Intravascular and hybrid intraoperative stent placement for baffle obstruction in transposition of the great arteries after atrial switch

Long-term outcome of patients with transposition of the great arteries and a systemic right ventricle: A systematic review and meta-analysis

BACKGROUND

Patients with a transposition of the great arteries (TGA) and a systemic right ventricle are at risk of heart failure (HF) development, arrhythmia and early mortality. Prognostic evaluations in clinical studies are hampered by small sample sizes and single-centred approaches. We aimed to investigate yearly rate of outcome and factors affecting it.

METHODS

A systematic literature search of four electronic databases (PubMed, EMBASE, Web of Science and Scopus) was conducted from inception to June 2022. Studies reporting the association of a systemic right ventricle with mortality with a minimal follow-up of 2 years during adulthood were selected. Incidence of HF hospitalization and/or arrhythmia were captured as additional endpoints. For each outcome, a summary effect estimate was calculated.

RESULTS

From a total of 3891 identified records, 56 studies met the selection criteria. These studies described the follow-up (on average 7.27 years) of 5358 systemic right ventricle patients. The mortality incidence was 1.3 (1-1.7) per 100 patients/year. The incidence of HF hospitalization was 2.6 (1.9-3.7) per 100 patients/year. Predictors of poor outcome were a lower left ventricular (LV) and right ventricular ejection fraction (RVEF) (standardized mean differences (SMD) of -0.43 (-0.77 to -0.09) and - 0.85 (-1.35 to -0.35), respectively), higher plasma concentrations of NT-proBNP (SMD of 1.24 (0.49-1.99)), and NYHA class ≥2 (risk ratio of 2.17 (1.40-3.35)).

CONCLUSIONS

TGA patients with a systemic right ventricle have increased incidence of mortality and HF hospitalization. A lower LVEF and RVEF, higher levels of NT-proBNP and NYHA class ≥2 are associated with poor outcome.

Contemporary Management Strategies of Baffle Leaks in Adults with a Failing Systemic Right Ventricle Late after Atrial Switch: A Case Series and Literature Overview

Baffle leaks are a frequently encountered and often overlooked complication after the atrial switch procedure for transposition of the great arteries. Baffle leaks are present in up to 50% of non-selected patients, and while they initially may not cause clear symptoms, they can complicate the hemodynamic course and influence the prognosis in this complex patient group. A shunt from the pulmonary venous atrium (PVA) to the systemic venous atrium (SVA) can lead to pulmonary overflow and subpulmonary left ventricular (LV) volume overload, while a shunt from the SVA to the PVA can result in (exercise-associated) cyanosis and paradoxical embolism. We report three cases of baffle leaks in patients with systemic right ventricular (sRV) failure late after the atrial switch procedure. Two symptomatic patients who presented with exercise-associated cyanosis due to SVA to PVA shunting over the baffle leak underwent successful percutaneous baffle leak closure with a septal occluder device. One patient with overt sRV failure and signs of subpulmonary LV volume overload due to PVA to SVA shunting was managed conservatively, as baffle leak closure was expected to lead to an increase in sRV end-diastolic pressure and aggravation of sRV dysfunction. These three cases illustrate the considerations made, challenges faced, and necessity of a patient-tailored approach when addressing baffle leaks.

Canadian Cardiovascular Society 2022 Guidelines for Cardiovascular Interventions in Adults With Congenital Heart Disease

Interventions in adults with congenital heart disease (ACHD) focus on surgical and percutaneous interventions in light of rapidly evolving ACHD clinical practice. To bring rigour to our process and amplify the cumulative nature of evidence ACHD care we used the ADAPTE process; we systematically adjudicated, updated, and adapted existing guidelines by Canadian, American, and European cardiac societies from 2010 to 2020. We applied this to interventions related to right and left ventricular outflow obstruction, tetralogy of Fallot, coarctation, aortopathy associated with bicuspid aortic valve, atrioventricular canal defects, Ebstein anomaly, complete and congenitally corrected transposition, and patients with the Fontan operation. In addition to tables indexed to evidence, clinical flow diagrams are included for each lesion to facilitate a practical approach to clinical decision-making. Excluded are recommendations for pacemakers, defibrillators, and arrhythmia-directed interventions covered in separate designated documents. Similarly, where overlap occurs with other guidelines for valvular interventions, reference is made to parallel publications. There is a paucity of high-level quality of evidence in the form of randomized clinical trials to support guidelines in ACHD. We accounted for this in the wording of the strength of recommendations put forth by our national and international experts. As data grow on long-term follow-up, we expect that the evidence driving clinical practice will become increasingly granular. These recommendations are meant to be used to guide dialogue between clinicians, interventional cardiologists, surgeons, and patients making complex decisions relative to ACHD interventions.

3D modeling: a future of cardiovascular medicine

Cardiovascular disease resulting from atypical cardiac structures continues to be a leading health concern despite advancements in diagnostic imaging and surgical techniques. However, the ability to visualize spatial relationships using current technologies remains a challenge. Therefore, 3D modeling has gained significant interest to understand complex and atypical cardiovascular disorders. Moreover, 3D modeling can be personalized and patient-specific. 3D models have been demonstrated to aid surgical planning and simulation, enhance communication among surgeons and patients, optimize medical device design, and can be used as a potential teaching tool in medical schools. In this review, we discuss the key components needed to generate cardiac 3D models. We highlight prevalent structural conditions that have utilized 3D modeling in pre-operative planning. Furthermore, we discuss the current limitations of routine use of 3D models in the clinic as well as future directions for utilization of this technology in the cardiovascular field.

Invasive Hemodynamics of Adult Congenital Heart Disease: From Shunts to Coarctation

Adults with congenital heart disease are a growing population with increasingly more complex disease, in large part due to improvements in delivery of care to the pediatric population. Cardiac catheterization is an integral component of diagnosis and management in these patients. Careful attention to detail and a thorough understanding of intracardiac hemodynamics are critical to performing complete diagnostic evaluations. This article outlines the most commonly encountered lesions with guidelines for invasive assessment to help guide further therapy.

Imaging the adult with transposition of the great arteries

PURPOSE OF REVIEW

Patients with complete and congenitally corrected transposition of the great arteries commonly survive into adulthood and present with a vast array of clinical residua.

RECENT FINDINGS

Echocardiography remains the primary imaging modality in the routine assessment of the adult with transposition of the great arteries. It provides a comprehensive anatomic and hemodynamic evaluation. Limitations to echocardiography include evaluation of the following: the systemic right ventricle, baffle patency following atrial switch procedure, coronary arteries following arterial switch procedure or Nikadoh, and multilevel right ventricular outflow tract obstruction.

SUMMARY

Each form of palliation for transposition of the great arteries results in unique long-term sequelae that affect outcomes. A multimodality approach to imaging is required for a complete evaluation.