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Leczycki P, Banach M, Maciejewski M, Bielecka-Dabrowa A. Heart Failure Risk Predictions and Prognostic Factors in Adults With Congenital Heart Diseases. Front Cardiovasc Med 2022; 9:692815. [PMID: 35282364 PMCID: PMC8907450 DOI: 10.3389/fcvm.2022.692815] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 01/31/2022] [Indexed: 11/30/2022] Open
Abstract
In recent decades the number of adults with congenital heart diseases (ACHD) has increased significantly. This entails the need for scrupulous evaluation of the current condition of these patients. The ACHD population is one of the most challenging in contemporary medicine, especially as well-known scales such as the NYHA classification have very limited application. At the moment, there is a lack of universal parameters or scales on the basis of which we can easily capture the moment of deterioration of our ACHD patients' condition. Hence it is crucial to identify factors that are widely available, cheap and easy to use. There are studies showing more and more potential prognostic factors that may be of use in clinical practice: thorough assessment with echocardiography and magnetic resonance imaging (e.g., anatomy, ventricular function, longitudinal strain, shunt lesions, valvular defects, pericardial effusion, and pulmonary hypertension), cardiopulmonary exercise testing (e.g., peak oxygen uptake, ventilatory efficiency, chronotropic incompetence, and saturation) and biomarkers (e.g., N-terminal pro-brain type natriuretic peptide, growth-differentiation factor 15, high-sensitivity troponin T, red cell distribution width, galectin-3, angiopoietin-2, asymmetrical dimethylarginine, and high-sensitivity C-reactive protein). Some of them are very promising, but more research is needed to create a specific panel on the basis of which we will be able to assess patients with specific congenital heart diseases.
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Affiliation(s)
- Patryk Leczycki
- Department of Cardiology and Congenital Diseases of Adults, Polish Mother's Memorial Hospital Research Institute, Łodź, Poland
- *Correspondence: Patryk Leczycki
| | - Maciej Banach
- Department of Cardiology and Congenital Diseases of Adults, Polish Mother's Memorial Hospital Research Institute, Łodź, Poland
- Department of Preventive Cardiology and Lipidology, Medical University of Lodz, Łodź, Poland
| | - Marek Maciejewski
- Department of Cardiology and Congenital Diseases of Adults, Polish Mother's Memorial Hospital Research Institute, Łodź, Poland
| | - Agata Bielecka-Dabrowa
- Department of Cardiology and Congenital Diseases of Adults, Polish Mother's Memorial Hospital Research Institute, Łodź, Poland
- Department of Preventive Cardiology and Lipidology, Medical University of Lodz, Łodź, Poland
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2
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Ferrari I, Shehu N, Nagdyman N, Martinoff S, Ewert P, Stern H, Meierhofer C. Improved Tricuspid Valve Function, Preload Recruitment and Ventricular Efficiency During Submaximal Exercise in Patients with Unoperated Ebstein's Anomaly: An MRI Study. J Magn Reson Imaging 2021; 55:1843-1850. [PMID: 34652053 DOI: 10.1002/jmri.27945] [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: 07/05/2021] [Revised: 09/23/2021] [Accepted: 09/23/2021] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Adolescents and adults with native Ebstein's anomaly (EA) are at the benign part of the Ebstein spectrum, having survived infancy without surgery. In this population, surgical indication and timing remain objects of controversy and depend, among other factors, on exercise capacity. PURPOSE To better understand the pathophysiology of exercise adaptation in native EA. STUDY TYPE Retrospective. POPULATION Ten patients with unoperated EA (age range 18-61 years) and 13 healthy subjects as controls. FIELD STRENGTH/SEQUENCE Balanced steady-state free precession cine and phase contrast flow sequences at 1.5 T. ASSESSMENT We measured volumes and flows at rest and during submaximal exercise. Hemodynamic parameters including stroke volume (SV), cardiac index (CI), ejection fraction (EF), and tricuspid regurgitation (TR) were calculated. STATISTICAL TESTS We used nonparametric Mann-Whitney U-test and Wilcoxon signed-rank test. A P-value of <0.05 was considered statistically significant. RESULTS Rest CI and SV were significantly higher in controls; rest heart rate (HR) was similar in the two groups (median 71 bpm by patients and 65 bpm by controls, P = 0.448). During exercise, CI increased significantly in both groups: from 2.40 to 3.35 L/min/m2 in the patient group and from 3.60 to 4.20 L/min/m2 in controls; HR increased significantly in both groups. SV increased significantly in the patient group, whereas it remained stable in controls (P = 0.5284). Patients' median TR decreased significantly: median 42% at rest and 30% during exercise; concomitantly, left ventricular (LV) preload increased significantly (+3% indexed LV end-diastolic volume) as did LVEF (median 59% at rest vs. 65% during exercise). DATA CONCLUSION During submaximal exercise, patients with mild to moderate EA improved their cardiovascular system's total efficiency by increasing CI; this was obtained by an increase in HR and by the recruitment of volume, as shown by an increased LV end-diastolic volume and SV, with simultaneous decrease in TR. This was different from healthy subjects in which CI increased only due to HR increase. LEVEL OF EVIDENCE 3 TECHNICAL EFFICACY STAGE: 3.
