Structural abnormalities of great arterial walls in congenital heart disease: light and electron microscopic analyses

Pediatric Hypertension: A Condition That Matters

Systemic hypertension has been considered mainly as an adult health issue for a long time, but it is now being increasingly acknowledged as a significant problem also among pediatric patients. The frequency of pediatric hypertension has grown mostly because of increases in childhood obesity and sedentary lifestyles, but secondary forms of hypertension play a role as well. Considering that unaddressed hypertension during childhood can result in enduring cardiovascular complications, timely identification and intervention are essential. Strategies for addressing this disease encompass not only lifestyle adjustments, but also the use of medications when needed. Lifestyle modifications entail encouraging a nutritious diet, consistent physical activity, and the maintenance of a healthy weight. Moreover, educating both children and their caregivers about monitoring blood pressure at home can aid in long-term management. Thus, the aim of this review is to discuss the etiologies, classification, and principles of the treatment of hypertension in pediatric patients.

A Systematic Comparison of Normal Structure and Function of the Greater Thoracic Vessels

The greater thoracic vessels are central to a well-functioning circulatory system and are often targeted in congenital heart surgeries, yet the structure and function of these vessels have not been well studied. Here we use consistent methods to quantify and compare microstructural features and biaxial biomechanical properties of the following six greater thoracic vessels in wild-type mice: ascending thoracic aorta, descending thoracic aorta, right subclavian artery, right pulmonary artery, thoracic inferior vena cava, and superior vena cava. Specifically, we determine volume fractions and orientations of the structurally significant wall constituents (i.e., collagen, elastin, and cell nuclei) using multiphoton imaging, and we quantify vasoactive responses and mechanobiologically relevant mechanical quantities (e.g., stress, stiffness) using computer-controlled biaxial mechanical testing. Similarities and differences across systemic, pulmonary, and venous circulations highlight underlying design principles of the vascular system. Results from this study represent another step towards understanding growth and remodeling of greater thoracic vessels in health, disease, and surgical interventions by providing baseline information essential for developing and validating predictive computational models.

The mid-term outcomes of aortic root replacement after surgical repair for CHD

OBJECTIVE

The purpose of this study is to assess the mid-term outcomes of aortic root replacement after repair of CHDs.

METHOD

This is a single-institutional retrospective, cohort study with consecutive patients undergoing aortic root replacement after surgical repair of CHDs between 1999 and 2022. Operative indications included aortic root dilatation with/without aortic insufficiency, sinus of Valsalva rupture, or aortic dissection involving the root.

RESULTS

Forty-four patients (36 male and 8 female) were enrolled. Mean age at the root replacement was 36.6 ± 11.9 years. The most frequent primary diagnosis was congenital aortic stenosis (n = 10) and ventricular septal defect (n = 10). Mean time from the surgical repair to aortic root replacement was 26.6 ± 13.0 years. Operative indications were aortic root enlargement with or without aortic valve aetiology (n = 40), sinus of Valsalva rupture (n = 2), and aortic dissection (n = 2). Forty-two patients underwent valve-replacing aortic root replacement, and two patients underwent valve-sparing, with 40 concomitant procedures. The median follow-up was 3.5 (1.3-7.6) years. There were one early and five late mortalities and five cardiovascular-related reoperations. Actuarial survival at 5-10 years after root replacement was 81.0 ± 6.6%. The cumulative incidence of cardiovascular-related reoperation and aortic root or valve-related reoperation at 5 years after root replacement was 11.9% and 5.6%, respectively.

CONCLUSION

The early and mid-term outcomes of aortic root replacement for patients with a history of repair of CHDs were favourable in terms of survival and aortic root or valve-related reoperation.

Growth of the Neo-Aortic Root and Prognosis of Transposition of the Great Arteries

BACKGROUND

Neo-aortic root dilatation can lead to significant late morbidity after the arterial switch operation (ASO) for dextro-transposition of the great arteries (d-TGA).

OBJECTIVES

We sought to examine the growth of the neo-aortic root in d-TGA.

METHODS

A single-center, retrospective cohort study of patients who underwent the ASO between July 1, 1981 and September 30, 2022 was performed. Morphology was categorized as dextro-transposition of the great arteries with intact ventricular septum (d-TGA-IVS), dextro-transposition of the great arteries with ventricular septal defect (d-TGA-VSD), and double-outlet right ventricle-transposition of the great arteries type (DORV-TGA). Echocardiographically determined diameters and derived z scores were measured at the annulus, sinus of Valsalva, and sinotubular junction immediately before the ASO and throughout follow-up. Trends in root dimensions over time were assessed using linear mixed-effects models. The association between intrinsic morphology and the composite of moderate-severe aortic regurgitation (AR) and neo-aortic valve or root intervention was evaluated with univariable and multivariable Cox proportional hazards models.

RESULTS

Of 1,359 patients who underwent the ASO, 593 (44%), 666 (49%), and 100 (7%) patients had d-TGA-IVS, d-TGA-VSD, and DORV-TGA, respectively. Each patient underwent a median of 5 echocardiograms (Q1-Q3: 3-10 echocardiograms) over a median follow-up of 8.6 years (range: 0.1-39.3 years). At 30 years, patients with DORV-TGA demonstrated greater annular (P < 0.001), sinus of Valsalva (P = 0.039), and sinotubular junction (P = 0.041) dilatation relative to patients with d-TGA-IVS. On multivariable analysis, intrinsic anatomy, older age at ASO, at least mild AR at baseline, and high-risk root dilatation were associated with moderate-severe AR and neo-aortic valve or root intervention at late follow-up (all P < 0.05).

CONCLUSIONS

Longitudinal surveillance of the neo-aortic root is warranted long after the ASO.

Longitudinal development of central SBP in children with congenital heart disease

AIMS

Central SBP (cSBP) was shown to be increased already in children with congenital heart disease (CHD). However, its development over time has not yet been investigated. The aim of this study was to evaluate the natural course of cSBP over time from longitudinal assessment in children with CHD.

METHODS

In this longitudinal study, 306 children and adolescents (11.3 ± 2.9 years, 34% girls) with various CHD were prospectively examined from July 2014 to May 2022. Over a mean follow-up length of 30.1 ± 18.9 months, 467 follow-up assessments have been conducted. cSBP was noninvasively assessed by oscillometric measurement via Mobil-O-Graph. A linear mixed effect model was performed to examine the course of cSBP.

RESULTS

cSBP increased significantly over time by 1.22 mmHg per year of age (P < 0.001). The longitudinal increase in cSBP over time remained significant when including sex (b = 0.68, P < 0.001), BMI (b = 1.12, P < 0.001), hypertensive medication (b = 1.13, P < 0.001), disease severity (b = 1.04, P < 0.001), and CHD type (b = 3.74, P = 0.03) in the model. Patients with transposition of the great arteries (TGA) after arterial switch had a significantly higher cSBP increase over time (b = 1.78, P < 0.001). The longitudinal cSBP increase was significantly higher in obese CHD children (b = 2.52, P = 0.005) and in boys (b = 0.85, P < 0.001).

CONCLUSION

This study shows a longitudinal increase in cSBP in children with CHD. Whether observed trajectories of cSBP are normal or abnormal needs to be investigated in further studies. Monitoring of the vascular function with a special focus on patients with TGA and obese CHD children seems indicated.

