Pulmonary hypertension in young adults with repaired coarctation of the aorta: An unrecognised factor associated with premature mortality and heart failure

Sex Differences in Outcomes of Adults With Isolated Coarctation of the Aorta

Background

Data are limited about the effect (or lack thereof) of sex on clinical outcomes in adults with coarctation of the aorta (COA). The purpose of this study was to compare atherosclerotic cardiovascular disease (ASCVD) risk profile, blood pressure (BP) data, echocardiographic indices, and mortality between men and women with COA.

Methods

Retrospective study of adults with COA, and no associated left-sided obstructive lesions, who received care at Mayo Clinic (2003-2022). ASCVD risk profile was assessed as the prevalence of hypertension, hyperlipidemia, type 2 diabetes, obesity, smoking history, and coronary artery disease. A 24-hour BP monitor was used to assess daytime and nighttime BP and calculate nocturnal dipping.

Results

Of 621 patients with isolated COA, 375 (60%) were men, and 246 (40%) were women. Women had similar ASCVD risk profile and daytime BP as men. However, women had less nocturnal dipping (7 ± 5 mm Hg vs 16 ± 7 mm Hg, P < 0.001), higher pulmonary artery mean pressure (23 mm Hg [interquartile range: 16-31] vs 20 mm Hg [interquartile range: 15-28], P = 0.04), and higher pulmonary vascular resistance index (3.41 ± 1.14 WU · m2 vs 3.02 ± 0.76 WU · m2, P = 0.006). Female sex was associated with all-cause mortality (adjusted hazard ratio 1.26, 95% confidence interval 1.04-1.94) and cardiovascular mortality (adjusted hazard ratio 1.38, 95% confidence interval 1.09-2.18).

Conclusions

Women had a higher risk of both cardiovascular mortality and all-cause mortality compared to the risks in men. This difference may be related to the higher-than-expected ASCVD risk factors, abnormal nocturnal blood pressure, and pulmonary hypertension observed in women in this cohort. Further studies are required to identify optimal measures to address these risk factors.

Prognostic Role of Tricuspid Annular Plane Systolic Excursion/Right Ventricular Systolic Pressure Ratio in Coarctation of Aorta

Background

Right ventricular (RV) systolic dysfunction and pulmonary hypertension are associated with mortality in adults with coarctation of aorta (COA). The tricuspid annular plane systolic excursion/RV systolic pressure (TAPSE/RVSP) ratio is a validated noninvasive tool for the assessment of RV-pulmonary arterial (RV-PA) coupling in patients with PA hypertension, but similar data are lacking in adults with COA. The purpose of this study was to assess the relationship between the TAPSE/RVSP ratio and outcomes in this population.

Methods

A retrospective cohort study of adults with repaired COA was performed. RV systolic dysfunction was defined as RV free wall strain ≥-24% at baseline, whereas new-onset RV systolic dysfunction was defined RV free wall strain ≥-24% during follow-up.

Results

Of 661 patients, TAPSE, RVSP, and TAPSE/pulmonary artery systolic pressure ratio were 22 ± 6 mm, 34 ± 12 mm Hg, and 0.71 (0.48-0.89) mm/mm Hg, respectively. Of 661 patients, 152 (23%) had RV systolic dysfunction at baseline, and TAPSE/RVSP <0.43 mm/mm Hg was the optimal threshold to detect RV systolic dysfunction. TAPSE/RVSP <0.43 mm Hg was associated with RV systolic dysfunction (adjusted odds ratio: 3.11 [1.83-6.19], P = 0.004). Of 509 patients with normal RV systolic function, 42 (8%) and 36 (7%) developed new-onset RV systolic dysfunction and new-onset right heart failure, respectively, during follow-up. TAPSE/RVSP <0.43 mm/mm Hg was associated with new-onset RV systolic dysfunction (adjusted hazard ratio: 1.95 [1.46-2.77], P = 0.008) and new-onset right heart failure (adjusted hazard ratio: 0.81 [0.68-0.92], P = 0.005).

