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Culp C, Andrews J, Sun KW, Hunter K, Cherry A, Podgoreanu M, Nicoara A. Right Ventricle-Pulmonary Artery Coupling in Patients Undergoing Cardiac Interventions. Curr Cardiol Rep 2024; 26:521-537. [PMID: 38581563 DOI: 10.1007/s11886-024-02052-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/25/2024] [Indexed: 04/08/2024]
Abstract
PURPOSE OF REVIEW This review aims to summarize the fundamentals of RV-PA coupling, its non-invasive means of measurement, and contemporary understanding of RV-PA coupling in cardiac surgery, cardiac interventions, and congenital heart disease. RECENT FINDINGS The need for more accessible clinical means of evaluation of RV-PA coupling has driven researchers to investigate surrogates using cardiac MRI, echocardiography, and right-sided pressure measurements in patients undergoing cardiac surgery/interventions, as well as patients with congenital heart disease. Recent research has aimed to validate these alternative means against the gold standard, as well as establish cut-off values predictive of morbidity and/or mortality. This emerging evidence lays the groundwork for identifying appropriate RV-PA coupling surrogates and integrating them into perioperative clinical practice.
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Affiliation(s)
- Crosby Culp
- Department of Anesthesiology, Duke University, 2301 Erwin Road, Box # 3094, Durham, NC, 27710, USA.
| | - Jon Andrews
- Department of Anesthesiology, Duke University, 2301 Erwin Road, Box # 3094, Durham, NC, 27710, USA
| | - Katherine Wang Sun
- Department of Anesthesiology, Duke University, 2301 Erwin Road, Box # 3094, Durham, NC, 27710, USA
| | - Kendall Hunter
- Department of Bioengineering, University of Colorado, Aurora, CO, USA
| | - Anne Cherry
- Department of Anesthesiology, Duke University, 2301 Erwin Road, Box # 3094, Durham, NC, 27710, USA
| | - Mihai Podgoreanu
- Department of Anesthesiology, Duke University, 2301 Erwin Road, Box # 3094, Durham, NC, 27710, USA
| | - Alina Nicoara
- Department of Anesthesiology, Duke University, 2301 Erwin Road, Box # 3094, Durham, NC, 27710, USA
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Abozied O, Miranda WR, Connolly HM, Younis A, Ahmed M, Kamath PS, Egbe AC. Temporal Change in Hepatic and Renal Function After Pulmonary Valve Replacement in Adults With Tetralogy of Fallot. Am J Cardiol 2023; 206:40-41. [PMID: 37677883 PMCID: PMC10827362 DOI: 10.1016/j.amjcard.2023.08.074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 08/05/2023] [Accepted: 08/12/2023] [Indexed: 09/09/2023]
Affiliation(s)
| | | | | | | | | | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
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Salamate S, El-Sayed Ahmad A, Bayram A, Sirat S, Bakhtiary F. Case report: Video-assisted minimally invasive mitral and pulmonary valve replacement as reoperation in patient with situs inversus totalis. Front Cardiovasc Med 2023; 10:1053923. [PMID: 37600051 PMCID: PMC10435878 DOI: 10.3389/fcvm.2023.1053923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 07/21/2023] [Indexed: 08/22/2023] Open
Abstract
Dextrocardia with situs inversus totalis is a rare congenital condition. We report herein a first experience of video-assisted minimally invasive mitral and pulmonary valve replacement through right anterior mini-thoracotomy as reoperation in patient with this complex anomaly. The good clinical and cosmetic results demonstrate that this innovative technique can be safely performed even in difficult anatomical conditions.
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Affiliation(s)
- Saad Salamate
- Department of Cardiac Surgery, University Hospital Bonn, Bonn, Germany
| | | | - Ali Bayram
- Department of Cardiac Surgery, Heart Centre Siegburg, Siegburg, Germany
| | - Sami Sirat
- Department of Cardiac Surgery, Heart Centre Siegburg, Siegburg, Germany
| | - Farhad Bakhtiary
- Department of Cardiac Surgery, University Hospital Bonn, Bonn, Germany
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Said SM, Hiremath G, Aggarwal V, Bass J, Sainathan S, Salem MI, Narasimhan S. Early Concerning Outcomes for the Edwards Inspiris Resilia Bioprosthesis in the Pulmonary Position. Ann Thorac Surg 2023; 115:1000-1007. [PMID: 36174775 DOI: 10.1016/j.athoracsur.2022.09.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 08/06/2022] [Accepted: 09/12/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND The Inspiris Resilia (Edwards Lifesciences LLC) bioprosthesis has gained widespread use in the aortic position; however no robust data are available about its use in the pulmonary position. METHODS We reviewed our outcomes for the Inspiris Resilia in the pulmonary position between August 2019 and October 2021. RESULTS Twenty-seven patients (15 female patients [56%]; mean age, 22.26 ± 14.99 years) were included. The most common original pathology was tetralogy of Fallot (13 patients, 48%). Five patients (18.5%) had prior transcatheter interventions. The mean right ventricular end-diastolic volume index was 164.25 ± 45.1 mL/m2. Sternotomy or repeat sternotomy was the most common approach (21 patients, 77.8%). The standard technique for pulmonary valve replacement was used in 22 patients (81.5%), whereas the prosthesis was implanted as a conduit in the remaining 5 (18.5%). Trivial to mild prosthetic regurgitation was present in 6 patients (22.2%) at the time of discharge. There was no early mortality. Follow-up was complete in all patients (mean, 16 ± 8 months), with no late mortality or late reoperations. New prosthetic regurgitation developed in 13 patients (48%), all of whom underwent replacement with the standard surgical technique. No regurgitation occurred in the conduit cases. This progressed to moderate regurgitation in 6 patients (22%) and severe in 3 (11%). Three patients (11%) underwent transcatheter valve-in-valve after their surgical pulmonary valve replacement. CONCLUSIONS The early data regarding the Inspiris Resilia bioprosthesis use in the pulmonary position is concerning. The prosthesis design may not be suitable for low-pressure circulation, or modification of its implantation technique may be needed.