Natural history of aortic root dilatation and pathologic aortic regurgitation in tetralogy of Fallot and its morphological variants

OBJECTIVE

We sought to characterize the natural history of aortic root dilatation and aortic regurgitation in tetralogy of Fallot (TOF).

METHODS

A single-center review of patients who underwent TOF repair from January 1960 to December 2022 was performed. Morphology was categorized as TOF-pulmonary stenosis or TOF-variant (including TOF-pulmonary atresia and TOF-pulmonary atresia-major aortopulmonary collateral arteries). Echocardiographically determined diameters and derived z scores were measured at the annulus, sinus of Valsalva, and sinotubular junction immediately before TOF repair and throughout follow-up. Linear mixed-effects models assessed trends in dimensions over time.

RESULTS

Of 2205 patients who underwent primary repair of TOF at a median age of 4.9 months (interquartile range, 2.3-20.5 months) and survived to discharge, 1608 (72.9%) patients had TOF-pulmonary stenosis and 597 (27.1%) patients had TOF-variant. At a median postoperative follow-up of 14.4 years (interquartile range, 3.3-27.6 years; range, 0.1-62.6 years), 313 (14.2%) patients had mild or greater aortic regurgitation and 34 (1.5%) patients required an aortic valve or root intervention. The overall mean rates of annular, sinus of Valsalva, and sinotubular junction growth were 0.5 ± 0.2, 0.6 ± 0.3, and 0.7 ± 0.5 mm/year, respectively. Root z scores remained stable with time. At baseline, patients with TOF-variant had larger diameters and z scores at the annulus, sinus of Valsalva, and sinotubular junction, compared with patients with TOF-pulmonary stenosis (all P values < .05). Over time, patients with TOF-variant demonstrated relatively greater annular (P = .020), sinus of Valsalva (P < .001), and sinotubular junction (P < .001) dilatation. Patients with ≥75th percentile root growth rates had a higher incidence of mild or greater aortic regurgitation (P < .001), moderate or greater aortic regurgitation (P < .001), and aortic valve repair or replacement (P = .045).

CONCLUSIONS

Patients with TOF-variant are at comparatively greater risk of pathologic root dilatation over time, warranting closer longitudinal follow-up.

Acquired cardiovascular disease in adults with congenital heart disease

Rates of successful surgical repair and life expectancy for patients with congenital heart disease have increased dramatically in recent decades. Thanks to advances in diagnosis, treatment, and follow-up care, an ever-increasing number of individuals with congenital heart disease are reaching advanced age. The exposure to cardiovascular risk factors during their lifetime is modifying the outlook and late clinical trajectory of adult congenital heart disease (ACHD). Their disease burden is shifting from congenital to acquired, primarily atherosclerotic cardiovascular disease (ASCVD) with worrisome consequences. In addition, the complex background of ACHD often curbs appropriate preventive strategies by general practitioners or adult cardiologists. Comprehensive guidance for the prevention and management of acquired heart disease in ACHD patients is currently not available, as this topic has not been covered by the European Society of Cardiology (ESC) guidelines on cardiovascular disease prevention or the ESC guidelines for the management of ACHD. In this document, a state-of-the-art overview of acquired heart disease in ACHD patients and guidance on ASCVD prevention for both ACHD specialists and non-ACHD cardiologists are provided. The aim is to provide a clinical consensus statement to foster the development of a sustainable strategy for the prevention of ASCVD in a practical and simple-to-follow way in this ever-growing cardiovascular cohort, thus reducing their cardiovascular burden.

Re: Impaired ascending aortic elasticity in fetuses with tetralogy of Fallot

This Correspondence comments on Xu et al. Click here to view the article.

Navigating the challenges of bicuspid aortic valve-aortopathy

Bicuspid aortic valve (BAV) is a congenital heart defect that affects 0.5-2% of the general population with familial predominance. The modifications in hemodynamics and structure change at cellular level contribute to the dilation of aorta, resulting in bicuspid aortopathy, which can result in catastrophic aortic events. The American Heart Association recommends screening first-degree relatives of patients with bicuspid aortic valve and aortic root disease. BAV may or may not be associated with a syndrome, with the non-syndromic variety having a higher chance of predisposition to congenital and vascular abnormalities. Many genes have been implicated in the etiology of non-syndromic aortic aneurysm such as ACTA2, MYH11, FLNA, and SMAD3. Common diagnostic modalities include transthoracic echocardiography (TTE), transesophageal echocardiography (TEE), multi system computer tomography (MSCT), and cardiac MRI. Medical management reduces the rate of disease progression and surgical management is indicated based on the diameter of the ascending aorta, which differs in American and European guidelines. Our article aims to explore the current understanding of the pathophysiology, clinical aspects, and surgical management of bicuspid aortic valve disease. Additionally, we have included a discussion on the management of this condition in special populations, such as athletes and pregnant women, who require distinct treatment recommendations.

Microvascular Endothelial Function Assessed Using Peripheral Arterial Tonometry in Adolescents with Repaired Congenital Heart Disease

Atherosclerosis can develop in adult patients with congenital heart disease (CHD) and should be given attention. Endothelial function is well known as a predictor of the development of atherosclerosis but has not been well investigated in patients with repaired CHD. This study aimed to clarify the endothelial function and its relationship with clinical backgrounds and parameters in adolescents with various types of repaired CHDs. Endothelial function was evaluated using peripheral arterial tonometry (PAT). The reactive hyperemia index (RHI) was evaluated and compared between adolescents with repaired CHD and those in the control group. The relationship between the clinical background and parameters was also investigated in patients with repaired CHD. Forty-eight patients with repaired CHD (age 14.0 ± 3.3 years) and 114 healthy volunteers were included in this study. Patients with repaired CHD comprised 16 with repaired non-cyanotic CHD, 14 with repaired tetralogy of Fallot, and 18 who underwent the Fontan procedure. RHI in the repaired CHD group was significantly lower than in the control group. There was no significant correlation between the RHI and blood biochemical markers, such as uric acid, creatine, and brain natriuretic peptide levels. The RHI was significantly higher in patients taking angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) than in those not taking them. Endothelial function was impaired in adolescents with repaired CHD compared to that in the control group. Microvascular endothelial dysfunction developed even in adolescents with simple non-cyanotic CHD.

Death, reoperation, and late cardiopulmonary function after truncus repair

Objective

To identify the late surgical outcomes of truncus arteriosus.

Methods

Fifty consecutive patients with truncus arteriosus who underwent surgery between 1978 and 2020 at our institute were enrolled in this retrospective, single institutional cohort study. The primary outcome was death and reoperation. The secondary outcome was late clinical status, including exercise capacity. The peak oxygen uptake was measured by a ramp-like progressive exercise test on a treadmill.

Results

Nine patients underwent palliative surgery, which resulted in 2 deaths. Forty-eight patients went on to truncus arteriosus repair, including 17 neonates (35.4%). The median age and body weight at repair were 92.5 days (interquartile range, 10-272 days) and 3.85 kg (interquartile range, 2.9-6.5 kg), respectively. The survival rate at 30 years was 68.5%. Significant truncal valve regurgitation (P = .030) was a risk factor for survival. Survival rates were similar between in the early 25 and late 25 patients (P = .452). The freedom from death or reoperation rate at 15 years was 35.8%. Significant truncal valve regurgitation was a risk factor (P = .001). The mean follow-up period in hospital survivors was 15.4 ± 12 years (maximum, 43 years). The peak oxygen uptake, which was performed in 12 long-term survivors at a median duration from repair of 19.7 years (interquartile range, 16.8-30.9 years), was 70.2% of predicted normal (interquartile range, 64.5%-80.4%).

