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Giannakoulas G, Gatzoulis MA. Pulmonary arterial hypertension in congenital heart disease: Current perspectives and future challenges. Hellenic J Cardiol 2016; 57:S1109-9666(16)30144-0. [PMID: 27642135 DOI: 10.1016/j.hjc.2016.05.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Accepted: 05/19/2016] [Indexed: 10/21/2022] Open
Abstract
Medical and scientific research in the field of pulmonary arterial hypertension (PAH) in adults with congenital heart disease (ACHD) has gradually become globalized, inclusive and collaborative over the past few years. The education of physicians, health administrators and patients on congenital heart disease (CHD), specifically in the field of PAH, is of paramount importance. It is also crucial for ACHD patients with PAH to be followed in tertiary centers and to benefit from a multidisciplinary approach. Shared care models dictate a closer collaboration between tertiary expert centers and local non-specialist services, as well as networking between expert physicians in CHD and PAH and geneticists/epidemiologists, with the inclusion of PAH-CHD patients in national and international registries with a detailed genotypic/phenotypic characterization.
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Affiliation(s)
- George Giannakoulas
- Cardiology Department, AHEPA University Hospital, Aristotle University of Thessaloniki, Greece.
| | - Michael A Gatzoulis
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Royal Brompton Hospital, London, UK; National Heart and Lung Institute, Imperial College, London, UK
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102
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103
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LI QINGLIN, YAN XIAOPEI, KONG HUI, XIE WEIPING, WANG HONG. Iptakalim influences the proliferation and apoptosis of human pulmonary artery smooth muscle cells. Mol Med Rep 2016; 14:715-20. [PMID: 27221642 PMCID: PMC4918544 DOI: 10.3892/mmr.2016.5333] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Accepted: 05/23/2016] [Indexed: 12/19/2022] Open
Abstract
The aim of the present study was to determine the effect of an ATP-sensitive K+ (KATP) channel opener iptakalim (IPT) on the proliferation and apoptosis of human pulmonary artery smooth muscle cells (HPASMCs), and examine the potential value of IPT to hypoxic pulmonary hyper-tension (HPH) at a cellular level. HPASMCs were divided into the control, ET-1, ET-1+IPT and ET-1+IPT+glibenclamide (GLI) groups. GLI was administered 30 min prior to ET-1 and IPT. The 4 groups were incubated with corresponding reagents for 24 h. Cell viability was evaluated using a CCK-8 assay, cell proliferation by 5-ethynyl-2'-deoxyuridine (EdU) incorporation assay, and cell apoptosis via the expression of apoptosis-related proteins, i.e., Bcl-2-associated X protein (Bax) and B-cell lymphoma 2 (Bcl-2) using western blotting. We incubated HPASMCs with varying concentrations of ET-1 for 24, 48 and 72 h, and found that cell survival rate was increased in a dose-dependent manner (P<0.05) rather than in a time-dependent manner (P>0.05). After co-incubation of HPASMCs with varying concentrations of IPT and ET-1 for 24 h, the cell survival rate was decreased in a dose-dependent manner. The cell survival rate in the IPT+ET-1 group was significantly lower than that in the ET-1 group (P<0.05). The cell viability (P<0.05) and proliferation (P<0.05) in the ET-1 group were higher than those in the control group, and the expression of Bax/Bcl-2 was lower than the control group (P<0.05). The cell viability (P<0.05) and proliferation (P<0.05) in the ET-1+IPT group were lower than those in the ET-1 group, and the expression of Bax/Bcl-2 was higher than that in the ET-1 group (P<0.05). The cell viability (P<0.05) and proliferation (P<0.05) in the ET-1+IPT+GLI group were higher than those in the ET-1+IPT group, and the expression of Bax/Bcl-2 was lower than that in the ET-1+IPT group (P<0.05). In conclusion, IPT inhibited ET-1‑induced HPASMC proliferation and promoted cell apoptosis. Thus, it may play an important role in the treatment of HPH.
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Affiliation(s)
- QINGLIN LI
- Department of Respiratory Medicine, The First Affiliated Clinical Medical College of Nanjing Medical University, Nanjing, Jiangsu 210029, P.R. China
| | - XIAOPEI YAN
- Department of Respiratory Medicine, The First Affiliated Clinical Medical College of Nanjing Medical University, Nanjing, Jiangsu 210029, P.R. China
| | - HUI KONG
- Department of Respiratory Medicine, The First Affiliated Clinical Medical College of Nanjing Medical University, Nanjing, Jiangsu 210029, P.R. China
| | - WEIPING XIE
- Department of Respiratory Medicine, The First Affiliated Clinical Medical College of Nanjing Medical University, Nanjing, Jiangsu 210029, P.R. China
| | - HONG WANG
- Department of Respiratory Medicine, The First Affiliated Clinical Medical College of Nanjing Medical University, Nanjing, Jiangsu 210029, P.R. China
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104
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Körten MA, Helm PC, Abdul-Khaliq H, Baumgartner H, Kececioglu D, Schlensak C, Bauer UMM, Diller GP. Eisenmenger syndrome and long-term survival in patients with Down syndrome and congenital heart disease. Heart 2016; 102:1552-7. [DOI: 10.1136/heartjnl-2016-309437] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Accepted: 05/10/2016] [Indexed: 11/03/2022] Open
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105
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Van De Bruaene A, Budts W. Pulmonary hypertension in the changing landscape of congenital heart disease: Global differences and a possible driver of end-stage heart failure. Neth Heart J 2016; 24:372-373. [PMID: 27170373 PMCID: PMC4887305 DOI: 10.1007/s12471-016-0844-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
- A Van De Bruaene
- Congenital and Structural Cardiology, University Hospitals Leuven and Department of Cardiovascular Sciences, Catholic University Leuven, Leuven, Belgium.
| | - W Budts
- Congenital and Structural Cardiology, University Hospitals Leuven and Department of Cardiovascular Sciences, Catholic University Leuven, Leuven, Belgium
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106
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Pulmonary arterial hypertension associated with congenital heart disease: Comparison of clinical and anatomic–pathophysiologic classification. J Heart Lung Transplant 2016; 35:610-8. [DOI: 10.1016/j.healun.2015.12.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Revised: 11/09/2015] [Accepted: 12/21/2015] [Indexed: 11/18/2022] Open
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107
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Couperus LE, Henkens IR, Jongbloed MRM, Hazekamp MG, Schalij MJ, Vliegen HW. Tailored circulatory intervention in adults with pulmonary hypertension due to congenital heart disease. Neth Heart J 2016; 24:400-409. [PMID: 27098530 DOI: 10.1007/s12471-016-0833-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Accepted: 03/08/2016] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Adults with pulmonary hypertension associated with congenital heart disease (PH-CHD) often have residual shunts. Invasive interventions aim to optimise pulmonary flow and prevent right ventricular failure. However, eligibility for procedures strongly depends on the adaptation potential of the pulmonary vasculature and right ventricle to resultant circulatory changes. Current guidelines are not sufficiently applicable to individual patients, who exhibit great diversity and complexity in cardiac anomalies. METHODS AND RESULTS We present four complex adult PH-CHD patients with impaired pulmonary flow, including detailed graphics of the cardiopulmonary circulation. All these patients had an ambiguous indication for shunt intervention. Our local multidisciplinary Grown-Ups with Congenital Heart Disease team reached consensus regarding a patient-tailored invasive treatment strategy, adjacent to relevant guidelines. Interventions improved pulmonary haemodynamics and short-term clinical functioning in all cases. CONCLUSIONS Individual evaluation of disease characteristics is mandatory for tailored interventional treatment in PH-CHD patients, adjacent to relevant guidelines. Both strict registration of cases and multidisciplinary and multicentre collaboration are essential in the quest for optimal therapy in this patient population.
