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Egbe AC, Jain CC, Abozied O, Burchill LJ, Younis A, Karnakoti S, Ahmed MH, Connolly HM. Differences in Right Heart Function After Pulmonary Valve Replacement in Patients With Pulmonary Valve Stenosis Versus Tetralogy of Fallot. J Am Heart Assoc 2024; 13:e034833. [PMID: 38958134 PMCID: PMC11292774 DOI: 10.1161/jaha.124.034833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 06/06/2024] [Indexed: 07/04/2024]
Abstract
BACKGROUND There are limited data about the impact of timing of pulmonary valve replacement (PVR) on right heart reverse remodeling in patients with pulmonary regurgitation following intervention for isolated pulmonary valve stenosis (PS). This study compared differences in postprocedural right heart reverse remodeling after early versus late PVR (defined as PVR before versus after attainment of the conservative consensus criteria proposed by Bokma et al, 2018) in patients with prior intervention for PS, using patients with tetralogy of Fallot as the reference group. METHOD AND RESULTS Right atrial reservoir strain and right ventricular free wall strain was measured at baseline, 1 and 3 years after PVR. There were 114 patients with PS (early PVR, 87 [76%]; late PVR, 27 [24%]) and 291 patients with tetralogy of Fallot (early PVR, 197 [67%]; late PVR, 96 [33%]). The PS group had greater improvement in right atrial reservoir strain at 1 year (12%±4% versus 8%±4%; P<0.001) and 3 years (15%±6% versus 9%±6%; P<0.001), and a greater improvement in right ventricular free wall strain at 1 year (12%±4% versus 7%±3%, P=0.008) and 3-years (16%±6% versus 12%±5%; P=0.01) after PVR compared with the tetralogy of Fallot group. There was no difference in right heart reverse remodeling between patients who underwent early versus later PVR within the PS group. In contrast, late PVR was associated with less right heart reverse remodeling within the tetralogy of Fallot group. CONCLUSIONS These data suggest that patients with palliated PS presenting pulmonary regurgitation have a more benign clinical course, and hence delaying PVR in this population may be appropriate.
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Affiliation(s)
- Alexander C. Egbe
- Department of Cardiovascular MedicineMayo Clinic RochesterRochesterMNUSA
| | - C. Charles Jain
- Department of Cardiovascular MedicineMayo Clinic RochesterRochesterMNUSA
| | - Omar Abozied
- Department of Cardiovascular MedicineMayo Clinic RochesterRochesterMNUSA
| | - Luke J. Burchill
- Department of Cardiovascular MedicineMayo Clinic RochesterRochesterMNUSA
| | - Ahmed Younis
- Department of Cardiovascular MedicineMayo Clinic RochesterRochesterMNUSA
| | - Snigdha Karnakoti
- Department of Cardiovascular MedicineMayo Clinic RochesterRochesterMNUSA
| | - Marwan H. Ahmed
- Department of Cardiovascular MedicineMayo Clinic RochesterRochesterMNUSA
| | - Heidi M. Connolly
- Department of Cardiovascular MedicineMayo Clinic RochesterRochesterMNUSA
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Meng H, Wan LY, Qu R, Liu QQ, Li MZ, Li YD, Pan SW, Li SJ, Wang Q, Yan J, Yang KM. Biventricular function after Ebstein anomaly repair from a single-center echocardiography study. Hellenic J Cardiol 2024:S1109-9666(24)00124-6. [PMID: 38844023 DOI: 10.1016/j.hjc.2024.05.019] [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: 02/16/2024] [Revised: 04/09/2024] [Accepted: 05/29/2024] [Indexed: 06/30/2024] Open
Abstract
OBJECTIVE We aimed to examine biventricular remodeling and function after Ebstein anomaly (EbA) surgical correction using echocardiographic techniques, particularly, the relations between the biventricular changes and the EbA types. METHODS From April 2015 to August 2022, 110 patients with EbA were included in this retrospective study based on the Carpentier classification. Echocardiography assessments during the preoperative, early, and mid-term postoperative periods were performed. RESULTS The 54 patients with types A and B EbA were included in group 1, whereas the 56 patients with types C and D were in group 2. Seventy-eight patients underwent surgical correction of EbA. The median age at operation was 8.8 years. During the mid-term follow-up, only 9.1% of the patients had moderate or severe tricuspid regurgitation. Right ventricular (RV) systolic function worsened in group 2 at discharge (fractional area change: 27.6 ± 11.2 vs. 35.4 ± 11.5 [baseline], P < 0.05; global longitudinal strain: -10.8 ± 4.4 vs. -17.9 ± 4.7 [baseline], P = 0.0001). RV function slowly recovered at a mean of 12 months of follow-up. Regarding left ventricular (LV) and RV systolic function, no statistical difference was found between before and after surgery in group 1. CONCLUSION A high success rate of surgical correction of EbA, with an encouraging durability of the valve, was noted. Biventricular systolic function was maintained fairly in most patients with types A and B postoperatively. A late increase in RV systolic function after an initial reduction and unchanged LV systolic function were observed in the patients with types C and D postoperatively.