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Affiliation(s)
- Sameh M Said
- Division of Pediatric Cardiovascular Surgery, Department of Surgery, Maria Fareri Children's Hospital, Westchester Medical Center, Valhalla, New York; Faculty of Medicine, Alexandria University, Alexandria, Egypt.
| | - Gurumurthy Hiremath
- Division of Pediatric Cardiology, Masonic Children's Hospital, University of Minnesota, Minneapolis, Minnesota
| | - Varun Aggarwal
- Division of Pediatric Cardiology, Masonic Children's Hospital, University of Minnesota, Minneapolis, Minnesota
| | - John Bass
- Division of Pediatric Cardiology, Masonic Children's Hospital, University of Minnesota, Minneapolis, Minnesota
| | - Sandeep Sainathan
- Department of Cardiothoracic Surgery, University of Miami, Miller School of Medicine, Miami, Florida
| | - Mahmoud I Salem
- Department of Cardiothoracic Surgery, Port Said University, Port Said, Egypt
| | - Shanti Narasimhan
- Division of Pediatric Cardiology, Masonic Children's Hospital, University of Minnesota, Minneapolis, Minnesota
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Al Mosa AFH, Madathil S, Bernier PL, Tchervenkov C. Long-Term Outcome Following Pulmonary Valve Replacement in Repaired Tetralogy of Fallot. World J Pediatr Congenit Heart Surg 2021; 12:616-627. [PMID: 34597203 DOI: 10.1177/21501351211027857] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Late pulmonary valve replacement following repair of tetralogy of Fallot may become necessary in patients with chronic pulmonary insufficiency. There is limited information on the long-term outcome of these prostheses, which is the focus of this study. METHODS We conducted a retrospective study of patients with repaired tetralogy of Fallot who underwent pulmonary valve replacement from 1990 to 2015 in our institution. We investigated imaging and clinical parameters including mortality and late adverse events (reintervention [surgical or transcatheter]), infective endocarditis, or arrhythmias requiring device implantation or ablation. RESULTS There were 69 patients divided into 3 groups: Carpentier-Edwards (n = 14), Contegra (n = 40), and pulmonary homograft (n = 15). The mean age at the time of pulmonary valve replacement was 21 ± 12 years. The mean follow-up was 8.5 ± 4.7 years. The mean preoperative and postoperative right ventricular end-diastolic volume index was 210 ± 42 and 120 ± 24 mL/m2, respectively. There were no mortalities. Late adverse events were observed in 23 (33%) patients: 15 (22%) reintervention (surgical or transcatheter), 11 (16%) endocarditis, and 11 (16%) arrhythmias. Overall, 1-, 5-, and 10-year freedom from surgical reintervention was 98.5%, 93.6%, and 79.3%, respectively. The Contegra group had significantly higher pulmonary valve gradients, a higher risk of developing late adverse events compared to Carpentier-Edwards (P = .046) and pulmonary homograft (P = .055) in multivariate analysis and increased risk for reintervention in the univariate analysis (hazard ratio: 3.4; 95% CI: 0.92-13; P value.066). CONCLUSION Pulmonary valve replacement in patients with repaired tetralogy of Fallot has acceptable short- and intermediate-term outcomes. Contegra prosthesis had a higher risk of late adverse events with higher pulmonary valve gradients.
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Affiliation(s)
- Alqasem Fuad H Al Mosa
- Cardiovascular Surgery, 54473McGill University Health Center (MUHC), Montreal, Quebec, Canada
| | | | - Pierre-Luc Bernier
- Cardiovascular Surgery, Montreal Children's Hospital (MCH), 5620McGill University Health Center (MUHC), Quebec, Canada
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Fadous M, Ordoñez MV, Guerrero-Chalela CE, Liu A, Guo L, Jutras L, Marelli AJ, Therrien J. Cardiac index in adults with repaired tetralogy of Fallot: Are we missing the forest for the trees? INTERNATIONAL JOURNAL OF CARDIOLOGY CONGENITAL HEART DISEASE 2021. [DOI: 10.1016/j.ijcchd.2021.100222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Lee C, Choi ES, Lee CH. Long-term outcomes of pulmonary valve replacement in patients with repaired tetralogy of Fallot. Eur J Cardiothorac Surg 2021; 58:246-252. [PMID: 32047919 DOI: 10.1093/ejcts/ezaa030] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 12/30/2019] [Accepted: 01/09/2020] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVES The objectives of this study were to evaluate long-term outcomes of pulmonary valve replacement (PVR) in patients with repaired tetralogy of Fallot (TOF) and to identify the factors associated with adverse clinical events (ACEs). METHODS A total of 190 patients who underwent PVR between 1998 and 2015 after repair of TOF were retrospectively analysed. ACE was defined as all-cause death, heart transplantation or new-onset sustained arrhythmia. Univariable Cox proportional hazards regression analysis was used to identify the factors associated with ACE after PVR. RESULTS The median age at PVR was 19 years. Preoperative magnetic resonance imaging (MRI) was performed in 143 (75%) patients, and the median right ventricular (RV) end-diastolic and end-systolic volume index was 164 and 82 ml/m2, respectively. The follow-up completeness was 94%, and the median follow-up duration was 9.8 years. The transplantation-free survival and freedom from ACE at 15 years was 95% and 90%, respectively. The factors associated with ACE were older age at PVR, older age at TOF repair, New York Heart Association functional class III or IV, presence of tachyarrhythmias, longer cardiopulmonary bypass time and concomitant arrhythmia surgery. In a subgroup analysis of 143 patients with preoperative MRI data, larger RV end-systolic volume index, larger left ventricular end-systolic volume index and lower left ventricular ejection fraction were associated with ACE. CONCLUSIONS Long-term outcomes of PVR in patients with repaired TOF were satisfactory. Proactive PVR before the onset of advanced symptoms, tachyarrhythmias and ventricular dysfunction may further improve the long-term survival of this patient population.
