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Rajagopalan V, Truong V, Wang S, Lopez J, Rosas V, Borzage M, Votava-Smith JK, Ponrartana S, Panigrahy A, Detterich J, Wood J. Non-invasive in-utero quantification of vascular reactivity in human placenta. Ultrasound Obstet Gynecol 2024; 63:481-488. [PMID: 37820067 DOI: 10.1002/uog.27512] [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] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 09/26/2023] [Accepted: 10/02/2023] [Indexed: 10/13/2023]
Abstract
OBJECTIVE Placental vascular reactivity (PlVR) indicates the ability of the placental vasculature to match blood supply to fetal demand. Many pregnancy disorders alter the characteristics of PlVR, resulting in suboptimal oxygen delivery, although current understanding is limited by the lack of non-invasive, repeatable methods to measure PlVR in utero. Our objective was to quantify PlVR by measuring the placental response to transient changes in maternal carbon dioxide (CO2) using blood-oxygen-level-dependent (BOLD) magnetic resonance imaging (MRI). We hypothesized that PlVR will increase with gestational age to meet the changing demands of a growing fetus, and that PlVR will be driven by a maternal response to changes in CO2 concentration. METHODS This was a cross-sectional study of 35 women with a healthy singleton pregnancy, of whom 31 were included in the analysis. The median gestational age was 32.6 (range, 22.6-38.4) weeks. Pregnant women were instructed to follow audiovisual breathing cues during a MRI scan. Maternal end-tidal CO2 (EtCO2) was measured concurrently with resting placental BOLD MRI for a total of 7-8 min. Preprocessing of magnetic resonance images consisted of manual delineation of placental anatomy and motion correction. In each placental voxel, vascular reactivity was computed using a coherence-weighted general linear model between MRI signal and EtCO2 stimulus. Global PlVR was computed as the mean of voxel-wise PlVR values across the placenta. RESULTS PlVR, quantified by the placental response to induced, transient changes in maternal CO2, was consistently measured in utero using BOLD MRI. PlVR increased non-linearly with advancing gestational age (P < 0.001) and was higher on the fetal side of the placenta. PlVR was associated positively with fetal brain volume after accounting for gestational age. PlVR did not show any significant associations with maternal characteristics. CONCLUSIONS We present, for the first time, a non-invasive paradigm to quantify PlVR in ongoing human pregnancies without the use of exogenous gases or contrast agents. Our findings suggest that PlVR is driven by a fetal response to changes in maternal CO2. Ease of translation to the clinical setting makes PlVR a promising biomarker for the identification and management of high-risk pregnancies. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- V Rajagopalan
- Department of Radiology, Children's Hospital Los Angeles, Keck School of Medicine University of Southern California, Los Angeles, CA, USA
| | - V Truong
- University of Southern California, Los Angeles, CA, USA
| | - S Wang
- Division of Cardiology, Department of Pediatrics, Children's Hospital Los Angeles, Keck School of Medicine University of Southern California, Los Angeles, CA, USA
| | - J Lopez
- Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - V Rosas
- Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - M Borzage
- Division of Neonatology, Department of Pediatrics, Children's Hospital Los Angeles, Keck School of Medicine University of Southern California, Los Angeles, CA, USA
| | - J K Votava-Smith
- Division of Cardiology, Department of Pediatrics, Children's Hospital Los Angeles, Keck School of Medicine University of Southern California, Los Angeles, CA, USA
| | - S Ponrartana
- University of Southern California, Los Angeles, CA, USA
| | - A Panigrahy
- Pediatric Imaging Research Lab, Department of Radiology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - J Detterich
- Division of Cardiology, Department of Pediatrics, Children's Hospital Los Angeles, Keck School of Medicine University of Southern California, Los Angeles, CA, USA
| | - J Wood
- Division of Cardiology, Department of Pediatrics, Children's Hospital Los Angeles, Keck School of Medicine University of Southern California, Los Angeles, CA, USA
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Tran M, Miner A, Merkel C, Sakurai K, Woon J, Ayala J, Nguyen J, Lopez J, Friedlich P, Votava-Smith JK, Tran NN. Sociodemographic profile associated with congenital heart disease among infants <1 year old. J Pediatr Nurs 2023; 73:e618-e623. [PMID: 37957083 PMCID: PMC10841755 DOI: 10.1016/j.pedn.2023.11.007] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 11/01/2023] [Accepted: 11/05/2023] [Indexed: 11/15/2023]
Abstract
PURPOSE Congenital heart disease affects thousands of newborns each year in the United States. Previous United States-based research has explored how sociodemographic factors may impact health outcomes in infants with congenital heart disease; however, their impact on the incidence of congenital heart disease is unclear. We explored the sociodemographic profile related to congenital heart disease to help address health disparities that arise from race and social determinants of health. Defining the sociodemographic factors associated with congenital heart disease will encourage implementation of potential preventative measures. DESIGN AND METHODS We conducted a secondary analysis of longitudinally collected data comparing 39 infants with congenital heart disease and 30 healthy controls. We used a questionnaire to collect sociodemographic data. Pearson's chi-square test/Fisher's exact tests analyzed the associations among different sociodemographic factors between infants with congenital heart disease and healthy controls. RESULTS We found a statistically significant difference in maternal education between our 2 groups of infants (p = 0.004). CONCLUSION Maternal education was associated with congenital heart disease. Future studies are needed to further characterize sociodemographic factors that may predict and impact the incidence of congenital heart disease and to determine possible interventions that may help decrease health disparities regarding the incidence of congenital heart disease. PRACTICE IMPLICATIONS Understanding the associations between maternal sociodemographic factors and infant congenital heart disease would allow clinicians to identify mothers at higher risk of having an infant with congenital heart disease.
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Affiliation(s)
- Michelle Tran
- Department of Population and Public Health Sciences, Keck School of Medicine of University of Southern California (KSOM USC) and Division of Research on Children, Youth, and Families, The Saban Research Institute, Children's Hospital Los Angeles (CHLA), Los Angeles, CA, United States of America.
| | - Anna Miner
- Department of Population and Public Health Sciences, Keck School of Medicine of University of Southern California (KSOM USC) and Division of Research on Children, Youth, and Families, The Saban Research Institute, Children's Hospital Los Angeles (CHLA), Los Angeles, CA, United States of America
| | - Carlin Merkel
- Department of Medicine, KSOM USC and Division of Research on Children, Youth, and Families, The Saban Research Institute, CHLA, Los Angeles, CA, United States of America
| | - Kenton Sakurai
- Department of Medicine, KSOM USC and Division of Research on Children, Youth, and Families, The Saban Research Institute, CHLA, Los Angeles, CA, United States of America
| | - Jessica Woon
- Department of Biological Sciences, USC Dornsife College of Letters, Arts, and Sciences and Division of Research on Children, Youth, and Families, The Saban Research Institute, CHLA, Los Angeles, CA, United States of America
| | - John Ayala
- Cardiac Registry Support, St. Cloud, MN, United States of America
| | - Jennifer Nguyen
- Department of Health and Human Sciences, USC Dornsife College of Letters, Arts, and Sciences and Division of Research on Children, Youth, and Families, The Saban Research Institute, CHLA, Los Angeles, CA, United States of America
| | - Jeraldine Lopez
- Division of Research on Children, Youth, and Families, The Saban Research Institute, CHLA, Los Angeles, CA, United States of America
| | - Philippe Friedlich
- Fetal and Neonatal Institute, Division of Neonatology, CHLA, and Department of Pediatrics, KSOM USC, Los Angeles, CA, United States of America
| | - Jodie K Votava-Smith
- Division of Cardiology, CHLA and KSOM USC, Los Angeles, CA, United States of America
| | - Nhu N Tran
- Division of Neonatology, CHLA, and KSOM USC, Los Angeles, CA, United States of America
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Miller TA, Hernandez EJ, Gaynor JW, Russell MW, Newburger JW, Chung W, Goldmuntz E, Cnota JF, Zyblewski SC, Mahle WT, Zak V, Ravishankar C, Kaltman JR, McCrindle BW, Clarke S, Votava-Smith JK, Graham EM, Seed M, Rudd N, Bernstein D, Lee TM, Yandell M, Tristani-Firouzi M. Genetic and clinical variables act synergistically to impact neurodevelopmental outcomes in children with single ventricle heart disease. Commun Med (Lond) 2023; 3:127. [PMID: 37758840 PMCID: PMC10533527 DOI: 10.1038/s43856-023-00361-2] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Accepted: 09/15/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND Recent large-scale sequencing efforts have shed light on the genetic contribution to the etiology of congenital heart defects (CHD); however, the relative impact of genetics on clinical outcomes remains less understood. Outcomes analyses using genetics are complicated by the intrinsic severity of the CHD lesion and interactions with conditionally dependent clinical variables. METHODS Bayesian Networks were applied to describe the intertwined relationships between clinical variables, demography, and genetics in a cohort of children with single ventricle CHD. RESULTS As isolated variables, a damaging genetic variant in a gene related to abnormal heart morphology and prolonged ventilator support following stage I palliative surgery increase the probability of having a low Mental Developmental Index (MDI) score at 14 months of age by 1.9- and 5.8-fold, respectively. However, in combination, these variables act synergistically to further increase the probability of a low MDI score by 10-fold. The absence of a damaging variant in a known syndromic CHD gene and a shorter post-operative ventilator support increase the probability of a normal MDI score 1.7- and 2.4-fold, respectively, but in combination increase the probability of a good outcome by 59-fold. CONCLUSIONS Our analyses suggest a modest genetic contribution to neurodevelopmental outcomes as isolated variables, similar to known clinical predictors. By contrast, genetic, demographic, and clinical variables interact synergistically to markedly impact clinical outcomes. These findings underscore the importance of capturing and quantifying the impact of damaging genomic variants in the context of multiple, conditionally dependent variables, such as pre- and post-operative factors, and demography.
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Grants
- UM1 HL098123 NHLBI NIH HHS
- P50 HD105351 NICHD NIH HHS
- U01 HL068269 NHLBI NIH HHS
- U01 HL068279 NHLBI NIH HHS
- U01 HL068288 NHLBI NIH HHS
- U10 HL068270 NHLBI NIH HHS
- U01 HL068270 NHLBI NIH HHS
- UM1 HL128711 NHLBI NIH HHS
- S10 OD021644 NIH HHS
- UM1 HL098147 NHLBI NIH HHS
- U01 HL068292 NHLBI NIH HHS
- U01 HL085057 NHLBI NIH HHS
- U01 HL068285 NHLBI NIH HHS
- U01 HL098163 NHLBI NIH HHS
- U01 HL128711 NHLBI NIH HHS
- UM1 HL098162 NHLBI NIH HHS
- U01 HL098153 NHLBI NIH HHS
- U01 HL131003 NHLBI NIH HHS
- R01 GM104390 NIGMS NIH HHS
- U01 HL068290 NHLBI NIH HHS
- U01 HL068281 NHLBI NIH HHS
- UM1 HL128761 NHLBI NIH HHS
- The clinical data for this project was supported by National Heart, Lung, and Blood Institute (NHLBI) Pediatric Heart Network grants HL068269, HL068270, HL068279, HL068281, HL068285, HL068288, HL068290, HL068292, and HL085057. The genomic data for this project was supported by the NHLBI Pediatric Cardiac Genomics Consortium (UM1-HL098147, UM1-HL128761, UM1-HL098123, UM1-HL128711, UM1-HL098162, U01-HL131003, U01-HL098153, U01-HL098163), the National Center for Research Resources (U01-HL098153), and the National Institutes for Health (R01-GM104390, 1S10OD021644-01A1).
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Affiliation(s)
- Thomas A Miller
- Department of Pediatrics, Maine Medical Center, Portland, ME, USA.
| | - Edgar J Hernandez
- Department of Human Genetics and Utah Center for Genetic Discovery, University of Utah, Salt Lake City, UT, USA
| | - J William Gaynor
- Department of Surgery, Children's Hospital of Philadelphia, and the Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Mark W Russell
- Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital, Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Wendy Chung
- Departments of Pediatrics and Medicine, Columbia University, New York, NY, USA
| | - Elizabeth Goldmuntz
- Division of Cardiology, Children's Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - James F Cnota
- Heart Institute, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Sinai C Zyblewski
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | | | | | - Chitra Ravishankar
- Division of Cardiology, Children's Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jonathan R Kaltman
- Division of Cardiology, Children's National Hospital, Washington, DC, USA
| | - Brian W McCrindle
- Labatt Family Heart Centre, The Hospital for Sick Children, Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Shanelle Clarke
- Department of Pediatrics Emory University School of Medicine, Atlanta, GA, USA
| | | | - Eric M Graham
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - Mike Seed
- Labatt Family Heart Centre, The Hospital for Sick Children, Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Nancy Rudd
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | | | - Teresa M Lee
- Departments of Pediatrics and Medicine, Columbia University, New York, NY, USA
| | - Mark Yandell
- Department of Human Genetics and Utah Center for Genetic Discovery, University of Utah, Salt Lake City, UT, USA.