Conclusions

Truncal valve regurgitation was a risk factor for both survival and reoperation, thus improvement of truncal valve surgery is essential for better life prognosis and quality of life. Slightly reduced exercise tolerance was common in long-term survivors.

Strategies for Complex Reoperative Aortic Arch Reconstruction in Patients With Congenital Heart Disease

Aortic dilation is common in patients with congenital heart disease including those with a bicuspid aortic valve, connective tissue disease, coarctation of the aorta, and conotruncal defects. In addition, neo-aortic dilation has been described in patients after aortic reconstruction including the Norwood procedure, the arterial switch operation, and the Ross procedure. Although aortic catastrophe is rare in patients with congenital heart disease, common pathologic endpoints in these patients likely manifest with similar aortic tissue behavior. A lifelong care model with similar indications for surveillance and prophylactic repair to other more common aortopathies is therefore warranted. Still, reoperative aortic arch reconstruction in these patients is often a complex and high-risk endeavor, and in all cases, a tailored and adaptable plan ensuring adequate myocardial and cerebral protection with appropriate rescue measures is paramount. A surgical team taking on these challenging cases should possess an armamentarium of open, hybrid, and endovascular techniques which can be individualized to a patient's unique anatomy, surgical history, and concomitant lesions as well as the team's measured outcomes and experience.

Thoracic aortopathy in Marfan syndrome overlaps with mechanisms seen in bicuspid aortic valve disease

Background

Thoracic aortopathy is a serious complication which is more often seen in patients with Marfan syndrome (MFS) and patients with a bicuspid aortic valve (BAV) than in individuals with a tricuspid aortic valve (TAV). The identification of common pathological mechanisms leading to aortic complications in non-syndromic and syndromic diseases would significantly improve the field of personalized medicine.

Objective

This study sought to compare thoracic aortopathy between MFS, BAV, and TAV individuals.

Materials and methods

Bicuspid aortic valve (BAV; n = 36), TAV (n = 23), and MFS (n = 8) patients were included. Ascending aortic wall specimen were studied for general histologic features, apoptosis, markers of cardiovascular ageing, expression of synthetic and contractile vascular smooth muscle cells (VSMC), and fibrillin-1 expression.

Results

The MFS group showed many similarities with the dilated BAV. Both patient groups showed a thinner intima (p < 0.0005), a lower expression of contractile VSMCs (p < 0.05), more elastic fiber thinning (p < 0.001), lack of inflammation (p < 0.001), and a decreased progerin expression (p < 0.05) as compared to the TAV. Other features of cardiovascular ageing differed between the BAV and MFS. Dilated BAV patients demonstrated less medial degeneration (p < 0.0001), VSMC nuclei loss (p < 0.0001), apoptosis of the vessel wall (p < 0.03), and elastic fiber fragmentation and disorganization (p < 0.001), as compared to the MFS and dilated TAV.

Conclusion

This study showed important similarities in the pathogenesis of thoracic aortic aneurysms in BAV and MFS. These common mechanisms can be further investigated to personalize treatment strategies in non-syndromic and syndromic conditions.

Impaired Elastic Properties of the Ascending Aorta in Fetuses With Coarctation of the Aorta

Background Abnormal aortic elastic properties are major notable vasculopathy involved in coarctation of the aorta (CoA). However, there are no reports on aortic wall elastic characteristics in fetuses with CoA. Methods and Results Fifty-six fetuses with CoA and 56 normal controls were included in this prospective case-control study. The dimensions of the cardiac chamber, the size of the aorta, left ventricular myocardial performance indexes, and aortic elastic properties, including the global circumferential strain, fractional area change and mean longitudinal strain, were measured serially in utero. The global circumferential strain, fractional area change, and mean longitudinal strain in fetuses with CoA were smaller than those in the normal group at both the first and last examinations (18.50% versus 37.73% for global circumferential strain, 38.90% versus 57.55% for fractional area change, 6.61% versus 11.81% for mean longitudinal strain at first scan, 16.62% versus 42.05% for global circumferential strain, 36.54% versus 59.7% for fractional area change, 6.2% versus 11.46% for mean longitudinal strain at last scan, all P<0.001). There were negative correlations between aortic elastic properties and left ventricular myocardial performance indexes in fetuses with CoA (P<0.01). Aortic elastic properties were correlated positively with aortic isthmus size in fetuses with CoA (P<0.01). Conclusions Aortic strain and the fractional area change were decreased in fetuses with CoA. Impairments of these aortic elastic properties were associated with diminished heart function and aortic isthmus size in utero. Further large-scale longitudinal studies are required to confirm the potential predictive value of cardiovascular morbidity (ie, hypertension) in fetuses with CoA.

Assessment of aortic and cerebral haemodynamics and vascular brain injury with 3 and 7 T magnetic resonance imaging in patients with aortic coarctation

Aims

Coarctation of the aorta (CoA) is characterized by a central arteriopathy resulting in increased arterial stiffness. The condition is associated with an increased risk of stroke. We aimed to assess the aortic and cerebral haemodynamics and the presence of vascular brain injury in patients with previous surgical CoA repair.

Methods and results

Twenty-seven patients with CoA (median age 22 years, range 12-72) and 25 age- and sex-matched controls (median age 24 years, range 12-64) underwent 3 T (heart, aorta, and brain) and 7 T (brain) magnetic resonance imaging scans. Haemodynamic parameters were measured using two-dimensional phase-contrast images of the ascending and descending aorta, internal carotid artery (ICA), basilar artery (BA), middle cerebral artery (MCA), and perforating arteries. Vascular brain injury was assessed by rating white matter hyperintensities, cortical microinfarcts, lacunes, and microbleeds. Pulse wave velocities in the aortic arch and descending aorta were increased and ascending aortic distensibility was decreased in patients with CoA vs. controls. Patients with CoA showed a higher mean flow velocity in the right ICA, left ICA, and BA and a reduced distensibility in the right ICA, BA, and left MCA. Haemodynamic parameters in the perforating arteries, total cerebral blood flow, intracranial volumes, and vascular brain injury were similar between the groups.

Conclusion

Patients with CoA show an increased flow velocity and reduced distensibility in the aorta and proximal cerebral arteries, which suggests the presence of a generalized arteriopathy that extends into the cerebral arterial tree. No substantial vascular brain injury was observed in this relatively young CoA population, although the study was inadequately powered regarding this endpoint.

Risk of pulmonary artery dissection in adults with congenital heart disease

BACKGROUND

There are limited data about the risk of pulmonary artery (PA) dissection in adults with congenital heart disease (CHD), and the purpose of this study was to estimate the incidence of PA dissection in this population.

METHODS

Retrospective cohort study of adults with CHD that underwent cross-sectional imaging (2003-2020). PA aneurysm was defined as main or branch PA diameter > 40 mm or > 30 mm respectively, and severe PA aneurysm was defined as main or branch PA diameter > 50 mm.

