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Opotowsky AR. The Pathophysiology(ies) of Heart Failure in Adults with Congenital Heart Disease. Heart Fail Clin 2024; 20:129-136. [PMID: 38462317 DOI: 10.1016/j.hfc.2024.01.001] [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
There is a growing, aging population of adults with congenital heart disease (CHD) with an increasing incidence of heart failure. Unquestioning extrapolation of widely applicable definitions of heart failure and guidelines for managing heart failure in adults with acquired heart failure to adults with CHD can be problematic. A nuanced and flexible application of clinical judgment founded on a deep understanding of underlying pathophysiology is needed to most effectively apply the many recent advances in managing acquired heart failure to the care of adults with CHD.
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Affiliation(s)
- Alexander R Opotowsky
- Cincinnati Adult Congenital Heart Disease Program, Department of Pediatrics, Heart Institute, Cincinnati Children's Hospital, University of Cincinnati College of Medicine, 3333 Burnet Avenue, MLC 2003, Cincinnati, OH 45229, USA.
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Special situations in pheochromocytomas and paragangliomas: pregnancy, metastatic disease, and cyanotic congenital heart diseases. Clin Exp Med 2021; 22:359-370. [PMID: 34591219 DOI: 10.1007/s10238-021-00763-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 09/18/2021] [Indexed: 01/08/2023]
Abstract
The aim of our study was to describe the epidemiology, diagnosis, and treatment of the most complex pheochromocytoma and paraganglioma (PGL) cases, including pheochromocytoma/PGL during pregnancy, in cyanotic congenital heart diseases (CCHDs), and metastatic pheochromocytoma. The English and Spanish literature was thoroughly evaluated searching for articles reporting clinical studies, case reports, or reviews of pheochromocytoma/PGL in pregnancy and in CCHD and metastatic pheochromocytoma/PGL. Particular settings in the diagnosis and management of pheochromocytoma and PGLs remain challenging. Those special situations include the diagnosis during pregnancy or in the context of CCHD since the typical clinical features of pheochromocytoma may be confounded with preeclampsia during pregnancy and with the complications commonly observed in CCHD. In addition, although some clinical and genetic features have been associated with higher risk of metastatic pheochromocytoma, the detection and prediction of the development of metastatic disease involve another complex situation that may require special hormonal determinations as plasmatic 3-methoxytyramine and nuclear medicine studies including 18FDG PET-CT or 18F-FDOPA PET-CT, among others. Furthermore, the selection of the most appropriate treatment in these situations, as well as the moment to carry it out, requires special care as limited evidence is available. This article reviews the epidemiology, diagnosis, and treatment of the pheochromocytoma/PGL during pregnancy, metastatic pheochromocytoma/PGL, and pheochromocytoma/PGL in CCHD. The diagnosis, and especially the treatment, of metastatic pheochromocytomas and pheochromocytoma/PGL during pregnancy and in CCHD is challenging. Thus, these cases should be management in reference centres by multidisciplinary teams specialized in the pheochromocytoma/PGL treatment.
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Albinni S, Marx M, Lang IM. Focused Update on Pulmonary Hypertension in Children-Selected Topics of Interest for the Adult Cardiologist. MEDICINA (KAUNAS, LITHUANIA) 2020; 56:E420. [PMID: 32825190 PMCID: PMC7559541 DOI: 10.3390/medicina56090420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 08/13/2020] [Accepted: 08/16/2020] [Indexed: 11/16/2022]
Abstract
Pulmonary hypertensive vascular disease (PHVD), and pulmonary hypertension (PH), which is a broader term, are severe conditions associated with high morbidity and mortality at all ages. Treatment guidelines in childhood are widely adopted from adult data and experience, though big differences may exist regarding aetiology, concomitant conditions and presentation. Over the past few years, paediatric aspects have been incorporated into the common guidelines, which currently address both children and adults with pulmonary hypertension (PH). There are multiple facets of PH in the context of cardiac conditions in childhood. Apart from Eisenmenger syndrome (ES), the broad spectrum of congenital heart disease (CHD) comprises PH in failing Fontan physiology, as well as segmental PH. In this review we provide current data and novel aspects on the pathophysiological background and individual management concepts of these conditions. Moreover, we focus on paediatric left heart failure with PH and its challenging issues, including end stage treatment options, such as mechanical support and paediatric transplantation. PH in the context of rare congenital disorders, such as Scimitar Syndrome and sickle cell disease is discussed. Based on current data, we provide an overview on multiple underlying mechanisms of PH involved in these conditions, and different management strategies in children and adulthood. In addition, we summarize the paediatric aspects and the pros and cons of the recently updated definitions of PH. This review provides deeper insights into some challenging conditions of paediatric PH in order to improve current knowledge and care for children and young adults.