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Merkel CA, Brady KM, Votava-Smith JK, Tran NN. A pilot study: Comparing a novel noninvasive measure of cerebrovascular stability index with an invasive measure of cerebral autoregulation in neonates with congenital heart disease. J Clin Transl Sci 2023; 7:e165. [PMID: 37588677 PMCID: PMC10425865 DOI: 10.1017/cts.2023.581] [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: 02/01/2023] [Revised: 06/20/2023] [Accepted: 06/24/2023] [Indexed: 08/18/2023] Open
Abstract
Infants with congenital heart disease (CHD) may have impaired cerebral autoregulation (CA) associated with cerebral fractional tissue oxygen extraction (FTOE). We conducted a pilot study in nine CHD neonates to validate a noninvasive CA measure, cerebrovascular stability index (CSI), by eliciting responses to postural tilts. We compared CSI to an invasive measure of CA and to FTOE collected during tilts (FTOESpot). FTOESpot correlated with CSI, as did the change in FTOE during tilts, but CSI's correlation with impaired CA did not reach significance. Larger trials are indicated to validate CSI, allowing for noninvasive CA measurements and measurements in outpatient settings.
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Affiliation(s)
| | - Kenneth M. Brady
- Division of Cardiac Anesthesia, Northwestern University Feinberg School of Medicine and Ann & Robert H, Lurie Children’s Hospital of Chicago, Chicago, IL, USA
| | - Jodie K. Votava-Smith
- Keck School of Medicine, Los Angeles, CA, USA
- Division of Cardiology, Department of Pediatrics, Children’s Hospital Los Angeles, Los Angeles, CA, USA
| | - Nhu N. Tran
- Keck School of Medicine, Los Angeles, CA, USA
- Division of Neonatology, Department of Pediatrics, Fetal and Neonatal Institute, Children’s Hospital Los Angeles, Los Angeles, CA, USA
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Tran M, Miner A, Merkel C, Sakurai K, Woon J, Ayala J, Nguyen J, Lopez J, Votava-Smith JK, Tran NN. Sociodemographic Profile Associated with Congenital Heart Disease among Infants Less than 1 Year Old. Res Sq 2023:rs.3.rs-2548938. [PMID: 36798365 PMCID: PMC9934769 DOI: 10.21203/rs.3.rs-2548938/v1] [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] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
Background Congenital heart disease (CHD) affects thousands of newborns each year in the United States (US). Infants born with CHD have an increased risk of adverse health outcomes compared to healthy infants. These outcomes include, but are not limited to, neurodevelopmental, surgical, and mortality-related outcomes. Previous US-based research has explored how sociodemographic factors may impact these health outcomes in infants with CHD; however, their impact on the risk of CHD is unclear. This study aims to explore the sociodemographic profile related to CHD to help address health disparities that arise from race and social determinants of health. Defining the sociodemographic factors associated with CHD will encourage policy change and the implementation of preventative measures. Methods This study is a secondary analysis of longitudinally collected data. We compared infants with CHD and healthy controls. We used a questionnaire to collect sociodemographic data. Pearson's chi-square test/Fisher's exact tests analyzed the associations among different sociodemographic factors between infants with CHD and healthy controls. Results We obtained sociodemographic factors from 30 healthy control infants and 39 infants with CHD. We found a statistically significant difference in maternal education between our 2 groups of infants (p=0.004). Conclusion Maternal education is associated with CHD. Future studies are needed to further characterize sociodemographic factors that may predict and impact the risk of CHD and to determine possible interventions that may help decrease health disparities regarding the risk of CHD.
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Affiliation(s)
- Michelle Tran
- University of Southern California/Children's Hospital of Los Angeles
| | - Anna Miner
- University of Southern California/Children's Hospital of Los Angeles
| | - Carlin Merkel
- University of Southern California/Children's Hospital of Los Angeles
| | - Kenton Sakurai
- University of Southern California/Children's Hospital of Los Angeles
| | - Jessica Woon
- University of Southern California/Children's Hospital of Los Angeles
| | | | - Jennifer Nguyen
- University of Southern California/Children's Hospital of Los Angeles
| | | | | | - Nhu N Tran
- University of Southern California/Children's Hospital of Los Angeles
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Tran NN, Mahdi EM, Ourshalimian S, Sanborn S, Alquiros MT, Kingston P, Lascano D, Herrington C, Votava-Smith JK, Kelley-Quon LI. Factors Associated With Gastrostomy Tube Complications in Infants With Congenital Heart Disease. J Surg Res 2022; 280:273-279. [PMID: 36030602 PMCID: PMC10231870 DOI: 10.1016/j.jss.2022.07.022] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 07/08/2022] [Accepted: 07/28/2022] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Children with congenital heart disease (CHD) often experience feeding intolerance due to aspiration, inability to tolerate feed volume, or reflux within the first few months of life, requiring a surgically placed gastrostomy tube (GT) for durable enteral access. However, complications such as GT dislodgement, cellulitis, and leakage related to GT use are common. GT-related complications can lead to unscheduled pediatric surgery clinic or emergency room (ER) visits, which can be time consuming for the family and increase overall healthcare costs. We sought to identify factors associated with GT complications within 2 wk after GT surgery and 1-y after discharge home following GT placement in infants with CHD. METHODS We performed a retrospective cohort study using the Society of Thoracic Surgeons database and electronic medical records from a tertiary children's hospital. We identified infants <1 y old underwent CHD surgery followed by GT surgery between September 2013-August 2018. Demographics, pre-operative feeding regimen, comorbidities, and GT-related utilization were measured. Postoperative GT complications (e.g., GT cellulitis, leakage, dislodgement, obstruction, and granulation tissue) within 2 wk after the GT surgery and an unplanned pediatric surgery clinic or ER visit within 1-y after discharge home were captured. Bivariate comparisons and multivariable logistic regression evaluated factors associated with GT complications and unplanned clinic or ER visits. A Kaplan-Meier failure curve examined the timing of ER/clinic visits. RESULTS Of 152 infants who underwent CHD then GT surgeries, 66% (N = 101) had postoperative GT complications. Overall, 83 unscheduled clinic visits were identified after discharge, with 37% (N = 31) due to concerns about granulation tissue. Of 137 ER visits, 48% (N = 66) were due to accidental GT dislodgement. Infants who were hospitalized for ≥2 wk after GT surgery had more complications than those discharged home within 2 wk of the GT surgery (40.6% versus 15.7%, P = 0.002). Infants receiving oral nutrition before CHD surgery (38.6% versus 60%, P=<0.001) or with single ventricle defects (19.8% versus 37.3%, P = 0.02) had fewer GT complications. After adjusting for type of cardiac anomaly, infants receiving oral nutrition prior to CHD surgery had a decreased likelihood of GT complications (odds ratio OR 0.46; 95% confidence intervals CI:0.23-0.93). A Kaplan-Meier failure curve demonstrated that 50% of the cohort experienced a complication leading to an unscheduled ER/clinic visit within 6 mo after discharge. CONCLUSIONS Unplanned visits to the ER or pediatric surgery clinic occur frequently for infants with CHD requiring a surgically placed GT. Oral feedings before cardiac surgery associated with fewer GT complications. Prolonged hospitalization associated with more GT complications. Optimizing outpatient care and family education regarding GT maintenance may reduce unscheduled visits for this high-risk, device-dependent infant population.
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Affiliation(s)
- Nhu N Tran
- Fetal and Neonatal Institute, Division of Neonatology, Children's Hospital Los Angeles, Department of Pediatrics, Keck School of Medicine of the University of Southern California, Los Angeles, California.
| | - Elaa M Mahdi
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Shadassa Ourshalimian
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Stephanie Sanborn
- Clinical Nutrition and Lactation Services, Children's Hospital Los Angeles, Los Angeles, California
| | - Maria Theresa Alquiros
- Division of Cardiothoracic Surgery, Children's Hospital Los Angeles, Los Angeles, CA Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Paige Kingston
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Danny Lascano
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Cynthia Herrington
- Division of Cardiothoracic Surgery, Children's Hospital Los Angeles, Los Angeles, CA Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Jodie K Votava-Smith
- Division of Cardiology, Children's Hospital Los Angeles and Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Lorraine I Kelley-Quon
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California; Department of Population and Public Health Sciences, University of Southern California, Los Angeles, California
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Votava-Smith JK, Gaesser J, Harbison AL, Lee V, Tran N, Rajagopalan V, del Castillo S, Kumar SR, Herrup E, Baust T, Johnson JA, Gabriel GC, Reynolds WT, Wallace J, Meyers B, Ceschin R, Lo CW, Schmithorst VJ, Panigrahy A. Clinical factors associated with microstructural connectome related brain dysmaturation in term neonates with congenital heart disease. Front Neurosci 2022; 16:952355. [PMID: 36466162 PMCID: PMC9717392 DOI: 10.3389/fnins.2022.952355] [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: 05/25/2022] [Accepted: 11/01/2022] [Indexed: 11/19/2022] Open
Abstract
Objective Term congenital heart disease (CHD) neonates display abnormalities of brain structure and maturation, which are possibly related to underlying patient factors, abnormal physiology and perioperative insults. Our primary goal was to delineate associations between clinical factors and postnatal brain microstructure in term CHD neonates using diffusion tensor imaging (DTI) magnetic resonance (MR) acquisition combined with complementary data-driven connectome and seed-based tractography quantitative analyses. Our secondary goal was to delineate associations between mild dysplastic structural brain abnormalities and connectome and seed-base tractography quantitative analyses. These mild dysplastic structural abnormalities have been derived from prior human infant CHD MR studies and neonatal mouse models of CHD that were collectively used to calculate to calculate a brain dysplasia score (BDS) that included assessment of subcortical structures including the olfactory bulb, the cerebellum and the hippocampus. Methods Neonates undergoing cardiac surgery for CHD were prospectively recruited from two large centers. Both pre- and postoperative MR brain scans were obtained. DTI in 42 directions was segmented into 90 regions using a neonatal brain template and three weighted methods. Clinical data collection included 18 patient-specific and 9 preoperative variables associated with preoperative scan and 6 intraoperative (e.g., cardiopulmonary bypass and deep hypothermic circulatory arrest times) and 12 postoperative variables associated with postoperative scan. We compared patient specific and preoperative clinical factors to network topology and tractography alterations on a preoperative neonatal brain MRI, and intra and postoperative clinical factors to network topology alterations on postoperative neonatal brain MRI. A composite BDS was created to score abnormal findings involving the cerebellar hemispheres and vermis, supratentorial extra-axial fluid, olfactory bulbs and sulci, hippocampus, choroid plexus, corpus callosum, and brainstem. The neuroimaging outcomes of this study included (1) connectome metrics: cost (number of connections) and global/nodal efficiency (network integration); (2) seed based tractography methods of fractional anisotropy (FA), radial diffusivity, and axial diffusivity. Statistics consisted of multiple regression with false discovery rate correction (FDR) comparing the clinical risk factors and BDS (including subcortical components) as predictors/exposures and the global connectome metrics, nodal efficiency, and seed based- tractography (FA, radial diffusivity, and axial diffusivity) as neuroimaging outcome measures. Results A total of 133 term neonates with complex CHD were prospectively enrolled and 110 had analyzable DTI. Multiple patient-specific factors including d-transposition of the great arteries (d-TGA) physiology and severity of impairment of fetal cerebral substrate delivery (i.e., how much the CHD lesion alters typical fetal circulation such that the highest oxygen and nutrient rich blood from the placenta are not directed toward the fetal brain) were predictive of preoperative reduced cost (p < 0.0073) and reduced global/nodal efficiency (p < 0.03). Cardiopulmonary bypass time predicted postoperative reduced cost (p < 0.04) and multiple postoperative factors [extracorporeal membrane oxygenation (ECMO), seizures and cardiopulmonary resuscitation (CPR)] were predictive of postoperative reduced cost and reduced global/nodal efficiency (p < 0.05). Anthropometric measurements (weight, length, and head size) predicted tractography outcomes. Total BDS was not predictive of brain network topology. However, key subcortical components of the BDS score did predict key global and nodal network topology: abnormalities of the cerebellum predicted reduced cost (p < 0.0417) and of the hippocampus predicted reduced global efficiency (p < 0.0126). All three subcortical structures predicted unique alterations of nodal efficiency (p < 0.05), including hippocampal abnormalities predicting widespread reduced nodal efficiency in all lobes of the brain, cerebellar abnormalities predicting increased prefrontal nodal efficiency, and olfactory bulb abnormalities predicting posterior parietal-occipital nodal efficiency. Conclusion Patient-specific (d-TGA anatomy, preoperative impairment of fetal cerebral substrate delivery) and postoperative (e.g., seizures, need for ECMO, or CPR) clinical factors were most predictive of diffuse postnatal microstructural dysmaturation in term CHD neonates. Anthropometric measurements (weight, length, and head size) predicted tractography outcomes. In contrast, subcortical components (cerebellum, hippocampus, olfactory) of a structurally based BDS (derived from CHD mouse mutants), predicted more localized and regional postnatal microstructural differences. Collectively, these findings suggest that brain DTI connectome and seed-based tractography are complementary techniques which may facilitate deciphering the mechanistic relative contribution of clinical and genetic risk factors related to poor neurodevelopmental outcomes in CHD.