RESULTS

Of 1, 673 patients (41 ± 10 years; male 58%), 493 (24%), 286 (19%), and 306 (20%) had aneurysms of the main, right, and left PA respectively, while 66 (4%) had severe PA aneurysm. During a median follow-up of 8.2 (interquartile range 3.7-10.3) years, there was one PA dissection in a patient with Eisenmenger syndrome, thus the incidence of PA dissection was 14 per 100,000 patient-years. Of 779 females, 163 had one or more pregnancies during follow-up, and 41 (25%) of these patients had known PA aneurysm at the time of conception. There was no PA dissection during pregnancy. Of the 163 patients, 91 (56%) had cross-sectional imaging before and after pregnancy, there was no significant difference in PA dimension before versus after pregnancy (main PA 35 ± 5 versus 36 ± 4 mm, p = 0.6; right PA 21 ± 3 versus 33 ± 4 mm, p = 0.1; and left PA 23 ± 4 versus 22 ± 4 mm, p = 0.4).

CONCLUSIONS

The risk of PA dissection was extremely low even in patients with severe PA aneurysm, or in patients with PA aneurysm that became pregnant. Collectively, these data suggest a benign natural history for patients without severe pulmonary hypertension and encourage and a conservative approach in managing patients with PA aneurysm.

Being Overweight Is Related to Neoaortic Sinus Dilatation After Arterial Switch Operation

Background

Neoaortic sinus dilatation is a late comorbidity after an arterial switch operation in patients with dextro-transposition of the great arteries. We aim to explore whether neoaortic sinus dilatation is related to overweight or obesity, as these affect aortic remodeling in such patients.

Methods

We measured neoaortic diameters including those for the annulus, sinus, sinotubular junction, and ascending aorta by echocardiography and studied the relationship between these diameters and body mass index in patients aged 15 years and older after an arterial switch operation.

Results

A total of 45 patients were studied. Median (interquartile range) age, body mass index, and systolic blood pressure at echocardiography were 20 (17–28) years, 21.2 (18.4–24.2) kg/m2, and 120 (112–127) mm Hg, respectively. Echocardiogram revealed the following median values (interquartile ranges): neoaortic annulus diameter, 22.2 (19.8–23.8) mm; sinus diameter, 34.6 (31.8–39.8) mm; sinotubular junction diameter, 27.5 (22.4–30.0) mm; and ascending aortic diameter, 20.4 (19.4–22.7) mm. The neoaortic sinus diameter was significantly correlated with body mass index (r = 0.41, P = .004) and was significantly larger in patients with concomitant ventricular septal defect (P &lt; .001) and those who were over-weight (body mass index ≥25 kg/m2; P = .006).

Conclusion

Neoaortic sinus dilatation after an arterial switch operation is associated with being overweight during adolescence and young adulthood. It is important to prevent obesity in patients after an arterial switch operation and educate them on a healthy lifestyle.

Experimental evidence of the genetic hypothesis on the etiology of bicuspid aortic valve aortopathy in the hamster model

Bicuspid aortopathy occurs in approximately 50% of patients with bicuspid aortic valve (BAV), the most prevalent congenital cardiac malformation. Although different molecular players and etiological factors (genetic and hemodynamic) have been suggested to be involved in aortopathy predisposition and progression, clear etiophysiopathological mechanisms of disease are still missing. The isogenic (genetically uniform) hamster (T) strain shows 40% incidence of BAV, but aortic dilatations have not been detected in this model. We have performed comparative anatomical, histological and molecular analyses of the ascending aorta of animals with tricuspid aortic valve (TAV) and BAV from the T strain (TTAV and TBAV, respectively) and with TAV from a control strain (HTAV). Aortic diameter, smooth muscle apoptosis, elastic waviness, and Tgf-β and Fbn-2 expression were significantly increased in T strain animals, regardless of the valve morphology. Strain and aortic valve morphology did not affect Mmp-9 expression, whereas Mmp-2 transcripts were reduced in BAV animals. eNOS protein amount decreased in both TBAV and TTAV compared to HTAV animals. Thus, histomorphological and molecular alterations of the ascending aorta appear in a genetically uniform spontaneous hamster model irrespective of the aortic valve morphology. This is a direct experimental evidence supporting the genetic association between BAV and aortic dilatation. This model may represent a population of patients with predisposition to BAV aortopathy, in which increased expression of Tgf-β and Fbn-2 alters elastic lamellae structure and induces cell apoptosis mediated by eNOS. Patients either with TAV or BAV with the same genetic defect may show the same risk to develop bicuspid aortopathy.

Vascular aging in adult congenital heart disease-a narrative review

Background and Objective

Many studies about the high prevalence of cardiovascular disease in adults with congenital heart disease (CHD) have been published in response to the growing number of adult patients with CHD. The aging process leads to hypertension and cardiovascular disease, which is caused by a degenerative change in the systemic arterial system characterized by the stiffening of elastic arteries (known as arteriosclerosis) and the enlargement of aorta. In patients with CHD, aortic dilatation (so-called aortopathy) is one of the most frequent complications. It is well known the anatomical and histological changes in aortopathy are similar to those in aging process. The increase of pulse wave velocity (PWV) enhances pressure wave reflection, and it augments left ventricular afterload and impairs the coronary supply-workload balance in aging. This article reviews the aortic function in patients with CHD, aiming to provide a new direction for the management of their cardiovascular aging process.

Methods

Papers on vascular physiology in CHD were retrieved. I searched all original papers and reviews about the vascular physiology in CHD using PubMed, published from January 1, 1973 to June 30, 2022, in English.

Key Content and Findings

Enhancement of pressure wave reflection has been reported in many CHDs. Although PWV in whole aorta is not necessarily elevated, the abnormal arterial stiffness gradient is common in patients with CHD.

Conclusions

Many reports concerning functional abnormalities of the aorta have been reported. The abnormalities can result in cardiovascular disease and organ damage. The practitioners should carefully treat patients with CHD while paying attention to their aging process.

Bicuspid Aortic Valves: an Up-to-Date Review on Genetics, Natural History, and Management

PURPOSE OF REVIEW

Bicuspid aortic valve (BAV) is the most common congenital cardiac abnormality. It has a wide spectrum of clinical manifestations including aortic regurgitation (AR), aortic stenosis, and an associated aortopathy with a small but increased risk of aortic dissection. This review describes current knowledge of BAV, from anatomy and genetics to a discussion of multifaceted strategies utilized in the management of this unique patient population. This review will also highlight critical knowledge gaps in areas of basic and clinical research to enhance further understanding of this clinical entity.

RECENT FINDINGS

The current knowledge regarding pathophysiologic mechanisms, screening, and surveillance guidelines for BAV and the associated aortopathy is discussed. We also discuss current management techniques for aortic valve repair versus replacement, indications for aortic surgery (root or ascending aorta), and the emergence of the Ross procedure as a viable management option not only in children, but also in adolescents and adults. The varied clinical phenotype of the BAV, resulting in its specific complex hemodynamic interactions, renders it an entity which is separate and distinct from the tricuspid aortic valve pathologies. While various aortic histopathologic and protein alterations in BAV patients have been described, it remains unclear if these changes are causal or the result of hemodynamic alterations imposed by sheer stress on the intrinsically dysfunctional BAV. Medical management for patients with BAV with AS, AI, or dilated aortic roots/ascending aortas remains challenging and needs further investigation. More than 50% of patients with BAV will undergo AVR during their lifetime, and more than 25% of patients with BAV undergo aortic surgery performed for dilation of the aortic root or ascending aorta, often concurrently with AVR. The search for the ultimate genetic or epigenetic cause of the different bicuspid phenotypes will ultimately be facilitated by the next-generation sequencing tools that allow for study of large populations at low cost. Improvements in diagnostic and stratification criteria to accurately risk assess BAV patients are critical to this process.