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Affiliation(s)
- L E Couperus
- Department of Cardiology, Leiden University Medical Center, Leiden, Netherlands.
| | - I R Henkens
- Department of Cardiology, Leiden University Medical Center, Leiden, Netherlands
| | - M R M Jongbloed
- Department of Cardiology, Leiden University Medical Center, Leiden, Netherlands
- Department of Anatomy, Leiden University Medical Center, Leiden, Netherlands
| | - M G Hazekamp
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands
| | - M J Schalij
- Department of Cardiology, Leiden University Medical Center, Leiden, Netherlands
| | - H W Vliegen
- Department of Cardiology, Leiden University Medical Center, Leiden, Netherlands
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108
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Monfredi O, Heward E, Griffiths L, Condliffe R, Mahadevan VS. Effect of dual pulmonary vasodilator therapy in pulmonary arterial hypertension associated with congenital heart disease: a retrospective analysis. Open Heart 2016; 3:e000399. [PMID: 27099763 PMCID: PMC4836289 DOI: 10.1136/openhrt-2016-000399] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 02/24/2016] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Patients with pulmonary arterial hypertension (PAH) are managed according to evidence-based treatment guidelines. METHODS AND RESULTS In this single-centre retrospective analysis, we examined outcomes of patients with PAH caused by congenital heart disease (PAH-CHD) with respect to exercise capacity and survival of adults treated with either bosentan or sildenafil monotherapy or bosentan-sildenafil dual therapy between January 2007 and January 2014. Of the 82 patients analysed, 29 had Down syndrome; 54 (65.8%) received bosentan monotherapy, 16 (19.5%) sildenafil monotherapy and 12 (14.6%) dual therapy. Mean treatment duration was 2.5 years for all patients and 4.1 years for 38 patients treated for ≥2 years. Pooled patient and treatment data showed initial improvement followed by stabilisation in mean 6 min walk distance (6MWD). For Down and non-Down patients, mean 6MWD increased and then stabilised on bosentan monotherapy. Mean 6MWD of patients on dual therapy at the time of analysis was 246.3 m before PAH-specific therapy initiation, 211.9 m immediately prior to addition of a second therapy and 214.4 m at last visit while on dual therapy. 1, 2 and 3-year survival rates for all patients from time of treatment initiation were 96%, 87% and 80%, respectively. CONCLUSIONS For the majority of patients, monotherapy with a PAH-specific medication provided improved and sustained exercise benefits. For the small percentage of patients who required it, add-on therapy appeared to prevent further deterioration in exercise capacity but did not improve 6MWD.
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Affiliation(s)
- Oliver Monfredi
- University of Manchester, Institute of Cardiovascular Sciences, Manchester, UK; Manchester Heart Centre, Manchester Royal Infirmary, UK; Laboratory of Cardiovascular Science, National Institute on Aging-Intramural Research Program, National Institutes of Health, Baltimore, Maryland, USA
| | - Elliot Heward
- University of Manchester, Institute of Cardiovascular Sciences , Manchester , UK
| | | | - Robin Condliffe
- Sheffield Pulmonary Vascular Disease Unit , Royal Hallamshire Hospital , Sheffield , UK
| | - Vaikom S Mahadevan
- University of Manchester, Institute of Cardiovascular Sciences, Manchester, UK; Manchester Heart Centre, Manchester Royal Infirmary, UK; Heart and Vascular Center, University of California, San Francisco, California, USA
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109
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Kozlik-Feldmann R, Hansmann G, Bonnet D, Schranz D, Apitz C, Michel-Behnke I. Pulmonary hypertension in children with congenital heart disease (PAH-CHD, PPHVD-CHD). Expert consensus statement on the diagnosis and treatment of paediatric pulmonary hypertension. The European Paediatric Pulmonary Vascular Disease Network, endorsed by ISHLT and DGPK. Heart 2016; 102 Suppl 2:ii42-8. [DOI: 10.1136/heartjnl-2015-308378] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Accepted: 10/14/2015] [Indexed: 12/21/2022] Open
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110
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Hoeper MM, Humbert M, Souza R, Idrees M, Kawut SM, Sliwa-Hahnle K, Jing ZC, Gibbs JSR. A global view of pulmonary hypertension. THE LANCET RESPIRATORY MEDICINE 2016; 4:306-22. [DOI: 10.1016/s2213-2600(15)00543-3] [Citation(s) in RCA: 242] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Revised: 12/15/2015] [Accepted: 12/17/2015] [Indexed: 10/22/2022]
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111
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Suntharalingam J, Ross RM, Easaw J, Robinson G, Coghlan G. Who should be referred to a specialist pulmonary -hypertension centre - a referrer's guide. Clin Med (Lond) 2016; 16:135-41. [PMID: 27037382 PMCID: PMC4952966 DOI: 10.7861/clinmedicine.16-2-135] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The introduction of pulmonary hypertension (PH)-specific drugs has allowed certain forms of PH to become more treatable. However, patients with these diseases can present to a number of medical specialties and can be challenging to identify, particularly in a non-specialist setting. This article provides guidance on who should be investigated and referred on to a specialist centre, highlighting the potential pitfalls during assessment.
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Affiliation(s)
| | | | - Jacob Easaw
- Cardiology Department, Royal United Hospital, Bath, UK
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112
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The role of cystatin C as a biomarker for prognosis in pulmonary arterial hypertension due to congenital heart disease. Int J Cardiol 2016; 209:242-7. [DOI: 10.1016/j.ijcard.2016.02.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Revised: 01/23/2016] [Accepted: 02/01/2016] [Indexed: 11/16/2022]
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113
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Reconciling paradigms of abnormal pulmonary blood flow and quasi-malignant cellular alterations in pulmonary arterial hypertension. Vascul Pharmacol 2016; 83:17-25. [PMID: 26804008 DOI: 10.1016/j.vph.2016.01.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Accepted: 01/19/2016] [Indexed: 01/29/2023]
Abstract
In pulmonary arterial hypertension (PAH) structural and functional abnormalities of the small lung vessels interact and lead to a progressive increase in pulmonary vascular resistance and right heart failure. A current pathobiological concept characterizes PAH as a 'quasi-malignant' disease focusing on cancer-like alterations in endothelial cells (EC) and the importance of their acquired apoptosis-resistant, hyper-proliferative phenotype in the process of vascular remodeling. While changes in pulmonary blood flow (PBF) have been long-since recognized and linked to the development of PAH, little is known about a possible relationship between an altered PBF and the quasi-malignant cell phenotype in the pulmonary vascular wall. This review summarizes recognized and hypothetical effects of an abnormal PBF on the pulmonary vascular bed and links these to quasi-malignant changes found in the pulmonary endothelium. Here we describe that abnormal PBF does not only trigger a pulmonary vascular cell growth program, but may also maintain the cancer-like phenotype of the endothelium. Consequently, normalization of PBF and EC response to abnormal PBF may represent a treatment strategy in patients with established PAH.
