6 kg (IQR 3.6-6.1 kg) with the smallest patient weighing 1.36 kg. There were 46 premature patients (6.4%). There were 149 patients (20.9%) patients who underwent deep hypothermic circulatory arrest with a median time of 26 min (IQR 21-41 min). Hospital mortality was 3.5% (24/714, 95% CI: 2.28-5.13). The incidence of neurological events as defined above was 0.84% (6/714, 95% CI: 0.31-1.82). Neurological imaging identified ischemic injury in 4 patients and intraventricular hemorrhage in 2. Conclusions: High flow/high hematocrit bypass strategy was associated with a low incidence of ANE in this vulnerable population.
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Affiliation(s)
- Abhishek Chakraborty
- Pediatric Cardiology, University of Tennessee, Le Bonheur Children's Hospital, Memphis, TN, USA
| | - Karthik Ramakrishnan
- Pediatric Cardiovascular Surgery, University of Tennessee, Le Bonheur Children's Hospital, Memphis, TN, USA
| | - Cihangir Buyukgoz
- Pediatric Critical Care Medicine, University of Tennessee, Le Bonheur Children's Hospital, Memphis, TN, USA
| | - Sachin Tadphale
- Pediatric Critical Care Medicine, University of Tennessee, Le Bonheur Children's Hospital, Memphis, TN, USA
| | - Jerry Allen
- Pediatric Cardiovascular Surgery, University of Tennessee, Le Bonheur Children's Hospital, Memphis, TN, USA
| | - Mohammed Absi
- Pediatric Cardiology, University of Tennessee, Le Bonheur Children's Hospital, Memphis, TN, USA
| | - Maria Briceno-Medina
- Pediatric Cardiology, University of Tennessee, Le Bonheur Children's Hospital, Memphis, TN, USA
| | - Umar Boston
- Pediatric Cardiovascular Surgery, University of Tennessee, Le Bonheur Children's Hospital, Memphis, TN, USA
| | - Christopher J Knott-Craig
- Pediatric Cardiovascular Surgery, University of Tennessee, Le Bonheur Children's Hospital, Memphis, TN, USA
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Jacobs J, Schroder J, Boston U, Zuckermann A. First Report of Pediatric Outcomes from the GUARDIAN Registry: Multi-Center Analysis of Advanced Organ Preservation for Pediatric Recipients. J Heart Lung Transplant 2022. [DOI: 10.1016/j.healun.2022.01.1205] [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: 11/28/2022] Open
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Radel L, Boston U, Beasley G, Goldberg J, Martinez H, Ryan K, Kramer J, Rayburn M, Towbin J, Absi M. Impact of Cangrelor Use in Children Supported on Paracorporeal Ventricular Assist Devices. J Heart Lung Transplant 2022. [DOI: 10.1016/j.healun.2022.01.1316] [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: 11/30/2022] Open
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Absi M, Radel L, Kramer J, Boston U. Use of Isolated Right Ventricular Assist Device for Refractory Graft Failure Following a Pediatric Orthotopic Heart Transplantation. J Heart Lung Transplant 2022. [DOI: 10.1016/j.healun.2022.01.1321] [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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Fahnhorst SE, Beasley G, Goldberg JF, Martinez HR, Ryan KA, Towbin JA, Boston U, Absi M. Novel use of cangrelor in pediatrics: A pilot cohort study demonstrating use in ventricular assist devices. Artif Organs 2020; 45:38-45. [PMID: 33180355 DOI: 10.1111/aor.13782] [Citation(s) in RCA: 2] [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] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 06/19/2020] [Accepted: 07/14/2020] [Indexed: 01/02/2023]
Abstract
Thromboembolic events and bleeding are major sources of morbidity among pediatric patients supported on a ventricular assist device (VAD). Pharmacokinetics and pharmacodynamics of enteral antiplatelet agents are affected and variable due to erratic enteral absorption in end-stage heart failure and VAD circulation. Additionally, 20%-40% of the population are poor metabolizers of clopidogrel, a prodrug, making cangrelor an alternative when antiplatelet therapy is crucial. Cangrelor has been used effectively and safely for short durations in adults during percutaneous coronary interventions, but the use of cangrelor is still under investigation in pediatrics. This case series utilized cangrelor, a novel short-acting, reversible, intravenous P2Y12 platelet inhibitor in managing pediatric patients supported with a VAD. We performed a retrospective, single-center