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Affiliation(s)
- Irene Ferrari
- Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Nerejda Shehu
- Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Nicole Nagdyman
- Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Stefan Martinoff
- Radiology German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Peter Ewert
- Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Heiko Stern
- Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Christian Meierhofer
- Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technical University of Munich, Munich, Germany
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3
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Wadey CA, Weston ME, Dorobantu DM, Pieles GE, Stuart G, Barker AR, Taylor RS, Williams CA. The role of cardiopulmonary exercise testing in predicting mortality and morbidity in people with congenital heart disease: a systematic review and meta-analysis. Eur J Prev Cardiol 2021; 29:513-533. [PMID: 34405863 DOI: 10.1093/eurjpc/zwab125] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 06/10/2021] [Indexed: 12/16/2022]
Abstract
AIMS The role of cardiopulmonary exercise testing (CPET) in predicting major adverse cardiovascular events (MACE) in people with congenital heart disease (ConHD) is unknown. A systematic review with meta-analysis was conducted to report the associations between CPET parameters and MACE in people with ConHD. METHODS AND RESULTS Electronic databases were systematically searched on 30 April 2020 for eligible publications. Two authors independently screened publications for inclusion, extracted study data, and performed risk of bias assessment. Primary meta-analysis pooled univariate hazard ratios across studies. A total of 34 studies (18 335 participants; 26.2 ± 10.1 years; 54% ± 16% male) were pooled into a meta-analysis. More than 20 different CPET prognostic factors were reported across 6 ConHD types. Of the 34 studies included in the meta-analysis, 10 (29%), 23 (68%), and 1 (3%) were judged as a low, medium, and high risk of bias, respectively. Primary univariate meta-analysis showed consistent evidence that improved peak and submaximal CPET measures are associated with a reduce risk of MACE. This association was supported by a secondary meta-analysis of multivariate estimates and individual studies that could not be numerically pooled. CONCLUSION Various maximal and submaximal CPET measures are prognostic of MACE across a variety of ConHD diagnoses. Further well-conducted prospective multicentre cohort studies are needed to confirm these findings.
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Affiliation(s)
- Curtis A Wadey
- Children's Health & Exercise Research Centre (CHERC), College of Life and Environmental Sciences, St. Luke's Campus, University of Exeter, Heavitree Road, Exeter EX1 2LU, UK
| | - Max E Weston
- Children's Health & Exercise Research Centre (CHERC), College of Life and Environmental Sciences, St. Luke's Campus, University of Exeter, Heavitree Road, Exeter EX1 2LU, UK.,School of Human Movement and Nutrition Sciences, Human Movement Studies Building, University of Queensland, QLD 4067, Brisbane, Australia
| | - Dan Mihai Dorobantu
- Children's Health & Exercise Research Centre (CHERC), College of Life and Environmental Sciences, St. Luke's Campus, University of Exeter, Heavitree Road, Exeter EX1 2LU, UK.,School of Population Health Sciences, University of Bristol, BS8 1QU, Bristol, UK
| | - Guido E Pieles
- National Institute for Health Research (NIHR) Cardiovascular Biomedical Research Centre, Bristol Heart Institute, Terrell St, BS2 8ED, Bristol, UK.,Bristol Congenital Heart Centre, The Bristol Heart Institute, University Hospitals Bristol NHS Foundation Trust, Upper Maudlin Street, BS2 8HW, Bristol, UK.,Institute of Sport Exercise and Health (ISEH), University College London, 170 Tottenham Court Rd, W1T 7HA, London, UK
| | - Graham Stuart
- National Institute for Health Research (NIHR) Cardiovascular Biomedical Research Centre, Bristol Heart Institute, Terrell St, BS2 8ED, Bristol, UK.,Bristol Congenital Heart Centre, The Bristol Heart Institute, University Hospitals Bristol NHS Foundation Trust, Upper Maudlin Street, BS2 8HW, Bristol, UK
| | - Alan R Barker
- Children's Health & Exercise Research Centre (CHERC), College of Life and Environmental Sciences, St. Luke's Campus, University of Exeter, Heavitree Road, Exeter EX1 2LU, UK
| | - Rod S Taylor
- MRC/CSO Social and Public Health Sciences Unit & Robertson Centre for Biostatistics, Institute of Health and Well Being, University of Glasgow, 99 Berkeley Street, G3 7HR, Glasgow, UK
| | - Craig A Williams
- Children's Health & Exercise Research Centre (CHERC), College of Life and Environmental Sciences, St. Luke's Campus, University of Exeter, Heavitree Road, Exeter EX1 2LU, UK
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Abstract
As the population of adult congenital heart disease patients ages and grows, so too does the burden of heart failure in this population. Despite the advances in medical and surgical therapies over the last decades, heart failure in adult congenital heart disease remains a formidable complication with high morbidity and mortality. This review focuses on the challenges in determining the true burden and management of heart failure in adult congenital heart disease. There is a particular focus on the need for developing a common language for classifying and reporting heart failure in adult congenital heart disease, the clinical presentation and prognostication of heart failure in adult congenital heart disease, the application of hemodynamic evaluation, and advanced heart failure treatment. A common case study of heart failure in adult congenital heart disease is utilized to illustrate these key concepts.