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114
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Yamasaki Y, Nagao M, Kamitani T, Yamanouchi T, Kawanami S, Yamamura K, Sakamoto I, Yabuuchi H, Honda H. Clinical impact of left ventricular eccentricity index using cardiac MRI in assessment of right ventricular hemodynamics and myocardial fibrosis in congenital heart disease. Eur Radiol 2016; 26:3617-25. [PMID: 26795615 DOI: 10.1007/s00330-015-4199-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Revised: 12/22/2015] [Accepted: 12/30/2015] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To investigate the utility of eccentricity index (EI) using cardiac cine MRI for the assessment of right ventricular (RV) hemodynamics in congenital heart disease (CHD). METHODS Fifty-five patients with CHD (32 women; mean age, 40.7 ± 20.9 years) underwent both cardiac MRI and right heart catheterization. EI was defined as the ratio of the distance between the anterior-posterior wall and the septal-lateral wall measured in the short-axis of mid-ventricular cine MRI. Correlations between EIs and RV hemodynamic parameters were analyzed. EIs were compared between patients with and without late gadolinium enhancement (LGE). RESULTS A strong correlation between mean pulmonary artery pressure (PAP) and systolic EI (r = 0.81, p < 0.0001) and a moderate negative correlation between diastolic EI and RV ejection fraction (EF) (r = -0.62, p < 0.0001) were observed. Receiver operating characteristic analysis revealed optimal EI thresholds for detecting patients with mean PAP ≥40 mmHg with C-statistics of 0.90 and patients with RVEF <40 % with C-statistics of 0.78. Systolic EIs were significantly greater for patients with LGE (1.45 ± 0.05) than for those without LGE (1.15 ± 0.07; p < 0.001). CONCLUSIONS EI offers a simple, comprehensive index that can predict pulmonary hypertension and RV dysfunction in CHD. KEY POINTS • EI offers a simple and comprehensive index of RV hemodynamics. • EI could predict pulmonary hypertension and RV dysfunction. • Left ventricular deformation expressed as high EI is related to myocardial fibrosis.
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Affiliation(s)
- Yuzo Yamasaki
- Departments of Clinical Radiology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan.
| | - Michinobu Nagao
- Molecular Imaging & Diagnosis, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takeshi Kamitani
- Departments of Clinical Radiology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Torahiko Yamanouchi
- Departments of Clinical Radiology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Satoshi Kawanami
- Molecular Imaging & Diagnosis, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kenichiro Yamamura
- Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Ichiro Sakamoto
- Cardiovascular Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Hidetake Yabuuchi
- Health SciencesGraduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Hiroshi Honda
- Departments of Clinical Radiology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
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115
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Jeung MS, Kong YH, Sung SI, Song J. Survival of the Infants with Bronchopulmonary Dysplasia and Congenital Heart Disease. NEONATAL MEDICINE 2016. [DOI: 10.5385/nm.2016.23.4.190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Min Sub Jeung
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young Hwa Kong
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Se In Sung
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jinyoung Song
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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116
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Talwar S, Keshri VK, Choudhary SK, Gupta SK, Ramakrishnan S, Juneja R, Saxena A, Kothari SS, Airan B. Surgical strategies for patients with congenital heart disease and severe pulmonary hypertension in low/middle-income countries. HEART ASIA 2015; 7:31-7. [PMID: 27326218 DOI: 10.1136/heartasia-2015-010645] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 08/02/2015] [Accepted: 09/18/2015] [Indexed: 11/04/2022]
Abstract
In this review, we discuss specific surgical strategies that are used in patients with congenital heart disease and severe pulmonary arterial hypertension. Our own experience, with the use of unidirectional valved patches in managing these patients, is also discussed in detail.
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Affiliation(s)
- Sachin Talwar
- Cardiothoracic Centre, All India Institute of Medical Sciences , New Delhi , India
| | - Vikas Kumar Keshri
- Cardiothoracic Centre, All India Institute of Medical Sciences , New Delhi , India
| | - Shiv Kumar Choudhary
- Cardiothoracic Centre, All India Institute of Medical Sciences , New Delhi , India
| | - Saurabh Kumar Gupta
- Cardiothoracic Centre, All India Institute of Medical Sciences , New Delhi , India
| | | | - Rajnish Juneja
- Cardiothoracic Centre, All India Institute of Medical Sciences , New Delhi , India
| | - Anita Saxena
- Cardiothoracic Centre, All India Institute of Medical Sciences , New Delhi , India
| | - Shyam Sunder Kothari
- Cardiothoracic Centre, All India Institute of Medical Sciences , New Delhi , India
| | - Balram Airan
- Cardiothoracic Centre, All India Institute of Medical Sciences , New Delhi , India
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117
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Strange G, Rose M, Kermeen F, O'Donnell C, Keogh A, Kotlyar E, Grigg L, Bullock A, Disney P, Dwyer N, Whitford H, Tanous D, Frampton C, Weintraub R, Celermajer DS. A binational registry of adults with pulmonary arterial hypertension complicating congenital heart disease. Intern Med J 2015; 45:944-50. [DOI: 10.1111/imj.12821] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2015] [Accepted: 05/20/2015] [Indexed: 12/30/2022]
Affiliation(s)
- G. Strange
- Department of Medicine; University of Notre Dame; Perth Western Australia Australia
- Pulmonary Hypertensions Society ANZ Inc.; Sydney New South Wales Australia
- Murdoch Children's Research Institute; Melbourne Victoria Australia
| | - M. Rose
- Department of Cardiology; Royal Children's Hospital; Melbourne Victoria Australia
| | - F. Kermeen
- Department of Respiratory Medicine; The Prince Charles Hospital; Brisbane Queensland Australia
| | - C. O'Donnell
- Department of Cardiology; Auckland City Hospital; Auckland New Zealand
| | - A. Keogh
- Department of Cardiology; St Vincent's Hospital; Sydney New South Wales Australia
| | - E. Kotlyar
- Department of Cardiology; St Vincent's Hospital; Sydney New South Wales Australia
| | - L. Grigg
- Department of Cardiology; Royal Melbourne Hospital; Melbourne Victoria Australia
| | - A. Bullock
- Department of Paediatric Cardiology; Royal Perth Hospital; Perth Western Australia Australia
| | - P. Disney
- The Royal Adelaide Hospital; Adelaide South Australia Australia
| | - N. Dwyer
- Department of Cardiology; Royal Hobart Hospital; Hobart Tasmania Australia
| | - H. Whitford
- Department of Respiratory Medicine; The Alfred Hospital; Melbourne Victoria Australia
| | - D. Tanous
- Department of Cardiology; Westmead Hospital; Sydney New South Wales Australia
| | - C. Frampton
- Department of Cardiology; University of Otago; Christchurch New Zealand
| | - R. Weintraub
- Murdoch Children's Research Institute; Melbourne Victoria Australia
- Department of Cardiology; Royal Children's Hospital; Melbourne Victoria Australia
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118
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Krieger EV, Leary PJ, Opotowsky AR. Pulmonary Hypertension in Congenital Heart Disease: Beyond Eisenmenger Syndrome. Cardiol Clin 2015; 33:599-609, ix. [PMID: 26471823 DOI: 10.1016/j.ccl.2015.07.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Patients with adult congenital heart disease have an increased risk of developing pulmonary hypertension. There are several mechanisms of pulmonary hypertension in patients with adult congenital heart disease, and understanding them requires a systematic approach to define the patient's hemodynamics and physiology. This article reviews the updated classification of pulmonary hypertension in patients with adult congenital heart disease with a focus on pathophysiology, diagnostics, and the evaluation of pulmonary hypertension in special adult congenital heart disease populations.