review of patients admitted to a tertiary medical center with end-stage heart failure requiring mechanical circulatory support and concomitant cangrelor administration between January 2019 and March 2020. Platelet function testing, cangrelor dose, bleeding complications, thromboembolic events, and frequency of circuit interventions during the use of cangrelor were recorded. Optimal platelet reactivity, defined as P2Y12 < 180 platelet reaction units (PRU), was measured with serial point-of-care testing (VerifyNow). Seven patients, median age of 4.9 years, met the above criteria. Three patients had a diagnosis of complex congenital heart disease. Four patients had dilated or restrictive cardiomyopathy. All patients were on continuous flow VADs. The median VAD duration was 84.5 days (IQR 61.5-103). The median duration on cangrelor was 43 days (IQR 8-70). The median cangrelor dose to reach the therapeutic threshold was 0.75 μg/kg/min with the mean P2Y12 , while on cangrelor of 164.75 PRU. Bleeding complications included mild gastrointestinal bleeding and hematuria. There was one patient with pump thrombosis requiring intervention. There were no cerebrovascular events while on cangrelor. We report the first successful long-term use of cangrelor in pediatric patients. The reversibility and short half-life of cangrelor make it a feasible antiplatelet agent in selected patients. This data supports the use of cangrelor in children as a viable antiplatelet option; with minimal bleeding complications and no cerebrovascular events demonstrated in this cohort.
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Affiliation(s)
- Sarah E Fahnhorst
- Division of Pediatric Cardiology, Le Bonheur Children's Hospital, University of Tennessee Health Sciences Center, Memphis, TN, USA
| | - Gary Beasley
- Division of Pediatric Cardiology, Le Bonheur Children's Hospital, University of Tennessee Health Sciences Center, Memphis, TN, USA
| | - Jason F Goldberg
- Division of Pediatric Cardiology, Le Bonheur Children's Hospital, University of Tennessee Health Sciences Center, Memphis, TN, USA
| | - Hugo R Martinez
- Division of Pediatric Cardiology, Le Bonheur Children's Hospital, University of Tennessee Health Sciences Center, Memphis, TN, USA
| | - Kaitlin A Ryan
- Division of Pediatric Cardiology, Le Bonheur Children's Hospital, University of Tennessee Health Sciences Center, Memphis, TN, USA
| | - Jeffrey A Towbin
- Division of Pediatric Cardiology, Le Bonheur Children's Hospital, University of Tennessee Health Sciences Center, Memphis, TN, USA
| | - Umar Boston
- Department of Pediatric Cardiothoracic Surgery, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Mohammed Absi
- Division of Pediatric Cardiology, Le Bonheur Children's Hospital, University of Tennessee Health Sciences Center, Memphis, TN, USA
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Absi M, Sainathan S, Beasley G, Boston U. Use of a novel antiplatelet agent cangrelor in an infant supported with a ventricular assist device. Artif Organs 2020; 44:532-533. [PMID: 31957028 DOI: 10.1111/aor.13613] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 10/09/2019] [Accepted: 11/18/2019] [Indexed: 01/26/2023]
Affiliation(s)
- Mohammed Absi
- Pediatric Cardiology, Le Bonheur Children's Hospital, Memphis, TN, USA
| | - Sandeep Sainathan
- Pediatric Cardiothoracic Surgery Department, Le Bonheur Children's Hospital, Memphis, TN, USA
| | - Gary Beasley
- Pediatric Cardiology, Le Bonheur Children's Hospital, Memphis, TN, USA
| | - Umar Boston
- Pediatric Cardiothoracic Surgery Department, Le Bonheur Children's Hospital, Memphis, TN, USA
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Kumar TKS, Zurakowski D, Briceno-Medina M, Shah A, Sathanandam S, Allen J, Sandhu H, Joshi VM, Boston U, Knott-Craig CJ. Experience of a single institution with femoral vein homograft as right ventricle to pulmonary artery conduit in stage 1 Norwood operation. J Thorac Cardiovasc Surg 2019; 158:853-862.e1. [PMID: 31204139 DOI: 10.1016/j.jtcvs.2019.03.123] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [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: 04/26/2018] [Revised: 02/21/2019] [Accepted: 03/06/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Femoral vein homograft can be used be used as valved right ventricle to