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Affiliation(s)
- Luke J Burchill
- Department of Cardiology, The Royal Melbourne Hospital, Grattan Street, Parkville, Melbourne, VIC 3050, Australia; Department of Medicine, The University of Melbourne, Melbourne, Australia.
| | - Melissa G Y Lee
- Department of Cardiology, The Royal Melbourne Hospital, Grattan Street, Parkville, Melbourne, VIC 3050, Australia; Heart Research, Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Australia; Department of Paediatrics, The University of Melbourne, Melbourne, Australia
| | - Vidang P Nguyen
- Department of Cardiology, Cedars-Sinai Heart Institute, 127 S San Vicente Boulevard a3600, Los Angeles, CA 90048, USA
| | - Karen K Stout
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, WA 98195, USA
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5
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Abstract
Ebstein anomaly comprises approximately 1% of all congenital heart diseases. It occurs when the tricuspid valve fails to properly delaminate from the right ventricle, resulting in a clinical spectrum of abnormal tricuspid valve morphology and right ventricular dysfunction. Due to the anatomy of the tricuspid valve and right ventricle, as well as associated right- and left-sided pathology, patients are at risk for both right and left ventricular failure and the associated symptoms of each. Ebstein patients are also at risk for atrial arrhythmias, due to the atrial enlargement intrinsic to the anatomy, as well as the presence of potential accessory pathways. Arrhythmias are generally poorly tolerated, particularly in the setting of ventricular dysfunction. Cyanosis may also be present in Ebstein patients, due to the common occurrence of atrial communications, which can exacerbate other symptoms of heart failure. Treatment of heart failure can be through pharmacologic and procedural interventions, depending on the underlying cause of heart failure. While early heart failure symptoms may be treated with medical management, most Ebstein patients will require surgery. Various surgical and catheter-based interventions targeting the tricuspid valve and the atrialized right ventricular tissue have been developed to help treat the underlying cause of the heart failure. The optimal timing of transcatheter and surgical intervention in the Ebstein patient to prevent or treat heart failure needs further study.
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Affiliation(s)
- Karen Schultz
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, 870 Quarry Road - Falk CVRC, Stanford, CA, 94305-5406, USA.