Surgical and endovascular treatment of late post-coarctation repair aortic aneurysms: results from an international multicenter study

OBJECTIVE

Formation of post-aortic coarctation aneurysms (pCoAA) is well described in the literature and carries a significant risk of rupture and death. Treatment strategies include open surgical, hybrid, and endovascular repair dependent on clinical presentation, risk assessment, and anatomy. The aim of this study is to report early and mid-term results of open surgical and endovascular repair of pCoAA.

METHODS

This is an international multicenter retrospective study including patients who underwent open surgical or endovascular repair for pCoAA between 2000 and 2021 at 14 highly specialized academic cardiovascular centers. The pre-, intra-, and postoperative data were recorded and analyzed.

RESULTS

A total of 74 patients [46 male, median age 44 years-old (IQR, 35-53)] underwent pCoAA repair. All patients had previously undergone surgical repair of aortic coarctation (CoA) at a median age of 11 years-old for the index procedure (IQR, 7-17). The most common first surgical correction was synthetic patch aortoplasty in 48 patients, followed by graft interposition in 11. Median pCoAA diameter was 54 mm (IQR, 44-63). The median time from the CoA repair to the pCoAA diagnosis was 33 years (IQR, 25-40). A total of 33 patients had symptoms at presentation, including thoracic or back pain in eight. Open surgical repair was performed in 28 patients, including four frozen elephant trunk (FET) procedures and one Bentall. The remaining 46 patients underwent endovascular repair of the pCoAA. Two in-hospital deaths were observed (one FET and one endovascular). After a median follow-up of 50 months (IQR, 14-127), there was a total of seven reinterventions.

CONCLUSIONS

This international multicenter study demonstrates that patients with pCoAA can be safely treated with either open surgical or endovascular interventions. Since the median time between the coarctation repair and the aneurysm formation was over 30 years, life-long surveillance of these patients is warranted.

Risk Factors and Outcomes Associated With Hypertensive Disorders of Pregnancy in Maternal Congenital Heart Disease

Background

Among women with congenital heart disease (CHD), risk factors for hypertensive disorders of pregnancy (HDP) and the association of HDP with adverse outcomes are unknown.

Objectives

The purpose of this study was to identify risk factors for HDP among women with and without CHD and to assess the association of HDP with adverse events.

Methods

This retrospective cohort study included the first live birth for each woman who was pregnant in Alberta, Canada, between January 1, 2005, and December 31, 2018. The prevalence of HDP among women with and without CHD was compared. Multivariable models were used to determine the independent associations between maternal characteristics and HDP and to assess the strength of associations between HDP and CHD with adverse events.

Results

Of the total birth events, 0.6% (N = 2,575) occurred in women with CHD. HDP were more common among women with CHD (11.2% vs 8.1%, P < 0.0001). Chronic hypertension and diabetes mellitus were strongly associated with HDP among women with CHD (adjusted odds ratio [aOR]: 4.56; 95% confidence interval [CI]: 2.95-7.03; and aOR: 3.33; 95% CI: 1.48-7.49, respectively). Coarctation of the aorta was the only CHD lesion independently associated with increased risk for HDP (aOR: 1.76; 95% CI: 1.02-3.02). HDP, as opposed to CHD, was more strongly associated with having a complicated delivery admission, preterm delivery, and small for gestational age infant.

Conclusions

HDP were more common among women with CHD. The strongest risk factors for HDP among women with CHD were acquired. The presence of HDP, rather than CHD, was more strongly associated with certain adverse outcomes.

Hybrid Transcarotid Exclusion of Postoperative Ascending Aortic Dissection in an Infant

Aortic dissection is very rare in pediatric patients, and associated risk factors include congenital heart disease, previous cardiac surgery, and vasculopathies. Acute postoperative aortic dissection in pediatric patients can be life-threatening. We performed a novel hybrid transcarotid covered stent exclusion of a postoperative ascending aortic dissection in an infant. (Level of Difficulty: Advanced.)

Diminished Endothelial Function but Normal Vascular Structure in Adults with Tetralogy of Fallot

The life expectancy of patients with Tetralogy of Fallot (ToF) has increased in recent years. As a result, other risk factors with later onset in life are in the focus of patient care. Endothelial function is an early indicator of cardiovascular risk and was investigated along further structural vessel properties. A total of 17 patients (41.7 ± 7.1 years, 8 women) with Tetralogy of Fallot were 1:2 matched for sex with 34 (38.9 ± 8.1 years, 16 women) healthy volunteers. Participants received an assessment of their endothelial function and a structural assessment of the aorta. Patients with ToF showed a reduced endothelial function determined by reactive hyperaemia index after adjusting for age, weight and height (ToF: 1.55 ± 0.31 vs. controls: 1.84 ± 0.47; p = 0.023). No differences in carotid intima-media thickness (cIMT) between the ToF and healthy controls (ToF: 0.542 ± 0.063 mm vs. controls: 0.521 ± 0.164 mm; p = 0.319) were found. Patients with ToF had reduced vascular function compared to healthy subjects. As the structural component is not affected, endothelial dysfunction seems not to have yet manifested itself as a morphological change. Nevertheless, long-term management of these patients should include vascular parameters.

Prevalence and risk of progressive aortic aneurysm and dissection in adults with conotruncal anomalies

AIMS

Conotruncal anomalies share common embryogenic defects of the outflow tracts and great arteries, which result in a predisposition to aortic aneurysms. The purpose of this study was to describe the prevalence and risk of progressive aortic aneurysms in adults with conotruncal anomalies.

METHODS AND RESULTS

Retrospective study of adults with conotruncal anomalies that underwent cross-sectional imaging 2003-20. Aneurysm was defined as aortic root/mid-ascending aorta >2.1 mm/m2/>1.9 mm/m2, progressive aneurysm as increase by >2 mm, and severe aneurysm as dimension >50 mm. Of 2261 patients (38 ± 12 years; male 58%), 1167 (52%) had an aortic aneurysm, and 205 (14%) had a severe aortic aneurysm. Mean annual increase in aortic root/mid-ascending aorta was 0.3 ± 0.1 mm/0.2 ± 0.1 mm. The 3-, 5-, and 7-year cumulative incidence of the progressive aortic aneurysm was 4%, 7%, and 9%, respectively. The rate of aneurysm growth decreased with age, with no significant growth after age 40 years. There was an excellent correlation between aortic indices from cross-sectional imaging and echocardiography. Of 950 females, 184 had ≥1 pregnancy, and 81 (44%) of the 184 patients had aortic aneurysm prior to pregnancy. There was no aortic dissection or progression of the aortic aneurysm during pregnancy. Overall, there was no aortic dissection during 7984 patient-years of follow-up.

