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Dodeja AK, Upadhyay S. Arrhythmias in Adult Congenital Heart Disease Heart Failure. Heart Fail Clin 2024; 20:175-188. [PMID: 38462322 DOI: 10.1016/j.hfc.2023.12.004] [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 and arrhythmias represent 2 major causes of mortality and morbidity in adults with congenital heart disease. Arrhythmias and heart failure are interdependent, and one may exacerbate the other. Treatment of one also has a positive impact on the other. Management approaches need to be multifaceted, including pharmacotherapy, optimization of hemodynamic status with catheter-based or surgical interventions, and specific management of arrhythmia with device or catheter ablation therapy.
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Affiliation(s)
- Anudeep K Dodeja
- Division of Pediatric Cardiology, Department of Pediatrics, Connecticut Children's, University of Connecticut School of Medicine, 282 Washington Street, Hartford, CT 06106, USA
| | - Shailendra Upadhyay
- Department of Pediatric Cardiology, Connecticut Children's, University of Connecticut School of Medicine, 282 Washington Street, Hartford, CT 06106, USA.
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Laubham M, Blais B, Kamp AN. Atrial Arrhythmias in Adults with Fontan Palliation. Cardiol Ther 2023; 12:473-487. [PMID: 37495769 PMCID: PMC10423191 DOI: 10.1007/s40119-023-00326-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 07/14/2023] [Indexed: 07/28/2023] Open
Abstract
Single ventricle physiology is a rare form of congenital heart disease and was, historically, a uniformly lethal condition. However, the atriopulmonary Fontan operation, and its successive iterations, the lateral tunnel and extracardiac conduit Fontan, became the fundamental approach to treating single ventricle heart disease. Over time, dysrhythmias are some of the most common complications with Fontan physiology, compounding morbidity and mortality. Atrial arrhythmias are prevalent in the Fontan population and occur in about 15-60% of patients with Fontan palliation, increasingly with age. Diagnosing atrial arrhythmias in patients with Fontan palliation may be challenging because of low voltage amplitudes arising from myopathic atrial tissue making it difficult to clearly assess atrial depolarization on surface electrocardiograms (ECG), vague symptoms not suggestive of tachyarrhythmia, or atrial arrhythmia with ventricular rates below 100 beats per minute. Intra-atrial reentrant tachycardia (IART) is the most common type of supraventricular tachycardia in adults with Fontan palliation. Acute management of atrial arrhythmias in patients with Fontan palliation involves prompt assessment of a patient's hemodynamic stability, anticoagulation and thrombosis risk, systemic ventricular function, and risk of sedation or anesthesia if needed. Long-term management of atrial arrhythmias is often multifactorial and may include long-term anti-arrhythmic therapy, permanent pacing, and ablation. The best approach for the management of atrial arrhythmias in adults with Fontan palliation is patient-specific and involves collaboration between congenital electrophysiologists, adult congenital cardiologists, and the patient.
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Affiliation(s)
- Matthew Laubham
- Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA.
| | - Ben Blais
- Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA
- The Ohio State University School of Medicine, Columbus, OH, USA
| | - Anna N Kamp
- Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA
- The Ohio State University School of Medicine, Columbus, OH, USA
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He H, Zhang Y, Xu J, Li Y, Fang H, Liu Y, Zhang S. Discovery of Orally Bioavailable SOS1 Inhibitors for Suppressing KRAS-Driven Carcinoma. J Med Chem 2022; 65:13158-13171. [PMID: 36173339 DOI: 10.1021/acs.jmedchem.2c00986] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
The interaction between son of sevenless 1 (SOS1) gene and Kirsten rat sarcoma viral oncogene (KRAS) is crucial for activating signals of proliferation and survival in a range of cancers. We previously discovered compound 40a with a tetracyclic quinazoline pharmacophore as a potent orally bioavailable SOS1 inhibitor. Herein, we disclosed the discovery of compound 13c, which substituted the third ring with the seven-membered ring, as a clinical drug candidate for suppressing KRAS-driven tumors. 13c strongly disrupted the protein-protein interaction between SOS1 and KRAS with low IC50 values of 3.9 nM (biochemical) and 21 nM (cellular). 13c showed a favorable pharmacokinetic profile with a bioavailability of 86.8% in beagles and exhibited 83.0% tumor suppression in Mia-paca-2 pancreas xenograft mice tumor models. 13c exhibited a weak time-dependent CY3A4P inhibition than BI-3406, thereby reducing the risk of drug-drug interaction in drug combination. Toxicological investigations revealed that 13c had a lower risk of sudden cardiac death than BI-3406. Overall, 13c has been under evaluation in preclinical trials.