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Affiliation(s)
- Hong Meng
- Echocardiographic Imaging Center, Beijing, PR China.
| | - Lin-Yuan Wan
- Echocardiographic Imaging Center, Beijing, PR China
| | - Ran Qu
- Echocardiographic Imaging Center, Beijing, PR China
| | | | - Mu-Zi Li
- Echocardiographic Imaging Center, Beijing, PR China
| | - Ye-Dan Li
- Echocardiographic Imaging Center, Beijing, PR China
| | - Shi-Wei Pan
- Department of Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shou-Jun Li
- Department of Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qiang Wang
- Department of Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jun Yan
- Department of Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ke-Ming Yang
- Department of Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Egbe AC, Connolly HM. Heart Failure Staging and Indications for Advanced Therapies in Adults with Congenital Heart Disease. Heart Fail Clin 2024; 20:147-154. [PMID: 38462319 DOI: 10.1016/j.hfc.2023.12.006] [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] [Indexed: 03/12/2024]
Abstract
Heart failure (HF) is common in adults with congenital heart disease (CHD), and it is the leading cause of death in this population. Adults with CHD presenting with stage D HF have a poor prognosis, and early recognition of signs of advanced HF and referral for advanced therapies for HF offer the best survival as compared with other therapies. The indications for advanced therapies for HF outlined in this article should serve as a guide for clinicians to determine the optimal time for referral. Palliative care should be part of the multidisciplinary care model for HF in patients with CHD.
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Affiliation(s)
- Alexander C Egbe
- Department of Cardiovascular Medicine, Mayo Clinic and Foundation, 200 First Street Southwest, Rochester, MN 55905, USA.
| | - Heidi M Connolly
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, USA
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Salama AA, Abozied OA, Anderson JH, Miranda WR, Connolly HM, Jain C, Cabalka A, Egbe AC. Cardiac Reverse Remodeling and Changes in Heart Failure Indices After Transcatheter Tricuspid Valve Replacement in Adults With Congenital Heart Disease. Circ Cardiovasc Interv 2024; 17:e013334. [PMID: 37942627 PMCID: PMC10841471 DOI: 10.1161/circinterventions.123.013334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 09/11/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND There are limited data about changes in cardiac function (cardiac reverse remodeling) and heart failure indices after transcatheter tricuspid valve-in-valve replacement (TT-VIVR). The purpose of this study was to evaluate cardiac reverse remodeling and temporal changes in heart failure indices after TT-VIVR in adults with congenital heart disease. METHODS Retrospective cohort study of adults with congenital heart disease that underwent TT-VIVR and had >6 months of follow-up (January 1, 2011, to April 30, 2023). Echocardiographic indices of cardiac remodeling and heart failure indices (New York Heart Association class, NT-proBNP (N-terminal pro-brain natriuretic peptide), glomerular filtration rate, and model for end-stage liver disease excluding international normalized ratio score) were assessed preintervention and at 1-, 3-, and 5-year postintervention. RESULTS Of 39 patients (age 39 [32-46] years), 14 (36%) and 25 (64%) received Melody valve and Sapien valve prosthesis, respectively. At 1-year post-TT-VIVR, there was a temporal improvement in right atrial reservoir strain (17±8% versus 22±8%, P<0.001), right atrial volume (81 [59-108] versus 63 [48-82] mL/m2, P<0.001), right atrial pressure (12±4% versus 6±4%, P<0.001), and right ventricular global longitudinal strain (-15±7% versus -20±7%, P<0.001). Similarly, there was a temporal improvement in NT-proBNP, glomerular filtration rate, model for end-stage liver disease excluding international normalized ratio score, and New York Heart Association class. The temporal improvements in heart failure indices and valve function were maintained at 3- and 5-year post-TT-VIVR. CONCLUSIONS Considering the significant mortality risk associated with reoperations for tricuspid valve replacement, these data suggest favorable outcomes after TT-VIVR, and support TT-VIVR as a viable alternative to surgical tricuspid valve replacement, especially in high-risk patients.