Conclusions

The TAPSE/RVSP ratio can potentially be used to identify patients at risk for new-onset RV systolic dysfunction and right heart failure and provide opportunity for proactive interventions to prevent adverse outcomes.

Determinants and Prognostic Implications of Hepatorenal Dysfunction in Adults With Congenital Heart Disease

BACKGROUND

There are limited data on the prognostic role of hepatorenal function indices in ambulatory patients with congenital heart disease (CHD). The purpose of this study was to determine the prevalence, risk factors, and prognostic implications of hepatorenal dysfunction, as measured by Model for End-Stage Liver Disease Excluding International Normalised Ratio (MELD-XI) score, in adults with CHD.

METHODS

In this retrospective study of CHD patients with comprehensive metabolic panels (2003-2019), mild/moderate and severe hepatorenal dysfunction was defined as MELD-XI 11-15 and > 15, respectively.

RESULTS

Of 4977 patients, 1376 (28%) had hepatorenal dysfunction (mild/moderate: n = 935 [19%]; severe: n = 441 [9%]). Hepatorenal dysfunction was most common in Fontan/unrepaired single ventricle (46%) and right heart disease (31%). Baseline MELD-XI was associated with all-cause mortality (HR 1.27, CI 1.21-1.33; P < 0.001) after adjustment for age, sex, and congenital heart lesion. In 3864 patients with serial MELD-XI data, there was a temporal increase in MELD-XI, and this was associated with an increased risk of mortality (HR 1.24, CI 1.15-1.36, per unit increase in MELD-XI; P = 0.004), independently from the baseline MELD-XI score. In the subset of 1856 patients that underwent surgical/transcatheter interventions, there was a postoperative reduction in MELD-XI, and this was associated with a lower risk of mortality (HR 0.94, CI 0.90-0.98, per unit decrease in MELD-XI; P = 0.008), independently from the baseline MELD-XI score.

CONCLUSIONS

Hepatorenal dysfunction was common in adults with CHD. Both baseline MELD-XI score and temporal changes in MELD-XI were associated with clinical outcomes, and therefore could be used to monitor therapeutic response to interventions and for deterioration in clinical status.

Right Heart Dysfunction in Adults With Coarctation of Aorta: Prevalence and Prognostic Implications

BACKGROUND

Chronic elevation of left heart filling pressure causes pulmonary vascular remodeling, pulmonary hypertension, and right heart dysfunction. Although diastolic dysfunction is relatively common in patients with coarctation of aorta, there are limited data about the prevalence and prognostic implications of pulmonary hypertension and right heart dysfunction in this population. The purpose of the study was to assess right heart function and hemodynamics in patients with coarctation of aorta and to determine the relationship between right heart indices and cardiovascular events defined as heart failure hospitalization, heart transplant, or cardiovascular death.

METHODS

Right heart structure, function, and hemodynamics were assessed with these indices: right atrial volume, right atrial pressure, right atrial reservoir strain, right ventricular global longitudinal strain, right ventricular end-diastolic area, right ventricular systolic pressure, and tricuspid regurgitation severity. Right heart hemodynamic score, range 0 to 5, was generated based on the correlation between the right heart indices and cardiovascular events, using half of the cohort (derivation cohort, n=411), and then tested on the validation cohort (n=410). The goodness of fit and discrimination power was compared using C statistics and risk score.

RESULTS

The median follow-up in the derivation cohort was 8.2 (4.0-11.1) years, and 59 (14%) patients had cardiovascular events during this period. Right heart hemodynamic score was independently associated with cardiovascular events (hazard ratio, 1.64 [95% CI, 1.38-2.17]) for every unit increase in right heart hemodynamic score after adjustment for clinical and echocardiographic indices (C statistic, 0.718 [95% CI, 0.682-0.746]). The right heart hemodynamic score was also independently associated with cardiovascular events in the validation cohort (C statistic, 0.711 [95% CI, 0.679-0.741]). The C statistic difference (0.007 [95% CI, 0.014-0.022]) and risk score (0.86 [95% CI, 0.54-1.17]) suggest a good model fit.