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Affiliation(s)
- Jodie K. Votava-Smith
- Division of Cardiology, Department of Pediatrics, Children’s Hospital Los Angeles, Keck School of Medicine of USC, Los Angeles, CA, United States
| | - Jenna Gaesser
- Department of Neurology, Children’s Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | | | - Vince Lee
- Department of Pediatric Radiology, Children’s Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States,Department of Bioengineering, Swanson School of Engineering, University of Pittsburgh, Pittsburgh, PA, United States
| | - Nhu Tran
- Division of Neonatology, Department of Pediatrics, Keck School of Medicine of USC, Children’s Hospital Los Angeles, Fetal and Neonatal Institute, Los Angeles, CA, United States
| | - Vidya Rajagopalan
- Department of Radiology, Children’s Hospital Los Angeles, Keck School of Medicine of USC, Los Angeles, CA, United States
| | - Sylvia del Castillo
- Department of Anesthesiology Critical Care Medicine Anesthesiology, Children’s Hospital Los Angeles, Keck School of Medicine of USC, Los Angeles, CA, United States
| | - S. Ram Kumar
- Division of Cardiothoracic Surgery, Department of Surgery, Children’s Hospital Los Angeles, Keck School of Medicine of USC, Los Angeles, CA, United States
| | - Elizabeth Herrup
- Division of Pediatric Cardiac Intensive Care, Department of Critical Care, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Tracy Baust
- Division of Pediatric Cardiac Intensive Care, Department of Critical Care, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Jennifer A. Johnson
- Division of Pediatric Cardiology, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - George C. Gabriel
- Department of Developmental Biology, University of Pittsburgh, Pittsburgh, PA, United States
| | - William T. Reynolds
- Department of Pediatric Radiology, Children’s Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Julia Wallace
- Department of Pediatric Radiology, Children’s Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Benjamin Meyers
- Department of Pediatric Radiology, Children’s Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Rafael Ceschin
- Department of Pediatric Radiology, Children’s Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States,Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, PA, United States
| | - Cecilia W. Lo
- Department of Developmental Biology, University of Pittsburgh, Pittsburgh, PA, United States
| | - Vanessa J. Schmithorst
- Department of Pediatric Radiology, Children’s Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Ashok Panigrahy
- Department of Pediatric Radiology, Children’s Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States,Department of Bioengineering, Swanson School of Engineering, University of Pittsburgh, Pittsburgh, PA, United States,Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, PA, United States,*Correspondence: Ashok Panigrahy,
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Tran NN, Desai J, Votava-Smith JK, Brecht ML, Vanderbilt D, Panigrahy A, Mackintosh L, Brady KM, Peterson BS. Factor Analysis of the Einstein Neonatal Neurobehavioral Assessment Scale in Infants with Congenital Heart Disease and Healthy Controls. J Child Neurol 2022; 37:851-863. [PMID: 35918821 PMCID: PMC9561959 DOI: 10.1177/08830738221115982] [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] [Indexed: 11/16/2022]
Abstract
Background: Administration of the Einstein Neonatal Neurobehavioral Assessment Scale (ENNAS) can be time-consuming, and items can be highly correlated. We aimed to determine: (1) its factor analytic structure; (2) the validity of the factor structure; and (3) the associations of physiologic measures with factor scores. Methods: A factor analysis reduced 21 ENNAS items into 5 factors in 57 congenital heart disease (CHD) and 35 healthy infants. Multiple linear regressions examined the association of factor scores with group, gestational age, and physiologic variables. Results: 5-factor solution: 1 (Orienting Reflex), 2 (Extensor Axial Tone), 3 (Primitive Reflexes), 4 (Flexor Tone), 5 (Reflexive Tone Around Extremity Joints). Moderate to strong evidence supported: face, discriminant, and construct validity of these factors, with Factor 2 having the strongest. Conclusions: Components of Factor 2 may provide similar information about neonatal development, thus reducing the time for and burden of administration for researchers and clinicians.
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Affiliation(s)
- Nhu N. Tran
- Institute for the Developing Mind, The Saban Research Institute, Children’s Hospital Los Angeles and Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, United States of America,Fetal and Neonatal Institute, Division of Neonatology Children's Hospital Los Angeles, Department of Pediatrics and Keck School of Medicine, University of Southern California, Los Angeles, United States of America,Corresponding Author
| | - Jay Desai
- Division of Neurology, Children’s Hospital Los Angeles and Keck School of Medicine, University of Southern California, Los Angeles, United States of America
| | - Jodie K. Votava-Smith
- Division of Cardiology, Children’s Hospital Los Angeles and Keck School of Medicine, University of Southern California, Los Angeles, United States of America
| | - Mary-Lynn Brecht
- School of Nursing, University of California, Los Angeles, Los Angeles, United States of America
| | - Douglas Vanderbilt
- Fetal and Neonatal Institute, Division of Neonatology Children's Hospital Los Angeles, Department of Pediatrics and Keck School of Medicine, University of Southern California, Los Angeles, United States of America
| | - Ashok Panigrahy
- University of Pittsburgh Medical Center, Children’s Hospital of Pittsburgh, Pittsburgh, United States of America and Department of Pediatric Radiology, Children’s Hospital Los Angeles, Los Angeles, United States of America
| | - Liza Mackintosh
- Division of General Pediatrics, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California, United States of America
| | - Kenneth M. Brady
- Lurie Children's Hospital of Chicago, Anesthesiology and Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, United States of America
| | - Bradley S. Peterson
- Institute for the Developing Mind, The Saban Research Institute, Children’s Hospital Los Angeles and Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, United States of America,Department of Psychiatry, Keck School of Medicine, University of Southern California, Los Angeles, United States of America
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9
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Tran NN, Tran M, Panigrahy A, Brady KM, Votava-Smith JK. Association of Cerebrovascular Stability Index and Head Circumference Between Infants With and Without Congenital Heart Disease. Pediatr Cardiol 2022; 43:1624-1630. [PMID: 35426499 DOI: 10.1007/s00246-022-02891-3] [Citation(s) in RCA: 1] [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: 01/05/2022] [Accepted: 03/23/2022] [Indexed: 11/30/2022]
Abstract
Congenital heart disease (CHD) is a common birth defect in the United States. CHD infants are more likely to have smaller head circumference and neurodevelopmental delays; however, the cause is unknown. Altered cerebrovascular hemodynamics may contribute to neurologic abnormalities, such as smaller head circumference, thus we created a novel Cerebrovascular Stability Index (CSI), as a surrogate for cerebral autoregulation. We hypothesized that CHD infants would have an association between CSI and head circumference. We performed a prospective, longitudinal study in CHD infants and healthy controls. We measured CSI and head circumference at 4 time points (newborn, 3, 6, 9 months). We calculated CSI by subtracting the average 2-min sitting from supine cerebral oxygenation (rcSO2) over three consecutive tilts (0-90°), then averaged the change score for each age. Linear regressions quantified the relationship between CSI and head circumference. We performed 177 assessments in total (80 healthy controls, 97 CHD infants). The average head circumference was smaller in CHD infants (39.2 cm) compared to healthy controls (41.6 cm) (p < 0.001) and head circumference increased by 0.27 cm as CSI improved in the sample (p = 0.04) overall when combining all time points. Similarly, head circumference increased by 0.32 cm as CSI improved among CHD infants (p = 0.04). We found CSI significantly associated with head circumference in our sample overall and CHD infants alone, which suggests that impaired CSI may affect brain size in CHD infants. Future studies are needed to better understand the mechanism of interaction between CSI and brain growth.
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Affiliation(s)
- Nhu N Tran
- Division of Neonatology, Children's Hospital Los Angeles (CHLA), Fetal and Neonatal Institute, 4650 Sunset Blvd., MS#137, Los Angeles, CA, 90027, USA. .,Department of Pediatrics, Keck School of Medicine, University of Southern California (KSOM USC), Los Angeles, CA, USA.
| | - Michelle Tran
- Department of Population and Public Health Sciences, KSOM USC, Los Angeles, CA, USA.,Division of Research on Children, Youth, and Families, The Saban Research Institute, CHLA, Los Angeles, CA, USA
| | - Ashok Panigrahy
- Department of Pediatric Radiology, CHLA, Los Angeles, CA, USA.,University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Ken M Brady
- Lurie Children's Hospital of Chicago, Anesthesiology and Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Jodie K Votava-Smith
- Department of Pediatrics, Keck School of Medicine, University of Southern California (KSOM USC), Los Angeles, CA, USA.,Division of Cardiology, Department of Pediatrics, CHLA and KSOM USC, Los Angeles, CA, USA
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10
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Schmithorst VJ, Adams PS, Badaly D, Lee VK, Wallace J, Beluk N, Votava-Smith JK, Weinberg JG, Beers SR, Detterich J, Wood JC, Lo CW, Panigrahy A. Impaired Neurovascular Function Underlies Poor Neurocognitive Outcomes and Is Associated with Nitric Oxide Bioavailability in Congenital Heart Disease. Metabolites 2022; 12:metabo12090882. [PMID: 36144286 PMCID: PMC9504090 DOI: 10.3390/metabo12090882] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Revised: 09/14/2022] [Accepted: 09/15/2022] [Indexed: 12/03/2022] Open
Abstract
We use a non-invasive MRI proxy of neurovascular function (pnvf) to assess the ability of the vasculature to supply baseline metabolic demand, to compare pediatric and young adult congenital heart disease (CHD) patients to normal referents and relate the proxy to neurocognitive outcomes and nitric oxide bioavailability. In a prospective single-center study, resting-state blood-oxygen-level-dependent (BOLD) and arterial spin labeling (ASL) MRI scans were successfully obtained from 24 CHD patients (age = 15.4 ± 4.06 years) and 63 normal referents (age = 14.1 ± 3.49) years. Pnvf was computed on a voxelwise basis as the negative of the ratio of functional connectivity strength (FCS) estimated from the resting-state BOLD acquisition to regional cerebral blood flow (rCBF) as estimated from the ASL acquisition. Pnvf was used to predict end-tidal CO2 (PETCO2) levels and compared to those estimated from the BOLD data. Nitric oxide availability was obtained via nasal measurements (nNO). Pnvf was compared on a voxelwise basis between CHD patients and normal referents and correlated with nitric oxide availability and neurocognitive outcomes as assessed via the NIH Toolbox. Pnvf was shown as highly predictive of PETCO2 using theoretical modeling. Pnvf was found to be significantly reduced in CHD patients in default mode network (DMN, comprising the ventromedial prefrontal cortex and posterior cingulate/precuneus), salience network (SN, comprising the insula and dorsal anterior cingulate), and central executive network (CEN, comprising posterior parietal and dorsolateral prefrontal cortex) regions with similar findings noted in single cardiac ventricle patients. Positive correlations of Pnvf in these brain regions, as well as the hippocampus, were found with neurocognitive outcomes. Similarly, positive correlations between Pnvf and nitric oxide availability were found in frontal DMN and CEN regions, with particularly strong correlations in subcortical regions (putamen). Reduced Pnvf in CHD patients was found to be mediated by nNO. Mediation analyses further supported that reduced Pnvf in these regions underlies worse neurocognitive outcome in CHD patients and is associated with nitric oxide bioavailability. Impaired neuro-vascular function, which may be non-invasively estimated via combined arterial-spin label and BOLD MR imaging, is a nitric oxide bioavailability dependent factor implicated in adverse neurocognitive outcomes in pediatric and young adult CHD.