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Affiliation(s)
- Abdalla A Salama
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, MN (A.A.S., O.A.A., J.H.A., W.R.M., H.M.C., C.J., A.C., A.C.E.)
- Department of Cardiovascular Diseases, Suez Canal University, Ismailia, Egypt (A.A.S.)
| | - Omar A Abozied
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, MN (A.A.S., O.A.A., J.H.A., W.R.M., H.M.C., C.J., A.C., A.C.E.)
| | - Jason H Anderson
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, MN (A.A.S., O.A.A., J.H.A., W.R.M., H.M.C., C.J., A.C., A.C.E.)
| | - William R Miranda
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, MN (A.A.S., O.A.A., J.H.A., W.R.M., H.M.C., C.J., A.C., A.C.E.)
| | - Heidi M Connolly
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, MN (A.A.S., O.A.A., J.H.A., W.R.M., H.M.C., C.J., A.C., A.C.E.)
| | - Charles Jain
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, MN (A.A.S., O.A.A., J.H.A., W.R.M., H.M.C., C.J., A.C., A.C.E.)
| | - Allison Cabalka
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, MN (A.A.S., O.A.A., J.H.A., W.R.M., H.M.C., C.J., A.C., A.C.E.)
| | - Alexander C Egbe
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, MN (A.A.S., O.A.A., J.H.A., W.R.M., H.M.C., C.J., A.C., A.C.E.)
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Téllez L, Payancé A, Tjwa E, Del Cerro MJ, Idorn L, Ovroutski S, De Bruyne R, Verkade HJ, De Rita F, de Lange C, Angelini A, Paradis V, Rautou PE, García-Pagán JC. EASL-ERN position paper on liver involvement in patients with Fontan-type circulation. J Hepatol 2023; 79:1270-1301. [PMID: 37863545 DOI: 10.1016/j.jhep.2023.07.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 07/06/2023] [Indexed: 10/22/2023]
Abstract
Fontan-type surgery is the final step in the sequential palliative surgical treatment of infants born with a univentricular heart. The resulting long-term haemodynamic changes promote liver damage, leading to Fontan-associated liver disease (FALD), in virtually all patients with Fontan circulation. Owing to the lack of a uniform definition of FALD and the competitive risk of other complications developed by Fontan patients, the impact of FALD on the prognosis of these patients is currently debatable. However, based on the increasing number of adult Fontan patients and recent research interest, the European Association for The Study of the Liver and the European Reference Network on Rare Liver Diseases thought a position paper timely. The aims of the current paper are: (1) to provide a clear definition and description of FALD, including clinical, analytical, radiological, haemodynamic, and histological features; (2) to facilitate guidance for staging the liver disease; and (3) to provide evidence- and experience-based recommendations for the management of different clinical scenarios.