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Affiliation(s)
- Cheul Lee
- Department of Thoracic and Cardiovascular Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Eun Seok Choi
- Division of Pediatric Cardiac Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Chang-Ha Lee
- Department of Thoracic and Cardiovascular Surgery, Sejong General Hospital, Bucheon, Republic of Korea
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Abstract
The number of rTOF patients who survive into adulthood is steadily rising, with currently more than 90% reaching the third decade of life. However, rTOF patients are not cured, but rather have a lifelong increased risk for cardiac and non-cardiac complications. Heart failure is recognized as a significant complication. Its occurrence is strongly associated with adverse outcome. Unfortunately, conventional concepts of heart failure may not be directly applicable in this patient group. This article presents a review of the current knowledge on HF in rTOF patients, including incidence and prevalence, the most common mechanisms of heart failure, i.e., valvular pathologies, shunt lesions, left atrial hypertension, primary left heart and right heart failure, arrhythmias, and coronary artery disease. In addition, we will review information regarding extracardiac complications, risk factors for the development of heart failure, clinical impact and prognosis, and assessment possibilities, particularly of the right ventricle, as well as management strategies. We explore potential future concepts that may stimulate further research into this field.
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Said SM, Marey G, Hiremath G, Aggarwal V, Kloesel B, Griselli M. Pulmonary valve replacement via left anterior minithoracotomy: Lessons learned and early experience. J Card Surg 2021; 36:1305-1312. [PMID: 33533086 DOI: 10.1111/jocs.15382] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 01/18/2021] [Accepted: 01/20/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Median sternotomy has been the standard for pulmonary valve replacement (PVR) in patients with free pulmonary regurgitation (PR) and right ventricular enlargement. With the introduction of transcatheter therapy, the search for an alternate to sternotomy is mandated. We present our early experience with a limited anterior left thoracotomy approach. METHODS We used a left anterior mini-thoracotomy in six male patients (15 ± 1.94 years of age) who developed progressive right ventricular enlargement due to chronic PR. RESULTS Primary diagnoses were tetralogy of Fallot in five patients and pulmonary atresia with an intact septum in another. Four patients had previous median sternotomy with transannular patch repair. The mean right ventricular end-diastolic volume index was 189 ± 27.13 ml/m2 . The procedure was feasible in all patients. All patients had satisfactory adult size pulmonary bioprosthesis (25 or 27 mm valve), with a mean peak gradient of 18 ± 2.40 mmHg across the prosthesis at discharge. All patients were extubated intraoperatively at the end of the procedure and required no intraoperative transfusions. There were no early or late mortalities. Early morbidities included left hemidiaphragm paralysis in one patient, and re-sternotomy for prosthetic valve endocarditis in one. One patient required late reoperation for a common femoral artery pseudoaneurysm. CONCLUSIONS Minimally invasive access for PVR is feasible in both primary and repeat settings, through a limited anterior left minithoracotomy in the absence of intracardiac shunts and the need for other concomitant cardiac procedures. Longer-term studies with a larger number of patients are needed to compare the efficacy of this approach to standard sternotomy.
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Affiliation(s)
- Sameh M Said
- Division of Pediatric Cardiovascular Surgery, Masonic Children's Hospital, University of Minnesota, Minneapolis, Minnesota, USA.,Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Gamal Marey
- Division of Pediatric Cardiovascular Surgery, Masonic Children's Hospital, University of Minnesota, Minneapolis, Minnesota, USA
| | - Gurumurthy Hiremath
- Divisions of Pediatric Cardiology, Masonic Children's Hospital, University of Minnesota, Minneapolis, Minnesota, USA
| | - Varun Aggarwal
- Divisions of Pediatric Cardiology, Masonic Children's Hospital, University of Minnesota, Minneapolis, Minnesota, USA
| | - Benjamin Kloesel
- Divisions of Pediatric Anestheiology, Masonic Children's Hospital, University of Minnesota, Minneapolis, Minnesota, USA
| | - Massimo Griselli
- Division of Pediatric Cardiovascular Surgery, Masonic Children's Hospital, University of Minnesota, Minneapolis, Minnesota, USA
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Otsuka K, Kawano H, Ishimatsu T, Yoshimuta T, Doi Y, Fukae S, Koga S, Ikeda S, Eishi K, Maemura K. Successful management of heart failure 45 years after surgical correction of tetralogy of Fallot. J Cardiol Cases 2020; 23:76-79. [PMID: 33520028 DOI: 10.1016/j.jccase.2020.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 09/01/2020] [Accepted: 09/13/2020] [Indexed: 10/23/2022] Open
Abstract
A 59-year-old Japanese woman was admitted with heart failure due to severe pulmonary regurgitation and tricuspid regurgitation, in addition to atrial fibrillation 45 years after surgical correction of tetralogy of Fallot (TOF). She had been under treatment with medication and catheter ablation for arrhythmia including ventricular tachycardia for the past 28 years. She underwent pulmonary valve replacement as well as tricuspid and mitral valvuloplasty, which obviously improved her status even though her right ventricular end-diastolic volume index exceeded the recommended threshold. Patients who have undergone surgical correction of TOF need to be managed over the long term. <Learning objective: For a long term after surgical correction of tetralogy of Fallot (TOF), appropriate managements are needed for arrhythmia and heart failure related to heart valve disease. Even though her right ventricular end-diastolic volume index exceeded the recommended threshold by the current published guidelines, re-operation for heart valve diseases improved the present patient. We have to accumulate evidence to make useful guideline of re-operation of TOF in Japan.>.