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Affiliation(s)
| | - Phillip S. Adams
- Department of Pediatric Anesthesiology, UPMC Children’s Hospital, Pittsburgh, PA 15224, USA
| | - Daryaneh Badaly
- Learning and Development Center, Child Mind Institute, New York, NY 10022, USA
| | - Vincent K. Lee
- Department of Pediatric Radiology, UPMC Children’s Hospital, Pittsburgh, PA 15224, USA
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Julia Wallace
- Department of Pediatric Radiology, UPMC Children’s Hospital, Pittsburgh, PA 15224, USA
| | - Nancy Beluk
- Department of Pediatric Radiology, UPMC Children’s Hospital, Pittsburgh, PA 15224, USA
| | | | | | - Sue R. Beers
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Jon Detterich
- Heart Institute, Children’s Hospital Los Angeles, Los Angeles, CA 90027, USA
| | - John C. Wood
- Heart Institute, Children’s Hospital Los Angeles, Los Angeles, CA 90027, USA
| | - Cecilia W. Lo
- Department of Developmental Biology, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Ashok Panigrahy
- Department of Pediatric Radiology, UPMC Children’s Hospital, Pittsburgh, PA 15224, USA
- Department of Radiology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
- Correspondence: ; Tel.: +1-412-692-5510; Fax: +1-412-692-6929
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11
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Meyers B, Lee VK, Dennis L, Wallace J, Schmithorst V, Votava-Smith JK, Rajagopalan V, Herrup E, Baust T, Tran NN, Hunter J, Licht DJ, Gaynor JW, Andropoulos DB, Panigrahy A, Ceschin R. Harmonization of Multi-Center Diffusion Tensor Tractography in Neonates with Congenital Heart Disease: Optimizing Post-Processing and Application of ComBat. Neuroimage Rep 2022; 2:100114. [PMID: 36258783 PMCID: PMC9575513 DOI: 10.1016/j.ynirp.2022.100114] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Advanced brain imaging of neonatal macrostructure and microstructure, which has prognosticating importance, is more frequently being incorporated into multi-center trials of neonatal neuroprotection. Multicenter neuroimaging studies, designed to overcome small sample sized clinical cohorts, are essential but lead to increased technical variability. Few harmonization techniques have been developed for neonatal brain microstructural (diffusion tensor) analysis. The work presented here aims to remedy two common problems that exist with the current state of the art approaches: 1) variance in scanner and protocol in data collection can limit the researcher's ability to harmonize data acquired under different conditions or using different clinical populations. 2) The general lack of objective guidelines for dealing with anatomically abnormal anatomy and pathology. Often, subjects are excluded due to subjective criteria, or due to pathology that could be informative to the final analysis, leading to the loss of reproducibility and statistical power. This proves to be a barrier in the analysis of large multi-center studies and is a particularly salient problem given the relative scarcity of neonatal imaging data. We provide an objective, data-driven, and semi-automated neonatal processing pipeline designed to harmonize compartmentalized variant data acquired under different parameters. This is done by first implementing a search space reduction step of extracting the along-tract diffusivity values along each tract of interest, rather than performing whole-brain harmonization. This is followed by a data-driven outlier detection step, with the purpose of removing unwanted noise and outliers from the final harmonization. We then use an empirical Bayes harmonization algorithm performed at the along-tract level, with the output being a lower dimensional space but still spatially informative. After applying our pipeline to this large multi-site dataset of neonates and infants with congenital heart disease (n= 398 subjects recruited across 4 centers, with a total of n=763 MRI pre-operative/post-operative time points), we show that infants with single ventricle cardiac physiology demonstrate greater white matter microstructural alterations compared to infants with bi-ventricular heart disease, supporting what has previously been shown in literature. Our method is an open-source pipeline for delineating white matter tracts in subject space but provides the necessary modular components for performing atlas space analysis. As such, we validate and introduce Diffusion Imaging of Neonates by Group Organization (DINGO), a high-level, semi-automated framework that can facilitate harmonization of subject-space tractography generated from diffusion tensor imaging acquired across varying scanners, institutions, and clinical populations. Datasets acquired using varying protocols or cohorts are compartmentalized into subsets, where a cohort-specific template is generated, allowing for the propagation of the tractography mask set with higher spatial specificity. Taken together, this pipeline can reduce multi-scanner technical variability which can confound important biological variability in relation to neonatal brain microstructure.
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Affiliation(s)
- Benjamin Meyers
- Department of Radiology, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Vincent K. Lee
- Department of Radiology, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Lauren Dennis
- Department of Radiology, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Julia Wallace
- Department of Radiology, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Vanessa Schmithorst
- Department of Radiology, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Jodie K. Votava-Smith
- Division of Cardiology, Department of Pediatrics, Children’s Hospital of Los Angeles and Keck School of Medicine University of Southern California, Los Angeles, CA
| | - Vidya Rajagopalan
- Department of Radiology, Children’s Hospital of Los Angeles and Keck School of Medicine University of Southern California Los Angeles, CA
| | - Elizabeth Herrup
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Tracy Baust
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Nhu N. Tran
- Division of Cardiology, Department of Pediatrics, Children’s Hospital of Los Angeles and Keck School of Medicine University of Southern California, Los Angeles, CA
| | - Jill Hunter
- Department of Radiology, Texas Children’s Hospital, Houston, TX
| | - Daniel J. Licht
- Department of Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - J. William Gaynor
- Department of Surgery, Children’s Hospital of Philadelphia, Philadelphia, PA
| | | | - Ashok Panigrahy
- Department of Radiology, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Department of Biomedical Informatics, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Rafael Ceschin
- Department of Radiology, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Department of Biomedical Informatics, University of Pittsburgh School of Medicine, Pittsburgh, PA
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12
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Tran NN, Tran M, Lemus RE, Woon J, Lopez J, Dang R, Votava-Smith JK. Preoperative Care of Neonates With Congenital Heart Disease. Neonatal Netw 2022; 41:200-210. [PMID: 35840337 DOI: 10.1891/nn-2021-0028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Congenital heart disease (CHD) is one of the most common types of birth defects, with 40,000 newborns diagnosed yearly in the United States. This article describes: (1) four common heart defects seen in neonatal intensive care units, (2) the typical medical/nursing care of these neonates, and (3) common surgical management for the defects. Hypoplastic left heart syndrome, dextro-transposition of the great arteries, tetralogy of Fallot, and pulmonary atresia with intact ventricular septum are four common types of CHD requiring NICU admission. Knowledge of these defects will help nurses to appropriately manage and treat neonates with these types of CHD.
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13
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Truong DT, Dionne A, Muniz JC, McHugh KE, Portman MA, Lambert LM, Thacker D, Elias MD, Li JS, Toro-Salazar OH, Anderson BR, Atz AM, Bohun CM, Campbell MJ, Chrisant M, D'Addese L, Dummer KB, Forsha D, Frank LH, Frosch OH, Gelehrter SK, Giglia TM, Hebson C, Jain SS, Johnston P, Krishnan A, Lombardi KC, McCrindle BW, Mitchell EC, Miyata K, Mizzi T, Parker RM, Patel JK, Ronai C, Sabati AA, Schauer J, Sexson-Tejtel SK, Shea JR, Shekerdemian LS, Srivastava S, Votava-Smith JK, White S, Newburger JW. Clinically Suspected Myocarditis Temporally Related to COVID-19 Vaccination in Adolescents and Young Adults. Circulation 2021; 145:345-356. [PMID: 34865500 DOI: 10.1161/circulationaha.121.056583] [Citation(s) in RCA: 100] [Impact Index Per Article: 33.3] [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] [Indexed: 11/16/2022]
Abstract
BACKGROUND Understanding the clinical course and short-term outcomes of suspected myocarditis following COVID-19 vaccination has important public health implications in the decision to vaccinate youth. METHODS We retrospectively collected data on patients <21 years-old presenting before 7/4/2021 with suspected myocarditis within 30 days of COVID-19 vaccination. Lake Louise criteria were used for cardiac magnetic resonance imaging (cMRI) findings. Myocarditis cases were classified as confirmed or probable based on the Centers for Disease Control and Prevention definitions. RESULTS We report on 139 adolescents and young adults with 140 episodes of suspected myocarditis (49 confirmed, 91 probable) at 26 centers. Most patients were male (N=126, 90.6%) and White (N=92, 66.2%); 29 (20.9%) were Hispanic; and median age was 15.8 years (range 12.1-20.3, IQR 14.5-17.0). Suspected myocarditis occurred in 136 patients (97.8%) following mRNA vaccine, with 131 (94.2%) following the Pfizer-BioNTech vaccine; 128 (91.4%) occurred after the 2nd dose. Symptoms started a median of 2 days (range 0-22, IQR 1-3) after vaccination. The most common symptom was chest pain (99.3%). Patients were treated with nonsteroidal anti-inflammatory drugs (81.3%), intravenous immunoglobulin (21.6%), glucocorticoids (21.6%), colchicine (7.9%) or no anti-inflammatory therapies (8.6%). Twenty-six patients (18.7%) were in the ICU, two were treated with inotropic/vasoactive support, and none required ECMO or died. Median hospital stay was 2 days (range 0-10, IQR 2-3). All patients had elevated troponin I (N=111, 8.12 ng/mL, IQR 3.50-15.90) or T (N=28, 0.61 ng/mL, IQR 0.25-1.30); 69.8% had abnormal electrocardiograms and/or arrythmias (7 with non-sustained ventricular tachycardia); and 18.7% had left ventricular ejection fraction (LVEF) <55% on echocardiogram. Of 97 patients who underwent cMRI at median 5 days (range 0-88, IQR 3-17) from symptom onset, 75 (77.3%) had abnormal findings: 74 (76.3%) had late gadolinium enhancement, 54 (55.7%) had myocardial edema, and 49 (50.5%) met Lake Louise criteria. Among 26 patients with LVEF <55% on echocardiogram, all with follow-up had normalized function (N=25). CONCLUSIONS Most cases of suspected COVID-19 vaccine myocarditis occurring in persons <21 years have a mild clinical course with rapid resolution of symptoms. Abnormal findings on cMRI were frequent. Future studies should evaluate risk factors, mechanisms, and long-term outcomes.
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Affiliation(s)
- Dongngan T Truong
- Division of Pediatric Cardiology, University of Utah and Primary Children's Hospital, Salt Lake City, UT
| | - Audrey Dionne
- Department of Cardiology, Boston Children's Hospital, Department of Pediatrics; Harvard Medical School, Boston, MA
| | | | - Kimberly E McHugh
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC
| | - Michael A Portman
- Seattle Children's, Department of Pediatrics, University of Washington, Seattle, WA
| | - Linda M Lambert
- Division of Pediatric Cardiology, University of Utah and Primary Children's Hospital, Salt Lake City, UT
| | - Deepika Thacker
- Nemours Cardiac Center, Nemours Children's Health, Wilmington, DE
| | - Matthew D Elias
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, PA
| | | | | | - Brett R Anderson
- Division of Pediatric Cardiology; NewYork-Presbyterian / Columbia University Irving Medical Center, New York, NY
| | - Andrew M Atz
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC
| | - C Monique Bohun
- Oregon Health & Science University, Division of Pediatric Cardiology, Department of Pediatrics, Portland, OR
| | | | - Maryanne Chrisant
- The Heart Institute, Joe DiMaggio Children's Hospital, Hollywood, FL
| | - Laura D'Addese
- The Heart Institute, Joe DiMaggio Children's Hospital, Hollywood, FL
| | - Kirsten B Dummer
- Division of Pediatric Cardiology, Department of Pediatrics, University of California San Diego and Rady Children's Hospital San Diego, San Diego, CA
| | - Daniel Forsha
- Division of Pediatric Cardiology, Children's Mercy Kansas City, Kansas City, MO
| | | | - Olivia H Frosch
- Division of Pediatric Cardiology, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI
| | - Sarah K Gelehrter
- Division of Pediatric Cardiology, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI
| | - Therese M Giglia
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Camden Hebson
- Children's of Alabama Department of Pediatrics, Division of Pediatric Cardiology; University of Alabama at Birmingham School of Medicine
| | - Supriya S Jain
- Maria Fareri Children's Hospital at Westchester Medical Center / New York Medical College, Valhalla, New York
| | - Pace Johnston
- University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | - Kristin C Lombardi
- Warren Alpert Medical School of Brown University, Division of Pediatric Cardiology, Hasbro Children's Hospital, Providence, RI
| | - Brian W McCrindle
- Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | | | - Koichi Miyata
- Kawasaki Disease Research Center, Department of Pediatrics, University of California San Diego, La Jolla, CA and Rady Children's Hospital San Diego, San Diego, CA
| | - Trent Mizzi
- Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Robert M Parker
- Division of Critical Care. Connecticut Children's. Hartford, CT
| | - Jyoti K Patel
- Division of Pediatric Cardiology, Riley Children's Hospital, Indianapolis, IN
| | - Christina Ronai
- Oregon Health & Science University, Division of Pediatric Cardiology, Department of Pediatrics, Portland, OR
| | - Arash A Sabati
- Division of Pediatric Cardiology, Phoenix Children's Hospital, Phoenix, AZ
| | - Jenna Schauer
- Seattle Children's, Department of Pediatrics, University of Washington, Seattle, WA
| | | | - J Ryan Shea
- University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | | | - Jodie K Votava-Smith
- Division of Cardiology, Children's Hospital Los Angeles and Keck School of USC, Los Angeles, CA
| | - Sarah White
- Division of Hospital Medicine, Children's Hospital of Los Angeles and Keck School of Medicine of USC, Los Angeles, CA
| | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital, Department of Pediatrics; Harvard Medical School, Boston, MA
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14
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Tran NN, Votava-Smith JK, Wood JC, Panigrahy A, Wee CP, Borzage M, Kumar SR, Murray PM, Brecht ML, Paquette L, Brady KM, Peterson BS. Cerebral oxygen saturation and cerebrovascular instability in newborn infants with congenital heart disease compared to healthy controls. PLoS One 2021; 16:e0251255. [PMID: 33970937 PMCID: PMC8109808 DOI: 10.1371/journal.pone.0251255] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 04/22/2021] [Indexed: 11/18/2022] Open
Abstract
Objective Infants with Congenital Heart Disease (CHD) are at risk for developmental delays, though the mechanisms of brain injury that impair development are unknown. Potential causes could include cerebral hypoxia and cerebrovascular instability. We hypothesized that we would detect significantly reduced cerebral oxygen saturation and greater cerebrovascular instability in CHD infants compared to the healthy controls. Methods We performed a secondary analysis on a sample of 43 term infants (28 CHD, 15 healthy controls) that assessed prospectively in temporal cross-section before or at 12 days of age. CHD infants were assessed prior to open-heart surgery. Cerebral oxygen saturation levels were estimated using Near-Infrared Spectroscopy, and cerebrovascular stability was assessed with the response of cerebral oxygen saturation after a postural change (supine to sitting). Results Cerebral oxygen saturation was 9 points lower in CHD than control infants in both postures (β = -9.3; 95%CI = -17.68, -1.00; p = 0.028), even after controlling for differences in peripheral oxygen saturation. Cerebrovascular stability was significantly impaired in CHD compared to healthy infants (β = -2.4; 95%CI = -4.12, -.61; p = 0.008), and in CHD infants with single ventricle compared with biventricular defects (β = -1.5; 95%CI = -2.95, -0.05; p = 0.04). Conclusion CHD infants had cerebral hypoxia and decreased cerebral oxygen saturation values following a postural change, suggesting cerebrovascular instability. Future longitudinal studies should assess the associations of cerebral hypoxia and cerebrovascular instability with long-term neurodevelopmental outcomes in CHD infants.