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Affiliation(s)
- Huan He
- Key Laboratory of Coal Conversion and New Carbon Materials of Hubei Province, College of Chemistry and Chemical Engineering, Institute of Advanced Materials and Nanotechnology, Wuhan University of Science and Technology, Wuhan 430081, P. R. China
- Wuhan Yuxiang Pharmaceutical Technology Co., Ltd., Wuhan 430200, P. R. China
| | - Yu Zhang
- Key Laboratory of Coal Conversion and New Carbon Materials of Hubei Province, College of Chemistry and Chemical Engineering, Institute of Advanced Materials and Nanotechnology, Wuhan University of Science and Technology, Wuhan 430081, P. R. China
| | - Juan Xu
- College of Chemistry and Chemical Engineering, Hubei Polytechnic University, Huangshi 435003, P. R. China
- Wuhan Yuxiang Pharmaceutical Technology Co., Ltd., Wuhan 430200, P. R. China
| | - Yuanyuan Li
- Wuhan Yuxiang Pharmaceutical Technology Co., Ltd., Wuhan 430200, P. R. China
- School of Life Science and Technology & School Chemical and Environmental Engineering, Wuhan Polytechnic University, Wuhan 430023, P. R. China
| | - Huaxiang Fang
- Wuhan Yuxiang Pharmaceutical Technology Co., Ltd., Wuhan 430200, P. R. China
| | - Yi Liu
- Key Laboratory of Coal Conversion and New Carbon Materials of Hubei Province, College of Chemistry and Chemical Engineering, Institute of Advanced Materials and Nanotechnology, Wuhan University of Science and Technology, Wuhan 430081, P. R. China
- School of Life Science and Technology & School Chemical and Environmental Engineering, Wuhan Polytechnic University, Wuhan 430023, P. R. China
- State Key Laboratory of Membrane Separation and Membrane Process & Tianjin Key Laboratory of Green Chemical Technology and Process Engineering, School of Chemistry, Tiangong University, Tianjin 300387, P. R. China
| | - Silong Zhang
- Key Laboratory of Coal Conversion and New Carbon Materials of Hubei Province, College of Chemistry and Chemical Engineering, Institute of Advanced Materials and Nanotechnology, Wuhan University of Science and Technology, Wuhan 430081, P. R. China
- Wuhan Yuxiang Pharmaceutical Technology Co., Ltd., Wuhan 430200, P. R. China
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Czosek RJ, Spar DS, Anderson JB, Khoury PR, Webster G. Predictors and Outcomes of Arrhythmia on Stage I Palliation of Single Ventricle Patients. JACC Clin Electrophysiol 2022; 8:1136-1144. [DOI: 10.1016/j.jacep.2022.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 06/16/2022] [Accepted: 06/19/2022] [Indexed: 11/28/2022]
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Kamp AN, Nair K, Fish FA, Khairy P. Catheter ablation of atrial arrhythmias in patients post-Fontan. Can J Cardiol 2022; 38:1036-1047. [PMID: 35240252 DOI: 10.1016/j.cjca.2022.02.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 02/18/2022] [Accepted: 02/20/2022] [Indexed: 12/25/2022] Open
Abstract
Atrial arrhythmias are highly prevalent in the aging Fontan population and contribute importantly to morbidity and mortality. Although the most common arrhythmia is scar-based intra-atrial re-entrant tachycardia, various other arrhythmias may occur including focal atrial tachycardia, atrioventricular node-dependent tachycardias, and atrial fibrillation. The type and prevalence of atrial arrhythmia is determined, in part, by the underlying congenital defect and variant of Fontan surgery. While the cumulative incidence of atrial tachyarrhythmias has decreased substantially from the atriopulmonary anastomosis to the more recent total cavopulmonary connection Fontan, the burden of atrial arrhythmias remains substantial. Management is often multi-faceted and can include anticoagulation, anti-arrhythmic drug therapy, pacing, and cardioversion. Catheter ablation plays a key role in arrhythmia control. Risks and benefits must be carefully weighed. Among the important considerations are the clinical burden of arrhythmia, ventricular function, hemodynamic stability in tachycardia, suspected