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Affiliation(s)
- Luis Téllez
- Gastroenterology and Hepatology Department, Hospital Universitario Ramón y Cajal, Madrid, Spain; Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), University of Alcalá, Madrid, Spain
| | - Audrey Payancé
- DHU Unity, Pôle des Maladies de l'Appareil Digestif, Service d'Hépatologie, Hôpital Beaujon, AP-HP, Clichy, France; Université Denis Diderot-Paris 7, Sorbonne Paris Cité, Paris, France
| | - Eric Tjwa
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - María Jesús Del Cerro
- Pediatric Cardiology Department, Hospital Universitario Ramón y Cajal, Madrid, Spain; Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), University of Alcalá, Madrid, Spain
| | - Lars Idorn
- Department of Pediatrics, Section of Pediatric Cardiology, Rigshospitalet, Copenhagen, Denmark
| | - Stanislav Ovroutski
- Department of Congenital Heart Disease/Pediatric Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Ruth De Bruyne
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Ghent University Hospital, Belgium
| | - Henkjan J Verkade
- Department of Pediatrics, Beatrix Children's Hospital/University Medical Center Groningen, The Netherlands
| | - Fabrizio De Rita
- Adult Congenital and Paediatric Heart Unit, Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Charlotte de Lange
- Department of Pediatric Radiology, Queen Silvia Childrens' Hospital, Sahlgrenska University Hospital, Behandlingsvagen 7, 41650 Göteborg, Sweden
| | - Annalisa Angelini
- Pathology of Cardiac Transplantation and Regenerative Medicine Unit, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Valérie Paradis
- Centre de recherche sur l'inflammation, INSERM1149, Université Paris Cité, Paris, France; Pathology Department, Beaujon Hospital, APHP.Nord, Clichy, France
| | - Pierre Emmanuel Rautou
- AP-HP, Service d'Hépatologie, Hôpital Beaujon, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, Clichy, France; Université Paris-Cité, Inserm, Centre de recherche sur l'inflammation, UMR 1149, Paris, France
| | - Juan Carlos García-Pagán
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Departament de Medicina i Ciències de la Salut, University of Barcelona, Barcelona, Spain; CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Spain.
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6
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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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Miranda WR, Kamath PS, Jain CC, Connolly HC, Egbe AC. Liver Fibrosis Scores Are Associated With Resting and Exercise Fontan and Pulmonary Artery Wedge Pressures: Insights Into FALD. Can J Cardiol 2023; 39:1349-1357. [PMID: 37150355 DOI: 10.1016/j.cjca.2023.04.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 04/03/2023] [Accepted: 04/27/2023] [Indexed: 05/09/2023] Open
Abstract
BACKGROUND Alterations in liver perfusion and venous hypertension have been implicated in the pathophysiology of Fontan-associated liver disease (FALD). However, the correlation between exercise hemodynamics and markers of FALD have not been studied. METHODS We performed a retrospective review of 32 consecutive adults undergoing exercise catheterisation at the Mayo Clinic, Minnesota. Invasive hemodynamics were correlated with aspartate transaminase to platelet ratio index (APRI) and the Fibrosis-4 (Fib-4) score, well validated surrogates of liver fibrosis. RESULTS The mean age was 30.9 ± 7 years. The mean APRI was 0.5 ± 0.2 and the mean Fib-4 score 1.3 ± 0.8. Fib-4 scores correlated with spleen size on abdominal imaging (r = 0.40; P = 0.03). Resting Fontan pressure was 13.9 ± 3.9 mm Hg and pulmonary artery wedge pressure (PAWP) 10.0 ± 3.5 mm Hg. At peak exercise (69.4 ± 23.2 W), Fontan pressures increased to 26.5 ± 6.2 mm Hg and PAWP to 22.4 ± 7.1 mm Hg. APRI and Fib-4 score were directly related to Fontan pressure and PAWP at rest and during exercise, and inversely related to exercise arterial O2 saturation. Fib-4 inversely correlated with O2 delivery indices. Similarly, when categorising patients according to high APRI (> 0.5 vs ≤ 0.5) or Fib-4 score (≥ 1.45 vs < 1.45) according to previously proposed cutoffs for diagnosis of liver fibrosis, those with elevated scores had higher resting and exercise Fontan and PAWP pressure with lower O2 arterial saturation. CONCLUSIONS APRI and Fib-4 score correlated with resting and exercise Fontan pressure and PAWP. In addition, Fib-4 scores were inversely related to O2 delivery indices. These findings support a role played by hepatic venous hypertension and reduced O2 supply in patients with FALD.