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Affiliation(s)
- Kaishi Otsuka
- Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Hiroaki Kawano
- Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Takashi Ishimatsu
- Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Tsuyoshi Yoshimuta
- Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Yoshiyuki Doi
- Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Satoki Fukae
- Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Seiji Koga
- Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Satoshi Ikeda
- Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Kiyoyuki Eishi
- Department of Cardiovascular Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Koji Maemura
- Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
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Egbe AC, Connolly HM, Miranda WR, Scott CG, Borlaug BA. Prognostic implications of inferior vena cava haemodynamics in ambulatory patients with tetralogy of Fallot. ESC Heart Fail 2020; 7:2589-2596. [PMID: 32588556 PMCID: PMC7524124 DOI: 10.1002/ehf2.12836] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 05/21/2020] [Accepted: 05/29/2020] [Indexed: 12/19/2022] Open
Abstract
AIMS Right atrial pressure (RAP) provides a composite measure of right ventricular diastolic dysfunction, right atrial compliance, and volume status, and these three variables are typically abnormal in adults with repaired tetralogy of Fallot (TOF). RAP is a well-established prognostic metric in patients with pulmonary hypertension, and recent data suggest that RAP is associated with clinical outcomes in TOF. The purpose of this study was to determine the role of inferior vena cava (IVC) haemodynamics (size and collapsibility) for the assessment of RAP and its potential application for risk stratification and prognostication in the TOF population. METHODS AND RESULTS Adult TOF patients with echocardiographic assessment of IVC haemodynamics were divided into patients with (derivation cohort, n = 256) and without (validation cohort, n = 492) cardiac catheterization data. We assessed the correlation between IVC haemodynamics, RAP, and disease severity indices [arrhythmias, peak oxygen consumption (VO2 ), and heart failure hospitalization] in derivation cohort and compared it with the correlations in the validation cohort. IVC haemodynamics correlated with RAP (r = 0.52, P < 0.001), with disease severity indices {atrial arrhythmias [area under the curve (AUC) 0.81], ventricular arrhythmias [AUC 0.67], heart failure hospitalizations [AUC 0.78], and peak VO2 [r = 0.53]}, and with transplant-free survival in the derivation cohort. Similar correlations between IVC haemodynamics, disease severity indices, and transplant-free survival were also observed in the validation cohort. CONCLUSIONS These findings suggest that IVC haemodynamics can potentially be used for risk stratification and prognostication in TOF patients and can complement the current risk models that are based predominately on right ventricular volumes and systolic function.
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Affiliation(s)
- Alexander C Egbe
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Heidi M Connolly
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - William R Miranda
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | | | - Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
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Impact of Inferior Venae Cava Assessment in Tetralogy of Fallot. CJC Open 2020; 2:129-134. [PMID: 32462126 PMCID: PMC7242499 DOI: 10.1016/j.cjco.2020.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 02/16/2020] [Indexed: 11/23/2022] Open
Abstract
Background Inferior vena cava (IVC) size and collapsibility provide a noninvasive estimate of right heart filling pressures, an important determinant of right heart hemodynamic performance that is not measured by cardiac magnetic resonance imaging (CMRI). We hypothesized that compared with CMRI risk model alone, a combined CMRI-IVC risk model will have better correlation with disease severity and peak oxygen consumption in patients with tetralogy of Fallot (TOF). Methods We performed a retrospective review of patients with TOF with moderate/severe pulmonary regurgitation who underwent CMRI and echocardiography. A CMRI risk model was constructed using right ventricular (RV) end-diastolic volume index, RV end-systolic volume index, RV ejection fraction, and left ventricular ejection fraction. We added IVC hemodynamic classification to the CMRI indices to create CMRI-IVC risk model, and IVC hemodynamics were modeled as a categorical variable: normal vs mild/moderately abnormal (dilated IVC or reduced collapsibility) vs severely abnormal IVC hemodynamics (dilated IVC and reduced collapsibility). We defined disease severity as atrial arrhythmias, ventricular arrhythmias, and heart failure hospitalization. Results Of 207 patients, 131 (63%), 72 (35%), and 4 (2%) had normal, mild/moderately abnormal, and severely abnormal IVC hemodynamics, respectively. Compared with the CMRI risk model, the CMRI-IVC risk model had a better correlation with disease severity (area under the curve, 0.62; 95% confidence interval, 0.51-0.74 vs area under the curve 0.84, 95% confidence interval, 0.78-0.91, P = 0.006) and peak oxygen consumption (r = 0.35, P = 0.042 vs r = 0.43, P = 0.031, Meng test P = 0.026). Conclusions The combined CMRI-IVC risk model had a better correlation with disease severity compared with CMRI indices alone and can potentially improve risk stratification in the population with TOF.