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Affiliation(s)
- Sulaima Albinni
- Paediatric Heart Centre Vienna, Department of Paediatrics and Adolescent Medicine, Medical University of Vienna, 1090 Wien, Austria;
| | - Manfred Marx
- Paediatric Heart Centre Vienna, Department of Paediatrics and Adolescent Medicine, Medical University of Vienna, 1090 Wien, Austria;
| | - Irene M. Lang
- AKH-Vienna, Department of Cardiology, Medical University of Vienna, 1090 Wien, Austria;
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Gumbiene L, Kapleriene L, Jancauskaite D, Laukyte-Sleniene M, Jureviciene E, Rudiene V, Paleviciute E, Mataciunas M, Sileikiene V. Insights to correlations and discrepancies between impaired lung function and heart failure in Eisenmenger patients. Pulm Circ 2020; 10:1350650120909729. [PMID: 32166016 PMCID: PMC7052468 DOI: 10.1177/2045894019899239] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 12/15/2019] [Indexed: 11/30/2022] Open
Abstract
Impaired lung function and spirometric signs of airway obstruction without common
risk factors for chronic obstructive pulmonary disease could be found in
patients with Eisenmenger syndrome. This study aimed to analyse the association
between lung function parameters and disease severity (including heart failure
markers, associated congenital heart defect) as well as the possible reasons for
airflow obstruction in Eisenmenger syndrome. The data of 25 patients with
Eisenmenger syndrome were retrospectively evaluated. The patients were divided
into groups according to airflow obstruction and a type of congenital heart
defect. Airflow obstruction was found in nearly third (32%) of our cases and was
associated with older age and worse survival. No relation was found between
airway obstruction, B-type natriuretic peptide level, complexity of congenital
heart defect and bronchial compression. Most of the patients (88%) had gas
diffusion abnormalities. A weak negative correlation was noticed between gas
diffusion (diffusing capacity of the lung for carbon monoxide) and B-type
natriuretic peptide level (r = −0.437, p = 0.033). Increased residual volume was
associated with higher mortality (p = 0.047 and p = 0.021, respectively). A link
between B-type natriuretic peptide and lung diffusion, but not airway
obstruction, was found. Further research and larger multicentre studies are
needed to evaluate the importance of pulmonary function parameters and
mechanisms of airflow obstruction in Eisenmenger syndrome.
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Affiliation(s)
- Lina Gumbiene
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Lina Kapleriene
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Dovile Jancauskaite
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Monika Laukyte-Sleniene
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Elena Jureviciene
- Clinic of Chest Diseases, Immunology and Allergology, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Virginija Rudiene
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Egle Paleviciute
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Mindaugas Mataciunas
- Department of Radiology, Nuclear Medicine and Medical Physics, Institute of Biomedical Science, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Virginija Sileikiene
- Clinic of Chest Diseases, Immunology and Allergology, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
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Affiliation(s)
- Alexander R Opotowsky
- Department of Cardiology, Boston Children's Hospital, Boston, MA Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Gary D Webb
- Cincinnati Children's Hospital Heart Institute, Cincinnati, OH
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Diller GP, Körten MA, Bauer UMM, Miera O, Tutarel O, Kaemmerer H, Berger F, Baumgartner H. Current therapy and outcome of Eisenmenger syndrome: data of the German National Register for congenital heart defects. Eur Heart J 2016; 37:1449-55. [PMID: 26843280 DOI: 10.1093/eurheartj/ehv743] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Accepted: 12/15/2015] [Indexed: 01/25/2023] Open
Abstract
AIMS We aimed to assess the contemporary outcome of Eisenmenger syndrome (ES), delineate the use of disease targeting therapies (DTT) in these patients and to investigate the effect of treatment on outcome in the community. METHODS AND RESULTS Patients with ES were systematically identified from the German National Register for Congenital Heart Defects. Data on underlying diagnosis, medical therapy, and survival were collected. The impact of DTT on survival was assessed using time-dependant Cox analysis. Overall, 153 ES patients were included (mean age 34.0 ± 13.3 years, 46% females). Of these, 88 (57.5%) were treated with at least one DTT (76.1% Bosentan, 20.5% Sildenafil) while 17.6% were on dual DTT. In addition, 24.8% of patients received digoxin, 10.5% angiotensin-converting enzyme-inhibitors/angiotensin receptor blockers, and 17.6% β-blockers. Moreover, 17.6% of patients were treated with oral anticoagulants, while 23.5% of patients received Aspirin. The survival rate at 1, 5, and 10 years of follow-up was only 92, 75, and 57% in the entire cohort, and was even worse in treatment naive ES patients (survival rate 86, 60, and 34% at 1, 5, and 10 years). Use of DTT was independently associated with a better survival (hazard ratio 0.42, P= 0.015). CONCLUSION This study illustrates the alarmingly poor survival prospects of Eisenmenger patients by community-based data even in the current era with advanced DTT and in a country with a wealthy health system. Treatment naive ES patients had especially high mortality rates approaching 60-70% at 10 years of follow-up. Treatment with DTT was associated with better survival.