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Affiliation(s)
- Nhu N. Tran
- Institute for the Developing Mind, The Saban Research Institute, Children’s Hospital Los Angeles, Los Angeles, California, United States of America
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, United States of America
- * E-mail:
| | - Jodie K. Votava-Smith
- Division of Cardiology, Children’s Hospital Los Angeles, Los Angeles, California, United States of America
- Keck School of Medicine, University of Southern California, Los Angeles, California, United States of America
| | - John C. Wood
- Division of Cardiology, Children’s Hospital Los Angeles, Los Angeles, California, United States of America
- Keck School of Medicine, University of Southern California, Los Angeles, California, United States of America
| | - Ashok Panigrahy
- University of Pittsburgh Medical Center, Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
- Department of Pediatric Radiology, Children’s Hospital Los Angeles, Los Angeles, California, United States of America
| | - Choo Phei Wee
- Department of Preventive Medicine, Southern California Clinical and Translational Science Institute, Keck School of Medicine, University of Southern California, Los Angeles, California, United States of America
| | - Matthew Borzage
- Keck School of Medicine, University of Southern California, Los Angeles, California, United States of America
- Division of Neonatology, Department of Pediatrics, Fetal and Neonatal Institute, Children’s Hospital Los Angeles, Los Angeles, California, United States of America
| | - S. Ram Kumar
- Keck School of Medicine, University of Southern California, Los Angeles, California, United States of America
- Division of Cardiothoracic Surgery, Children’s Hospital Los Angeles, Los Angeles, California, United States of America
| | - Paula M. Murray
- Institute for Nursing and Interprofessional Research, Children’s Hospital Los Angeles, Los Angeles, California, United States of America
| | - Mary-Lynn Brecht
- School of Nursing, University of California, Los Angeles, Los Angeles, California, United States of America
| | - Lisa Paquette
- Keck School of Medicine, University of Southern California, Los Angeles, California, United States of America
- Division of Neonatology, Department of Pediatrics, Fetal and Neonatal Institute, Children’s Hospital Los Angeles, Los Angeles, California, United States of America
| | - Kenneth M. Brady
- Lurie Children’s Hospital of Chicago, Anesthesiology and Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States of America
| | - Bradley S. Peterson
- Department of Psychiatry, Keck School of Medicine, University of Southern California, Los Angeles, California, United States of America
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15
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Tran NN, Tran M, Lopez J, Ogbaa M, Votava-Smith JK, Brady KM. Near-Infrared Spectroscopy: Clinical Use in High-Risk Neonates. Neonatal Netw 2021; 40:73-79. [PMID: 33731373 DOI: 10.1891/0730-0832/11-t-678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/06/2020] [Indexed: 11/25/2022]
Abstract
In this review, we describe the near-infrared spectroscopy (NIRS) technology and its clinical use in high-risk neonates in critical care settings. We searched databases (e.g., PubMed, Google Scholar, EBSCOhost) to find studies describing the use of NIRS on critically ill and high-risk neonates. Near-infrared spectroscopy provides continuous noninvasive monitoring of venous oxygen saturation. It uses technology similar to pulse oximetry to measure the oxygen saturation of hemoglobin in a tissue bed to describe the relative delivery and extraction of oxygen. Near-infrared spectroscopy can be a valuable bedside tool to provide clinicians indirect evidence of perfusion. It may prompt early interventions that promote oxygen delivery, which can improve high-risk neonatal outcomes.
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16
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Miller TA, Ghanayem NS, Newburger JW, McCrindle BW, Hu C, DeWitt AG, Cnota JF, Tractenberg FL, Pemberton VL, Wolf MJ, Votava-Smith JK, Fifer CG, Lambert LM, Shah A, Graham EM, Pizarro C, Jacobs JP, Miller SG, Minich LL. Gestational Age, Birth Weight, and Outcomes Six Years After the Norwood Procedure. Pediatrics 2019; 143:peds.2018-2577. [PMID: 30979811 PMCID: PMC6564065 DOI: 10.1542/peds.2018-2577] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [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] [Accepted: 01/29/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Preterm delivery and low birth weight (LBW) are generally associated with worse outcomes in hypoplastic left heart syndrome (HLHS), but an individual preterm or small neonate may do well. We sought to explore the interactions between gestational age, birth weight, and birth weight for gestational age with intermediate outcomes in HLHS. METHODS We analyzed survival, growth, neurodevelopment, length of stay, and complications to age 6 years in subjects with HLHS from the Single Ventricle Reconstruction trial. Univariate and multivariable survival and regression analyses examined the effects and interactions of LBW (<2500 g), weight for gestational age, and gestational age category. RESULTS Early-term delivery (n = 234) was more common than term (n = 219) delivery. Small for gestational age (SGA) was present in 41% of subjects, but only 14% had LBW. Preterm, compared with term, delivery was associated with an increased risk of death or transplant at age 6 years (all: hazard ratio = 2.58, confidence interval = 1.43-4.67; Norwood survivors: hazard ratio = 1.96, confidence interval = 1.10-3.49) independent of LBW and weight for gestational age. Preterm delivery, early-term delivery, LBW, and SGA were each associated with lower weight at 6 years. Neurodevelopmental outcomes were worst in the LBW cohort. CONCLUSIONS Preterm delivery in HLHS was associated with worse survival, even beyond Norwood hospitalization. LBW, SGA, and early-term delivery were associated with worse growth but not survival. LBW was associated with worse neurodevelopment, despite similar length of stay and complications. These data suggest that preterm birth and LBW (although often concomitant) are not equivalent, impacting clinical outcomes through mechanisms independent of perioperative course complexity.
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Affiliation(s)
- Thomas A. Miller
- Department of Pediatrics, The University of Utah, Salt Lake City, Utah
| | - Nancy S. Ghanayem
- Department of Pediatrics, Texas Children’s Hospital and Baylor College of Medicine, Houston, Texas
| | - Jane W. Newburger
- Department of Cardiology, Boston Children’s Hospital and Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Brian W. McCrindle
- Department of Pediatrics, University of Toronto and Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Canada
| | - Chenwei Hu
- New England Research Institute, Watertown, Massachusetts
| | - Aaron G. DeWitt
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - James F. Cnota
- Heart Institute, Cincinnati Children’s Hospital, Cincinnati, Ohio
| | | | - Victoria L. Pemberton
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Michael J. Wolf
- Department of Pediatrics, School of Medicine, Emory University, Atlanta, Georgia
| | - Jodie K. Votava-Smith
- Department of Pediatrics, Children’s Hospital of Los Angeles, Los Angeles, California
| | - Carlen G. Fifer
- Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - Linda M. Lambert
- Department of Pediatrics, The University of Utah, Salt Lake City, Utah
| | - Amee Shah
- Department of Pediatrics, Columbia University, New York, New York
| | - Eric M. Graham
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - Christian Pizarro
- Departments of Surgery and Pediatrics, Thomas Jefferson University, Wilmington, Delaware
| | - Jeffrey P. Jacobs
- The Congenital Heart Institute of Florida, St. Petersburg, Florida; and
| | - Stephen G. Miller
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
| | - L. LuAnn Minich
- Department of Pediatrics, The University of Utah, Salt Lake City, Utah
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17
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Rajagopalan V, Votava-Smith JK, Zhuang X, Brian J, Marshall L, Panigrahy A, Paquette L. Fetuses with single ventricle congenital heart disease manifest impairment of regional brain growth. Prenat Diagn 2018; 38:1042-1048. [PMID: 30328635 DOI: 10.1002/pd.5374] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 10/02/2018] [Accepted: 10/04/2018] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Anomalous neurological development associated with congenital heart disease (CHD) has been reported as early as third trimester of fetal development. While several studies have characterized variations in CHD neurodevelopmental outcomes in early childhood, these reports are often confounded by postnatal factors such as surgical outcome. Recent studies have focused on the comparing neurological variations between fetuses with CHD and normal controls. In this work, we present a comparison of in utero variations in brain development between fetuses with different types of CHD, by analyzing them under categories of single ventricle versus biventricular cardiac anatomy. METHODS Using recent advances in fetal magnetic resonance imaging (MRI), we quantify the volumetric trajectories of various brain tissues (such as cortical plate, developing white matter, cerebrospinal fluid [CSF], and cerebellum). RESULTS Our study is the first to differentiate between intraventricular and extra-axial CSF thereby allowing us to better identify variations in brain composition of the fetuses. CONCLUSIONS Overall, our findings show that while total brain volume is similar between fetuses with single and biventricular anatomy, they exhibit statistically significant disparity in brain composition.
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Affiliation(s)
- Vidya Rajagopalan
- Department of Radiology, Children's Hospital Los Angeles, Los Angeles, California.,Rudi Schulte Research Institute, Santa Barbara, California
| | - Jodie K Votava-Smith
- Department of Pediatrics, Division of Cardiology, Children's Hospital Los Angeles, Los Angeles, California.,Keck University School of Medicine, University of Southern California, Los Angeles, California
| | - Xiaowei Zhuang
- Department of Biomedical Engineering, University of Southern California, Los Angeles, California
| | - Jessica Brian
- Department of Biomedical Engineering, University of Southern California, Los Angeles, California
| | - Lila Marshall
- Department of Biomedical Engineering, University of Southern California, Los Angeles, California
| | - Ashok Panigrahy
- Department of Pediatric Radiology, Children's Hospital Pittsburgh of UPMC, Pittsburgh, Pennsylvania.,University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Lisa Paquette
- Keck University School of Medicine, University of Southern California, Los Angeles, California.,Department of Pediatrics, Division of Neonatology, Children's Hospital Los Angeles, Los Angeles, California
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18
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Akhtar Ali S, Ng C, Votava-Smith JK, Randolph LM, Pitukcheewanont P. Bisphosphonate therapy in an infant with generalized arterial calcification with an ABCC6 mutation. Osteoporos Int 2018; 29:2575-2579. [PMID: 30206659 DOI: 10.1007/s00198-018-4639-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [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: 02/05/2018] [Accepted: 07/10/2018] [Indexed: 01/31/2023]
Abstract
Generalized arterial calcification of infancy (GACI) is a rare genetic disorder with high infantile mortality, described to be due to ENPP1, and less commonly ABCC6 mutations. Bisphosphonate treatment has been described to improve survival in ENPP1-positive GACI patients, but few studies have described bisphosphonate treatment in ABCC6-positive patients. Without therapy, patients will die before 6 months of age. Our patient is now 3 years old, former recipient twin of twin-to-twin transfusion syndrome (TTTS). Initial fetal echocardiogram at 19 weeks showed calcifications of the ascending aorta and pulmonary artery (PA). She underwent utero laser therapy, and despite resolution of the TTTS, her follow-up scans showed progressive calcification of the aorta and PA. Postnatal echocardiogram showed calcification and supravalvar stenosis of the aorta and PA. CT on day of life 6 showed calcifications in the PAs, aortic arch, and descending aorta. Quantification of valvular calcification can be difficult; in our patient, increasing outflow tract gradient on echocardiogram was used to monitor disease progression. Molecular testing revealed an ABCC6 gene mutation. She was started on weekly IV pamidronate (0.1-0.3 mg/kg/week) on day 8 of life then transitioned to oral etidronate (15-20 mg/kg/day). Given progressive supravalvar aortic and pulmonary stenosis, she underwent surgical repair with patch augmentation of the PA and ascending aorta at 4 months old. She has done well post-operatively, continuing on enteral bisphosphonate therapy with no side effects to date. Her identical twin was confirmed to have the same mutation and remains asymptomatic with no calcifications. Aggressive bisphosphonate therapy should be started as soon as possible in patients with infantile arterial calcinosis due to ABCC6 or ENPP1 mutations. Echocardiographic evaluation can be used to monitor disease progression by arterial gradients. Molecular testing is also essential to evaluate for possible co-morbidities in these patients and pregnancy management for the future.