pulmonary artery conduit in the Norwood operation. We describe the results of this approach, including pulmonary artery growth and ventricular function. METHODS A retrospective chart review of 24 consecutive neonates with hypoplastic left heart syndrome or complex single ventricle undergoing this approach between June 2012 and December 2017 was performed. Conduit valve competency and ventricular function were estimated using transthoracic echocardiogram, and pulmonary artery growth was measured using Nakata's index. Changes in ventricular function pre-Glenn and at latest follow-up were assessed by ordinal logistic regression with a general linear model to account for the correlation within the same patient over time. RESULTS Median age at surgery was 4 days, and mean weight was 3 kg. There was no interstage mortality. A total of 21 patients have undergone Glenn operation, and 9 patients have completed the Fontan operation. None of the conduits developed thrombosis. Sixty-three percent of conduits remained competent in the first month, and 33% remained competent after 3 months of operation. Catheter interventions on conduits were necessary in 14 patients. Median Nakata index at pre-Glenn catheterization was 228 mm2/m2 (interquartile range, 107-341 mm2/m2). Right ventricular function was preserved in 83% of patients at a median follow-up of 34 (interquartile range, 10-46) months. CONCLUSIONS Femoral vein homograft as a right ventricle to pulmonary artery conduit in the Norwood operation is safe and associated with good pulmonary artery growth and preserved ventricular function as assessed by subjective echocardiography. Catheter intervention of the conduit may be necessary.
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Affiliation(s)
- T K Susheel Kumar
- Department of Pediatric Cardiothoracic Surgery, Le Bonheur Children's Hospital and University of Tennessee Health Science Center, Memphis, Tenn.
| | - David Zurakowski
- Departments of Anesthesiology and Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Mario Briceno-Medina
- Department of Pediatric Cardiology, Le Bonheur Children's Hospital and University of Tennessee Health Science Center, Memphis, Tenn
| | - Aditya Shah
- Department of Pediatric Cardiothoracic Surgery, Le Bonheur Children's Hospital and University of Tennessee Health Science Center, Memphis, Tenn
| | - Shyam Sathanandam
- Department of Pediatric Cardiology, Le Bonheur Children's Hospital and University of Tennessee Health Science Center, Memphis, Tenn
| | - Jerry Allen
- Department of Pediatric Cardiothoracic Surgery, Le Bonheur Children's Hospital and University of Tennessee Health Science Center, Memphis, Tenn
| | - Hitesh Sandhu
- Department of Pediatric Cardiology, Le Bonheur Children's Hospital and University of Tennessee Health Science Center, Memphis, Tenn
| | - Vijaya M Joshi
- Department of Pediatric Cardiology, Le Bonheur Children's Hospital and University of Tennessee Health Science Center, Memphis, Tenn
| | - Umar Boston
- Department of Pediatric Cardiothoracic Surgery, Le Bonheur Children's Hospital and University of Tennessee Health Science Center, Memphis, Tenn
| | - Christopher J Knott-Craig
- Department of Pediatric Cardiothoracic Surgery, Le Bonheur Children's Hospital and University of Tennessee Health Science Center, Memphis, Tenn
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Bayle KM, Boston U, Sainathan S, Naik R, Knott-Craig CJ. Ross-Konno Operation in an Infant With a Quadricuspid Pulmonary Valve and Anomalous Aortic Origin of the Right Coronary Artery. Ann Thorac Surg 2019; 109:e41-e43. [PMID: 31181204 DOI: 10.1016/j.athoracsur.2019.04.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 02/27/2019] [Accepted: 04/01/2019] [Indexed: 11/19/2022]
Abstract
Anomalous aortic origin of the right coronary artery from the left aortic sinus is a rare congenital anomaly that is generally repaired during adolescence when the condition is associated with symptoms. It is rarely diagnosed in infancy. Similarly, a quadricuspid pulmonary valve is also a rare finding, and there are scant data to evaluate whether this malformation of the pulmonary valve is suitable to be used for a Ross operation. This report describes a case in which both these anomalies coexisted in an infant who underwent a successful Ross-Konno operation.