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Deshaies C, Trottier H, Khairy P, Al-Aklabi M, Beauchesne L, Bernier PL, Dhillon S, Gandhi SK, Haller C, Hancock Friesen CL, Hickey EJ, Horne D, Jacques F, Kiess MC, Perron J, Rodriguez M, Poirier NC. Tricuspid Intervention Following Pulmonary Valve Replacement in Adults With Congenital Heart Disease. J Am Coll Cardiol 2020; 75:1033-1043. [PMID: 32138963 DOI: 10.1016/j.jacc.2019.12.053] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 12/02/2019] [Accepted: 12/10/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Tricuspid regurgitation (TR) is common among adults with corrected tetralogy of Fallot (TOF) or pulmonary stenosis (PS) referred for pulmonary valve replacement (PVR). Yet, combined valve surgery remains controversial. OBJECTIVES This study sought to evaluate the impact of concomitant tricuspid valve intervention (TVI) on post-operative TR, length of hospital stay, and on a composite endpoint consisting of 7 early adverse events (death, reintervention, cardiac electronic device implantation, infection, thromboembolic event, hemodialysis, and readmission). METHODS The national Canadian cohort enrolled 542 patients with TOF or PS and mild to severe TR who underwent isolated PVR (66.8%) or PVR+TVI (33.2%). Outcomes were abstracted from charts and compared between groups using multivariable logistic and negative binomial regression. RESULTS Median age at reintervention was 35.3 years. Regardless of surgery type, TR decreased by at least 1 echocardiographic grade in 35.4%, 66.9%, and 92.8% of patients with pre-operative mild, moderate, and severe insufficiency. In multivariable analyses, PVR+TVI was associated with an additional 2.3-fold reduction in TR grade (odds ratio [OR]: 0.44; 95% confidence interval [CI]: 0.25 to 0.77) without an increase in early adverse events (OR: 0.85; 95% CI: 0.46 to 1.57) or hospitalization time (incidence rate ratio: 1.17; 95% CI: 0.93 to 1.46). Pre-operative TR severity and presence of transvalvular leads independently predicted post-operative TR. In contrast, early adverse events were strongly associated with atrial tachyarrhythmia, extracardiac arteriopathy, and a high body mass index. CONCLUSIONS In patients with TOF or PS and significant TR, concomitant TVI is safe and results in better early tricuspid valve competence than isolated PVR.
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Affiliation(s)
- Catherine Deshaies
- Queen Elizabeth II Halifax Infirmary, Dalhousie University, Halifax, Nova Scotia, Canada; Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada; Centre hospitalier universitaire Sainte-Justine, Université de Montréal, Montreal, Quebec, Canada.
| | - Helen Trottier
- Centre hospitalier universitaire Sainte-Justine, Université de Montréal, Montreal, Quebec, Canada
| | - Paul Khairy
- Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Mohammed Al-Aklabi
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Luc Beauchesne
- University of Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Santokh Dhillon
- Izaak Walton Killam Health Center, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Sanjiv K Gandhi
- St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Christoph Haller
- Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Camille L Hancock Friesen
- Queen Elizabeth II Halifax Infirmary, Dalhousie University, Halifax, Nova Scotia, Canada; Izaak Walton Killam Health Center, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Edward J Hickey
- Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - David Horne
- Queen Elizabeth II Halifax Infirmary, Dalhousie University, Halifax, Nova Scotia, Canada; Izaak Walton Killam Health Center, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Frédéric Jacques
- Institut universitaire de cardiologie et de pneumologie de Québec, Université Laval, Quebec City, Quebec, Canada
| | - Marla C Kiess
- St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jean Perron
- Institut universitaire de cardiologie et de pneumologie de Québec, Université Laval, Quebec City, Quebec, Canada
| | - Maria Rodriguez
- University of Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Nancy C Poirier
- Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada; Centre hospitalier universitaire Sainte-Justine, Université de Montréal, Montreal, Quebec, Canada
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Left ventricular filling pressure in Tetralogy of Fallot: Correlation between invasive and noninvasive indices. IJC HEART & VASCULATURE 2020; 26:100457. [PMID: 31909179 PMCID: PMC6938956 DOI: 10.1016/j.ijcha.2019.100457] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 11/16/2019] [Accepted: 12/16/2019] [Indexed: 01/10/2023]
Abstract
Background Left heart filling pressures, as measured by pulmonary artery wedge pressure (PAWP), is associated with heart failure related mortality. Because of the prognostic importance of PAWP, several echocardiographic indices have been proposed for noninvasive assessment of PAWP. However, these indices have not been validated in the congenital heart disease population. The purpose of this study was to determine the correlation between echocardiographic indices of PAWP, and the effect of high PAWP on transplant-free survival in adults with tetralogy of Fallot (TOF). Methods Retrospective study of adult TOF patients that underwent cardiac catheterization at Mayo Clinic, 1990–2017. We selected these pre-defined set of echocardiographic indices of LV diastolic function: mitral valve early velocity (E), mitral valve early and late velocity ratio (E/A), mitral valve deceleration time (DT), mitral annular tissue Doppler early velocity (e′), and left atrial volume index (LAVI). Results Of the echocardiographic indices analyzed among 213 patients (age 37 ± 14 years), only E velocity (β = 5.83, standard error = 1.52, p < 0.001) and LAVI (β = 0.14, standard error = 0.05, p = 0.007) correlated with PAWP. LAVI > 28 ml/m2 had sensitivity of 79% and specificity of 63% (AUC 0.712), and E velocity > 1.0 m/s had sensitivity of 66% and specificity of 89% (AUC 0.692), for detecting PAWP > 15 mmHg. LAVI > 28 ml/m2 was associated with reduced 10-year transplant-free survival (49% vs 90%, p < 0.001). Conclusion This study supports the use of LAVI for noninvasive assessment of PAWP and for prognostication. Further studies are required to validate these results in a different population.