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Affiliation(s)
- William R Miranda
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - C Charles Jain
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Heidi C Connolly
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Alexander C Egbe
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
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8
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Rathgeber SL. Liver Stiffness vs Vibrosis After Fontan Palliation: Is Transient Elastography the Solution to Early Detection of Progressive Liver Disease? Can J Cardiol 2023; 39:1346-1348. [PMID: 37331621 DOI: 10.1016/j.cjca.2023.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Revised: 06/09/2023] [Accepted: 06/12/2023] [Indexed: 06/20/2023] Open
Affiliation(s)
- Steven L Rathgeber
- Division of Pediatric Cardiology, Department of Pediatrics, Faculty of Medicine University of British Columbia, Vancouver, British Columbia, Canada.
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Bütikofer S, Greutmann-Yantiri M, Gubler C, Reiner C, Alkadhi H, Pfammatter T, Puippe G, Santos Lopes B, Possner M, Bonassin F, Meier L, Babic D, Attenhofer Jost C, Jüngst C, Müllhaupt B, Bernsmeier C, Schwerzmann M, Tobler D, Lenggenhager D, Marques Maggio E, Greutmann M. Determinants of Advanced Liver Fibrosis in Adult Patients After Fontan Palliation: Usefulness of Ultrasound Transient Elastography. Can J Cardiol 2023; 39:1338-1345. [PMID: 37116790 DOI: 10.1016/j.cjca.2023.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 04/20/2023] [Accepted: 04/21/2023] [Indexed: 04/30/2023] Open
Abstract
BACKGROUND Fontan-associated liver disease is an increasing concern. Our aim was to assess prevalence and predictors of advanced liver fibrosis with a specific focus on utility of liver stiffness measurement by ultrasound transient elastography. METHODS A total of 97 adult Fontan patients (55% male, median age: 23.1 years, interquartile range [IQR]: 18.7-30.6); 92 (95%) were evaluated with transient elastography, and 50 (52%) underwent transjugular liver biopsy. Advanced liver fibrosis was defined as congestive hepatic fibrosis score 3 or 4. RESULTS Only 4 patients (4%) had liver stiffness values < 10 kilopascal (kPa). Liver-stiffness measurements correlated weakly with peak oxygen uptake on exercise testing and Fontan pressure but not with Model for End-Stage Liver Disease excluding INR (MELD-XI) score or spleen size. Serial follow-up liver stiffness measurements in 73 clinically stable patients showed large variability among individual patients. Advanced liver fibrosis was present in 35 of 50 (70%) patients on liver biopsy and was associated to MELD-XI-Score ≥ 11 and splenomegaly but not to liver-stiffness measurements. Advanced liver fibrosis was not associated with patient age or time since Fontan operation but with younger age at completion of Fontan (3.7 years, IQR: 2.3-6.3 vs 6.8 years; IQR: 3.5-12.1; P = 0.037). CONCLUSIONS In our cohort, advanced liver fibrosis was present in the majority of adult Fontan patients. Liver stiffness as measured by transient elastography was not associated with the degree of liver fibrosis. Because of its high variability on serial measurements, it seems not to be useful for clinical decision making. The unexpected finding that younger age at completion of Fontan was associated with advanced liver fibrosis merits further evaluation.
