Bicuspid aortic valve supporting supravalvular "substrate" for multiple ventricular tachycardias

Brazilian Guideline for Exercise Testing in Children and Adolescents - 2024

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Bicuspid Aortic Valve, from the Unknown till the Perfection of the Species

The bicuspid aortic valve (BAV) is the most common congenital cardiac abnormality. Though most often isolated, BAV may be associated with other cardiovascular malformations. BAV-related aortopathy is the most common, sharing genetic alterations and phenotypic heterogeneity characteristics. Sometimes silent for a lifetime, BAV may manifest as aortic valve dysfunction, aortic aneurysm, or more emergent situations, such as endocarditis or aortic dissection. Its embryological origin and the characterization of the genes involved, as well as the histopathological and hemodynamic aspects of its natural history, are becoming increasingly clear. In addition, emerging evidence of rhythm disorders associated with BAV has been identified. A new international nomenclature and classification has been introduced to interpret all the advances made in recent years for the comprehension of this condition. In the guidelines, more attention has been paid to the diagnosis of BAV and related aortopathy, together with surveillance, and family screening. Surgical treatment remains the gold standard, especially in young low-risk patients, and valve repair techniques have been shown to be effective and durable. Finally, the new era of transcatheter techniques is also being applied to dysfunctional BAV, allowing the treatment of patients at high surgical risk, with increasingly promising results, and the possibility of expanding indications through the introduction of more advanced devices. This review aims to comprehensively describe the BAV conundrum, focusing on anatomy, pathophysiology, genetics, diagnosis of BAV-related disorders, and the different treatment options available in the transcatheter era.

Arrhythmias in Patients With Valvular Heart Disease: Gaps in Knowledge and the Way Forward

The prevalence of both organic valvular heart disease (VHD) and cardiac arrhythmias is high in the general population, and their coexistence is common. Both VHD and arrhythmias in the elderly lead to an elevated risk of hospitalization and use of health services. However, the relationships of the two conditions is not fully understood and our understanding of their coexistence in terms of contemporary management and prognosis is still limited. VHD-induced left ventricular dysfunction/hypertrophy and left atrial dilation lead to both atrial and ventricular arrhythmias. On the other hand, arrhythmias can be considered as an independent condition resulting from a coexisting ischemic or non-ischemic substrate or idiopathic ectopy. Both atrial and ventricular VHD-induced arrhythmias may contribute to clinical worsening and be a turning point in the natural history of VHD. Symptoms developed in patients with VHD are not specific and may be attributable to hemodynamical consequences of valve disease but also to other cardiac conditions including arrhythmias which are notably prevalent in this population. The issue how to distinguish symptoms related to VHD from those related to atrial fibrillation (AF) during decision making process remains challenging. Moreover, AF is a traditional limit of echocardiography and an important source of errors in assessment of the severity of VHD. Despite recent progress in understanding the pathophysiology and prognosis of postoperative AF, many questions remain regarding its prevention and management. Furthermore, life-threatening ventricular arrhythmias can predispose patients with VHD to sudden cardiac death. Evidence for a putative link between arrhythmias and outcome in VHD is growing but available data on targeted therapies for VHD-related arrhythmias, including monitoring and catheter ablation, is scarce. Despite growing evidences, more research focused on the prognosis and optimal management of VHD-related arrhythmias is still required. We aimed to review the current evidence and identify gaps in knowledge about the prevalence, prognostic considerations, and treatment of atrial and ventricular arrhythmias in common subtypes of organic VHD.

Intracardiac Echocardiography to Guide Mapping and Ablation of Arrhythmias in Patients with Congenital Heart Disease

Catheter ablation of arrhythmias in congenital heart disease can be a challenging undertaking with often complicated anatomic considerations. Understanding this anatomy and the prior surgical repairs is key to procedural planning and a successful outcome. Intracardiac echocardiography (ICE) adds complimentary real-time visualization of anatomy and catheter positioning along with other imaging modalities. In addition, ICE can visualize suture lines, baffles, and conduits from repaired congenital heart disease and forms a useful part of the toolkit required to deal with these complex arrhythmias.

Retrograde aortic access during ventricular tachycardia ablation: Indications, techniques, and challenges

The retrograde aortic (RA) route is a widely used access route for mapping and ablation of ventricular tachycardias (VT) arising from the left ventricular endocardium. With the expanding role of VT ablation in patients with significant comorbidity, the choice between the RA and transseptal access routes is an increasingly important consideration. An individualized decision based on the location of the arrhythmogenic substrate, vascular anatomy, aortic valve morphology, and operator experience is necessary when deciding on the optimal access route. Among patients with challenging vascular anatomy, growing experience from structural interventions such as transcatheter aortic valve replacements and peripheral vascular interventions has provided valuable insights into techniques for safe retrograde access. The present review focuses on patient selection for RA access, potential complications associated with the technique, and optimal approaches for access in patients with challenging vascular or aortic valve anatomy.

Sudden Cardiac Deaths in Adults with Congenital Heart Disease with Structural Abnormalities: A Retrospective Review of Cases in the Cook County Medical Examiner's Office

Sudden cardiac death is a significant cause of mortality in adults with congenital heart disease (CHD). The Cook County Medical Examiner's Office database was queried for cases of CHD as a cause of death in the period between July 2008 and April 2019. Twenty-two cases were identified, including 11 decedents with simple defects and 10 decedents with complex defects. All of the subjects were in apparent good health at the time of death. In the absence of other obvious causes of death, simple defects were considered cases of sudden cardiac death. Significant cardiac morphological changes were common in complex defects. While 16 cases had known, diagnosed/treated CHD, 5 cases had no diagnosis prior to autopsy. In these cases, the ability to recognize CHD (sometimes subtle) helped in determining the causes of death. Therefore, forensic pathologists must be able to properly recognize various forms of CHD and request consultations, when needed.