CONCLUSIONS

Aortic aneurysm was common in patients with conotruncal anomalies. However, the risk of progressive aneurysm or dissection was low. Collectively, these data suggest a benign natural history and perhaps a less frequent need for cross-sectional imaging. Further studies are required to determine the optimal timing for surgical intervention in this population.

Bilateral Acute Renal Infarction Due to Paradoxical Embolism in a Patient with Eisenmenger Syndrome and a Ventricular Septal Defect

A 52-year-old man who was diagnosed with Eisenmenger syndrome due to a muscular-type ventricular septal defect 30 years previously, visited our emergency room after experiencing six hours of severe left flank pain and vomiting. On laboratory examination, azotemia and microscopic haematuria were identified. Contrast-enhanced computed tomography also revealed pulmonary embolism (PE) and bilateral acute renal infarction. The flank pain resolved after heparin was administered for anti-coagulation and aspiration thrombectomy was performed. The patient was discharged on warfarin as anticoagulant therapy. In this case, a paradoxical embolism was considered to have been the cause of PE and bilateral acute renal infarction in a patient with Eisenmenger syndrome.

Valve-Sparing Reimplantation for Right Coronary Artery Compression after Fontan Procedure

An incidental finding of right coronary artery compression, between the dilated aortic root and the sternum, was detected on follow-up cardiac catheterization after Fontan completion for tricuspid atresia with transposition of the great arteries. Although this 31-year-old man had no subjective symptoms, an exercise stress test and perfusion scan revealed ischemic changes in the inferior region. Valve-sparing aortic root replacement using the reimplantation technique proved to be an effective approach for this condition. The possibility of coronary artery compression associated with aortic root dilatation should be considered in patients with adult congenital heart disease.

Cardiac Structures in Marine Animals Provide Insight on Potential Directions for Interventions for Pediatric Congenital Heart Defects

Despite recent advances in pediatric diagnosis and surgical intervention, mortality and morbidity continue to be a prevalent issue in both Tetralogy of Fallot (ToF) and Hypoplastic Left Heart Syndrome (HLHS). Therefore, novel approaches to studying both of these conditions is warranted. Investigating cardiac anatomical features of different species in the animal kingdom similar to the defects and complications present in ToF and HLHS (as well as others) could serve as a new avenue for improving the management of congenital heart diseases (CHD). This review reveals that although structures found in HLHS and ToF are pathological, similar structures are found in diving mammals and reptiles that are adaptive. Pathologic aortic dilation in CHD resembles the aortic bulb present in diving mammals, but the latter is more elastic and distensible compared to the former. The unrepaired HLHS heart resembles the univentricular heart of non-crocodilian reptiles. Right ventricle hypertrophy is pathological in HLHS and ToF, but adaptive in crocodilians and diving mammals. Lastly, the increased pulmonary resistance due to pulmonary stenosis in ToF is comparable to increased pulmonary resistance in crocodilians due to the presence of an active valve proximal to the pulmonary valve. Some of these anatomical structures could potentially be adapted for palliative surgery in children with HLHS or ToF. Moreover, further investigating the underlying molecular signals responsible for the adaptive tissue responses seen in other species may also be useful for developing novel strategies for preventing some of the complications that occur after surgical repair in both of these CHDs.

Aortic dissection and ruptures in adult congenital heart disease in Texas from 2009 to 2019

OBJECTIVES

Acute thoracic aortic dissection and rupture (TADR) has an incidence of 5-7 per 100 000-person years. Today, most children with congenital heart disease (CHD) survive to become adults with congenital heart disease (ACHD). This study evaluates TADR in patients with ACHD in a large, hospitalized patient population over 11 years to evaluate the incidence, risk factors and outcomes associated with TADR.

METHODS

This was a retrospective review of the Texas Inpatient Discharge Data Set from 1 January 2009 to 31 December 2019. All non-trauma discharges of patients ≥18 years were included. ACHD discharges were identified by International Classification of Diseases, 9th edition (ICD-9)/10 diagnosis codes. TADR were identified using 2 definitions: TADR1 is an ICD-9/10 code for TADR, and TADR2 is TADR1 with an ICD-9/10 procedure code for aortic intervention. Descriptive, univariate and logistic regression statistics were used.

RESULTS

A total of 22 154 664 eligible discharges were identified, of which 12 584 (0.06%) were TADR1 and a subgroup of 5699 (0.03%) were TADR2. CHD was more prevalent in TADR1 (0.2% vs 0.05%; P < 0.001) and TADR2 (0.3% vs 0.04%; P < 0.001). Adjusting for known TADR risk factors, CHD had an odds ratio of 1.69 (95% confidence interval: 1.09-2.63; P = 0.020) for TADR1 and an odds ratio of 1.69 (95% confidence interval: 0.99-2.88; P = 0.056) for TADR2. No in-hospital deaths were found in patients with CHD with TADR.

CONCLUSIONS

ACHD discharges had a higher frequency of TADR versus the general population (0.9-1.2 vs 0.3-0.6 per 1000 discharges). There is an indication that CHD confers an increased adjusted odds of TADR. As the ACHD population continues to grow in number as well as age, it will be important to continue to assess the risk of TADR from CHD and how traditional risk factors impact this risk.

Aortenisthmusstenose – eine lebenslange Systemerkrankung

Koarktation der Aorta (CoA) ist eine Systemerkrankung aller prästenotischen Arterien. Während im Säuglingsalter die chirurgische Behandlung im Vordergrund steht, werden erwachsene Patienten mit CoA oder Re-CoA nach chirurgischer Initialbehandlung, heute überwiegend mit Stents behandelt, wenn dies technisch möglich ist. Trotz erfolgreicher Beseitigung der aortalen Enge bleiben viele Patienten hypertensiv. Die Ursache des arteriellen Hypertonus ist multifaktoriell. Erwachsene CoA-Patienten müssen zum einen regelmäßig in einem EMAH-Zentrum evaluiert werden und benötigen zum anderen häufig eine permanente antihypertensive medikamentöse Therapie.

Characteristics of the aortic root morphology in conotruncal anomaly of the congenital heart disease

BACKGROUND

Aortopathy is a well-known feature of conotruncal anomalies, but it remains unknown whether valve-sparing aortic root replacement, such as the David procedure, is feasible in young patients with severe aortic regurgitation. We assessed the aortic valve complex and aortic root morphology in patients with conotruncal anomalies using echocardiography. Furthermore, we evaluated the relevant factors associated with aortopathy in this population.

METHODS

A total of 172 adult patients with conotruncal anomalies were enrolled in this study. Dimensions of the aortic valve complex were measured at the level of the sinus of Valsalva (SV) and sinotubular junction (STJ). The geometric height (GH), effective height (EH), and coaptation length (CL) were also assessed to analyze the aortic valve complex in detail.

RESULTS

Sixteen of 172 patients were excluded due to poor imaging; 105 patients with tetralogy of Fallot, 24 with double outlet right ventricle, and 27 with transposition of the great arteries totaling 156 patients (32+/-11 years old) were included in the analysis. The patients were divided into four groups: Group 1 (98 patients) had no dilatation of SV or STJ; Group 2 (32 patients) had dilated SV and STJ; Group 3 (14 patients) had dilated SV; and Group 4 (12 patients) had dilated STJ. GH and EH in Group 2 were also highest among the four, whereas CL was not significantly shortened. Multivariate analysis revealed that male sex, age, and conduit repair were risk factors for aortopathy in this population.

