Thoracic Duct-to-Pulmonary Vein Shunt in the Treatment of Experimental Right Heart Failure

Cole, William R.; Witte, Marlys H.; Kash, Stephen L.; Rodger, Malcolm; Bleisch, Virgil R.; Muelheims, Gerhard H.

doi:10.1161/01.cir.36.4.539

Cited by 36 publications

(15 citation statements)

References 6 publications

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“…It is also notable that, in our experience, the only surgical procedure other than transplantation that provided lasting resolution of protein-losing enteropathy was diversion of an obstructed thoracic duct to an alternate systemic vein. To our knowledge, although this technique was not reported previously in protein-losing enteropathy, the response in this case bears striking similarity to clinical improvements seen in studies of thoracic duct externalisation and drainage in adults with congestive heart failure 74 or thoracic duct-to-pulmonary vein shunting in an animal model of right heart failure, 75 and supports the concept of a physiologically taxed but potentially treatable lymphatic system. Notably, full clinical improvement in this patient was not apparent until protein repletion had occurred through rigorous dietary attention, highlighting the profound degree of protein depletion that can occur in patients with chronic protein-losing enteropathy and the need to address both protein loss and production to achieve meaningful improvement in this disease.…”

Section: Discussionsupporting

confidence: 79%

Protein-losing enteropathy: integrating a new disease paradigm into recommendations for prevention and treatment

Meadows

Jenkins

2011

Cardiol Young

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Protein-losing enteropathy is a relatively uncommon complication of Fontan procedures for palliation of complex congenital cardiac disease. However, the relative infrequency of protein-losing enteropathy belies the tremendous medical, psychosocial and financial burdens it places upon afflicted patients, their families and the healthcare system that supports them. Unfortunately, because of the complexity and rarity of this disease process, the pathogenesis and pathophysiology of protein-losing enteropathy remain poorly understood, and attempts at treatment seldom yield long-term success. The most comprehensive analyses of protein-losing enteropathy in this patient population are now over a decade old, and re-evaluation of the prevalence and progress in treatment of this disease is needed. This report describes a single institution experience with the evaluation, management, and treatment of protein-losing enteropathy in patients with congenital cardiac disease in the current era, follows with a comprehensive review of protein-losing enteropathy, focused upon what is known and not known about the pathophysiology of protein-losing enteropathy in this patient population, and concludes with suggestions for prevention and treatment.

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Section: Discussionsupporting

confidence: 79%

Protein-losing enteropathy: integrating a new disease paradigm into recommendations for prevention and treatment

Meadows

Jenkins

2011

Cardiol Young

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“…However, in most instances it was possible to demonstrate that the main lymphatic channels were intact after denervation. Furthermore, there is evidence that increased resistance to lymph flow may under certain circumstances lead to antinatriuresis rather than to natriuresis (19). One might also question whether phenol itself might have been directly responsible for the observed effects.…”

Section: Resultsmentioning

confidence: 99%

Effects of acute unilateral renal denervation in the rat.

Bello‐Reuss¹,

Colindres²,

Pastoriza-Munoz³

et al. 1975

J. Clin. Invest.

215

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A B S T R A C T Studies were undertaken to characterize the renal responses to acute unilateral renal denervation and the mechanisms involved in these responses. Denervation was produced in anesthetized nondiuretic rats by application of phenol to the left renal artery. Studies were also performed in sham-denervated nondiuretic rats. Whole kidney and individual nephron studies were performed before and after denervation or sham denervation. Denervation increased urine volume from the left kidney to about twice its control value (P < 0.001) and increased urinary sodium excretion from 332 neq min' to 1,887 neq min' (P <0.001). Glomerular filtration rate (GFR) and renal plasma flow (RPF) remained unchanged in both kidneys after the procedure. The innervated right kidney showed no changes in urine volume or in sodium excretion. After denervation, late proximal ratio of tubular fluid inulin concentration to that of plasma [ (F/P) In] decreased from 2.23 to 1.50 (P < 0.001) while single nephron GFR remained unchanged. Absolute reabsorption decreased from 16.5 to 9.9 nl min' (P <0.001). (F/P) i ratios were also decreased in early distal (from 6.21 to 3.18, P <0.001) and late distal convolutions (from 16.41 to 8.33, P < 0.001) during the experimental period. (F/P) Na ratios remained unchanged in the early distal convolutions, but increased from 0.18 to 0.38 (P < 0.01) in late distal convolutions after denervation. Absolute Na reabsorption after denervation increased in the loop of Henle, distal convolution, and collecting ducts. Any changes in intrarenal hydrostatic pressures