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Affiliation(s)
- Ken-Michael Bayle
- Division of Pediatric Cardiology, Le Bonheur Children's Hospital and the University of Tennessee Health Sciences Center, Memphis, Tennessee
| | - Umar Boston
- Division of Pediatric Cardiothoracic Surgery, Le Bonheur Children's Hospital and the University of Tennessee Health Sciences Center, Memphis, Tennessee
| | - Sandeep Sainathan
- Division of Pediatric Cardiothoracic Surgery, Le Bonheur Children's Hospital and the University of Tennessee Health Sciences Center, Memphis, Tennessee
| | - Ronak Naik
- Division of Pediatric Cardiology, Le Bonheur Children's Hospital and the University of Tennessee Health Sciences Center, Memphis, Tennessee
| | - Christopher J Knott-Craig
- Division of Pediatric Cardiothoracic Surgery, Le Bonheur Children's Hospital and the University of Tennessee Health Sciences Center, Memphis, Tennessee.
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Philip R, Nathaniel Johnson J, Naik R, Kimura D, Boston U, Chilakala S, Hendrickson B, Rush Waller B, Sathanandam S. Effect of patent ductus arteriosus on pulmonary vascular disease. CONGENIT HEART DIS 2019; 14:37-41. [PMID: 30811787 DOI: 10.1111/chd.12702] [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] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2018] [Accepted: 10/16/2018] [Indexed: 11/28/2022]
Abstract
The hemodynamic effects of a patent ductus arteriosus (PDA) are well known including systemic hypoperfusion and volume overload on the left ventricle. This article aims to provide a review of the long-standing effect of a hemodynamically significant PDA on the pulmonary vasculature and the role of cardiac catheterization in preterm infants with a PDA and pulmonary hypertension.
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Affiliation(s)
- Ranjit Philip
- Division of Pediatric Cardiology, University of Tennessee Health Science Center, Le Bonheur Children's Hospital, Memphis, Tennessee
| | - Jason Nathaniel Johnson
- Division of Pediatric Cardiology, University of Tennessee Health Science Center, Le Bonheur Children's Hospital, Memphis, Tennessee.,Pediatric Radiology, University of Tennessee Health Science Center, Le Bonheur Children's Hospital, Memphis, Tennessee
| | - Ronak Naik
- Division of Pediatric Cardiology, University of Tennessee Health Science Center, Le Bonheur Children's Hospital, Memphis, Tennessee
| | - Dai Kimura
- Division of Pediatric Cardiology, University of Tennessee Health Science Center, Le Bonheur Children's Hospital, Memphis, Tennessee.,Division of Pediatric Critical Care, University of Tennessee Health Science Center, Le Bonheur Children's Hospital, Memphis, Tennessee
| | - Umar Boston
- Division of Pediatric Cardiology, University of Tennessee Health Science Center, Le Bonheur Children's Hospital, Memphis, Tennessee
| | - Sandeep Chilakala
- Division of Pediatric Cardiology, University of Tennessee Health Science Center, Le Bonheur Children's Hospital, Memphis, Tennessee
| | - Benjamin Hendrickson
- Division of Pediatric Cardiology, University of Tennessee Health Science Center, Le Bonheur Children's Hospital, Memphis, Tennessee
| | - Benjamin Rush Waller
- Division of Pediatric Cardiology, University of Tennessee Health Science Center, Le Bonheur Children's Hospital, Memphis, Tennessee
| | - Shyam Sathanandam
- Division of Pediatric Cardiology, University of Tennessee Health Science Center, Le Bonheur Children's Hospital, Memphis, Tennessee
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17
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Boston U, Kumar TS, Shah J, Street T, Towbin J, Knott-Craig CJ. Successful Heart Transplantation in Two Infants With Dextrocardia-Heterotaxy Syndrome. Ann Thorac Surg 2018; 107:e111-e114. [PMID: 30081023 DOI: 10.1016/j.athoracsur.2018.06.046] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 06/03/2018] [Accepted: 06/08/2018] [Indexed: 02/01/2023]
Abstract
Infants with dextrocardia-heterotaxy syndrome pose significant surgical challenges to a successful orthotopic heart transplant. Herein we report on 2 infants with dextrocardia-heterotaxy syndrome who underwent complex heart transplantation. A combination of preoperative 3-dimensional chest computed tomography to predict optimal donor size and unique surgical technique resulted in successful outcomes.