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Affiliation(s)
- Gerhard-Paul Diller
- Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital Muenster, Albert-Schweitzer-Str. 33, Muenster 48149, Germany Competence Network for Congenital Heart Defects, Germany
| | | | - Ulrike M M Bauer
- Competence Network for Congenital Heart Defects, Germany National Register for Congenital Heart Defects, Berlin, Germany
| | - Oliver Miera
- Department of Congenital Heart Disease and Pediatric Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Oktay Tutarel
- Competence Network for Congenital Heart Defects, Germany Department of Cardiology & Angiology, Hannover Medical School, Hannover, Germany
| | - Harald Kaemmerer
- Competence Network for Congenital Heart Defects, Germany Department of Pediatric Cardiology and Congenital Heart Disease, The German Heart Centre, Technical University Munich, Munich, Germany
| | - Felix Berger
- Competence Network for Congenital Heart Defects, Germany Department of Congenital Heart Disease and Pediatric Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Helmut Baumgartner
- Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital Muenster, Albert-Schweitzer-Str. 33, Muenster 48149, Germany Competence Network for Congenital Heart Defects, Germany
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Krieger EV, Valente AM. The Sophistication of Simplicity. Circ Cardiovasc Imaging 2015; 8:CIRCIMAGING.115.004201. [DOI: 10.1161/circimaging.115.004201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Eric V. Krieger
- From the Division of Cardiology, Departments of Medicine and Pediatrics, University of Washington School of Medicine, Seattle (E.V.K.); Department of Cardiology, Boston Children’s Hospital and Department of Pediatrics, Harvard Medical School, Boston, MA (A.M.V.); and Cardiovascular Division, Brigham and Women’s Hospital and Department of Medicine, Harvard Medical School, Boston, MA (A.M.V.)
| | - Anne Marie Valente
- From the Division of Cardiology, Departments of Medicine and Pediatrics, University of Washington School of Medicine, Seattle (E.V.K.); Department of Cardiology, Boston Children’s Hospital and Department of Pediatrics, Harvard Medical School, Boston, MA (A.M.V.); and Cardiovascular Division, Brigham and Women’s Hospital and Department of Medicine, Harvard Medical School, Boston, MA (A.M.V.)
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Krieger EV, Leary PJ, Opotowsky AR. Pulmonary Hypertension in Congenital Heart Disease: Beyond Eisenmenger Syndrome. Cardiol Clin 2015; 33:599-609, ix. [PMID: 26471823 DOI: 10.1016/j.ccl.2015.07.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Patients with adult congenital heart disease have an increased risk of developing pulmonary hypertension. There are several mechanisms of pulmonary hypertension in patients with adult congenital heart disease, and understanding them requires a systematic approach to define the patient's hemodynamics and physiology. This article reviews the updated classification of pulmonary hypertension in patients with adult congenital heart disease with a focus on pathophysiology, diagnostics, and the evaluation of pulmonary hypertension in special adult congenital heart disease populations.
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Affiliation(s)
- Eric V Krieger
- Seattle Adult Congenital Heart Service, Division of Cardiology, Department of Medicine, University of Washington School of Medicine, 1959 Northeast Pacific Street, Seattle, WA 98195, USA.