CONCLUSIONS

Patients with dilated SV and STJ (Group 2) were the most common among the patients with aortopathy (Groups 2, 3, and 4). The aortic valve leaflets themselves were enlarged, and the poor coaptation of the valve tips was compensated in spite of aortic root dilatation, which plays an important role in preventing severe aortic regurgitation in this population. Overall, valve-sparing aortic valve replacement is more feasible in the young populations than we expected.

Arterial Stiffness and Left Ventricular Myocardial Function in Children with a Well-Functioning Bicuspid Aortic Valve

Fundamento:

A rigidez arterial é um importante preditor de aortopatia e remodelamento miocárdico em pacientes com válvula aórtica bicúspide, podendo estar aumentada na infância.

Objetivo:

Avaliar a rigidez arterial e a função miocárdica do ventrículo esquerdo em crianças com válvula aórtica bicúspide funcional.

Métodos:

Quarenta e quatro crianças com válvula aórtica bicúspide e 41 pares saudáveis com válvula aórtica tricúspide foram incluídos neste estudo caso-controle. Foram obtidos os diâmetros e os escores-z relacionados da raiz aórtica e da aorta ascendente. Quanto à função miocárdica do ventrículo esquerdo, juntamente com as velocidades de fluxo mitral e parâmetros do Modo M, as velocidades miocárdicas e os intervalos de tempo foram avaliados com Doppler tecidual. A análise da onda de pulso foi realizada por aparelho oscilométrico (Mobil-o-Graph). Um valor de p<0,05 foi considerado significativo.

Resultados:

O índice da massa ventricular esquerda, a velocidade A do fluxo mitral, o diâmetro e o escore z da aorta ascendente e o índice de desempenho miocárdico estavam significativamente maiores nos pacientes (p = 0,04, p = 0,02, p = 0,04, p <0,001 e p <0,001 respectivamente). O índice de desempenho miocárdico correlacionou-se positivamente com o diâmetro da aorta ascendente e a velocidade A (r=0,272; p=0,01, r=356; p=0,001, respectivamente). A análise multivariada revelou que o índice de desempenho miocárdico estava relacionado ao diâmetro da aorta ascendente (p = 0,01). O índice de aumento e a velocidade da onda de pulso foram semelhantes entre os grupos (p> 0,05).

Conclusão:

De acordo com a análise da onda de pulso oscilométrico, as crianças com válvula aórtica bicúspide funcional apresentam rigidez arterial semelhante a seus pares saudáveis. O diâmetro da aorta ascendente foi estabelecido como preditor independente da função miocárdica do ventrículo esquerdo. A rigidez arterial pode não ser um fator de risco grave em pacientes pediátricos sem dilatação acentuada da aorta ascendente.

Histologic Abnormalities of the Ascending Aorta: Effects on Aortic Remodeling after Intracardiac Repair of Tetralogy of Fallot

We evaluated aortic tissue specimens from patients undergoing tetralogy of Fallot repair, to determine whether histologic abnormalities affect postsurgical aortic remodeling and other patient-related variables. Using light microscopy, we studied full-thickness aortic wall tissue operatively excised from 118 consecutive patients undergoing intracardiac repair of tetralogy of Fallot. We performed multiple linear regression analysis to identify independent predictors of change in aortic root dimensions, which we measured with echocardiography after repair and every 3 months thereafter. Thirty histologically normal specimens were used as controls. Elastic fiber fragmentation was found in 74.6% of the abnormal specimens, mucoid extracellular matrix accumulation in 49.2%, smooth muscle cell nuclei loss in 39%, smooth muscle cell disorganization in 28.8%, and medial fibrosis in 52.5%. At a mean follow-up time of 83.55 ± 42.08 months, mean aortic sinotubular diameter decreased from 28.79 ± 9.15 to 27.16 ± 8.52 mm/m2 (r =-0.43; P <0.001). Aortic sinotubular diameter decreased by 0.6 mm/m2 among females (β =0.6, SE=0.31; P =0.05) and by 0.88 mm/m2 in patients who had elastic fiber fragmentation or loss (β =0.88, SE=0.38; P =0.02). In bivariate and multiple linear regression analysis, duration of follow-up emerged as an independent predictor of aortic remodeling. The aortic histopathologic changes in our patients had an independent negative impact on the degree of aortic remodeling after surgery. We observed the most improved aortic sinotubular diameter in patients who had either histologically normal aortas or aortas with elastic fragmentation.

Association between Objectively Measured Physical Activity and Arterial Stiffness in Children with Congenital Heart Disease

BACKGROUND

The association between physical activity (PA) and arterial stiffness is particularly important in children with congenital heart disease (CHD) who are at risk for arterial stiffening. The aim of this study was to examine the association between objectively measured PA and arterial stiffness in children and adolescents with CHD.

METHODS

In 387 children and adolescents with various CHD (12.2 ± 3.3 years; 162 girls) moderate-to-vigorous PA (MVPA) was assessed with the "Garmin vivofit jr." for 7 consecutive days. Arterial stiffness parameters including pulse wave velocity (PWV) and central systolic blood pressure (cSBP) were non-invasively assessed by oscillometric measurement via Mobil-O-Graph®.

RESULTS

MVPA was not associated with PWV (ß = -0.025, p = 0.446) and cSBP (ß = -0.020, p = 0.552) in children with CHD after adjusting for age, sex, BMI z-score, peripheral systolic blood pressure, heart rate and hypertensive agents. Children with CHD were remarkably active with 80% of the study population reaching the WHO recommendation of average 60 min of MVPA per day. Arterial stiffness did not differ between low-active and high-active CHD group after adjusting for age, sex, BMI z-score, peripheral systolic blood pressure, heart rate and hypertensive agents (PWV: F = 0.530, p = 0.467; cSBP: F = 0.843, p = 0.359).

CONCLUSION

In this active cohort, no association between PA and arterial stiffness was found. Longer exposure to the respective risk factors of physical inactivity might be necessary to determine an impact of PA on the vascular system.

Magnetic resonance imaging assessment of aortic dilatation and distensibility in 269 patients with repaired tetralogy of Fallot

PURPOSE

To determine the prevalence and degree of aortic dilatation (A_dilatation), severity of aortic stiffness (A_stiff), factors for A_dilatation, and level of aortic root most sensitive to A_stiff in patients with repaired tetralogy of Fallot (rTOF).

MATERIALS AND METHODS

269 patients with rTOF (mean age 14.9 ± standard deviation 5.0 years) were analyzed for A_dilatation at annulus, sinus, sinotubular junction, and ascending aorta (aAo). Aortic size index was graded as Z score < 2, 2-2.99, 3-4.99 and ≥ 5. Aortic distensibility (aA_dis) was categorized according to 4 aortic levels and dilatation severity. Factors for A_dilatation and level of aortic root most sensitive to A_stiff were analyzed.

RESULTS

Sinus and aAo were the two most common sites of A_dilatation, with a prevalence of 84% and 76%, respectively. A decreased aA_dis was found (mean 5.38 ± 1.79 10^-3 mmHg^-1). aA_dis only declined significantly at the sinus level (p = 0.009). Male sex, age-at-repair and aortic regurgitation were significant factors for A_dilatation, with male sex as the strongest factor (odds ratio 2.94). There was a significant decline in aA_dis at sinus level (p = 0.002) as A_dilatation progressed.