| | - Christiane L Haeffele
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, 870 Quarry Road - Falk CVRC, Stanford, CA, 94305-5406, USA
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6
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Cieplucha A, Trojnarska O, Bartczak-Rutkowska A, Kociemba A, Rajewska-Tabor J, Kramer L, Pyda M. Severity Scores for Ebstein Anomaly: Credibility and Usefulness of Echocardiographic vs Magnetic Resonance Assessments of the Celermajer Index. Can J Cardiol 2019; 35:1834-1841. [DOI: 10.1016/j.cjca.2019.08.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 07/28/2019] [Accepted: 08/07/2019] [Indexed: 12/28/2022] Open
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7
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Right Ventricular Diastolic Function and Right Atrial Function and Their Relation With Exercise Capacity in Ebstein Anomaly. Can J Cardiol 2019; 35:1824-1833. [DOI: 10.1016/j.cjca.2019.05.036] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 05/24/2019] [Accepted: 05/31/2019] [Indexed: 11/17/2022] Open
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8
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Rajpal S, Alshawabkeh L, Almaddah N, Joyce CM, Shafer K, Gurvitz M, Waikar SS, Mc Causland FR, Landzberg MJ, Opotowsky AR. Association of Albuminuria With Major Adverse Outcomes in Adults With Congenital Heart Disease: Results From the Boston Adult Congenital Heart Biobank. JAMA Cardiol 2019. [PMID: 29541749 DOI: 10.1001/jamacardio.2018.0125] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Importance Albuminuria is associated with adverse outcomes in diverse groups of patients, but the importance of albuminuria in the emerging population of increasingly complex adults with congenital heart disease (ACHD) remains unknown. Objective To assess the prevalence, risk factors, and prognostic implications of albuminuria in ACHD. Design, Setting, and Participants This prospective study assessed a cohort of ambulatory patients aged 18 years and older who were examined at an ACHD referral center and enrolled in the Boston ACHD Biobank between May 17, 2012, to August 5, 2016. Albuminuria was defined as an urine albumin-to-creatinine (ACR) ratio of 30 mg/g or more. Main Outcomes and Measures Death or nonelective cardiovascular hospitalization, defined as overnight admission for heart failure, arrhythmia, thromboembolic events, cerebral hemorrhage, and/or disease-specific events. Results We measured the ACR of 612 adult patients with CHD (mean [SD] age, 38.6 [13.4] years; 308 [50.3%] women). Albuminuria was present in 106 people (17.3%) and was associated with older age (patients with ACR <30 mg/g: mean [SD]: 37.5 [13.2] years; vs patients with ACR ≥30 mg/g: 43.8 [13.1] years; P < .001), presence of diabetes mellitus (ACR <30 mg/g: 13 of 506 [2.6%]; vs ≥30 mg/g: 11 of 106 [10.4%]; P < .001), lower estimated glomerular filtration rate (ACR <30 mg/g: median [interquartile range (IQR)]: 103.3 [90.0-116.4] mL/min/1.73 m2; ACR ≥30 mg/g: 99.1 [78.8-108.7] mL/min/1.73 m2; P = .002), and cyanosis (ACR <30 mg/g: 23 of 506 [5.1%]; vs ACR ≥30 mg/g: 21 of 106 [22.6%]; P < .001). After a mean (SD) follow-up time of 270 (288) days, 17 patients (2.5%) died, while 68 (11.1%) either died or experienced overnight inpatient admission. Albuminuria predicted outcome, with 30 of 106 patients with albuminuria (28.3%) affected vs 38 of 506 patients without albuminuria (7.5%; hazard ratio [HR], 3.0; 95% CI, 1.9-4.9; P < .001). Albuminuria was also associated with increased mortality (11 of 106 [10.4%]; vs 6 of 506 [1.2%] in patients with and without albuminuria, respectively; HR, 6.4; 95% CI, 2.4-17.3; P < .001). Albuminuria was associated with the outcomes only in patients with a biventricular circulation (HR, 4.5; 95% CI, 2.5-8.0) and not those with single-ventricle circulation (HR, 1.0; 95% CI, 0.4-2.8; P = 0.01 compared with biventricular circulation group). Among 133 patients (21.7%) in NYHA functional class 2, albuminuria was strongly associated with death or nonelective hospitalization. Conclusions and Relevance Albuminuria is common and is associated with increased risk for adverse outcome in patients with ACHD with biventricular circulation. Albuminuria appears especially useful in stratifying risk in patients categorized as NYHA functional class 2.