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Affiliation(s)
- Eric V Krieger
- Seattle Adult Congenital Heart Service, Division of Cardiology, Department of Medicine, University of Washington School of Medicine, 1959 Northeast Pacific Street, Seattle, WA 98195, USA.
| | - Peter J Leary
- Pulmonary Vascular Disease Program, Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, 1959 Northeast Pacific Street, Seattle, WA 98195, USA
| | - Alexander R Opotowsky
- Boston Adult Congenital Heart and Pulmonary Hypertension Service, Department of Cardiology, Boston Children's Hospital and Brigham and Women's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
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119
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D'Alto M, Merola A, Dimopoulos K. Pulmonary hypertension related to congenital heart disease: A comprehensive review. Glob Cardiol Sci Pract 2015. [DOI: 10.5339/gcsp.2015.42] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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120
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Favilli S, Spaziani G, Ballo P, Fibbi V, Santoro G, Chiappa E, Arcangeli C. Advanced therapies in patients with congenital heart disease-related pulmonary arterial hypertension: results from a long-term, single center, real-world follow-up. Intern Emerg Med 2015; 10:445-50. [PMID: 25573622 DOI: 10.1007/s11739-014-1185-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Accepted: 12/22/2014] [Indexed: 10/24/2022]
Abstract
Pulmonary arterial hypertension (PAH) is a common finding in patients with congenital heart disease (CHD), and has relevant prognostic implications. The recent introduction of advanced therapies (AT) considerably improved the clinical outcome of these patients, but real-world data are still lacking. We aimed at reporting the results of a long-term follow-up of CHD patients with PAH undergoing AT, followed at a tertiary Center during the two last decades. The study population included a total of 34 patients with an established diagnosis of CHD-related PAH. In addition to conventional treatment, 97% of patients started AT during the follow-up. Over a median follow-up of 9 [3-31] years, 11 (32.4%) patients died: 7 of them were affected by Eisenmenger syndrome and the majority of patients were in NYHA class ≥3 at the time of death. Among the 23 patients who were alive at the last follow-up, the majority were in NYHA class I-II. Oxygen saturation and 6-min walking distance improved in all subjects within the first 6 months after starting of AT. One patient with ventricular septum defect and high pulmonary resistances was successfully treated with AT to lower resistances and underwent defect closure. A good clinical outcome was also observed in the subset (n = 8) with Down syndrome. The results of this real-world experience suggest that, despite a relatively high mortality rate mostly related to late commencement of AT, the clinical outcome of subjects with CHD-related PAH undergoing AT are characterized by a good quality of life and clinical improvement in most patients.
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Affiliation(s)
- Silvia Favilli
- Pediatric Cardiology, Meyer Hospital, Viale Pieraccini 24, 50134, Florence, Italy
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Bhatt AB, Foster E, Kuehl K, Alpert J, Brabeck S, Crumb S, Davidson WR, Earing MG, Ghoshhajra BB, Karamlou T, Mital S, Ting J, Tseng ZH. Congenital Heart Disease in the Older Adult. Circulation 2015; 131:1884-931. [DOI: 10.1161/cir.0000000000000204] [Citation(s) in RCA: 158] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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122
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Schwerzmann M, Pfammatter JP. Approaching atrial septal defects in pulmonary hypertension. Expert Rev Cardiovasc Ther 2015; 13:693-701. [DOI: 10.1586/14779072.2015.1047763] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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123
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Blok IM, van Riel ACMJ, Schuuring MJ, Duffels MG, Vis JC, van Dijk APJ, Hoendermis ES, Mulder BJM, Bouma BJ. Decrease in quality of life predicts mortality in adult patients with pulmonary arterial hypertension due to congenital heart disease. Neth Heart J 2015; 23:278-84. [PMID: 25911012 PMCID: PMC4409603 DOI: 10.1007/s12471-015-0666-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background Decrease in quality of life (QoL) in left-sided heart failure precedes poor survival, which can be reversed with exercise training. We investigated whether QoL is associated with mortality in pulmonary arterial hypertension due to congenital heart disease (PAH-CHD) patients. Methods In this observational study, PAH-CHD adults referred for PAH-specific therapy were included. QoL surveys (SF36) were recorded during 2 years of therapy. Based on shift in SF36 scores during this period, patients had either decreased or non-decreased QoL. Subsequently, the patients were followed for mortality. Results Thirty-nine PAH-CHD patients (mean age 42, 44 % male, 49 % Down’s syndrome) were analysed. Following PAH-specific therapy, SF36 physical component summary (PCS) decreased in 13 (35–31 points, p = 0.001) and showed no decrease in 26 patients (34–43 points, mean values, p < 0.001). Post-initiation phase, median follow-up was 4.5 years, during which 12 deaths occurred (31 %), 10 (56 %) in the decreased and 2 (10 %) in the non-decreased group (p = 0.002). Cox regression showed a decrease in SF36 PCS predicted mortality (HR 3.4, 95 % CI 1.03–11, p = 0.045). Conclusions In PAH-CHD patients, decrease in SF36 PCS following initiation of PAH-specific therapy is a determinant of mortality. Electronic supplementary material The online version of this article (doi:10.1007/s12471-015-0666-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- I M Blok
- Department of Cardiology, Academic Medical Centre, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
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Ryan JJ, Huston J, Kutty S, Hatton ND, Bowman L, Tian L, Herr JE, Johri AM, Archer SL. Right ventricular adaptation and failure in pulmonary arterial hypertension. Can J Cardiol 2015; 31:391-406. [PMID: 25840092 PMCID: PMC4385216 DOI: 10.1016/j.cjca.2015.01.023] [Citation(s) in RCA: 136] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Revised: 01/19/2015] [Accepted: 01/19/2015] [Indexed: 01/22/2023] Open
Abstract
Pulmonary arterial hypertension (PAH) is an obstructive pulmonary vasculopathy, characterized by excess proliferation, apoptosis resistance, inflammation, fibrosis, and vasoconstriction. Although PAH therapies target some of these vascular abnormalities (primarily vasoconstriction), most do not directly benefit the right ventricle (RV). This is suboptimal because a patient's functional state and prognosis are largely determined by the success of the adaptation of the RV to the increased afterload. The RV initially hypertrophies but might ultimately decompensate, becoming dilated, hypokinetic, and fibrotic. A number of pathophysiologic abnormalities have been identified in the PAH RV, including: ischemia and hibernation (partially reflecting RV capillary rarefaction), autonomic activation (due to G protein receptor kinase 2-mediated downregulation and desensitization of β-adrenergic receptors), mitochondrial-metabolic abnormalities (notably increased uncoupled glycolysis and glutaminolysis), and fibrosis. Many RV abnormalities are detectable using molecular imaging and might serve as biomarkers. Some molecular pathways, such as those regulating angiogenesis, metabolism, and mitochondrial dynamics, are similarly deranged in the RV and pulmonary vasculature, offering the possibility of therapies that treat the RV and pulmonary circulation. An important paradigm in PAH is that the RV and pulmonary circulation constitute a unified cardiopulmonary unit. Clinical trials of PAH pharmacotherapies should assess both components of the cardiopulmonary unit.