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Affiliation(s)
- Simon Bütikofer
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Mehtap Greutmann-Yantiri
- University Heart Centre Zurich, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Christoph Gubler
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Cecilia Reiner
- Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Hatem Alkadhi
- Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Thomas Pfammatter
- Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Gilbert Puippe
- Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Bruno Santos Lopes
- University Heart Centre Zurich, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Mathias Possner
- University Heart Centre Zurich, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Francesca Bonassin
- University Heart Centre Zurich, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Lukas Meier
- University Heart Centre Zurich, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Daniela Babic
- University Heart Centre Zurich, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Christine Attenhofer Jost
- University Heart Centre Zurich, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Christoph Jüngst
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Beat Müllhaupt
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Christine Bernsmeier
- Department of Gastroenterology and Hepatology, University Hospital Basel, Basel, Switzerland
| | - Markus Schwerzmann
- Center for Congenital Heart Disease, University Hospital Inselspital, University of Bern, Bern, Switzerland
| | - Daniel Tobler
- Department of Cardiology, University Hospital Basel, Basel, Switzerland
| | - Daniela Lenggenhager
- Department of Pathology and Molecular Pathology, University Hospital Zurich, Zurich, Switzerland
| | - Ewerton Marques Maggio
- Department of Pathology and Molecular Pathology, University Hospital Zurich, Zurich, Switzerland
| | - Matthias Greutmann
- University Heart Centre Zurich, University Hospital Zurich, University of Zurich, Zurich, Switzerland.
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10
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Egbe AC, Miranda WR, Jain CC, Stephens EH, Andi K, Abozied O, Connolly HM. Temporal Changes in Clinical Characteristics and Outcomes of Adults With Congenital Heart Disease. Am Heart J 2023; 264:1-9. [PMID: 37301316 PMCID: PMC10823874 DOI: 10.1016/j.ahj.2023.05.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 05/03/2023] [Accepted: 05/27/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND The purpose of this study was to assess differences in the clinical characteristics (defined by congenital heart disease [CHD] anatomic and physiologic classification scheme) of adults with CHD across different eras, and how these differences influence outcomes (heart failure hospitalization and all-cause mortality). METHOD Patients were divided into depending on year of baseline encounter: cohort #1 (1991-2000, n = 1,984 [27%]), cohort #2 (2001-2010, n = 2,448 [34%]), and cohort #3 (2011-2020, n = 2,847 [39%]). Patients were classified into 3 anatomic groups (simple, moderate, and complex CHD) and 4 physiologic stages (stage A-D). RESULTS There was a temporal increase in the proportion of patients in physiologic stage C (17% vs 21% vs 24%, P < .001), and stage D (7% vs 8% vs 10%, P = .09), with a corresponding decrease in physiologic stage A (39% vs 35% vs 28%, P < .001). No temporal change in anatomic groups. There was a temporal decrease in the incidence of all-cause mortality (12.7 vs 10.6 vs 9.5 per 1,000 patient-years, P < .001). However, there was a temporal increase in the incidence of heart failure hospitalization (6.8 vs 8.4 vs 11.2 per 1,000 patient-years, P < .001). CHD physiologic stage (but not anatomic groups) was associated with heart failure hospitalization and all-cause mortality. CONCLUSIONS There is a need for better strategies to identify and treat heart failure, and to modify the risk factors associated with heart failure and all-cause mortality.
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Affiliation(s)
- Alexander C Egbe
- Department of Cardiovascular Medicine, Mayo Clinic and Foundation, Rochester, MN.