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Key Words
- AUC, Area under the curve
- DT, Deceleration time
- E, mitral valve early velocity
- Echocardiography
- LAVI, Left atrial volume index
- LV, Left ventricle
- LVEDP, Left ventricular end-diastolic pressure
- Left heart filling pressure
- PAWP, Pulmonary artery wedge pressure
- Pulmonary artery wedge pressure
- RV, Right ventricle
- TOF, Tetralogy of Fallot
- Tetralogy of Fallot
- e′, mitral annular tissue Doppler early velocity
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15
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Egbe AC, Pellikka PA, Afzal A, Jain V, Thotamgari S, Miranda WR, Connolly HM. Prognostic Implications of Left Ventricular Cardiomyopathy in Adults With Tetralogy of Fallot. CJC Open 2020; 2:1-7. [PMID: 32159130 PMCID: PMC7063625 DOI: 10.1016/j.cjco.2019.11.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 11/12/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Despite the significant risk of cardiovascular mortality after tetralogy of Fallot (TOF) repair, there are limited data about left ventricular (LV) cardiomyopathy in this population, thus creating important knowledge gaps. This study aims to address some of these knowledge gaps by describing the risk and prognostic implications of LV systolic dysfunction (LVD) after TOF repair. METHODS We performed a cohort study of adult patients after TOF repair with an echocardiographic assessment of LV ejection fraction (LVEF) to determine the association between LVD and cardiovascular events, defined as sustained ventricular tachycardia, aborted sudden death, heart transplantation, or death. Prevalent and incidence LVD were defined as LVEF < 50% at baseline or new decrease in LVEF to < 50% during follow-up, respectively. RESULTS Of 574 patients (age 38 ± 13 years), the baseline LVEF was 57% ± 9% and 68 (12%) had prevalent LVD. Cardiovascular events occurred in 126 patients (22%) during 10.5 ± 6.2 years of follow-up. LVEF was an independent predictor of mortality (hazard ratio, 1.16; 95% confidence interval, 1.16-1.24; P = 0.003) per 5%-point decrease in LVEF. Among the 357 patients with preserved LVEF and echocardiographic follow-up, incident LVD occurred in 23 (6%) during 3.8 ± 1.6 years of follow-up. Event-free survival was significantly lower in patients with incident LVD compared with patients without incident LVD (87% vs 71%, P = 0.021). CONCLUSION Prevalent and incident LVD occurred in 12% and 6% of this cohort, respectively, and were associated with lower event-free survival. Incident LVD suggests the presence of subclinical LV cardiomyopathy, and further studies are required to determine optimal strategies for diagnosing and treating subclinical LV cardiomyopathy to improve outcomes in the population with TOF.
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Affiliation(s)
- Alexander C. Egbe
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
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16
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Egbe AC, Vallabhajosyula S, Connolly HM. Trends and outcomes of pulmonary valve replacement in tetralogy of Fallot. Int J Cardiol 2020; 299:136-139. [DOI: 10.1016/j.ijcard.2019.07.063] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 05/10/2019] [Accepted: 07/17/2019] [Indexed: 01/10/2023]
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17
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Egbe AC, Bonnichsen C, Reddy YNV, Anderson JH, Borlaug BA. Pathophysiologic and Prognostic Implications of Right Atrial Hypertension in Adults With Tetralogy of Fallot. J Am Heart Assoc 2019; 8:e014148. [PMID: 31701796 PMCID: PMC6915294 DOI: 10.1161/jaha.119.014148] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 10/14/2019] [Indexed: 12/31/2022]
Abstract
Background Right atrial pressure (RAP), a composite metric of right ventricular diastolic function, volume status, and right heart compliance, is a predictor of mortality in patients with heart failure due to acquired heart disease. Because patients with tetralogy of Fallot (TOF) might have abnormal right atrial and ventricular mechanics caused by myocardial injury and remodeling, we hypothesized that RAP would be associated with disease severity and cardiovascular adverse events in this population. Methods and Results We performed a cohort study of adults with TOF who underwent right heart catheterization at the Mayo Clinic Rochester between 1990 and 2017. The objective was to determine the association between RAP and multiple domains of disease severity in TOF (percentage of predicted peak oxygen consumption, atrial or ventricular arrhythmia, and heart failure hospitalization), as well as cardiovascular adverse events, defined as sustained ventricular tachycardia, resuscitated or aborted sudden death, heart transplantation, or death. Among 225 patients (113 male; mean age: 39±14 years), mean RAP was 10.7±5.2 mm Hg and median was 10 mm Hg (interquartile range: 7-13 mm Hg). Increasing RAP was associated with atrial or ventricular arrhythmias (odds ratio: 5.01; 95% CI, 1.22-23.49; P<0.001), heart failure hospitalization (odds ratio: 1.47; 95% CI, 1.10-2.39; P=0.033) per 5 mm Hg, and worsening exercise capacity (peak oxygen consumption; R2=0.74, r=-0.86, P<0.001). RAP was a predictor of cardiovascular adverse events (hazard ratio: 1.28; 95% CI, 1.10-1.47; P=0.028) per 5 mm Hg. Conclusions In symptomatic patients with TOF, increasing RAP correlates with multiple domains of disease severity (risk stratification) and predicts future cardiovascular events (prognostication). These data have potential clinical implications in the target population of symptomatic TOF patients.