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Affiliation(s)
- S Akhtar Ali
- Center For Endocrinology, Diabetes and Metabolism, Children's Hospital Los Angeles and Keck School of Medicine of University of Southern California, Los Angeles, CA, USA
| | - C Ng
- Division of Pediatric Endocrinology, Huntington Health Physicians, Huntington, CA, USA
| | - J K Votava-Smith
- Division of Pediatric Cardiology, Children's Hospital Los Angeles and Keck School of Medicine of University of Southern California, Los Angeles, CA, USA
| | - L M Randolph
- Division of Medical Genetics, Children's Hospital Los Angeles and Keck School of Medicine of University of Southern California, Los Angeles, CA, USA
| | - P Pitukcheewanont
- Center For Endocrinology, Diabetes and Metabolism, Children's Hospital Los Angeles and Keck School of Medicine of University of Southern California, Los Angeles, CA, USA.
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19
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Domadia S, Kumar SR, Votava-Smith JK, Pruetz JD. Neonatal Outcomes in Total Anomalous Pulmonary Venous Return: The Role of Prenatal Diagnosis and Pulmonary Venous Obstruction. Pediatr Cardiol 2018; 39:1346-1354. [PMID: 29796693 DOI: 10.1007/s00246-018-1901-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [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: 01/21/2018] [Accepted: 05/08/2018] [Indexed: 11/28/2022]
Abstract
The objective of this study is to evaluate neonatal outcomes of total anomalous pulmonary venous return (TAPVR) and identify fetal echocardiography findings associated with preoperative pulmonary venous obstruction (PPVO). This retrospective study evaluated TAPVR cases from 2005 to 2014 for preoperative and postoperative outcomes based on prenatal diagnosis, PPVO, and heterotaxy syndrome. Fetal pulmonary and vertical vein Dopplers were analyzed as predictors of PPVO. Of 137 TAPVR cases, 12% were prenatally diagnosed; 60% had PPVO, and 21% had heterotaxy. Of the prenatally diagnosed patients, 63% also had heterotaxy. TAPVR repair was performed in 135 cases and survival to discharge was 82% (112/137). Heterotaxy was the only independent predictor of mortality on multiple regression analysis [OR 5.5 (CI 1.3-16.7), p = 0.02]. PPVO was associated with preoperative acidosis, need for inhaled nitric oxide, and more emergent surgery, but not postoperative mortality. Fetal vertical vein Doppler peak velocity > 0.74 m/s mmHg predicted PPVO (93% sensitivity; 83% specificity) while pulmonary vein Doppler did not. TAPVR has severe neonatal morbidity and mortality with low prenatal diagnosis rates in the absence of heterotaxy. Patients with obstructed TAPVR had greater preoperative morbidity, but only heterotaxy was independently associated with increased postoperative mortality. Vertical vein velocity helped prenatally identify those at risk of PPVO.
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Affiliation(s)
- Shelly Domadia
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - S Ram Kumar
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.,Division of Cardiothoracic Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Jodie K Votava-Smith
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.,Division of Pediatric Cardiology, Department of Pediatrics, Children's Hospital Los Angeles, 4650 Sunset Blvd. Mailstop #34, Los Angeles, CA, 90027, USA
| | - Jay D Pruetz
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA. .,Division of Pediatric Cardiology, Department of Pediatrics, Children's Hospital Los Angeles, 4650 Sunset Blvd. Mailstop #34, Los Angeles, CA, 90027, USA. .,Department of Obstetrics & Gynecology, University of Southern California, Los Angeles, CA, USA.
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20
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Gertsvolf N, Votava-Smith JK, Ceschin R, Del Castillo S, Lee V, Lai HA, Bluml S, Paquette L, Panigrahy A. Association between Subcortical Morphology and Cerebral White Matter Energy Metabolism in Neonates with Congenital Heart Disease. Sci Rep 2018; 8:14057. [PMID: 30232359 PMCID: PMC6145929 DOI: 10.1038/s41598-018-32288-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Accepted: 09/05/2018] [Indexed: 12/11/2022] Open
Abstract
Complex congenital heart disease (CHD) is associated with neurodevelopmental impairment, the mechanism of which is unknown. Cerebral cortical dysmaturation in CHD is linked to white matter abnormalities, including developmental vulnerability of the subplate, in relation to oxygen delivery and metabolism deficits. In this study, we report associations between subcortical morphology and white matter metabolism in neonates with CHD using quantitative magnetic resonance imaging (MRI) and spectroscopy (MRS). Multi-modal brain imaging was performed in three groups of neonates close to term-equivalent age: (1) term CHD (n = 56); (2) preterm CHD (n = 37) and (3) preterm control group (n = 22). Thalamic volume and cerebellar transverse diameter were obtained in relation to cerebral metrics and white matter metabolism. Short echo single-voxel MRS of parietal and frontal white matter was used to quantitate metabolites related to brain maturation (n-acetyl aspartate [NAA], choline, myo-inositol), neurotransmitter (glutamate), and energy metabolism (glutamine, citrate, creatine and lactate). Multi-variate regression was performed to delineate associations between subcortical morphological measurements and white matter metabolism controlling for age and white matter injury. Reduced thalamic volume, most pronounced in the preterm control group, was associated with increased citrate levels in all three group in the parietal white matter. In contrast, reduced cerebellar volume, most pronounced in the preterm CHD group, was associated with reduced glutamine in parietal grey matter in both CHD groups. Single ventricle anatomy, aortic arch obstruction, and cyanotic lesion were predictive of the relationship between reduced subcortical morphometry and reduced GLX (particularly glutamine) in both CHD cohorts (frontal white matter and parietal grey matter). Subcortical morphological associations with brain metabolism were also distinct within each of the three groups, suggesting these relationships in the CHD groups were not directly related to prematurity or white matter injury alone. Taken together, these findings suggest that subplate vulnerability in CHD is likely relevant to understanding the mechanism of both cortical and subcortical dysmaturation in CHD infants. Future work is needed to link this potential pattern of encephalopathy of CHD (including the constellation of grey matter, white matter and brain metabolism deficits) to not only abnormal fetal substrate delivery and oxygen conformance, but also regional deficits in cerebral energy metabolism.
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Affiliation(s)
- Nina Gertsvolf
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Jodie K Votava-Smith
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Department of Pediatrics, Division of Cardiology, Children's Hospital of Los Angeles, Los Angeles, CA, USA
| | - Rafael Ceschin
- Department of Pediatric Radiology, Children's Hospital of Pittsburgh of UPMC and University of Pittsburgh School of Medicine, Pittsburgh, USA
- Department of Biomedical Informatics, University of Pittsburgh School of Medicine, Pittsburgh, USA
| | - Sylvia Del Castillo
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Department of Anesthesiology, Critical Care Medicine Children's Hospital of Los Angeles, Los Angeles, CA, USA
| | - Vince Lee
- Department of Pediatric Radiology, Children's Hospital of Pittsburgh of UPMC and University of Pittsburgh School of Medicine, Pittsburgh, USA
| | - Hollie A Lai
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Department of Radiology, Children's Hospital of Los Angeles, Los Angeles, CA, USA
| | - Stefan Bluml
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Department of Radiology, Children's Hospital of Los Angeles, Los Angeles, CA, USA
| | - Lisa Paquette
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Department of Pediatrics, Division of Neonatology, Children's Hospital of Los Angeles, Los Angeles, CA, USA
| | - Ashok Panigrahy
- Department of Pediatric Radiology, Children's Hospital of Pittsburgh of UPMC and University of Pittsburgh School of Medicine, Pittsburgh, USA.
- Department of Biomedical Informatics, University of Pittsburgh School of Medicine, Pittsburgh, USA.
- Department of Radiology, Children's Hospital of Los Angeles, Los Angeles, CA, USA.
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21
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Schmithorst VJ, Votava-Smith JK, Tran N, Kim R, Lee V, Ceschin R, Lai H, Johnson JA, De Toledo JS, Blüml S, Paquette L, Panigrahy A. Structural network topology correlates of microstructural brain dysmaturation in term infants with congenital heart disease. Hum Brain Mapp 2018; 39:4593-4610. [PMID: 30076775 DOI: 10.1002/hbm.24308] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [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: 02/14/2018] [Revised: 06/26/2018] [Accepted: 06/26/2018] [Indexed: 12/22/2022] Open
Abstract
Neonates with complex congenital heart disease (CHD) demonstrate microstructural brain dysmaturation, but the relationship with structural network topology is unknown. We performed diffusion tensor imaging (DTI) in term neonates with CHD preoperatively (N = 61) and postoperatively (N = 50) compared with healthy term controls (N = 91). We used network topology (graph) analyses incorporating different weighted and unweighted approaches and subject-specific white matter segmentation to investigate structural topology differences, as well as a voxel-based analysis (VBA) to confirm the presence of microstructural dysmaturation. We demonstrate cost-dependent network inefficiencies in neonatal CHD in the pre- and postoperative period compared with controls, related to microstructural differences. Controlling for cost, we show the presence of increased small-worldness (hierarchical fiber organization) in CHD infants preoperatively, that persists in the postoperative period compared with controls, suggesting the early presence of brain reorganization. Taken together, topological microstructural dysmaturation in CHD infants is accompanied by hierarchical fiber organization during a protracted critical period of early brain development. Our methodology also provides a pipeline for quantitation of network topology changes in neonates and infants with microstructural brain dysmaturation at risk for perinatal brain injury.
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Affiliation(s)
- Vincent J Schmithorst
- Department of Pediatric Radiology, Children's Hospital of Pittsburgh of UPMC and University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Jodie K Votava-Smith
- Division of Cardiology, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California
| | - Nhu Tran
- Division of Cardiology, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California
| | - Richard Kim
- Division of Pediatric Cardiothoracic Surgery, Department of Surgery, Children's Hospital Los Angeles, Los Angeles, California
| | - Vince Lee
- Department of Pediatric Radiology, Children's Hospital of Pittsburgh of UPMC and University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Rafael Ceschin
- Department of Pediatric Radiology, Children's Hospital of Pittsburgh of UPMC and University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Hollie Lai
- Department of Radiology, Children's Hospital Los Angeles, Los Angeles, California
| | - Jennifer A Johnson
- Division of Pediatric Cardiology, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Joan Sanchez De Toledo
- Pediatric Cardiac Intensive Care Division, Department of Critical Care, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Stefan Blüml
- Department of Radiology, Children's Hospital Los Angeles, Los Angeles, California
| | - Lisa Paquette
- Department of Pediatrics, Division of Neonatology, Children's Hospital Los Angeles, Los Angeles, California
| | - Ashok Panigrahy
- Department of Pediatric Radiology, Children's Hospital of Pittsburgh of UPMC and University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Department of Radiology, Children's Hospital Los Angeles, Los Angeles, California
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22
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Pruetz JD, Votava-Smith JK, Chmait HR, Korst LM, Llanes A, Chmait RH. Recipient Twin Circular Shunt Physiology Before Fetal Laser Surgery: Survival and Risks for Postnatal Right Ventricular Outflow Tract Obstruction. J Ultrasound Med 2017; 36:1595-1605. [PMID: 28370096 DOI: 10.7863/ultra.16.08038] [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] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Accepted: 11/07/2016] [Indexed: 06/07/2023]
Abstract
OBJECTIVES To evaluate risk for congenital heart disease (CHD) in recipient twins with circular shunt physiology (CSP). METHODS This prospective study enrolled twin-twin transfusion syndrome (TTTS) cases from 2006 to 2015. Fetal echocardiography (FE) was performed before laser surgery when cardiac involvement was suspected. Diagnosis of recipient twin CSP required tricuspid and pulmonary regurgitation, right ventricular dysfunction, and flow reversal in the ductus arteriosus. Outcomes were assessed at 30 days after birth. RESULTS Of the 496 TTTS pregnancies, 20 (4%) met the criteria for CSP. Among those born alive, who had documented cardiac outcomes (n = 457), patients with CSP were more likely to have CHD, specifically right ventricular outflow tract obstruction (5 of 18 [27.8%] versus 22 of 439 [5.0%], odd ratio [OR] 7.29, 95% confidence interval [CI] 2.05-24.72, P = .0025). Of the recipient twins with preoperative FE (n = 259, 52%) who were born alive and had documented cardiac outcomes (n = 242), those with CSP were still more likely to have right ventricular outflow tract obstruction (5 of 18 [27.8%] versus 14 of 224 [6.3%], OR 5.77, CI 1.54-20.92, P = .0077). With both analyses, twins with CSP had higher Quintero stage, but similar patient characteristics and 30-day mortality compared with those without CSP. Subgroup analyses of the CSP cohort identified no differences in preoperative characteristics or FE findings predictive of CHD. CONCLUSIONS Recipient twins with preoperative CSP were at increased risk for postnatal right ventricular outflow tract obstruction, but appeared to have comparable survival after fetal laser surgery despite these dramatic pathophysiological prenatal findings. Preoperative FE in TTTS remains important for prediction of postnatal CHD.