arrhythmia mechanisms, risks associated with anaesthesia, venous access, approaches to reaching the pulmonary venous atrium, and accompanying co-morbidities. Careful review of surgical notes, electrocardiographic tracings, and advanced imaging is paramount, with particular attention to anatomic abnormalities such as venous obstructions and displaced conduction systems. Despite numerous challenges, ablation of atrial arrhythmias is effective in improving clinical status. Nevertheless, onset of new arrhythmias is common during long-term follow-up. Advanced technologies such as high-density mapping catheters and remote magnetic guided ablation carry the potential to further improve outcomes. Fontan patients with atrial arrhythmias should be referred to centers with dedicated expertise in congenital heart disease including catheter ablation, anaesthesia support, and advanced imaging.
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Affiliation(s)
- Anna N Kamp
- Nationwide Children's Hospital, Ohio State University, Columbus, OH, USA
| | - Krishnakumar Nair
- University Health Network, Toronto General Hospital, Toronto, Canada
| | - Frank A Fish
- Vanderbilt University Medical Center, Nashville, TN, USA; and
| | - Paul Khairy
- Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada.
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Bessière F, Mondésert B, Chaix MA, Khairy P. Arrhythmias in adults with congenital heart disease and heart failure. Heart Rhythm O2 2021; 2:744-753. [PMID: 34988526 PMCID: PMC8710623 DOI: 10.1016/j.hroo.2021.10.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Arrhythmias and heart failure are among the most common complications encountered by adults with congenital heart disease (CHD). In this contemporary review, we explore the interactions between arrhythmias and heart failure and discuss management strategies. Major knowledge gaps are highlighted throughout. Interactions between arrhythmias and heart failure are complex and bidirectional, with one begetting the other. Arrhythmias can provoke heart failure through various mechanisms: conduction disturbances may contribute to inefficient ventricular filling and contraction patterns; bradyarrhythmias and tachyarrhythmias can result in a reduction in cardiac output; hypoxemia may be exacerbated by right-to-left shunting; and tachycardia-induced cardiomyopathy has potentially devastating consequences if the diagnosis is delayed. In turn, heart failure promotes arrhythmogenesis through various structural (eg, fibrosis, chamber dilation, hypertrophy) and electrical remodeling effects that include changes to ion currents and channels and connexin expression, along with shortening of atrial and ventricular refractory periods with increased heterogeneity. Several shared comorbidities can contribute to, and modulate the impact of, arrhythmias and heart failure. Preemptive arrhythmia management can potentially mitigate effects on heart failure exacerbations. Similarly, optimal heart failure control could curtail its impact on arrhythmogenesis. Treatment strategies to prevent or treat heart failure in adults with CHD encompass pharmacological agents, catheter ablation, and device therapies including defibrillators, cardiac resynchronization therapy, and His bundle pacing. High-priority research avenues with major knowledge gaps include tachycardia-induced cardiomyopathy, catheter ablation of atrial fibrillation, defibrillator indications in high-risk subsets, and the role of cardiac resynchronization therapy and His bundle pacing in diverse forms of CHD.
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Affiliation(s)
- Francis Bessière
- Hôpital cardiologique Louis Pradel, Hospices Civils de Lyon, Université de Lyon, Lyon, France
| | | | - Marie-A Chaix
- Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | - Paul Khairy
- Montreal Heart Institute, Université de Montréal, Montreal, Canada
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