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Affiliation(s)
- Umar Boston
- Department of Pediatric Cardiothoracic Surgery, Le Bonheur Children's Hospital and University of Tennessee, Memphis, Tennessee.
| | - Tk Susheel Kumar
- Department of Pediatric Cardiothoracic Surgery, Le Bonheur Children's Hospital and University of Tennessee, Memphis, Tennessee
| | - Jignesh Shah
- Department of Pediatric Radiology, Le Bonheur Children's Hospital and University of Tennessee, Memphis, Tennessee
| | - Tiffany Street
- Department of Pediatric Cardiology, Le Bonheur Children's Hospital and University of Tennessee, Memphis, Tennessee
| | - Jeffrey Towbin
- Department of Pediatric Cardiology, Le Bonheur Children's Hospital and University of Tennessee, Memphis, Tennessee
| | - Christopher J Knott-Craig
- Department of Pediatric Cardiothoracic Surgery, Le Bonheur Children's Hospital and University of Tennessee, Memphis, Tennessee
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18
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Balduf K, Kumar TKS, Boston U, Sathanandam S, Lee MV, Jancelewicz T, Knott-Craig CJ. Improved Outcomes in Management of Hypoplastic Left Heart Syndrome Associated With Congenital Diaphragmatic Hernia: an Algorithmic Approach. Semin Thorac Cardiovasc Surg 2018; 30:191-196. [PMID: 29448010 DOI: 10.1053/j.semtcvs.2018.02.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/05/2018] [Indexed: 12/27/2022]
Abstract
Hypoplastic left heart syndrome (HLHS) is the second most common congenital heart disease associated with congenital diaphragmatic hernia (CDH). The reported survival rate of neonates with CDH and HLHS is only 1%-5%. We review our experience with CDH and HLHS and compare our outcomes with published literature. Retrospective review of all neonates with CDH and HLHS at our institution over a 10-year period was performed. The morphology of cardiac and diaphragm defects, clinical course, treatment strategies, and outcomes were reviewed, and an algorithmic approach was proposed. Five patients with CDH and HLHS were treated between 2006 and 2016. All had mitral stenosis with aortic stenosis. Four patients had a left-sided Bochdalek diaphragmatic hernia and 1 patient had a large bilateral Morgagni hernia. Two (2/4) of the Bochdalek hernias were associated with significant pulmonary hypoplasia and required patch closure of the CDH; both were palliated with percutaneous ductal stents and both died. Three patients underwent primary Norwood operation followed by repair of less severe CDH defect. All 3 patients are currently well and have survived bidirectional Glenn anastomosis; one patient is well after Fontan operation. Successful palliation of neonates with HLHS and associated CDH is possible in the current era. Outcome is determined primarily by the severity of the CDH and the degree of associated pulmonary hypoplasia. An algorithmic team approach is helpful in management of this difficult group of patients.