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18
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Egbe AC, Banala K, Vojjini R, Osman K, Afzal A, Jain V, Thotamgari S, Ammash NM. The applications and potential limitations of right ventricular volumes as surrogate marker in tetralogy of fallot. IJC HEART & VASCULATURE 2019; 26:100430. [PMID: 31763442 PMCID: PMC6864123 DOI: 10.1016/j.ijcha.2019.100430] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 10/03/2019] [Accepted: 10/06/2019] [Indexed: 11/17/2022]
Abstract
Cardiac magnetic resonance imaging derived right ventricular (RV) volumes are often necessary for optimal timing of pulmonary valve replacement in patients with tetralogy of Fallot (TOF). This practice is based on previous studies that reported preoperative RV volumetric thresholds that predicted postoperative RV remodeling. As a result, pulmonary valve replacements are being performed even in asymptomatic patients based on RV volumetric thresholds that predict complete postoperative RVOT remodeling. Hence, RV volumes are now being used as surrogate markers/endpoints for future cardiovascular outcomes. Unfortunately, there are no studies showing survival benefit for performing pulmonary valve replacement at smaller RV volumes. This review underscores some of the limitations of using RV volumes as surrogate markers for clinical outcomes, and also highlights knowledge gaps about the pathophysiologic mechanism of cardiovascular death in the TOF population.
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Affiliation(s)
- Alexander C. Egbe
- Corresponding author at: Mayo Clinic and Foundation, 200 First Street SW, Rochester, MN 55905, United States.
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Visser LC, Nishimura S, Oldach MS, Bélanger C, Gunther-Harrington CT, Stern JA, Hsue W. Echocardiographic assessment of right heart size and function in dogs with pulmonary valve stenosis. J Vet Cardiol 2019; 26:19-28. [PMID: 31794914 DOI: 10.1016/j.jvc.2019.11.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 10/28/2019] [Accepted: 11/04/2019] [Indexed: 10/25/2022]
Abstract
INTRODUCTION/OBJECTIVES We sought to determine the prevalence and clinical significance of right heart remodeling and right ventricular (RV) dysfunction in dogs with pulmonary valve stenosis (PS). We also sought to evaluate repeatability of several measurements of severity of PS, right heart size, and RV function in dogs with PS. ANIMALS, MATERIALS AND METHODS Several indices of right atrial (RA) size and RV size and function were prospectively evaluated in 48 dogs with PS. Regression analysis was used to determine if indices of right heart size and function were independently associated with maximum transpulmonary pressure gradient (max PG) and adverse clinical findings (exercise intolerance, syncope, or right heart failure). Eight dogs underwent a second echocardiogram performed by the same operator to assess repeatability of the echocardiographic indices, which was quantified by coefficient of variation (CV) and repeatability coefficient. RESULTS Increased RA size (81%), increased RV wall thickness (83%), and decreased tricuspid annular plane systolic excursion (TAPSE [81%]) were common. Right atrial size, end-diastolic RV area, and RV wall thickness were independently associated with max PG. Decreased TAPSE was independently associated with adverse clinical findings. All indices except RA area (18.6%) and RV systolic velocity (20.7%) had CVs <15%. Repeatability coefficients are available to help distinguish a true change versus measurement variability during serially obtained exams. CONCLUSIONS Right heart remodeling and RV dysfunction are common in dogs with PS and are associated with echocardiographic and clinical severity. Results support the quantitative assessment of right heart size and function in dogs with PS.
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Affiliation(s)
- L C Visser
- Department of Medicine and Epidemiology, School of Veterinary Medicine, University of California, Davis, One Shields Ave, Davis, CA, 95616, USA.