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Affiliation(s)
- Jay D Pruetz
- Division of Pediatric Cardiology, Children's Hospital Los Angeles, University of Southern California, Los Angeles, California, USA
- Department of Obstetrics & Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Jodie K Votava-Smith
- Division of Pediatric Cardiology, Children's Hospital Los Angeles, University of Southern California, Los Angeles, California, USA
| | - Hikmat R Chmait
- Department of Obstetrics & Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Lisa M Korst
- Childbirth Research Associates, North Hollywood, California, USA
| | - Arlyn Llanes
- Department of Obstetrics & Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Ramen H Chmait
- Department of Obstetrics & Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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23
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Votava-Smith JK, Statile CJ, Taylor MD, King EC, Pratt JM, Nelson DP, Michelfelder EC. Impaired cerebral autoregulation in preoperative newborn infants with congenital heart disease. J Thorac Cardiovasc Surg 2017. [PMID: 28634025 DOI: 10.1016/j.jtcvs.2017.05.045] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [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: 11/30/2022]
Abstract
OBJECTIVES To characterize cerebral autoregulation (CA) in preoperative newborn infants with congenital heart disease (CHD). METHODS This was a prospective, pilot study of term newborns with CHD who required intensive care. Continuous mean arterial blood pressure (MAP), cerebral tissue oxygen saturation (SCTO2) via near-infrared spectroscopy, and arterial oxygen saturation (SaO2) were collected. Significant low-frequency coherence between MAP and SCTO2 was used to define impaired CA in 20-minute epochs. Cerebral fractional tissue oxygen extraction (FTOE) = (SaO2 - SCTO2)/SaO2 was calculated. Spearman's and rank bi-serial correlations and logistic linear models accounting for multiple measures were used to identify associations with impaired CA and coherence. RESULTS Twenty-four term neonates were evaluated for 23.4 ± 1.8 hours starting the first day of life. Periods of SaO2 variability >5% were excluded, leaving 63 ± 10 epochs per subject, 1515 total for analysis. All subjects demonstrated periods of abnormal CA, mean 15.3% ± 12.8% of time studied. Significant associations with impaired CA per epoch included greater FTOE (P = .02) and lack of sedation (P = .02), and associations with coherence included greater FTOE (P = .03), lack of sedation (P = .03), lower MAP (P = .006), and lower hemoglobin (P = .02). CONCLUSIONS Term newborns with CHD display time-varying CA abnormalities. Associations seen between abnormal CA and greater FTOE, lack of sedation, and lower hemoglobin suggest that impaired oxygen delivery and increased cerebral metabolic demand may overwhelm autoregulatory capacity in these infants. Further studies are needed to determine the significance of impaired CA in this population.
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Affiliation(s)
- Jodie K Votava-Smith
- Division of Cardiology, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, Calif.
| | | | - Michael D Taylor
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Eileen C King
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jesse M Pratt
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - David P Nelson
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Erik C Michelfelder
- Emory University School of Medicine, Sibley Heart Center Cardiology, Children's Healthcare of Atlanta, Atlanta, Ga
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Harbison AL, Votava-Smith JK, del Castillo S, Kumar SR, Lee V, Schmithorst V, Lai HA, O'Neil S, Bluml S, Paquette L, Panigrahy A. Clinical Factors Associated with Cerebral Metabolism in Term Neonates with Congenital Heart Disease. J Pediatr 2017; 183:67-73.e1. [PMID: 28109537 PMCID: PMC5368020 DOI: 10.1016/j.jpeds.2016.12.061] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [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: 09/18/2016] [Revised: 11/15/2016] [Accepted: 12/20/2016] [Indexed: 01/16/2023]
Abstract
OBJECTIVE To determine associations between patient and clinical factors with postnatal brain metabolism in term neonates with congenital heart disease (CHD) via the use of quantitative magnetic resonance spectroscopy. STUDY DESIGN Neonates with CHD were enrolled prospectively to undergo pre- and postoperative 3T brain magnetic resonance imaging. Short-echo single-voxel magnetic resonance spectroscopy of parietal white matter was used to quantify metabolites related to brain maturation (n-acetyl aspartate, choline, myo- inositol), neurotransmitters (glutamate and gamma-aminobutyric acid), energy metabolism (glutamine, citrate, glucose, and phosphocreatine), and injury/apoptosis (lactate and lipids). Multivariable regression was performed to search for associations between (1) patient-specific/prenatal/preoperative factors with concurrent brain metabolism and (2) intraoperative and postoperative factors with postoperative brain metabolism. RESULTS A total of 83 magnetic resonance images were obtained on 55 subjects. No patient-specific, prenatal, or preoperative factors associated with concurrent metabolic brain dysmaturation or elevated lactate could be identified. Chromosome 22q11 microdeletion and age at surgery were predictive of altered concurrent white matter phosphocreatine (P < .0055). The only significant intraoperative association found was increased deep hypothermic circulatory arrest time with reduced postoperative white matter glutamate and gamma-aminobutyric acid (P < .0072). Multiple postoperative factors, including increased number of extracorporeal membrane oxygenation days (P < .0067), intensive care unit, length of stay (P < .0047), seizures in the intensive care unit (P < .0009), and home antiepileptic use (P < .0002), were associated with reduced postoperative white matter n-acetyl aspartate. CONCLUSION Multiple postoperative factors were found to be associated with altered brain metabolism in term infants with CHD, but not patient-specific, preoperative, or intraoperative factors.
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Affiliation(s)
- Anna Lonyai Harbison
- Division of Cardiology, Department of Pediatrics, Critical Care Medicine, Children’s Hospital of Los Angeles, Los Angeles, CA
| | - Jodie K. Votava-Smith
- Division of Cardiology, Department of Pediatrics, Critical Care Medicine, Children’s Hospital of Los Angeles, Los Angeles, CA
| | - Sylvia del Castillo
- Department of Anesthesiology, Critical Care Medicine, Children’s Hospital of Los Angeles, Los Angeles, CA
| | - S. Ram Kumar
- Division of Cardiac Surgery, Department of Surgery, Children’s Hospital of Los Angeles/University of Southern California, Los Angeles, CA
| | - Vince Lee
- Department of Pediatric Radiology, Children’s Hospital of Pittsburgh of UPMC and University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Vincent Schmithorst
- Department of Pediatric Radiology, Children’s Hospital of Pittsburgh of UPMC and University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Hollie A. Lai
- Division of Radiology, Department of Pediatrics, Children’s Hospital of Los Angeles, Los Angeles, CA
| | - Sharon O'Neil
- Division of Neurology, Department of Pediatrics, Children’s Hospital of Los Angeles, Los Angeles, CA
| | - Stefan Bluml
- Division of Radiology, Department of Pediatrics, Children’s Hospital of Los Angeles, Los Angeles, CA
| | - Lisa Paquette
- Division of Neonatology, Department of Pediatrics, Children’s Hospital of Los Angeles, Los Angeles, CA
| | - Ashok Panigrahy
- Department of Pediatric Radiology, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center and University of Pittsburgh School of Medicine, Pittsburgh, PA.
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Domadia S, Kumar SR, Votava-Smith JK, Pruetz JD. 207: Neonatal outcomes in Total Anomalous Pulmonary Venous Return (TAPVR): the role of prenatal diagnosis and pulmonary venous obstruction. Am J Obstet Gynecol 2017. [DOI: 10.1016/j.ajog.2016.11.112] [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: 10/20/2022]
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Panigrahy A, Lee V, Ceschin R, Zuccoli G, Beluk N, Khalifa O, Votava-Smith JK, DeBrunner M, Munoz R, Domnina Y, Morell V, Wearden P, De Toledo JS, Devine W, Zahid M, Lo CW. Brain Dysplasia Associated with Ciliary Dysfunction in Infants with Congenital Heart Disease. J Pediatr 2016; 178:141-148.e1. [PMID: 27574995 PMCID: PMC5085835 DOI: 10.1016/j.jpeds.2016.07.041] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [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: 02/26/2016] [Revised: 06/03/2016] [Accepted: 07/27/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To test for associations between abnormal respiratory ciliary motion (CM) and brain abnormalities in infants with congenital heart disease (CHD) STUDY DESIGN: We recruited 35 infants with CHD preoperatively and performed nasal tissue biopsy to assess respiratory CM by videomicroscopy. Cranial ultrasound scan and brain magnetic resonance imaging were obtained pre- and/or postoperatively and systematically reviewed for brain abnormalities. Segmentation was used to quantitate cerebrospinal fluid and regional brain volumes. Perinatal and perioperative clinical variables were collected. RESULTS A total of 10 (28.5%) patients with CHD had abnormal CM. Abnormal CM was not associated with brain injury but was correlated with increased extraaxial cerebrospinal fluid volume (P < .001), delayed brain maturation (P < .05), and a spectrum of subtle dysplasia including the hippocampus (P < .0078) and olfactory bulb (P < .034). Abnormal CM was associated with higher composite dysplasia score (P < .001), and both were correlated with elevated preoperative serum lactate (P < .001). CONCLUSIONS Abnormal respiratory CM in infants with CHD is associated with a spectrum of brain dysplasia. These findings suggest that ciliary defects may play a role in brain dysplasia in patients with CHD and have the potential to prognosticate neurodevelopmental risks.
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Affiliation(s)
- Ashok Panigrahy
- Department of Pediatric Radiology, Childrens Hospital of Pittsburgh of University of Pittsburgh Medical Center and University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, PA.
| | - Vincent Lee
- Department of Pediatric Radiology, Childrens Hospital of Pittsburgh of UPMC and University of Pittsburgh School of Medicine
| | - Rafael Ceschin
- Department of Pediatric Radiology, Childrens Hospital of Pittsburgh of UPMC and University of Pittsburgh School of Medicine,Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, PA
| | - Giulio Zuccoli
- Department of Pediatric Radiology, Childrens Hospital of Pittsburgh of UPMC and University of Pittsburgh School of Medicine
| | - Nancy Beluk
- Department of Pediatric Radiology, Childrens Hospital of Pittsburgh of UPMC and University of Pittsburgh School of Medicine
| | - Omar Khalifa
- Dept. of Developmental Biology, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Jodie K Votava-Smith
- Department of Pediatric, Division of Cardiology, Childrens Hospital of Los Angeles., Los Angeles, CA
| | - Mark DeBrunner
- Division of Pediatric Cardiology, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Ricardo Munoz
- Cardiac Intensive Care Division, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Yuliya Domnina
- Cardiac Intensive Care Division, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Victor Morell
- Division of Pediatric Cardiothoracic Surgery, Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Peter Wearden
- Division of Pediatric Cardiothoracic Surgery, Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Joan Sanchez De Toledo
- Cardiac Intensive Care Division, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - William Devine
- Dept. of Developmental Biology, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Maliha Zahid
- Dept. of Developmental Biology, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Cecilia W. Lo
- Dept. of Developmental Biology, University of Pittsburgh School of Medicine, Pittsburgh, PA
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Earhart BA, Williams ME, Zamora I, Randolph LM, Votava-Smith JK, Marcy SN. Phenotype of 7q11.23 duplication: A family clinical series. Am J Med Genet A 2016; 173:114-119. [DOI: 10.1002/ajmg.a.37966] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 08/04/2016] [Indexed: 11/12/2022]
Affiliation(s)
- Beth A. Earhart
- USC University Center for Excellence in Developmental Disabilities; Children's Hospital Los Angeles; Los Angeles California
| | - Marian E. Williams
- Department of Pediatrics, USC University Center for Excellence in Developmental Disabilities; University of Southern California Keck School of Medicine of USC, Children's Hospital Los Angeles; Los Angeles California
| | - Irina Zamora
- Department of Pediatrics, USC University Center for Excellence in Developmental Disabilities; University of Southern California Keck School of Medicine of USC, Children's Hospital Los Angeles; Los Angeles California
| | - Linda Marie Randolph
- Division of Medical Genetics, Department of Pediatrics; University of Southern California, Children's Hospital Los Angeles; Los Angeles California
| | - Jodie K. Votava-Smith
- Division of Cardiology, Department of Pediatrics; University of Southern California, Children's Hospital Los Angeles; Los Angeles California
| | - Stephanie N. Marcy
- Department of Pediatrics, USC University Center for Excellence in Developmental Disabilities; University of Southern California Keck School of Medicine of USC, Children's Hospital Los Angeles; Los Angeles California
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Votava-Smith JK, Pitukcheewanont P, Randolph LM, Chmait RH. Generalized Arterial Calcification in a Recipient Twin: Discordant Fetal Hemodynamics Result in Differing Phenotypes in Monozygotic Twins with an ABCC6 Mutation. Fetal Diagn Ther 2016; 41:234-236. [PMID: 26982014 DOI: 10.1159/000444852] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [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: 10/22/2015] [Accepted: 02/16/2016] [Indexed: 11/19/2022]
Abstract
Recipients of the twin-twin transfusion syndrome (TTTS) often develop cardiac manifestations, but arterial calcification has rarely been reported. Generalized arterial calcification of infancy (GACI) is a genetic disorder with high infantile mortality. We report the case of a TTTS recipient with moderate cardiomyopathy at diagnosis who developed progressive calcification of the pulmonary arteries and aorta after successful in utero laser therapy. Postnatally, both twins were diagnosed with a heterozygous ABCC6 gene mutation associated with GACI. The recipient had progressive supravalvular pulmonary and aortic stenosis, was treated with bisphosphonate therapy, and successfully underwent cardiac surgery at 4 months of age. The donor twin with the same mutation remained phenotypically normal at 15 months of age. This case illustrates monozygotic fetuses with discordant in utero hemodynamics, with subsequent development of phenotypic differences. TTTS recipients with arterial calcifications should undergo genetic testing for GACI.