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Affiliation(s)
- Kaitlin Balduf
- Department of Pediatric Cardiology, University of Tennessee Health Science Center, Memphis, Tennessee
| | - T K Susheel Kumar
- Department of Pediatric Cardiothoracic Surgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Umar Boston
- Department of Pediatric Cardiothoracic Surgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Shyam Sathanandam
- Department of Pediatric Cardiology, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Marc V Lee
- Department of Pediatric Cardiology, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Tim Jancelewicz
- Department of Pediatric Surgery, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Christopher J Knott-Craig
- Department of Pediatric Cardiothoracic Surgery, University of Tennessee Health Science Center, Memphis, Tennessee.
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19
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Kumar TKS, Balduf K, Boston U, Knott-Craig C. Diaphragmatic fenestration for refractory chylothorax after congenital cardiac surgery in infants. J Thorac Cardiovasc Surg 2017; 154:2062-2068. [PMID: 28916211 DOI: 10.1016/j.jtcvs.2017.08.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Revised: 07/14/2017] [Accepted: 08/09/2017] [Indexed: 01/31/2023]
Abstract
OBJECTIVE Medically refractory chylous pleural effusion after congenital heart surgery is associated with significant morbidity and mortality, especially in infants. We reviewed our experience with diaphragmatic fenestration procedure in this group of patients. METHODS A retrospective chart review of all patients who had diaphragmatic fenestrations for chylous effusion at our institution over a 2-year period was performed. RESULTS A total of 9 diaphragmatic fenestration procedures were performed in 8 patients who had failed medical management of chylous pleural effusions. All procedures except 1 were performed on the right side. The median age at time of procedure was 4.6 months (range, 3 weeks to 14 months). The average time between primary congenital cardiac surgery and fenestration was 26 days (range, 4-53 days). Three patients had single ventricle repair. Average time of chest tube removal after procedure was 4 days. Average time to extubation was 3 days. All patients but 1 were able to advance to full feedings without reaccumulation of chylous effusion within 12 days. No complications developed in the patients. Recurrent effusion over a median follow-up period of 19 months did not develop in the patients. CONCLUSIONS Diaphragmatic fenestration is an effective and safe strategy for management of persistent chylous effusions after congenital cardiac surgery.
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Affiliation(s)
- T K Susheel Kumar
- Department of Pediatric Cardiothoracic Surgery, Le Bonheur Children's Hospital and University of Tennessee Health Science Center, Memphis, Tenn.
| | - Kaitlin Balduf
- Department of Pediatric Cardiology, Le Bonheur Children's Hospital and University of Tennessee Health Science Center, Memphis, Tenn
| | - Umar Boston
- Department of Pediatric Cardiothoracic Surgery, Le Bonheur Children's Hospital and University of Tennessee Health Science Center, Memphis, Tenn
| | - Christopher Knott-Craig
- Department of Pediatric Cardiothoracic Surgery, Le Bonheur Children's Hospital and University of Tennessee Health Science Center, Memphis, Tenn
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20
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Sathanandam S, Kumar TKS, Boston U, Knott-Craig CJ. Surgical Management of Simultaneous Left Coronary Atresia and Anomalous Right Coronary Artery Origin. Ann Thorac Surg 2017; 103:e513-e515. [DOI: 10.1016/j.athoracsur.2017.01.056] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 12/26/2016] [Accepted: 01/09/2017] [Indexed: 11/29/2022]
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21
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Naik R, Johnson J, Kumar TKS, Philip R, Boston U, Knott-Craig CJ. Right ventricular function after repair of tetralogy of Fallot: a comparison between bovine pericardium and porcine small intestinal extracellular matrix. Cardiol Young 2017; 27:1-7. [PMID: 28552087 DOI: 10.1017/s1047951117000646] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [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] [Indexed: 12/22/2022]
Abstract