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Affiliation(s)
- Saurabh Rajpal
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts.,Department of Cardiology, Nationwide Children's Hospital, Columbus, Ohio.,Department of Medicine, Ohio State University, Columbus
| | - Laith Alshawabkeh
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts.,Division of Cardiovascular Medicine, Department of Medicine, University of California, San Diego
| | - Nureddin Almaddah
- Department of Medicine, North Shore Medical Center, Salem, Massachusetts
| | - Caroline M Joyce
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Keri Shafer
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Michelle Gurvitz
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Sushrut S Waikar
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | | | - Michael J Landzberg
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Alexander R Opotowsky
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
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9
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Buber J, Shafer K. Cardiopulmonary exercise testing and sports participation in adults with congenital heart disease. Heart 2019; 105:1670-1679. [PMID: 31273028 DOI: 10.1136/heartjnl-2018-313928] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 04/29/2019] [Accepted: 05/27/2019] [Indexed: 11/04/2022] Open
Affiliation(s)
- Jonathan Buber
- Department of Medicine, Division of Cardiology, University of Washington School of Medicine, Seattle, Washington, USA
| | - Keri Shafer
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA.,Division of Cardiology, Brigham and Women's Hospital, Boston, MA, United Startes of America
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10
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Non-invasive Hemodynamic CMR Parameters Predicting Maximal Exercise Capacity in 54 Patients with Ebstein's Anomaly. Pediatr Cardiol 2019; 40:792-798. [PMID: 30726509 DOI: 10.1007/s00246-019-02066-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 01/29/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Exercise capacity is a well-defined marker of outcome in congenital heart disease. We analyzed seventeen cardiovascular magnetic resonance (CMR) derived parameters and their correlation to exercise capacity in patients with Ebstein's anomaly (EA). METHODS Fifty-four surgery free patients, age 5 to 69 years (median 30 years) prospectively underwent CMR examination and cardiopulmonary exercise testing (CPET). The following volume/flow parameters were compared with peak oxygen uptake as the percentage of normal (peakVO2%) using univariate and multivariate analysis: right and left ventricular ejection fraction (RVEF and LVEF), the indexed end-diastolic and end-systolic volumes (RVEDVi, RVESVi, LVEDVi, and LVESVi), the indexed stroke volumes (RVSVi and LVSVi), the total normalized right and left heart volumes; the total right to left heart volume ratio (R/L-ratio). The indexed antegrade flow (ante), indexed net flow (net) as well as cardiac index (CI) in the aorta (Ao) and pulmonary artery (PA) were used. RESULTS RVEF (R2 0.2788), indexed flow PA net (R2 0.2330), and PA ante (R2 0.1912) showed the best correlation with peakVO2% (all p < 0.001) in the univariate model. Further significant correlation could also be demonstrated with CI-PA, LVEF, LVSVi, Aorta net, RVESVi, and Aorta ante. Multivariate analysis for RVEF and indexed net flow PA revealed a R2 of 0.4350. CONCLUSION Functional CMR parameters as RVEF and LVEF and flow data of cardiac forward flow correlate to peakVO2%. Evaluation of the indexed net flow in the pulmonary artery and the overall function of the right ventricle best predicts the maximal exercise capacity in patients with EA.
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11
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Rutz T, Kühn A. The challenge of risk stratification in Ebstein's anomaly. Int J Cardiol 2019; 278:89-90. [PMID: 30554929 DOI: 10.1016/j.ijcard.2018.12.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 12/04/2018] [Indexed: 10/27/2022]
Affiliation(s)
- Tobias Rutz
- Service of Cardiology, Heart and Vessel Department, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.
| | - Andreas Kühn
- Department of Paediatric Cardiology and Congenital Heart Disease, Deutsches Herzzentrum München an der Technischen Universität München, Munich, Germany
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12
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Prota C, Di Salvo G, Sabatino J, Josen M, Paredes J, Sirico D, Pernia MU, Hoschtitzky A, Michielon G, Citro R, Fraisse A, Ghez O. Prognostic value of echocardiographic parameters in pediatric patients with Ebstein's anomaly. Int J Cardiol 2018; 278:76-83. [PMID: 30686335 DOI: 10.1016/j.ijcard.2018.10.046] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 09/12/2018] [Accepted: 10/12/2018] [Indexed: 01/04/2023]
Abstract
BACKGROUND Accurate risk stratification of patients with Ebstein's anomaly (EA) is crucial. Aim of the study was to assess the prognostic value of echocardiography, including 2D speckle tracking (STE) derived myocardial deformation indices, for predicting outcome in pediatric and young adult unrepaired EA patients. METHODS Fifty consecutive EA patients (1 day-18 years, 52% males) underwent echocardiography and were followed for a mean follow-up of 60 ± 41 months for clinical outcome (ventricular tachyarrhythmia, heart failure, need for surgery and/or death). Clinical and instrumental features of EA patients with stable disease were compared with those of EA patients with progressive disease. RESULTS Twenty-four (48%) EA patients had progressive disease. A more severe grade of tricuspid valve (TV) displacement [59.7 mm/m2 (IQR 27.5-83) vs 28.4 mm/m2 (IQR 17.5-47); p = 0.002], a lower functional right ventricle (RV) fractional area change (FAC) (29.2 ± 7.7% vs 36.7 ± 9.6%; p = 0.004), a higher Celermajer index [0.8 (IQR 0.7-0.98) vs 0.55 (IQR 0.4-0.7); p = 0.000], a lower functional RV-longitudinal strain (-10.2 ± 6.2% vs -16.2 ± 7.3%; p = 0.003) and a lower right atrium peak systolic strain (RA-PALS) (25.2 ± 13.5% vs 36.3 ± 12.5%; p = 0.004) were detected in progressive disease group compared to stable one, respectively. Functional RV-FAC and RA-PALS were independent predictors of progressive disease at multivariate analysis. CONCLUSION Our study demonstrated for the first time the prognostic role of RV-FAC and RA-PALS in a long-term follow-up of EA young patients. A complete echocardiographic evaluation should be regular part in the evaluation and risk-stratification of EA children.