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Affiliation(s)
- John J Ryan
- Division of Cardiovascular Medicine, Department of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Jessica Huston
- Department of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Shelby Kutty
- Pediatric Cardiology, University of Nebraska Medical Center, Children's Hospital and Medical Center, Omaha, Nebraska, USA
| | - Nathan D Hatton
- Division of Pulmonary Medicine, Department of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Lindsay Bowman
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Lian Tian
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Julia E Herr
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Amer M Johri
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Stephen L Archer
- Department of Medicine, Queen's University, Kingston, Ontario, Canada.
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125
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Lau EM, Humbert M. A Critical Appraisal of the Updated 2014 Nice Pulmonary Hypertension Classification System. Can J Cardiol 2015; 31:367-74. [DOI: 10.1016/j.cjca.2014.09.033] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2014] [Revised: 09/28/2014] [Accepted: 09/28/2014] [Indexed: 01/07/2023] Open
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[Pulmonary hypertension associated with congenital heart disease and Eisenmenger syndrome]. ARCHIVOS DE CARDIOLOGIA DE MEXICO 2015; 85:32-49. [PMID: 25650280 DOI: 10.1016/j.acmx.2014.11.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Revised: 11/12/2014] [Accepted: 11/14/2014] [Indexed: 11/24/2022] Open
Abstract
Pulmonary arterial hypertension is a common complication of congenital heart disease (CHD). Congenital cardiopathies are the most frequent congenital malformations. The prevalence in our country remains unknown, based on birthrate, it is calculated that 12,000 to 16,000 infants in our country have some cardiac malformation. In patients with an uncorrected left-to-right shunt, increased pulmonary pressure leads to vascular remodeling and endothelial dysfunction secondary to an imbalance in vasoactive mediators which promotes vasoconstriction, inflammation, thrombosis, cell proliferation, impaired apotosis and fibrosis. The progressive rise in pulmonary vascular resistance and increased pressures in the right heart provocated reversal of the shunt may arise with the development of Eisenmenger' syndrome the most advanced form de Pulmonary arterial hypertension associated with congenital heart disease. The prevalence of Pulmonary arterial hypertension associated with CHD has fallen in developed countries in recent years that is not yet achieved in developing countries therefore diagnosed late as lack of hospital infrastructure and human resources for the care of patients with CHD. With the development of targeted medical treatments for pulmonary arterial hypertension, the concept of a combined medical and interventional/surgical approach for patients with Pulmonary arterial hypertension associated with CHD is a reality. We need to know the pathophysiological factors involved as well as a careful evaluation to determine the best therapeutic strategy.
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127
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New predictors of mortality in adults with congenital heart disease and pulmonary hypertension: Midterm outcome of a prospective study. Int J Cardiol 2015; 181:270-6. [DOI: 10.1016/j.ijcard.2014.11.222] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2014] [Revised: 11/12/2014] [Accepted: 11/26/2014] [Indexed: 11/22/2022]
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Sidharta PN, Krähenbühl S, Dingemanse J. Pharmacokinetic and pharmacodynamic evaluation of macitentan , a novel endothelin receptor antagonist for the treatment of pulmonary arterial hypertension. Expert Opin Drug Metab Toxicol 2015; 11:437-49. [PMID: 25604973 DOI: 10.1517/17425255.2015.1000859] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Pulmonary arterial hypertension (PAH) is a chronic disorder of the pulmonary vasculature characterized by elevated mean pulmonary arterial pressure eventually leading to right-sided heart failure and premature death. Macitentan is an oral, once-daily, dual endothelin (ET)A and ETB receptor antagonist with high affinity and sustained receptor binding that was approved in the USA, Europe, Canada, and Switzerland for the treatment of PAH. AREAS COVERED This review discusses the pharmacokinetics (PK) and pharmacodynamics (PD) of macitentan and its drug interaction potential based on preclinical and clinical data. EXPERT OPINION Up to date, macitentan is the only registered treatment for PAH that significantly reduced morbidity and mortality as a combined endpoint in a long-term event-driven study. The safety profile of macitentan is favorable with respect to hepatic safety and edema/fluid retention and may be better than that of other ET receptor antagonists such as bosentan and ambrisentan. The PK profile supports a once-a-day dosing regimen. Macitentan has limited interactions with other drugs. Based on these characteristics macitentan is an important new addition to the treatment of PAH.