| | - William R Miranda
- Department of Cardiovascular Medicine, Mayo Clinic and Foundation, Rochester, MN
| | - C Charles Jain
- Department of Cardiovascular Medicine, Mayo Clinic and Foundation, Rochester, MN
| | | | - Kartik Andi
- Department of Cardiovascular Medicine, Mayo Clinic and Foundation, Rochester, MN
| | - Omar Abozied
- Department of Cardiovascular Medicine, Mayo Clinic and Foundation, Rochester, MN
| | - Heidi M Connolly
- Department of Cardiovascular Medicine, Mayo Clinic and Foundation, Rochester, MN
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Egbe AC, Miranda WR, Jain CC, Andi K, Abozied O, Younis AK, Kandlakunta S, Salama AA, Stephens EH, Connolly HM. Prognostic Performance of Right Ventricular Global Longitudinal Strain Measurements in Patients With Ebstein Anomaly. J Am Coll Cardiol 2023; 82:503-513. [PMID: 37532420 DOI: 10.1016/j.jacc.2023.05.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 05/03/2023] [Accepted: 05/11/2023] [Indexed: 08/04/2023]
Abstract
BACKGROUND There are limited data on the prognostic role of right ventricular global longitudinal strain (RVGLS) in patients with Ebstein anomaly. OBJECTIVES This study sought to assess the relationship between RVGLS and mortality and to compare prognostic performance of RVGLS with conventional echocardiographic indices of right ventricular (RV) systolic function. METHODS This study identified adults with Ebstein anomaly with echocardiographic assessment of RV systolic function (RVGLS, RV fractional area change [RVFAC], RV tissue Doppler systolic velocity [RV s'], and tricuspid annular plane systolic excursion [TAPSE]) from 2003 to 2020. For ease of presentation, RVGLS was modeled as absolute values (ie, without the negative sign). RESULTS Of 620 patients (median age 37 years; men 261 [42%]), the mean absolute RVGLS, RVFAC, RV s', and TAPSE were 18% ± 5%, 32% ± 9%, 14 ± 6 cm/s, and 22 ± 8 mm, respectively. There were correlations between absolute RVGLS and RVFAC (r = 0.71; P < 0.001), between absolute RVGLS and RV s' (r = 0.41; P = 0.03), and between absolute RVGLS and TAPSE (r = 0.44; P = 0.002). Of 620 patients, 47 (8%) died during follow-up, and 34 of these deaths were cardiovascular. Absolute RVGLS was independently associated with all-cause mortality (adjusted HR: 0.94; 95% CI: 0.92-0.96 per unit increase) and cardiovascular mortality (adjusted HR: 0.92; 95% CI: 0.90-0.94 per unit increase). Absolute RVGLS had superior prognostic power (ie, ability to predict mortality) as compared with RVFAC, RV s', or TAPSE. CONCLUSIONS These data support the use of RVGLS for risk stratification in Ebstein anomaly, and further studies are required to assess how interventions may affect different patients according to risk stratification.
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Affiliation(s)
- Alexander C Egbe
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.
| | - William R Miranda
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - C Charles Jain
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Kartik Andi
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Omar Abozied
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Ahmed K Younis
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Abdalla A Salama
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA; Department of Cardiovascular Diseases, Suez Canal University, Ismailia, Egypt
| | | | - Heidi M Connolly
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Yogeswaran A, Zedler D, Richter MJ, Steinke S, Rako ZA, Kremer NC, Grimminger F, Seeger W, Ghofrani HA, Gall H, Tello K. Hepatorenal dysfunction in patients with chronic thromboembolic pulmonary hypertension. Front Med (Lausanne) 2023; 10:1207474. [PMID: 37547612 PMCID: PMC10399740 DOI: 10.3389/fmed.2023.1207474] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 07/10/2023] [Indexed: 08/08/2023] Open
Abstract
Background Cardiac interactions with organs such as the liver or kidneys have been described in different cardiovascular diseases. However, the clinical relevance of hepatorenal dysfunction in chronic thromboembolic pulmonary hypertension (CTEPH) remains unclear. We determined the association of hepatorenal dysfunction (measured using the Model for End-stage Liver Disease Sodium [MELDNa] score) with right heart function and survival in patients with CTEPH. Methods We analyzed all patients with CTEPH in the Giessen Pulmonary Hypertension Registry who had available MELDNa scores and were not taking vitamin K antagonists. The MELDNa score was calculated as MELD score - serum Na - (0.025 * MELD score * (140 - serum Na)) + 140; the MELD score was calculated as 10*(0.957*ln(creatinine)+0.378*ln(bilirubin)+1.12*ln(International Normalized Ratio))+6.43. Results Seventy-two patients were included (74% female; median [Q1, Q3] MELDNa: 9 [6, 11]). MELDNa correlated well with right atrial and ventricular function and pulmonary hemodynamics. Forward regression analysis revealed that hepatorenal dysfunction mainly depends on right atrial strain and tricuspid regurgitation, but not right ventricular systolic dysfunction. Hepatorenal dysfunction predicted mortality at baseline and follow-up (adjusted hazard ratios [95% confidence intervals] per unit increase of MELDNa: 1.6 [1.1, 2.4] and 1.8 [1.1, 2.9], respectively). Changes in hepatorenal function also predicted mortality. Conclusion Hepatorenal dysfunction in CTEPH is primarily associated with venous congestion rather than cardiac forward failure. As a surrogate parameter for hepatorenal dysfunction, MELDNa is a simple method to identify at-risk patients at baseline and follow-up.