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“…As shown in Table 1, there generally seems to exist a threshold level in the outflow venous pressure above which thoracic duct flow decreases significantly. In the experiments inserting a catheter in the thoracic duct or in the efferent duct of the caudal mediastinal lymph node, such a threshold has also been observed when raising the outflow level of the catheter (Cole, Witte, Kash, Rodger, Bleisch & Muelheims, 1967;Szab o & Magyar, 1967;Drake et al 1985). In experiments using the interposed cannula in the thoracic duct (W egria et al 1963), a threshold was, however, not observed in anaesthetized dogs.…”

Section: Effect Of Outflow Venous Pressurementioning

confidence: 97%

Lymph Flow Pattern in the Intact Thoracic Duct in Sheep

Onizuka

Flatebø

Nicolaysen

1997

The Journal of Physiology

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To study the lymph flow dynamics in the intact thoracic duct, we applied an ultrasound transit‐time flow probe in seven anaesthetized and four unanaesthetized adult sheep (.60 kg). In unanaesthetized non‐fasting animals we found that lymph flow in the thoracic duct was always regular pulsatile (pulsation frequency, 5.2 ± 0.8 min−1) with no relation to heart or respiratory activity. At baseline the peak level of the thoracic duct pulse flow was 11.6–20.7 ml min−1 with a nadir of 0–3.6 ml min−1. Mean lymph flow was 5.4 ± 3.1 ml min−1. The flow pattern of lymph in the thoracic duct was essentially the same in the anaesthetized animals. In both the anaesthetized and unanaesthetized animals, the lymph flow response to a stepwise increase in the outflow venous pressure showed interindividual variation. Some were sensitive to any increase in outflow venous pressure, but others were resistant in that lymph flow did not decrease until outflow venous pressure was increased to higher levels. This resistance was also observed in the high lymph flow condition produced by fluid infusion in the anaesthetized animal and mechanical constriction of the caudal vena cava in the unanaesthetized animals. Pulsation frequency of the thoracic duct flow initially increased and then decreased with a stepwise increase in the outflow venous pressure. This initial increase might be a compensatory response to maintain lymph flow against elevated outflow venous pressure. To test the effect of long‐term outflow venous pressure elevation in unanaesthetized sheep, outflow venous pressure was increased by inflation of a cuff around the cranial vena cava for 1, 5 or 25 h. The cuff was inflated to a level where lymph flow was reduced. Lymph flow remained low or decreased further during the entire cuff‐inflation period. We calculated the lymph debt caused by the outflow venous pressure elevation and the amount ‘repaid’ when venous pressure returned to normal. Lymph debt for 25 h was 6400 ml but only 200 ml was repaid. Since we observed no visible oedema formation in the lower body of the sheep, the non‐colloidal components of the lymph must have been reabsorbed into the bloodstream, most likely in the lymph nodes.

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Thoracic Duct-to-Pulmonary Vein Shunt in the Treatment of Experimental Right Heart Failure

Cited by 36 publications

References 6 publications

Protein-losing enteropathy: integrating a new disease paradigm into recommendations for prevention and treatment

Protein-losing enteropathy: integrating a new disease paradigm into recommendations for prevention and treatment

Effects of acute unilateral renal denervation in the rat.

Lymph Flow Pattern in the Intact Thoracic Duct in Sheep

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