| | - S Nishimura
- Department of Medicine and Epidemiology, School of Veterinary Medicine, University of California, Davis, One Shields Ave, Davis, CA, 95616, USA
| | - M S Oldach
- Department of Medicine and Epidemiology, School of Veterinary Medicine, University of California, Davis, One Shields Ave, Davis, CA, 95616, USA
| | - C Bélanger
- Department of Medicine and Epidemiology, School of Veterinary Medicine, University of California, Davis, One Shields Ave, Davis, CA, 95616, USA
| | - C T Gunther-Harrington
- Department of Medicine and Epidemiology, School of Veterinary Medicine, University of California, Davis, One Shields Ave, Davis, CA, 95616, USA
| | - J A Stern
- Department of Medicine and Epidemiology, School of Veterinary Medicine, University of California, Davis, One Shields Ave, Davis, CA, 95616, USA
| | - W Hsue
- Department of Medicine and Epidemiology, School of Veterinary Medicine, University of California, Davis, One Shields Ave, Davis, CA, 95616, USA
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Mongeon FP, Ben Ali W, Khairy P, Bouhout I, Therrien J, Wald RM, Dallaire F, Bernier PL, Poirier N, Dore A, Silversides C, Marelli A. Pulmonary Valve Replacement for Pulmonary Regurgitation in Adults With Tetralogy of Fallot: A Meta-analysis-A Report for the Writing Committee of the 2019 Update of the Canadian Cardiovascular Society Guidelines for the Management of Adults With Congenital Heart Disease. Can J Cardiol 2019; 35:1772-1783. [PMID: 31813508 DOI: 10.1016/j.cjca.2019.08.031] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 08/11/2019] [Accepted: 08/16/2019] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND There is no systematic evidence review of the long-term results of surgical pulmonary valve replacement (PVR) dedicated to adults with repaired tetralogy of Fallot (rTOF) and pulmonary regurgitation. METHODS Our primary objective was to determine whether PVR reduced long-term mortality in adults with rTOF compared with conservative therapy. Secondary objectives were to determine the postoperative incidence rate of death, the changes in functional capacity and in right ventricular (RV) volumes and ejection fraction after PVR, and the postoperative incidence rate of sustained ventricular arrhythmias. A systematic search of multiple databases for studies was conducted without limits. RESULTS No eligible randomized controlled trial or cohort study compared outcomes of PVR and conservative therapy in adults with rTOF. We selected 10 cohort studies (total 657 patients) reporting secondary outcomes. After PVR, the pooled incidence rate of death was 1% per year (95% confidence interval [CI] 0-1% per year) and the pooled incidence rate of sustained ventricular arrhythmias was 1% per year (95% CI 1%-2% per year). PVR improved symptoms (odds ratio for postoperative New York Heart Association functional class > II 0.08, 95% CI 0.03-0.24). Indexed RV end-diastolic (-61.29 mL/m2, -43.64 to -78.94 mL/m2) and end-systolic (-37.20 mL/m2, -25.58 to -48.82 mL/m2) volumes decreased after PVR, but RV ejection fraction did not change (0.19%, -2.36% to 2.74%). The effect of PVR on RV volumes remained constant regardless of functional status. CONCLUSION Studies comparing PVR and conservative therapy exclusively in adults with rTOF are lacking. After PVR, the incidence rates of death and ventricular tachycardia are both 1 per 100 patient-years. Pooled analyses demonstrated an improved functional status and a reduction in RV volumes.
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Affiliation(s)
- François-Pierre Mongeon
- Adult Congenital Heart Center, Department of Specialized Medicine, Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada.
| | - Walid Ben Ali
- Department of surgery, Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | - Paul Khairy
- Adult Congenital Heart Center, Department of Specialized Medicine, Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | - Ismail Bouhout
- Department of surgery, Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | - Judith Therrien
- Jewish General Hospital, McGill University, Montréal, Québec, Canada
| | - Rachel M Wald
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Frederic Dallaire
- Division of Pediatric and Fetal Cardiology, Centre Hospitalier Universitaire de Sherbrooke, Université de Sherbrooke, Sherbrooke, Québec, Canada
| | - Pierre-Luc Bernier
- Department of surgery, McGill University Health Center, McGill University, Montréal, Québec, Canada
| | - Nancy Poirier
- Department of surgery, Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada; Department of surgery, CHU-Sainte-Justine, Université de Montréal, Montréal, Québec, Canada
| | - Annie Dore
- Adult Congenital Heart Center, Department of Specialized Medicine, Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | - Candice Silversides
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Ariane Marelli
- McGill Adult Unit for Congenital Heart Disease (MAUDE Unit), McGill University, Montréal, Québec, Canada
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Egbe AC, Vallabhajosyula S, Akintoye E, Connolly HM. Trends and Outcomes of Infective Endocarditis in Adults With Tetralogy of Fallot: A Review of the National Inpatient Sample Database. Can J Cardiol 2019; 35:721-726. [PMID: 31151707 DOI: 10.1016/j.cjca.2019.02.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 02/06/2019] [Accepted: 02/10/2019] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Lesion complexity and prosthetic valves are known risk factors for infective endocarditis in patients with congenital heart disease. Tetralogy of Fallot (TOF) is the most common complex/cyanotic congenital heart disease and often requires prosthetic valve implantation. Population-based risk of endocarditis in TOF patients is unknown. METHODS We reviewed the National Inpatient Sample (NIS) and identified admissions in TOF patients (>18 years), 2000 to 2014. The primary outcome was to describe incidence of endocarditis-related admissions. To assess trends, we divided the study period into tertiles: early (2000 to 2004), mid (2005 to 2009) and late (2010 to 2014) eras. The secondary outcome was to compare in-hospital mortality, complications, and health care resource utilization between admissions with and without endocarditis. RESULTS There were 393 (2.1%) endocarditis-related admissions among 18,353 admissions, and the incidence of endocarditis-related admissions increased over time: 1.9% (early era) vs 2.2% (mid-era) vs 2.4% (late era), P < 0.001. Overall in-hospital mortality was 6%. In addition to previously described risk factors for endocarditis, such as previous pacemaker/defibrillator or prosthetic valve implantation, we observed an association between endocarditis-related admissions and male gender, black race, and lower socioeconomic class. In comparison with admissions without endocarditis, the endocarditis-related admissions had higher in-hospital mortality, complications, and health care resource utilization measured by length of stay, inflation-adjusted hospitalization cost, and type of hospital discharge. CONCLUSIONS Incidence of endocarditis-related admissions increased over time and was associated with higher mortality, complications, and health care resource utilization. Further studies are required to investigate the observed temporal increase in incidence of endocarditis and explore new strategies to improve outcomes.
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Affiliation(s)
- Alexander C Egbe
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.
| | | | - Emmanuel Akintoye
- Division of Cardiovascular Medicine, University of Iowa Hospitals and Clinic, Iowa City, Iowa, USA
| | - Heidi M Connolly
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
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