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Affiliation(s)
- Costantina Prota
- Paediatric Cardiology, Royal Brompton Hospital, London, United Kingdom; Heart Department, University Hospital San Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy
| | - Giovanni Di Salvo
- Paediatric Cardiology, Royal Brompton Hospital, London, United Kingdom.
| | - Jolanda Sabatino
- Paediatric Cardiology, Royal Brompton Hospital, London, United Kingdom
| | - Manjit Josen
- Paediatric Cardiology, Royal Brompton Hospital, London, United Kingdom
| | - Josefa Paredes
- Paediatric Cardiology, Royal Brompton Hospital, London, United Kingdom
| | - Domenico Sirico
- Paediatric Cardiology, Royal Brompton Hospital, London, United Kingdom
| | - Marisol Uy Pernia
- Paediatric Cardiology, Royal Brompton Hospital, London, United Kingdom
| | | | - Guido Michielon
- Paediatric Cardiology, Royal Brompton Hospital, London, United Kingdom
| | - Rodolfo Citro
- Heart Department, University Hospital San Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy
| | - Alain Fraisse
- Paediatric Cardiology, Royal Brompton Hospital, London, United Kingdom
| | - Olivier Ghez
- Paediatric Cardiology, Royal Brompton Hospital, London, United Kingdom
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Rydman R, Shiina Y, Diller GP, Niwa K, Li W, Uemura H, Uebing A, Barbero U, Bouzas B, Ernst S, Wong T, Pennell DJ, Gatzoulis MA, Babu-Narayan SV. Major adverse events and atrial tachycardia in Ebstein's anomaly predicted by cardiovascular magnetic resonance. Heart 2017; 104:37-44. [PMID: 28684436 PMCID: PMC5749347 DOI: 10.1136/heartjnl-2017-311274] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 05/26/2017] [Accepted: 05/26/2017] [Indexed: 11/17/2022] Open
Abstract
Objectives Patients with Ebstein’s anomaly of the tricuspid valve (EA) are at risk of tachyarrhythmia, congestive heart failure and sudden cardiac death. We sought to determine the value of cardiovascular magnetic resonance (CMR) for predicting these outcomes. Methods Seventy-nine consecutive adult patients (aged 37±15 years) with unrepaired EA underwent CMR and were followed prospectively for a median 3.4 (range 0.4–10.9) years for clinical outcomes, namely major adverse cardiovascular events (MACEs: sustained ventricular tachycardia/heart failure hospital admission/cardiac transplantation/death) and first-onset atrial tachyarrhythmia (AT). Results CMR-derived variables associated with MACE (n=6) were right ventricular (RV) or left ventricular (LV) ejection fraction (EF) (HR 2.06, 95% CI 1.168 to 3.623, p=0.012 and HR 2.35, 95% CI 1.348 to 4.082, p=0.003, respectively), LV stroke volume index (HR 2.82, 95% CI 1.212 to 7.092, p=0.028) and cardiac index (HR 1.71, 95% CI 1.002 to 1.366, p=0.037); all remained significant when tested solely for mortality. History of AT (HR 11.16, 95% CI 1.30 to 95.81, p=0.028) and New York Heart Association class >2 (HR 7.66, 95% CI 1.54 to 38.20, p=0.013) were also associated with MACE; AT preceded all but one MACE, suggesting its potential role as an early marker of adverse outcome (p=0.011). CMR variables associated with first-onset AT (n=17; 21.5%) included RVEF (HR 1.55, 95% CI 1.103 to 2.160, p=0.011), total R/L volume index (HR 1.18, 95% CI 1.06 to 1.32, p=0.002), RV/LV end diastolic volume ratio (HR 1.55, 95% CI 1.14 to 2.10, p=0.005) and apical septal leaflet displacement/total LV septal length (HR 1.03, 95% CI 1.00 to 1.07, p=0.041); the latter two combined enhanced risk prediction (HR 6.12, 95% CI 1.67 to 22.56, p=0.007). Conclusion CMR-derived indices carry prognostic information regarding MACE and first-onset AT among adults with unrepaired EA. CMR may be included in the periodic surveillance of these patients.