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Affiliation(s)
- Jodie K Votava-Smith
- Division of Cardiology, Children's Hospital Los Angeles, Los Angeles, Calif., USA
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Chmait RH, Pruetz JD, Votava-Smith JK, Korst LM, Llanes A, Chmait HR. 862: Circular shunt physiology in recipient twins is associated with increased risk for postnatal right ventricular outflow tract obstruction. Am J Obstet Gynecol 2016. [DOI: 10.1016/j.ajog.2015.10.912] [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]
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Castellanos D, Travelli FC, Reyhan I, Votava-Smith JK, Ramanathan A, Bar-Cohen Y. Acute Aortic and Mitral Valve Perforations Caused by Granulomatosis With Polyangiitis. Circulation 2015; 131:e527-9. [PMID: 26078373 DOI: 10.1161/circulationaha.114.014304] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [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: 11/16/2022]
Affiliation(s)
- Daniel Castellanos
- From Department of Pediatrics (D.C.) and Divisions of Cardiology (F.C.T., J.K.V.-S., Y.B.-C.) and Rheumatology (I.R., A.R.), Department of Pediatrics, Children's Hospital Los Angeles, CA; and Keck School of Medicine, University of Southern California, Los Angeles (F.C.T., I.R., J.K.V.-S., A.R., Y.B.-C.)
| | - Frances C Travelli
- From Department of Pediatrics (D.C.) and Divisions of Cardiology (F.C.T., J.K.V.-S., Y.B.-C.) and Rheumatology (I.R., A.R.), Department of Pediatrics, Children's Hospital Los Angeles, CA; and Keck School of Medicine, University of Southern California, Los Angeles (F.C.T., I.R., J.K.V.-S., A.R., Y.B.-C.)
| | - Iris Reyhan
- From Department of Pediatrics (D.C.) and Divisions of Cardiology (F.C.T., J.K.V.-S., Y.B.-C.) and Rheumatology (I.R., A.R.), Department of Pediatrics, Children's Hospital Los Angeles, CA; and Keck School of Medicine, University of Southern California, Los Angeles (F.C.T., I.R., J.K.V.-S., A.R., Y.B.-C.)
| | - Jodie K Votava-Smith
- From Department of Pediatrics (D.C.) and Divisions of Cardiology (F.C.T., J.K.V.-S., Y.B.-C.) and Rheumatology (I.R., A.R.), Department of Pediatrics, Children's Hospital Los Angeles, CA; and Keck School of Medicine, University of Southern California, Los Angeles (F.C.T., I.R., J.K.V.-S., A.R., Y.B.-C.)
| | - Anusha Ramanathan
- From Department of Pediatrics (D.C.) and Divisions of Cardiology (F.C.T., J.K.V.-S., Y.B.-C.) and Rheumatology (I.R., A.R.), Department of Pediatrics, Children's Hospital Los Angeles, CA; and Keck School of Medicine, University of Southern California, Los Angeles (F.C.T., I.R., J.K.V.-S., A.R., Y.B.-C.)
| | - Yaniv Bar-Cohen
- From Department of Pediatrics (D.C.) and Divisions of Cardiology (F.C.T., J.K.V.-S., Y.B.-C.) and Rheumatology (I.R., A.R.), Department of Pediatrics, Children's Hospital Los Angeles, CA; and Keck School of Medicine, University of Southern California, Los Angeles (F.C.T., I.R., J.K.V.-S., A.R., Y.B.-C.).
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Agarwal A, Medical student SB, Lim-Stavros S, Votava-Smith JK, Ramanathan A. Pediatric systemic lupus erythematosus presenting with coronary arteritis: A case series and review of the literature. Semin Arthritis Rheum 2015; 45:42-7. [DOI: 10.1016/j.semarthrit.2015.02.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Revised: 02/26/2015] [Accepted: 02/27/2015] [Indexed: 02/08/2023]
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32
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Votava-Smith JK, Habli M, Cnota JF, Divanovic A, Polzin W, Lim FY, Michelfelder EC. Diastolic dysfunction and cerebrovascular redistribution precede overt recipient twin cardiomyopathy in early-stage twin-twin transfusion syndrome. J Am Soc Echocardiogr 2015; 28:533-40. [PMID: 25577184 DOI: 10.1016/j.echo.2014.12.003] [Citation(s) in RCA: 11] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2014] [Indexed: 11/16/2022]
Abstract
BACKGROUND Indications for intervention in early-stage (Quintero I and II) twin-twin transfusion syndrome (TTTS) are not standardized. Fetal echocardiography can be used to guide the management of early-stage patients. The aim of this study was to identify early cardiovascular findings that may precede progression to overt recipient twin (RT) cardiomyopathy in early-stage TTTS. METHODS This was a retrospective review of pregnancies evaluated from 2004 to 2010. Subjects were included when initial evaluation identified Quintero I or II TTTS without evidence of "overt" RT cardiomyopathy, defined on the basis of atrioventricular valve regurgitation, ventricular hypertrophy, and abnormal Doppler myocardial performance indices. Patients elected management with observation or amnioreduction. Pregnancies were grouped by whether the RT developed overt cardiomyopathy. Initial values, including myocardial performance index, diastolic filling time corrected for heart rate (Doppler inflow duration/cardiac cycle length), pulsatility indices of the ductus venosus, umbilical artery, and middle cerebral artery, and cerebroplacental ratio (middle cerebral artery PI/umbilical artery PI), were compared. RESULTS Of 174 pregnancies evaluated with early-stage TTTS, 45 (26%) did not show evidence of RT cardiomyopathy. Follow-up echocardiography identified cardiomyopathy in 20 of 45 RTs (44%). Those RTs with subsequent cardiomyopathy had shorter diastolic filling times corrected for heart rate, higher ductus venosus PIs, lower middle cerebral artery PIs, and lower cerebroplacental ratios on initial echocardiography. CONCLUSION Diastolic dysfunction and cerebroplacental redistribution precede findings of overt cardiomyopathy in RTs with early-stage TTTS. Assessment of these parameters may allow earlier identification of RTs with cardiac disease and help guide management. Prospective studies are needed to assess the role of echocardiography in patient selection for the treatment of early-stage TTTS.
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Affiliation(s)
- Jodie K Votava-Smith
- Fetal Heart Program, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Mounira Habli
- Fetal Care Center of Cincinnati, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - James F Cnota
- Fetal Heart Program, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Allison Divanovic
- Fetal Heart Program, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - William Polzin
- Fetal Care Center of Cincinnati, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Foong-Yen Lim
- Fetal Care Center of Cincinnati, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Erik C Michelfelder
- Fetal Heart Program, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
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Villa CR, Habli M, Votava-Smith JK, Cnota JF, Lim FY, Divanovic AA, Wang Y, Michelfelder EC. Assessment of fetal cardiomyopathy in early-stage twin-twin transfusion syndrome: comparison between commonly reported cardiovascular assessment scores. Ultrasound Obstet Gynecol 2014; 43:646-651. [PMID: 24151229 DOI: 10.1002/uog.13231] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/15/2013] [Indexed: 06/02/2023]
Abstract
OBJECTIVES To assess the relationship between commonly reported fetal cardiomyopathy scoring systems in early-stage twin-twin transfusion syndrome (TTTS). METHODS We reviewed retrospectively 100 cases of Quintero Stages I and II TTTS referred to our center for evaluation from 2008 to 2010. The cases were divided into groups of 25, representing each of four grades of TTTS cardiomyopathy as assessed by Cincinnati stage: no cardiomyopathy, Stage IIIa, Stage IIIb and Stage IIIc. Spearman correlation (rs ) was calculated between the Children's Hospital of Philadelphia (CHOP) score, cardiovascular profile score (CVPS), Cincinnati stage and myocardial performance index (MPI). RESULTS There was a weak correlation between the Cincinnati stage and the CHOP score (rs = 0.36) and CVPS (rs = -0.39), while correlation was strong between the CHOP score and CVPS (rs = -0.72). MPI elevation was concordant with Cincinnati stage more frequently (82% of cases) than were ventricular hypertrophy (43%) or atrioventricular valve regurgitation (28%). 51% of fetuses with minimally elevated CHOP score (0-1) and 48% of fetuses with minimally depressed CVPS (9-10) had significant elevation (Z-score ≥ +3) in right ventricular or left ventricular MPI. CONCLUSIONS MPI has a strong influence on grading the severity of fetal cardiomyopathy using the Cincinnati stage among fetuses with mild TTTS. Furthermore, significant elevation of the MPI is common among fetuses with mild disease as assessed by the CHOP score and CVPS. These differences should be understood when assessing and grading cardiomyopathy in TTTS, particularly in early (Quintero Stages I and II) disease.
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Affiliation(s)
- C R Villa
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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Votava-Smith JK, Glickstein JS, Simpson LL, Williams IA. Comparison of method of conception in fetuses undergoing echocardiography at a tertiary referral center. Prenat Diagn 2014; 34:445-9. [PMID: 24496858 DOI: 10.1002/pd.4327] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2013] [Revised: 01/11/2014] [Accepted: 01/12/2014] [Indexed: 11/11/2022]
Abstract
OBJECTIVES We compared the proportion of conception with and without in vitro fertilization (IVF) in fetuses with and without congenital heart disease (CHD). METHODS This was a retrospective review of fetal echocardiograms at Columbia University from 2007 to 2010, to identify the mode of conception. RESULTS Echocardiography was performed on 2828 fetuses, and 2761 (97.6%) had the method of conception documented. CHD was diagnosed in 22.4%, consisting predominantly of complex CHD. The proportion of IVF conception was lower in fetuses with CHD (6.9% CHD vs 10.3% no CHD, OR = 0.65 [95% CI 0.46-0.92], p = 0.01). IVF fetuses were conceived by elder mothers and were more likely part of a multiple gestation than those without IVF. In a multivariate model controlling for maternal age and multiple gestation, IVF was not associated with CHD diagnosis (OR = 1.1 [95% CI 0.77-1.7], p = 0.51). CONCLUSION At a tertiary referral center, fetuses with CHD were not more likely to be conceived by IVF after controlling for maternal age and multiple gestation. These results differ from those of several previous reports, which may be related to our study population, and the exclusion of isolated atrial shunts and patent ductus arteriosus, which are normal fetal findings.
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Affiliation(s)
- Jodie K Votava-Smith
- Department of Pediatrics, Division of Pediatric Cardiology, Columbia University Medical Center, Morgan Stanley Children's Hospital, New York, NY, USA
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Votava-Smith JK, Perens GS, Alejos JC. Bosentan for increased pulmonary vascular resistance in a patient with single ventricle physiology and a bidirectional Glenn shunt. Pediatr Cardiol 2007; 28:314-6. [PMID: 17563825 DOI: 10.1007/s00246-007-0037-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [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: 01/31/2007] [Accepted: 03/17/2007] [Indexed: 11/25/2022]
Abstract
We present a case of the successful use of bosentan for increased pulmonary vascular resistance (PVR) in a 10-year-old male who underwent late single ventricle surgical palliation for double-inlet left ventricle with pulmonary artery banding and a bidirectional Glenn shunt. The patient was treated with bosentan for 16 weeks, with decreases in mean pulmonary artery pressure from 23 to 16 mmHg on the right and from 31 to 21 mmHg on the left, and a decrease of the transpulmonary gradient by 7-8 mmHg. Cardiopulmonary exercise testing demonstrated an increase in peak oxygen consumption (VO2) by 8% and peak work rate by 10%. Bosentan is a relatively new oral therapy option for increased PVR in patients with single ventricle physiology and bidirectional Glenn shunts.
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Affiliation(s)
- J K Votava-Smith
- Department of Pediatric Cardiology, Mattel Children's Hospital at UCLA, 10833 Le Conte Avenue, B2-427 MDCC, Los Angeles, CA 90095-1743, USA
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Abstract
Varicella-like rash after immunization with the live attenuated varicella vaccine is relatively common. Such vaccine-associated rashes generally consist of fewer lesions than occur in chickenpox. We describe a 15-month-old girl who experienced the onset of recurring papular urticaria after varicella immunization. The rash was varicella-like and thought by us to be caused by vaccine virus.
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Affiliation(s)
- David E Bronstein
- Department of Pediatrics, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
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