CONCLUSIONS

We observed a high prevalence of A_dilatation and A_stiff in patients with rTOF. Male sex is the strongest factor for A_dilatation. The sinus is the most sensitive area for determining a negative aA_dis effect.

Early vascular aging in adult patients with congenital heart disease

Many studies have reported that adults with congenital heart disease suffer from hypertension and cardiovascular disease even at younger ages. Therefore, we analyzed early vascular aging, which is defined as pulse wave velocity values higher than the 95th percentile for age and sex, and clarified the relationship between early vascular aging and many parameters related to cardiovascular disorders in adults with congenital heart disease. We enrolled 72 adult patients with congenital heart disease and measured their brachial-ankle pulse wave velocity. Comparing the data between age- and sex-matched controls, patients with a pulse wave velocity higher than the 95th percentile for age and sex were defined as exhibiting early vascular aging. The parameters of patients with and without early vascular aging were compared. Early vascular aging was observed in 15.6% of the patients. Age, systolic blood pressure, diastolic blood pressure, pulse pressure, blood sugar, hemoglobin A1c, uric acid, low-density lipoprotein cholesterol, and triglyceride levels were positive determinants of early vascular aging. Logistic regression analysis proved that systolic blood pressure was a significant determinant of early vascular aging (odds ratio, 1.128, 95% confidence interval, 1.049-1.214; p = 0.001). The prevalence of early vascular aging is high in adult patients with congenital heart disease. Because early vascular aging can damage a patient's vulnerable heart, careful follow-up of blood pressure and pulse wave velocity is essential.

Provision of medical health care for adults with congenital heart disease associated with aortic involvement

Background

All patients with congenital heart disease (CHD) are chronically ill from their cardiac disease. Despite the increasing evidence that aortic alterations are becoming relevant, the importance of aortopathy in CHD has long been underestimated. This study was conducted to determine the health status of patients and/or the provision of health services of adults with CHD (ACHD) with manifest aortopathy or at risk thereof.

Methods

In a questionnaire-based cross-sectional survey, the "real life"-care of ACHD was analysed, comparing patients with risk of developing aortopathy and/or manifest aortopathy.

Results

Of the 563 enrolled ACHD (49.6% female, mean age 35.8±12.1, 18-86 years) 56.8% (n=320) had a risk of developing aortopathy and/or manifest aortopathy. Of the 320 patients at risk, 187 (33.2% of the total number) had a proven aortopathy. Within this subgroup, the basic medical care for CHD-independent medical problems was given by primary medical care providers [family doctors/general practitioners (GP) in 89.4% (n=286), internists in 13.4% (n=43), physicians of another specialty in 2.5% (n=8)]. Almost all primary medical care providers knew about the CHD of their patients. Even for CHD-specific health problems, the basic medical care of risk patients was provided by a family doctor or GP in 56.6% (n=181) and by an internist in 18.4% (n=59). 30.0% (n=96) primarily consulted another specialist, including cardiologists. Only 32.8% of ACHD at risk had ever been referred to a CHD specialist by a GP for cardiac problems related to their CHD. In contrast, the need for advice was high for ACHD with aortopathy and related mainly to physical activity, employment and education, pregnancy, rehabilitation or health and life insurance. Only 35.5% of patients at risk indicated that their information on specific care structures for ACHD was sufficient, and a further 38.1% of patients were aware of patient organizations.

Conclusions

Even today, aortic involvement in ACHD is an often-overlooked condition, although considerable negative effects on morbidity and mortality exist. As aortopathy gains in importance with increasing age and complexity of CHD, almost all affected ACHD need lifelong medical advice and access to modern, scientifically based care concepts. According to the study-results, primary care providers and also patients are mostly insufficiently informed about the specialized ACHD facilities. The future goal is therefore to create a better awareness of CHD problems among both primary care physicians and the patients concerned.

Metabolic syndrome and coronary artery disease in adults with congenital heart disease

In adults with congenital heart disease (ACHD), conditions acquired with aging, such as metabolic syndrome, hypertension, diabetes mellitus, and obesity, can negatively influence the original cardiovascular disease. Metabolic syndrome has a higher prevalence in ACHD than in the general population. In contrast, coronary artery disease shows a similar prevalence in adults with acyanotic CHD and the general population, while adults with cyanotic CHD, even after repair, have an even lower incidence of coronary artery disease than the general population/adults with acyanotic CHD. However, even in those with cyanotic CHD, coronary artery disease can develop when they have risk factors such as obesity, dyslipidemia, hypertension, diabetes mellitus, smoking habit, or limited exercise. The prevalence of risk factors for cardiovascular disease is similar between ACHD and the general population, but an increased risk of coronary atherosclerosis has been observed for congenital coronary artery anomalies, dextro-transposition of the great arteries after arterial switch operation, Ross procedure, and coarctation of the aorta. Aortopathy may be an additional risk factor for cardiovascular disease. As ACHD have other abnormalities that may make the heart more vulnerable to both the development of atherosclerosis and adverse cardiovascular sequelae, regular evaluation of their cardiovascular disease risk status is recommended. Metabolic syndrome is more common among ACHD than in the general population, and may therefore increase the future incidence of atherosclerotic coronary artery disease even in ACHD. Thus, ACHD should be screened for metabolic syndrome to eliminate risk factors for atherosclerotic coronary artery disease.

Predictors of neo-aortic valve regurgitation in the long term after arterial switch operation

Although arterial switch operations (ASOs) have been performed globally to repair d-transposition of the great arteries (d-TGA) in neonates and infants, few studies have been reported regarding the influence of the hemodynamics of patients with d-TGA who have undergone ASO on the development of neo-aortic valve regurgitation (AR). We aimed to investigate the relationship between the hemodynamics and development of AR after ASO in patients with d-TGA by catheter evaluation. This observational study screened 114 consecutive patients who underwent ASO for d-TGA or Taussig-Bing anomaly and who subsequently underwent catheter evaluations in our institution. We reviewed their records for the past 20 years and collected their first catheterization data post-ASO in early childhood. Thirty-six post-ASO patients who underwent catheter evaluations in both the early surgical and long-term phases were finally analyzed. Patients were divided into the following groups according to the presence of significant AR in the long-term phase: the AR group (n = 9 with AR ≥ grade II by the Sellers classification) and the non-AR group (n = 27 with AR < grade II). In the long-term phase, the diastolic blood pressure was significantly lower and the ascending aortic diameter was significantly larger in the AR group than in the non-AR group (p = 0.004 and p = 0.006, respectively). The systolic blood pressure (SBP) and pulse pressure (PP) were similar in both groups. Meanwhile, in the early surgical phase, SBP and PP were significantly higher in the AR group than in the non-AR group (p = 0.029 and p = 0.002, respectively). The receiver operating characteristic curve for late AR showed that the area under the curve for SBP and PP in the early surgical phase were 0.746 and 0.853, respectively. Even though sensitivity analysis was performed, SBP or PP greater than the cutoff value in the early surgical phase was identified as predictors for late AR. Our results suggested that high SBP or PP in the early surgical phase could influence the development of AR in the long term after ASO.