BACKGROUND The porcine small intestinal extracellular matrix reportedly has the potential to differentiate into viable myocardial cells. When used in tetralogy of Fallot repair, it may improve right ventricular function. We evaluated right ventricular function after repair of tetralogy of Fallot with extracellular matrix versus bovine pericardium. METHOD Subjects with non-transannular repair of tetralogy of Fallot with at least 1 year of follow-up were selected. The extracellular matrix and bovine pericardium groups were compared. We used three-dimensional right ventricular ejection fraction, right ventricle global longitudinal strain, and tricuspid annular plane systolic excursion to assess right ventricular function. RESULTS The extracellular matrix group had 11 patients, whereas the bovine pericardium group had 10 patients. No differences between the groups were found regarding sex ratio, age at surgery, and cardiopulmonary bypass time. The follow-up period was 28±12.6 months in the extracellular matrix group and 50.05±17.6 months in the bovine pericardium group (p=0.001). The mean three-dimensional right ventricular ejection fraction (55.7±5.0% versus 55.3±5.2%, p=0.73), right ventricular global longitudinal strain (-18.5±3.0% versus -18.0±2.2%, p=0.44), and tricuspid annular plane systolic excursions (1.59±0.16 versus 1.59±0.2, p=0.93) were similar in the extracellular matrix group and in the bovine pericardium group, respectively. Right ventricular global longitudinal strain in healthy children is reported at -29±3% in literature. CONCLUSION In a small cohort of the patients undergoing non-transannular repair of tetralogy of Fallot, there was no significant difference in right ventricular function between groups having extracellular matrix versus bovine pericardium patches followed-up for more than 1 year. Lower right ventricular longitudinal strain noted in both the groups compared to healthy children.
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Affiliation(s)
- Ronak Naik
- 1Division of Pediatric Cardiology,University of Tennessee Health Science Center,Le Bonheur Children's Hospital,Memphis,Tennessee,United States of America
| | - Jason Johnson
- 1Division of Pediatric Cardiology,University of Tennessee Health Science Center,Le Bonheur Children's Hospital,Memphis,Tennessee,United States of America
| | - T K S Kumar
- 2Cardiothoracic Surgery,University of Tennessee Health Science Center,Le Bonheur Children's Hospital,Memphis,Tennessee,United States of America
| | - Ranjit Philip
- 1Division of Pediatric Cardiology,University of Tennessee Health Science Center,Le Bonheur Children's Hospital,Memphis,Tennessee,United States of America
| | - Umar Boston
- 2Cardiothoracic Surgery,University of Tennessee Health Science Center,Le Bonheur Children's Hospital,Memphis,Tennessee,United States of America
| | - Christopher J Knott-Craig
- 2Cardiothoracic Surgery,University of Tennessee Health Science Center,Le Bonheur Children's Hospital,Memphis,Tennessee,United States of America
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22
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Simpson K, Miller J, Lancaster T, Henn M, Epstein D, Schuessler R, Balzer D, Shahanavaz S, Murphy J, Eghtesady P, Boston U, Canter C. Improved Transplant Survival in Failed Fontan Patients With Preserved Ventricular Function in the Current Era. J Heart Lung Transplant 2015. [DOI: 10.1016/j.healun.2015.01.086] [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: 12/01/2022] Open
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23
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Abstract
BNP is increasingly utilized in the management of pediatric HT recipients. Performing a retrospective single-center chart review, we sought to describe BNP changes during the first year after HT and identify factors that affect its trend. After exclusion for rejection, 316 BNP levels from 50 patients were evaluated. BNP underwent an exponential decline 120 days after HT followed by a plateau. Log10 BNP decline strongly correlated with time (r = -0.70, p < 0.0001). Initial BNP was less in pretransplant VAD (p = 0.0016) and lower post-HT inotrope use (p = 0.0043). Infant recipients, IT >4 h, and those bridged medically were associated with higher plateau BNP. Multivariable logistic regression demonstrated IT >4 h independently predicted plateau BNP in the upper quartile (OR 7.1, p = 0.02). No significant change in BNP coincided with rejection (N = 6 patients) without severe hemodynamic compromise. BNP correlated modestly with right atrial pressure (r = 0.4652, p < 0.0001) and pulmonary capillary wedge pressure (r = 0.2660, p < 0.001), but poorly with echocardiogram (r = -0.18, p = 0.003). Trending BNP could help provide insight into how the graft recovers after HT and IT >4 h independently predicted higher plateau BNP and may reflect subtle changes in graft performance.