CONCLUSIONS

The current study underscores the prognostic importance of right heart dysfunction in patients with coarctation of aorta and suggests that right heart indices should be used for risks stratification in this population.

Hemodynamics in Adults With the Shone Complex

Patients with Shone complex (SC) have multiple left-sided obstructive lesions and thus are at risk for left ventricular (LV) remodeling, LV diastolic dysfunction and pulmonary hypertension. Yet, to date, there has been no description of hemodynamics in adults with SC. Retrospective chart review of 25 patients with SC who underwent cardiac catheterization at Mayo Clinic, MN between 2002 and 2019 was performed. SC was defined as multiple left-sided obstructive lesions in the presence of an anatomically abnormal mitral valve. Median age was 32 years (22.5, 42) and 15 patients (60%) were female. The majority of patients (84%) had history of coarctation of the aorta, 10 (40%) had subaortic stenosis, 11 (44%) had prior aortic valve replacement, and 10 (40%) had prior mitral valve replacement. Structural disease at the time of catheterization which warranted intervention within the next year was present in 13 patients (52%). The mean LV end-diastolic pressure was 21.3 ± 9.0 mm Hg (>15 mm Hg in 71%), pulmonary artery peak systolic pressure was 55.4 ± 13.4 mm Hg, and the pulmonary artery mean pressure was 37.0 ± 9.4 mm Hg (>20 mm Hg in 96%). During a mean follow-up of 8.3 ± 4.4 years, there were 7 deaths (28%) and 3 additional patients (12%) underwent cardiac transplantation. In conclusion, adults with SC who underwent catheterization showed significant left-sided heart and pulmonary vascular remodeling. Elevated LV end-diastolic pressure and pulmonary artery pressures were highly prevalent. There were high mortality and cardiac transplant rates in our cohort.

Sudden Cardiac Death in Adult Congenital Heart Disease

Sudden death of presumed arrhythmic etiology is a leading cause of mortality in adults with congenital heart disease. Anticipated benefits of the implantable cardioverter-defibrillator (ICD) must be weighed against high complication rates. Without robust evidence from randomized trials, caregivers face difficult decisions in selecting appropriate candidates. Although secondary prevention indications are often clear-cut, risk stratification for primary prevention ICDs is more challenging. Factors associated with sudden death in patients with tetralogy of Fallot are reasonably consistent across studies. In contrast, identification of high-risk patients with systemic right ventricles or univentricular hearts remains controversial.

Diagnostic Value of Transthoracic Echocardiography in Patients with Coarctation of Aorta: The Chinese Experience in 53 Patients Studied between 2008 and 2012 in One Major Medical Center

Although aortography is well known as the "gold standard" for the diagnosis of coarctation of aorta (CoA), the method is invasive, expensive and not readily accepted by some patients. Ultrasound diagnosis for CoA is non-invasive, inexpensive, readily accepted by every patient, and can be repeated as frequently as necessary. The purpose of this presentation is to evaluate the applicability of transthoracic echocardiography for the diagnosis of CoA. The echocardiographic appearances of 53 patients with CoA who had undergone surgery during a 5-year period from January 2008 to October 2012 were analyzed retrospectively, and the results were compared with findings at surgery. Fifty-three patients with CoA include six with isolated CoA and 47 of CoA associated with other cardiac anomalies. Of the 53 operated patients, 48 were correctly diagnosed preoperatively by echocardiography, while two were misdiagnosed as interrupted aortic arch and the diagnosis were missed in three other patients. Thus the diagnostic accuracy rate was 90.6%, and the misdiagnosis rate was 9.4%. Preoperative echocardiographic evaluation offers very satisfactory anatomic assessment in most patients with CoA. It makes preoperative angiography unnecessary. Thus transthoracic echocardiography should be the first-line method for the diagnosis of coarctation of the aorta.