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Affiliation(s)
- Riikka Rydman
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, London, England.,Department of Molecular Medicine and Surgery, Section of Clinical Physiology, Karolinska Institutet, Stockholm, Sweden
| | - Yumi Shiina
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, London, England.,Cardiovascular Centre, St. Luke's International Hospital, Tokyo, Japan
| | - Gerhard-Paul Diller
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, London, England.,National Heart and Lung Institute, Imperial College, London, England.,Department of Cardiovascular Medicine, Division of Adult Congenital and Valvular Heart Disease, University Hospital Muenster, Muenster, Germany
| | - Koichiro Niwa
- Cardiovascular Centre, St. Luke's International Hospital, Tokyo, Japan
| | - Wei Li
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, London, England
| | - Hideki Uemura
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, London, England
| | - Anselm Uebing
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, London, England
| | - Umberto Barbero
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, London, England.,Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | - Beatriz Bouzas
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, London, England
| | - Sabine Ernst
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, London, England.,National Heart and Lung Institute, Imperial College, London, England
| | - Tom Wong
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, London, England
| | - Dudley J Pennell
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, London, England.,National Heart and Lung Institute, Imperial College, London, England
| | - Michael A Gatzoulis
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, London, England.,National Heart and Lung Institute, Imperial College, London, England
| | - Sonya V Babu-Narayan
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, London, England.,National Heart and Lung Institute, Imperial College, London, England
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14
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Müller J, Kühn A, Tropschuh A, Hager A, Ewert P, Schreiber C, Vogt M. Exercise performance in Ebstein's anomaly in the course of time - Deterioration in native patients and preserved function after tricuspid valve surgery. Int J Cardiol 2016; 218:79-82. [PMID: 27232916 DOI: 10.1016/j.ijcard.2016.05.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2016] [Revised: 04/25/2016] [Accepted: 05/12/2016] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The purpose of this study was to assess the longitudinal follow-up of exercise performance in patients with native Ebstein anomaly and patients who had received previous tricuspid valve surgery. PATIENTS AND METHODS We identified 59 patients with Ebstein anomaly who had performed at least two cardiopulmonary exercise tests within a minimum of 6months. 22 patients (15 female, 29.0±13.4years) with native conditions, 37 patients (21 female, 32.1±15.3years) had undergone surgery of their tricuspid valve before baseline testing. RESULTS In the non-operated group peak workload (2.58±0.7 to 2.38±0.7W/kg, p=.019) declined during a mean follow-up of 4.6±2.6years, whereas peak workload remained stable in the surgical group (2.02±0.6 to 2.06±0.7W/kg, p=.229) throughout the follow-up of 3.4±2.3years. In the 18 patients who had their surgery less than one year prior to the first CPET the exercise performance even increased during the follow-up. Peak blood pressure as a marker of cardiac adaption to exercise increased in the follow-up examination only in the surgical group (159±23 vs. 171±30mmHg, p=.007). In the non-operated group blood pressure remained unchanged at follow-up (161±26 vs. 166±29, p=.358). CONCLUSION Exercise performance deteriorates in non-operated patients with Ebstein anomaly in contrast to patients after tricuspid valve surgery where exercise performance remains stable. These facts promote a surgical intervention latest at the time when exercise performance decreases.
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Affiliation(s)
- Jan Müller
- Institute of Preventive Pediatrics, Technische Universität München, Munich, Germany; Department of Pediatric Cardiology and Congenital Heart Disease, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany.