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Affiliation(s)
- Patricia N Sidharta
- Actelion Pharmaceuticals Ltd., Department of Clinical Pharmacology , Gewerbestrasse 16, CH-4123 Allschwil , Switzerland +41 61 656686 ; +41 61 5656200 ;
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129
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Affiliation(s)
- Toshio Nakanishi
- Department of Pediatric Cardiology, Heart Institute, Tokyo Women’s Medical University
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130
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Pulmonary arterial hypertension associated with congenital heart disease: Recent advances and future directions. Int J Cardiol 2014; 177:340-7. [DOI: 10.1016/j.ijcard.2014.09.024] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Accepted: 09/16/2014] [Indexed: 11/19/2022]
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131
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Adult Congenital Heart Disease: A Growing Epidemic. Can J Cardiol 2014; 30:S410-9. [DOI: 10.1016/j.cjca.2014.07.749] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2014] [Revised: 07/08/2014] [Accepted: 07/23/2014] [Indexed: 11/23/2022] Open
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132
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Okumura K, Humpl T, Dragulescu A, Mertens L, Friedberg MK. Longitudinal Assessment of Right Ventricular Myocardial Strain in Relation to Transplant-Free Survival in Children with Idiopathic Pulmonary Hypertension. J Am Soc Echocardiogr 2014; 27:1344-51. [DOI: 10.1016/j.echo.2014.09.002] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Indexed: 12/15/2022]
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133
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Evaluation of Right Ventricular Systolic Function by Echocardiography in Pulmonary Hypertension Associated With Congenital Heart Disease: a Cross Sectional Study. RAZAVI INTERNATIONAL JOURNAL OF MEDICINE 2014. [DOI: 10.5812/rijm.23416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Bonello B, Renard S, Mancini J, Hubert S, Habib G, Fraisse A. Life span of patients with Eisenmenger syndrome is not superior to that of patients with other causes of pulmonary hypertension. Cardiovasc Diagn Ther 2014; 4:341-9. [PMID: 25414820 DOI: 10.3978/j.issn.2223-3652.2014.10.03] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2014] [Accepted: 10/13/2014] [Indexed: 11/14/2022]
Abstract
BACKGROUND Patients with Eisenmenger syndrome (ES) carry a better prognosis from diagnosis than patients with other causes of pulmonary hypertension (PH), but their life span has not yet been clarified. AIMS To clarify both survival from diagnosis and life span in ES, and in closed shunt with pulmonary arterial hypertension (PAH), as compared with other causes of PH. METHODS Data on all adult patients with PH attending our centre over the past decade was collected. Outcome was defined as death or transplantation. RESULTS We studied 149 patients, including 30 (20%) patients with ES and 12 (8%) patients with closed shunt with PAH. Median age at diagnosis was lower for patients with ES and closed-shunt with PAH compared to patients with other causes of PH (P<0.001 and P=0.008 respectively). Median follow-up was 4.25 years. Survival from diagnosis was longer in ES compared to other causes of PH (logrank; P=0.02) and similar between closed-shunt with PAH and other causes of PH (logrank; P=0.3). Survival rates at 3, 6 and 9 years from diagnosis were: 73%, 50% and 47% for ES, 75%, 25% and 0% for closed-shunt with PAH, 65%, 23% and 9% for other causes of PH. Life span was similar in those three groups (logrank; P=0.2 and P=0.7, respectively). CONCLUSIONS Life span is similar in patients with ES, with a closed-shunt associated with PAH, and in patients with other causes of PH.
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Affiliation(s)
- Béatrice Bonello
- 1 Congenital heart disease unit, 2 Cardiologie Unit B, 3 Statistics department, La Timone University hospital, 13385 Marseille, France
| | - Sébastien Renard
- 1 Congenital heart disease unit, 2 Cardiologie Unit B, 3 Statistics department, La Timone University hospital, 13385 Marseille, France
| | - Julien Mancini
- 1 Congenital heart disease unit, 2 Cardiologie Unit B, 3 Statistics department, La Timone University hospital, 13385 Marseille, France
| | - Sandrine Hubert
- 1 Congenital heart disease unit, 2 Cardiologie Unit B, 3 Statistics department, La Timone University hospital, 13385 Marseille, France
| | - Gilbert Habib
- 1 Congenital heart disease unit, 2 Cardiologie Unit B, 3 Statistics department, La Timone University hospital, 13385 Marseille, France
| | - Alain Fraisse
- 1 Congenital heart disease unit, 2 Cardiologie Unit B, 3 Statistics department, La Timone University hospital, 13385 Marseille, France
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136
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Crompton JG, Nacev BA, Upham T, Azoury SC, Eil R, Cameron DE, Haider AH. Traumatic ventricular septal defect resulting in severe pulmonary hypertension. J Surg Case Rep 2014; 2014:rju107. [PMID: 25326917 PMCID: PMC4201838 DOI: 10.1093/jscr/rju107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Traumatic ventricular septal defect (VSD) is a widely-recognized complication of both penetrating and blunt trauma. Most cases are repaired operatively without the long-term complications of pulmonary hypertension and heart failure that are associated with unrepaired congenital VSD in the pediatric population. To our knowledge, this is the first case report of a patient with a traumatic VSD who declined surgical repair at the time of injury and subsequently developed long-term complications of pulmonary hypertension and heart failure. With nearly 20 years of follow-up, this case demonstrates that the absence of surgical treatment in asymptomatic adult patients at the time of injury can lead to long-term complications associated with VSD. This case also shows that aggressive surgical treatment in patients with severe pulmonary vascular disease and heart failure secondary to traumatic VSD can be performed safely and should be considered in cases refractory to efficacious medical interventions.
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Affiliation(s)
- Joseph G Crompton
- Department of Surgery, University of California Los Angeles, Los Angeles, CA, USA National Institutes of Health, Surgery Branch, Bethesda, MD, USA
| | | | - Trevor Upham
- National Institutes of Health, Surgery Branch, Bethesda, MD, USA
| | - Saïd C Azoury
- National Institutes of Health, Surgery Branch, Bethesda, MD, USA Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Robert Eil
- National Institutes of Health, Surgery Branch, Bethesda, MD, USA
| | | | - Adil H Haider
- Johns Hopkins School of Medicine, Baltimore, MD, USA
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137
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Abstract
The population of adults with CHD continues to expand,and thus the number of women with CHD who contemplate pregnancy or become pregnant is also growing. Mothers with low-risk defects can be managed by general cardiologist,whereas those with more complex defects should be managed by or with the assistance of ACHD cardiologists. It is important to acknowledge that all patients with CHD may have unique anatomy or physiology, despite their classification as having a simple, moderate, or complex defect. As such, clinicians evaluating these patients should have adequate knowledge and expertise when assessing patient's risk for pregnancy,when performing imaging or hemodynamic studies, and when managing these patients during pregnancy. The American Board of Medical Specialties has recently recognized ACHD as a subspecialty of cardiovascular disease to treat the specialized needs of these patients in adulthood. ACHD experts can provide expertise in the management of specific defects or lesions, imaging techniques, prepregnancy risk assessment,and can manage these patients or comanage them with other medical providers during their pregnancy. Because many of these ACHD patients are lost to follow-up in adulthood, pregnancy represents a time when these patients seek medical care(and for some, represents a time of vulnerability and increased risk). This represents an opportunity to establish or reestablish care with ACHD specialists and to reestablish continuing long-term care for their CHD. Pregnancy also provides an opportunity to create partnerships between primary care physicians,adult cardiologists, and ACHD specialists to provide optimal care for these women throughout their lives.
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Affiliation(s)
- M Elizabeth Brickner
- From the University of Texas Southwestern Medical Center, Division of Cardiology, Dallas.
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138
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Abstract
The epidemiology of pulmonary arterial hypertension (PAH) has changed over the last decade. Remarkable advances in understanding the pathobiology and clinical care required in PAH have resulted in improved quality of life and survival. Despite such important progress, the long-term rate of survival is still unacceptable. The epidemiology of PAH could not be easily generalized globally, due to the fact that nearly all of the present data has been gathered from Western, multicenter, prospective registries. There are potentially marked differences in PAH patients from Western and Eastern populations, and from developed and developing countries. Therefore, it is clear that more registry data will be needed to address novel questions emerging with improved knowledge of PAH.