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Affiliation(s)
- Joshua D Sparks
- Division of Pediatric Cardiology, Department of Pediatrics, University of Louisville, Louisville, KY, USA
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24
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Towe C, Utterson E, Sweet S, Michelson P, Eghtesady P, Boston U, Faro A. Acidic Gastroesophageal Reflux and Aspiration Are Not Associated with Earlier Development of Bronchiolitis Obliterans in Pediatric Lung Transplant. J Heart Lung Transplant 2014. [DOI: 10.1016/j.healun.2014.01.766] [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: 11/29/2022] Open
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25
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Simpson KE, Esmaeeli A, Khanna G, White F, Turnmelle Y, Eghtesady P, Boston U, Canter CE. Liver cirrhosis in Fontan patients does not affect 1-year post-heart transplant mortality or markers of liver function. J Heart Lung Transplant 2013; 33:170-7. [PMID: 24365764 DOI: 10.1016/j.healun.2013.10.033] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.1] [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: 07/24/2013] [Revised: 08/29/2013] [Accepted: 10/23/2013] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Liver cirrhosis is recognized with long-term follow-up of patients after the Fontan procedure. The effect of liver cirrhosis on the use of heart transplant (HT) and on post-HT outcomes is unknown. METHODS We reviewed Fontan patients evaluated for HT from 2004 to 2012 with hepatic computed tomography (CT) imaging, classified as normal, non-cirrhotic changes, or cirrhosis. The primary outcome was 1-year all-cause mortality, and the secondary outcome was differences in serial post-HT liver evaluation. RESULTS CT imaging in 32 Fontan patients evaluated for HT revealed 20 (63%) with evidence of liver disease, including 13 (41%) with cirrhosis. Twenty underwent HT, including 5 non-cirrhotic and 7 cirrhosis patients. Characteristics at listing between normal or non-cirrhotic (n = 13) and cirrhosis (n = 7) groups were similar, except cirrhosis patients were older (median 17.6 vs 9.6 years, p = 0.002) and further from Fontan (median 180 vs 50 months, p < 0.05). Serial liver evaluation was similar, including aspartate aminotransferase, alanine aminotransferase, bilirubin, albumin, and tacrolimus dose at 1, 3, 6, 9, and 12 months. Overall patient survival was 80% at 1 year, with no difference between cirrhosis and non-cirrhosis patients (86% vs 77%, p = 0.681). Liver biopsies were performed in 7 patients before HT, and all specimens showed architectural changes with bridging fibrosis. CONCLUSIONS Most patients evaluated for HT had abnormal liver findings by CT, with cirrhosis in 41%. One-year mortality and serial liver evaluation were similar between groups after HT. Liver cirrhosis identified by CT imaging may not be an absolute contraindication to HT alone in this population.
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Affiliation(s)
- Kathleen E Simpson
- Department of Pediatrics, Washington University School of Medicine, Saint Louis, Missouri.
| | - Amir Esmaeeli
- School of Medicine, Washington University School of Medicine, Saint Louis, Missouri
| | - Geetika Khanna
- Department of Radiology, Washington University School of Medicine, Saint Louis, Missouri
| | - Francis White
- Department of Pathology, Washington University School of Medicine, Saint Louis, Missouri
| | - Yumirle Turnmelle
- Department of Pediatrics, Washington University School of Medicine, Saint Louis, Missouri
| | - Pirooz Eghtesady
- Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri
| | - Umar Boston
- Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri
| | - Charles E Canter
- Department of Pediatrics, Washington University School of Medicine, Saint Louis, Missouri
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26
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Arshad A, Taveras CM, Mohammed T, Prosper G, Mendez M, Absi MAA, Turpin D, Boston U, Taylor HM, Valero-Fonseca J. Index of suspicion. Pediatr Rev 2010; 31:75-80. [PMID: 20124278 DOI: 10.1542/pir.31-2-75] [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: 11/24/2022]
Affiliation(s)
- Arslan Arshad
- Lincoln Medical and Mental Health Center, Bronx, NY, USA
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