| | - Andreas Kühn
- Department of Pediatric Cardiology and Congenital Heart Disease, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Andrea Tropschuh
- Department of Pediatric Cardiology and Congenital Heart Disease, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Alfred Hager
- Department of Pediatric Cardiology and Congenital Heart Disease, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Peter Ewert
- Department of Pediatric Cardiology and Congenital Heart Disease, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Christian Schreiber
- Department of Cardiac Surgery, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Manfred Vogt
- Department of Pediatric Cardiology and Congenital Heart Disease, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany; Kinderherz-Praxis, Leopoldstr. 27, 80802 Munich, Germany
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15
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Ross HJ, Law Y, Book WM, Broberg CS, Burchill L, Cecchin F, Chen JM, Delgado D, Dimopoulos K, Everitt MD, Gatzoulis M, Harris L, Hsu DT, Kuvin JT, Martin CM, Murphy AM, Singh G, Spray TL, Stout KK. Transplantation and Mechanical Circulatory Support in Congenital Heart Disease. Circulation 2016; 133:802-20. [DOI: 10.1161/cir.0000000000000353] [Citation(s) in RCA: 102] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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16
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Stout KK, Broberg CS, Book WM, Cecchin F, Chen JM, Dimopoulos K, Everitt MD, Gatzoulis M, Harris L, Hsu DT, Kuvin JT, Law Y, Martin CM, Murphy AM, Ross HJ, Singh G, Spray TL. Chronic Heart Failure in Congenital Heart Disease. Circulation 2016; 133:770-801. [DOI: 10.1161/cir.0000000000000352] [Citation(s) in RCA: 219] [Impact Index Per Article: 27.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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17
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Kempny A, Diller GP, Dimopoulos K, Alonso-Gonzalez R, Uebing A, Li W, Babu-Narayan S, Swan L, Wort SJ, Gatzoulis MA. Determinants of outpatient clinic attendance amongst adults with congenital heart disease and outcome. Int J Cardiol 2016; 203:245-50. [DOI: 10.1016/j.ijcard.2015.10.081] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Revised: 09/15/2015] [Accepted: 10/12/2015] [Indexed: 10/22/2022]
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18
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Bouzo-López R, González-Represas A. [Assessment of exercise capacity in congenital heart disease]. ARCHIVOS DE CARDIOLOGIA DE MEXICO 2015; 86:51-63. [PMID: 26476482 DOI: 10.1016/j.acmx.2015.08.005] [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: 03/05/2015] [Revised: 08/17/2015] [Accepted: 08/27/2015] [Indexed: 10/22/2022] Open
Abstract
For many years, the treatment of congenital heart diseases has been a field in which, based on the seriousness of these conditions, treatment options were viewed with the greatest deference. This has conditioned, in many cases, the interventions to be undertaken in each. In this sense, exercise was thought to have a negative impact and thus the practise of almost any physical activity was limited. Although there has recently been a change in the paradigm with respect to exercise, this idea continues to hold sway. For many cardiopathies, the information obtained through a stress test is essential in order to implement and supervise an exercise program. The aim of this study is to analyze the parameters within the stress test which allow for an adequate stratification of the risk to subjects with congenital heart diseases who undertake exercise, as well as their values in accordance with the type of pathology, the gravity of such, and the age of the patients. Furthermore, these parameters will be analyzed for both their survival markers and the protocols that can best be adjusted for patients with these characteristic.
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Affiliation(s)
| | - Alicia González-Represas
- Departamento de Biología Funcional y Ciencias de la Salud, Facultad de Fisioterapia, Universidad de Vigo, Vigo, España.
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19
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Ohuchi H, Negishi J, Noritake K, Hayama Y, Sakaguchi H, Miyazaki A, Kagisaki K, Yamada O. Prognostic Value of Exercise Variables in 335 Patients after the Fontan Operation: A 23-year Single-center Experience of Cardiopulmonary Exercise Testing. CONGENIT HEART DIS 2014; 10:105-16. [DOI: 10.1111/chd.12222] [Citation(s) in RCA: 75] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/11/2014] [Indexed: 11/27/2022]
Affiliation(s)
- Hideo Ohuchi
- Department of Pediatric Cardiology; National Cerebral and Cardiovascular Center; Osaka Japan
| | - Jun Negishi
- Department of Pediatric Cardiology; National Cerebral and Cardiovascular Center; Osaka Japan
| | - Kanae Noritake
- Department of Pediatric Cardiology; National Cerebral and Cardiovascular Center; Osaka Japan
| | - Yosuke Hayama
- Department of Pediatric Cardiology; National Cerebral and Cardiovascular Center; Osaka Japan
| | - Heima Sakaguchi
- Department of Pediatric Cardiology; National Cerebral and Cardiovascular Center; Osaka Japan
| | - Aya Miyazaki
- Department of Pediatric Cardiology; National Cerebral and Cardiovascular Center; Osaka Japan
| | - Koji Kagisaki
- Department of Thoracic Surgery; National Cerebral and Cardiovascular Center; Osaka Japan
| | - Osamu Yamada
- Department of Pediatric Cardiology; National Cerebral and Cardiovascular Center; Osaka Japan
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20
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Arya P, Beroukhim R. Ebstein Anomaly: Assessment, Management, and Timing of Intervention. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2014; 16:338. [DOI: 10.1007/s11936-014-0338-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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21
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Tulino V, Cacace C, Tulino D, Imbalzano E, Dattilo G. Clinical variants in Ebstein's anomaly. Int J Cardiol 2013; 168:4969-70. [DOI: 10.1016/j.ijcard.2013.07.138] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2013] [Accepted: 07/13/2013] [Indexed: 11/25/2022]
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