| | - Peter J Leary
- Pulmonary Vascular Disease Program, Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, 1959 Northeast Pacific Street, Seattle, WA 98195, USA
| | - Alexander R Opotowsky
- Boston Adult Congenital Heart and Pulmonary Hypertension Service, Department of Cardiology, Boston Children's Hospital and Brigham and Women's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
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Opotowsky AR, Moko LE, Ginns J, Rosenbaum M, Greutmann M, Aboulhosn J, Hageman A, Kim Y, Deng LX, Grewal J, Zaidi AN, Almansoori G, Oechslin E, Earing M, Landzberg MJ, Singh MN, Wu F, Vaidya A. Pheochromocytoma and paraganglioma in cyanotic congenital heart disease. J Clin Endocrinol Metab 2015; 100:1325-34. [PMID: 25581599 PMCID: PMC4399286 DOI: 10.1210/jc.2014-3863] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
CONTEXT Aberrant cellular oxygen sensing is a leading theory for development of pheochromocytoma (PHEO) and paraganglioma (PGL). OBJECTIVE The objective of the study was to test the hypothesis that chronic hypoxia in patients with cyanotic congenital heart disease (CCHD) increases the risk for PHEO-PGL. DESIGN/SETTING/PARTICIPANTS We investigated the association between CCHD and PHEO-PGL with two complementary studies: study 1) an international consortium was established to identify congenital heart disease (CHD) patients with a PHEO-PGL diagnosis confirmed by pathology or biochemistry and imaging; study 2) the 2000-2009 Nationwide Inpatient Survey, a nationally representative discharge database, was used to determine population-based cross-sectional PHEO-PGL frequency in hospitalized CCHD patients compared with noncyanotic CHD and those without CHD using multivariable logistic regression adjusted for age, sex, and genetic PHEO-PGL syndromes. RESULTS In study 1, we identified 20 PHEO-PGL cases, of which 18 had CCHD. Most presented with cardiovascular or psychiatric symptoms. Median cyanosis duration for the CCHD PHEO-PGL cases was 20 years (range 1-57 y). Cases were young at diagnosis (median 31.5 y, range 15-57 y) and 7 of 18 had multiple tumors (two bilateral PHEO; six multifocal or recurrent PGL), whereas 11 had single tumors (seven PHEO; four PGL). PGLs were abdominal (13 of 17) or head/neck (4 of 17). Cases displayed a noradrenergic biochemical phenotype similar to reported hypoxia-related PHEO-PGL genetic syndromes but without clinical signs of such syndromes. In study 2, hospitalized CCHD patients had an increased likelihood of PHEO-PGL (adjusted odds ratio 6.0, 95% confidence interval 2.6-13.7, P < .0001) compared with those without CHD; patients with noncyanotic CHD had no increased risk (odds ratio 0.9, P = .48). CONCLUSIONS There is a strong link between CCHD and PHEO-PGL. Whether these rare diseases coassociate due to hypoxic stress, common genetic or developmental factors, or some combination requires further investigation.
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Affiliation(s)
- Alexander R Opotowsky
- Department of Cardiology (A.R.O., L.E.M., M.J.L., M.N.S., F.W.), Boston Children's Hospital, Boston, Massachusetts 02115; Division of Cardiovascular Medicine, (A.R.O., M.J.L., M.N.S., F.W.), Division of Endocrinology (A.V.), Diabetes, and Hypertension, Brigham and Women's Hospital, Boston, Massachusetts 02115; Department of Medicine (J.Gi., M.R.), Columbia University Medical Center, New York, New York 10027; Adult Congenital Heart Disease Program (M.G.), University Hospital Zurich, CH-8032 Zurich, Switzerland; Department of Medicine (J.A.,A.H.), Division of Cardiology, University of California, Los Angeles, Medical Center, Ahmanson/UCLA Adult Congenital Heart Disease Center, Los Angeles, California 90095; Department of Cardiology (Y.K., L.X.D.), The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104; Department of Medicine (Y.K., L.X.D.), Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania 19104; Division of Cardiology (J.Gr.), St Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada V5Z 4H4; The Heart Center (A.N.Z.), Nationwide Children's Hospital, Columbus, Ohio 43205; Department of Internal Medicine (A.N.Z.), The Ohio State University Wexner Medical Center, Columbus, Ohio 43210; Department of Medicine (G.A., E.O.), University Health Network and University of Toronto, Toronto, Ontario, CanadaM5G2C4; Department of Pediatrics (M.E.), Medical College of Wisconsin, Milwaukee, Wisconsin 53226; Center for Adrenal Disorders (A.V.), Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Boston, Massachusetts 02115
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Update on the challenges facing the adult with congenital heart disease community: for both the patient and provider. Curr Opin Pediatr 2014; 26:521-6. [PMID: 25102108 DOI: 10.1097/mop.0000000000000134] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The success in the management of congenital heart disease has resulted in a growing population now expected to reach adulthood. The declining mortality during childhood results in adults with decades of cardiovascular disease burden. The purpose of this review is to provide an update on some of the common issues encountered when caring for the adult with congenital heart disease through a review of recently published articles. RECENT FINDINGS This review focuses on addressing the lack of information, gaps in clinical care, single ventricle complications, and heart failure in the adults with congenital heart disease population. SUMMARY The advancing age of the congenital heart population comes with a substantial life cardiovascular risk. Despite this, they typically experience and report a good quality of life. Providing care to adults with congenital heart disease requires a comprehensive team to address the many complications that are known to arise. This comprehensive team should be available to all.
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