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Affiliation(s)
- Xin Jiang
- Thrombosis Medicine Center, State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China, 100037
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139
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Abstract
Dramatic advances in the diagnosis and treatment of congenital heart disease (CHD), the most common inborn defect, has resulted in a growing population of adults with CHD. Eisenmenger syndrome (ES) represents the extreme form of pulmonary arterial hypertension associated with CHD, characterized by markedly increased pulmonary vascular resistance with consequently reversed or bidirectional shunting. While ES is a direct consequence of a heart defect, it is a fundamentally multisystem syndrome with wide-ranging clinical manifestations. The introduction of targeted pulmonary hypertension therapies aimed has subtly shifted clinical focus from preventing iatrogenic and other adverse events toward cautious therapeutic activism.
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141
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Abstract
OPINION STATEMENT There is a growing patient population with adult congenital heart disease that needs specialized medical attention and careful long-term evaluation. Pulmonary arterial hypertension (PAH) associated with congenital heart disease (PAH-CHD) is a common late complication, and is associated with increased morbidity and mortality. There are no clear current guidelines for the treatment of PAH-CHD. There are few trials to date investigating PAH treatment specifically in this group of patients. However, the available data seems to demonstrate that with the advent of PAH-targeted therapies, the quality of life, exercise capacity, and outcomes in these patients is improving. In addition, PAH-targeted therapies may be useful in select patients for a combined medical-surgical approach to treatment. Here we discuss the epidemiology and pathophysiology of PAH-CHD, current therapies, and the data supporting their use, and how to evaluate feasibility of late surgical repair.
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142
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Schuuring MJ, Vis JC, van Dijk AP, van Melle JP, Vliegen HW, Pieper PG, Sieswerda GT, de Bruin-Bon RH, Mulder BJ, Bouma BJ. Impact of bosentan on exercise capacity in adults after the Fontan procedure: a randomized controlled trial. Eur J Heart Fail 2014; 15:690-8. [DOI: 10.1093/eurjhf/hft017] [Citation(s) in RCA: 104] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Mark J. Schuuring
- Department of Cardiology; Academic Medical Centre; Meibergdreef 9 1105 AZ Amsterdam The Netherlands
- Interuniversity Cardiology Institute of the Netherlands; Utrecht The Netherlands
| | - Jeroen C. Vis
- Department of Cardiology; Academic Medical Centre; Meibergdreef 9 1105 AZ Amsterdam The Netherlands
| | - Arie P.J. van Dijk
- Department of Cardiology; University Nijmegen Medical Centre; Nijmegen The Netherlands
| | - Joost P. van Melle
- Department of Cardiology; University Medical Centre Groningen; Groningen The Netherlands
| | - Hubert W. Vliegen
- Department of Cardiology; Leiden University Medical Centre; Leiden The Netherlands
| | - Petronella G. Pieper
- Department of Cardiology; University Medical Centre Groningen; Groningen The Netherlands
| | - Gertjan T. Sieswerda
- Department of Cardiology; University Medical Centre Utrecht; Utrecht The Netherlands
| | | | - Barbara J.M. Mulder
- Department of Cardiology; Academic Medical Centre; Meibergdreef 9 1105 AZ Amsterdam The Netherlands
- Interuniversity Cardiology Institute of the Netherlands; Utrecht The Netherlands
| | - Berto J. Bouma
- Department of Cardiology; Academic Medical Centre; Meibergdreef 9 1105 AZ Amsterdam The Netherlands
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143
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Radke RM, Diller GP, Baumgartner H. The challenge of managing pulmonary arterial hypertension in adults with congenital heart disease. Expert Rev Cardiovasc Ther 2014; 11:919-31. [DOI: 10.1586/14779072.2013.811966] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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144
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Kiefer TL, Bashore T. Anatomy of Congenital Heart Disease Lesions Associated With Pulmonary Arterial Hypertension. ACTA ACUST UNITED AC 2013. [DOI: 10.21693/1933-088x-11.4.166] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Adult congenital heart disease represents a growing population of patients. Many patients survive to adulthood and lead functional, productive lives. In fact, there are more adults living with congenital heart disease than pediatric patients. Many adult patients will have had prior surgical repair as children. However, some patients present in adulthood with a new diagnosis of congenital heart disease. Furthermore, there are a variety of complications associated with each individual congenital lesion and specific surgical repair procedure.
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Affiliation(s)
- Todd L. Kiefer
- Assistant Professor, Division of Cardiology, Duke University Medical Center, Durham, NC
| | - Thomas Bashore
- Professor of Medicine, Senior Vice Chief, Division of Cardiology, Duke University Medical Center, Durham, NC
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145
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Updated Clinical Classification of Pulmonary Hypertension. J Am Coll Cardiol 2013; 62:D34-41. [DOI: 10.1016/j.jacc.2013.10.029] [Citation(s) in RCA: 2067] [Impact Index Per Article: 187.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Accepted: 10/22/2013] [Indexed: 12/13/2022]
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146
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Inohara T, Niwa K, Yao A, Inuzuka R, Sakazaki H, Ohuchi H, Inai K. Survey of the current status and management of Eisenmenger syndrome: a Japanese nationwide survey. J Cardiol 2013; 63:286-90. [PMID: 24145195 DOI: 10.1016/j.jjcc.2013.08.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Revised: 08/26/2013] [Accepted: 08/28/2013] [Indexed: 12/01/2022]
Abstract
BACKGROUND The management of Eisenmenger syndrome (ES) has dramatically changed since the advent of disease-targeted therapy (DTT). However, guidelines for ES management, including DTT, have not been established. We aimed to clarify the current incidence, underlying disease, and management of ES in Japan, using a nationwide survey. METHODS A written questionnaire was sent to members of the Japanese Society for Adult Congenital Heart Disease, through which information was obtained from 86 institutions. RESULTS A total of 251 patients with ES (80.5% cases≥20 years of age) were followed as of February 2012; DTT was performed in 124 (49.4%) patients. Unrepaired simple anatomy was reported as an underlying condition in 165 patients (65.7%). Among patients with ES, 55 (21.9%), 128 (51%), 53 (21.1%), and 12 (4.8%) were classified into functional classes I, II, III, and IV, respectively. DTT was routinely performed at 52 (60.5%) institutions, but there were variations in the DTT therapeutic strategy at these institutions. Combined therapy was more often used than monotherapy; an endothelin receptor antagonist was the most frequently prescribed medication. There were institutional differences regarding heart failure treatment and indications for anticoagulation. Digitalis and angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers were widely used, but beta-blockers were infrequently used to manage heart failure. CONCLUSIONS This survey describes the current status, including prevalence and underlying disease, and variations in the practical management of ES in Japan. The results will help in the creation of future guidelines for ES management.