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Affiliation(s)
- Athiththan Yogeswaran
- Department of Internal Medicine, Member of the German Center for Lung Research (DZL), Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany
| | - Daniel Zedler
- Department of Internal Medicine, Member of the German Center for Lung Research (DZL), Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany
| | - Manuel J. Richter
- Department of Internal Medicine, Member of the German Center for Lung Research (DZL), Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany
| | - Sonja Steinke
- Department of Internal Medicine, Member of the German Center for Lung Research (DZL), Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany
| | - Zvonimir A. Rako
- Department of Internal Medicine, Member of the German Center for Lung Research (DZL), Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany
| | - Nils C. Kremer
- Department of Internal Medicine, Member of the German Center for Lung Research (DZL), Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany
| | - Friedrich Grimminger
- Department of Internal Medicine, Member of the German Center for Lung Research (DZL), Institute for Lung Health (ILH), Cardio-Pulmonary Institute (CPI), Universities of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany
| | - Werner Seeger
- Department of Internal Medicine, Member of the German Center for Lung Research (DZL), Institute for Lung Health (ILH), Cardio-Pulmonary Institute (CPI), Universities of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany
| | - Hossein Ardeschir Ghofrani
- Department of Internal Medicine, Member of the German Center for Lung Research (DZL), Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany
| | - Henning Gall
- Department of Internal Medicine, Member of the German Center for Lung Research (DZL), Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany
| | - Khodr Tello
- Department of Internal Medicine, Member of the German Center for Lung Research (DZL), Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany
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Special Considerations in Critical Care of the Congenital Heart Disease Patient. Can J Cardiol 2023; 39:544-557. [PMID: 36682483 DOI: 10.1016/j.cjca.2023.01.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 01/16/2023] [Accepted: 01/17/2023] [Indexed: 01/21/2023] Open
Abstract
Outcomes of congenital heart disease have improved markedly over the past 20 years, with survival to adulthood now close to 90%. The mean age of admission to an intensive care unit (ICU) is 40 years. The incidence of hospital and critical care admissions have increased significantly as a consequence of this improved survival. Intensivists are now confronted with the management not only of complex adult congenital heart disease (ACHD) lesions from a cardiac perspective, but also of extracardiac organ consequences of years of abnormal circulation after surgical or palliative correction. Kidney and liver dysfunction and respiratory and hematologic abnormalities are very common in this population. ACHD patients can present to the ICU for a vast number of reasons, classified in this review as medical noncardiac, medical cardiac, and surgical. Community/hospital-acquired infections, cerebrovascular accidents, and respiratory failure, alongside arrhythmias and heart failure, are responsible for medical admissions. Surgical admissions include postoperative management after correction or palliation, but also medical optimisation and work-up for advanced therapies. ICU management of this large heterogeneous group requires a thorough understanding of the pathophysiology in order to apply conventional adult critical care modalities; left ventricular or right ventricular dysfunction, pulmonary hypertension, intracardiac, extracardiac, and palliative surgical shunts can be present and require additional consideration. This review focuses on the pathophysiology, long-term sequelae, and different treatment modalities to supply a framework for the ICU physician caring for these patients. Successful outcome, especially in complex lesions, depends on early involvement of specialised ACHD centres.
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