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Affiliation(s)
- Taku Inohara
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan; Department of Cardiology, Cardiovascular Center, St. Luke's International Hospital, Tokyo, Japan.
| | - Koichiro Niwa
- Department of Cardiology, Cardiovascular Center, St. Luke's International Hospital, Tokyo, Japan
| | - Atsushi Yao
- Division for Health Service Promotion, The University of Tokyo, Tokyo, Japan
| | - Ryo Inuzuka
- Department of Pediatrics, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Hisanori Sakazaki
- Department of Pediatric Cardiology, Hyogo Prefectural Amagasaki Hospital, Amagasaki, Japan
| | - Hideo Ohuchi
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Kei Inai
- Department of Pediatric Cardiology, Tokyo Women's Medical University, Tokyo, Japan
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Crepaz R, Romeo C, Montanaro D, De Santis S. Long-term results of treatment with bosentan in adult Eisenmenger's syndrome patients with Down's syndrome related to congenital heart disease. BMC Cardiovasc Disord 2013; 13:74. [PMID: 24047157 PMCID: PMC3848635 DOI: 10.1186/1471-2261-13-74] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2013] [Accepted: 09/04/2013] [Indexed: 11/20/2022] Open
Abstract
Background Patients with Down’s syndrome and shunt lesions are at high risk of developing pulmonary arterial hypertension (PAH) earlier than patients without Down’s syndrome. However, data on the efficacy of PAH-specific therapy in patients with Down’s syndrome are limited. The aim of this retrospective analysis was to determine the long-term efficacy of the dual endothelin receptor antagonist, bosentan, in Eisenmenger's syndrome (ES) patients with Down’s syndrome. Methods In this observational study adults with Down’s syndrome with a confirmed diagnosis of ES (World Health Organization functional class III) and receiving bosentan therapy and were followed up long term. Clinical evaluation at baseline and follow-up visits included resting transcutaneous arterial oxygen saturation and laboratory assessments. Exercise capacity was evaluated using a 6-minute walk test where transcutaneous arterial oxygen saturation at peak exercise (SpO2), 6-minute walk distance (6MWD) and Borg dyspnoea index were assessed. A full echocardiographic assessment was conducted at baseline and follow-up visits. Results Overall, seven adults (mean age 29.6 ± 11.2 years; 57% male) received bosentan at a starting dose of 62.5 mg twice daily. This was increased to the target dose of 125 mg twice daily 4 weeks later. All patients remained on bosentan until the end of the study. After a mean (± standard deviation) duration of 52.2 ± 3.9 months (range: 46.0–55.5 months), 6MWD had increased from 199.6 ± 69.1 metres to 303.7 ± 99.9 metres (P < 0.05) and SpO2 at the end of the 6-minute walk test had increased from 61.6 ± 7.6% to 74.7 ± 6.2% (P < 0.05). Echocardiography demonstrated a significant change in acceleration time from 62.9 ± 11.6 m/s to 83.0 ± 9.6 m/s (P = 0.0156), and acceleration time/ejection time ratio from the pulmonary flow from 0.24 ± 0.04 at baseline to 0.30 ± 0.02 (P = 0.0156) at final follow-up. Conclusions Long-term treatment with bosentan significantly improved exercise capacity and oxygen saturation following exercise in adult ES patients with Down’s syndrome. These data confirm that the presence of Down’s syndrome does not affect the response to oral bosentan therapy.
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Affiliation(s)
- Roberto Crepaz
- Department of Cardiology and Pediatric Cardiology, Regional Hospital of Bolzano, Bolzano, Italy.
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148
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Becker-Grünig T, Klose H, Ehlken N, Lichtblau M, Nagel C, Fischer C, Gorenflo M, Tiede H, Schranz D, Hager A, Kaemmerer H, Miera O, Ulrich S, Speich R, Uiker S, Grünig E. Efficacy of exercise training in pulmonary arterial hypertension associated with congenital heart disease. Int J Cardiol 2013; 168:375-81. [DOI: 10.1016/j.ijcard.2012.09.036] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2012] [Revised: 08/31/2012] [Accepted: 09/15/2012] [Indexed: 01/09/2023]
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149
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Left-to-Right Shunt with Congenital Heart Disease: Single Center Experience. ISRN CARDIOLOGY 2013; 2013:301617. [PMID: 23862073 PMCID: PMC3706015 DOI: 10.1155/2013/301617] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/09/2013] [Accepted: 05/29/2013] [Indexed: 12/01/2022]
Abstract
Objective. The objective of this study was to determine the frequency of pulmonary arterial hypertension (PAH) in congenital heart disease (CHD) with an isolated, large left-to-right shunt and to indicate the factors in the development of PAH. Methods. The pressure measurements in the cardiac chambers and the calculations based on the Fick's principle were compared among 3 separate groups of patients, respectively, with PAH, with hyperkinetic pulmonary hypertension (HPH), and with neither PAH nor HPH. Results. PAH was diagnosed in 30 (12.3%) patients, HPH in 35 (14.4%), while 177 (73.1%) were free of either. The highest risk for the development of PAH was found in the presence of perimembranous ventricular septal defect. A statistically significant difference was seen among these groups as to their left atrial pressure (p = 0.005) and the mean pulmonary arterial pressure (PAPmean; p < 0.001). While a correlation was present between RpI on one hand and age on the other (p = 0.014), a multiple linear regression could not evidence any correlation among age (p = 0.321), gender (p = 0.929). Conclusion. Our findings do not allow establishing a correlation between the duration of the high pulmonary flow and pulmonary vascular resistance increase or PAH development in isolated left-to-right shunts with congenital heart diseases.
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Rose ML, Strange G, King I, Arnup S, Vidmar S, O'Donnell C, Kermeen F, Grigg L, Weintraub RG, Celermajer DS. Congenital heart disease-associated pulmonary arterial hypertension: preliminary results from a novel registry. Intern Med J 2013; 42:874-9. [PMID: 22212153 DOI: 10.1111/j.1445-5994.2011.02708.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND/AIMS Pulmonary arterial hypertension (PAH) frequently accompanies childhood congenital heart disease (CHD) and may persist into adult life. The advent of specific PAH therapies for PAH prompted formation of a national Australian and New Zealand registry in 2010 to document the incidence, demographics, presentation and outcomes for these patients. METHODS This multicentre, prospective, web-based registry enrols patients with CHD-associated PAH being followed in a tertiary centre. The inclusion criteria stipulated patient age ≥16 years, a measured mean pulmonary arterial pressure >25 mmHg at rest or echocardiographical evidence of PAH or a diagnosis of Eisenmenger syndrome, and followed since 1 January 2000. A single observer collected standardised data during a series of site visits. RESULTS Of the first 50 patients enrolled, 30 (60%) were female. The mean age (standard deviation (SD)) at the time of PAH diagnosis or confirmation in an adult centre was 27.23 (10.07) years, and 32 (64%) patients are currently aged >30 years. Fourteen (28%) patients were in World Health Organization Functional Class II and 36 (72%) in Class III at the time of diagnosis. Forty-seven of 50 (94%) had congenital systemic-pulmonary shunts, and 36 (72%) never underwent intervention. Thirteen (26%) had Down syndrome. Confirmation of PAH by recent cardiac catheterisation was available in 30 (60%) subjects. During follow up, a total of 32 (64%) patients received a PAH-specific therapy. CONCLUSIONS CHD associated with PAH in adult life has resulted in a new population with unique needs. This registry will allow documentation of clinical course and long-term outcomes for these patients.
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Affiliation(s)
- M L Rose
- Department of Cardiology, Royal Children's Hospital, Melbourne, Australia
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