Long-term outcomes following transcatheter pulmonary valve implantation with the sapien 3 valve: an international multicentre registry

Background

Transcatheter pulmonary valve implantation (TPVI) is indicated to treat right-ventricular outflow tract dysfunction related to congenital heart disease. Long-term outcomes following TPVI with the new-generation SAPIEN 3 valve are not well documented.

Purpose

We investigated mid-term outcomes in a large cohort of patients who underwent TPVI using the SAPIEN 3 valve.

Methods

We retrospectively analysed data from a multicentre observational registry of patients who underwent TPVI with SAPIEN 3 in 30 centres in 12 countries from Europe, the Middle East, and Canada. Patient-related, procedural, and mid-term-outcome data were assessed.

Results

We obtained data for 713 patients treated in 2014–2021. Number of procedures performed among centres varied from 1 to 190 with a median of 15. Median age was 29.4-year-old [19.0–42.8]. The most common underlying diagnosis was cono-truncal defect (68.9%), with a native or patched right-ventricular outflow tract, a bioprosthetic valve, a homograft and a conduit, in 50.8%, 19.6%, 16.5% and 13.2% patients, respectively. Pre-stenting was performed in 74.8% patients. The 20-mm, 23-mm, 26-mm, and 29-mm valves were used in 0.4%, 28.2%, 31.2%, and 40.2% of patients, respectively. Valve implantation was successful in 98.6% patients. Life-threatening peri-procedural adverse events occurred in 3.7% patients, including 0.6% peri-procedural death. Median follow-up was 1.4 years (maximum, 5.9 years; 1160 patient-years), At last follow-up, pulmonary regurgitation grade 2, 3 and 4 was noted in 6.9%, 0.9% and 0.0% patients, respectively. Median maximal gradient at last follow-up was 18 mmHg.

Six patients experienced infective endocarditis (0.5 per 100 patient-years) of whom 1 died and 2 required pulmonary valve replacement. Nine patients (0.8 per 100 patient-years) had secondary pulmonary valve replacement (including 2 by valve-in-valve TPVI; 7 patients had 23-mm and 2 had 26-mm valves). Four patients experienced pulmonary valve thrombosis (0.6 per 100 patient-year) of whom one died and 3 resolved under anticoagulation therapy.

Cumulative incidences of infective endocarditis, secondary pulmonary valve replacement and valve thrombosis were 0.7%, 1.3% and 1.3%; 0.4%, 1.3% and 4.6%; 0.5%, 0.5% and 0.8% at 1, 3 and 5 years after TPVI respectively.

Conclusion

TPVI with the SAPIEN 3 valve was feasible and safe in a wide range of patients with congenital heart defects, most of whom had large native right-ventricular outflow tracts. Mid-term outcomes were favourable.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): The study is promoted and financially supported by a Research grant of the Groupe Hospitalier Paris Saint Joseph

Cardiovascular Comorbidities and Covid-19 in Women

Background

While women account for 40-50 % of patients hospitalized for coronavirus disease 2019 (Covid-19), no specific data have been reported in this population.

Purpose

Assess the burden of cardiovascular comorbidities on outcomes in women hospitalized for Covid-19.

Methods

We conducted a retrospective observational multicenter study from February 26 to April 20, 2020 in 24 French hospitals including all adults admitted for Covid-19. Primary composite outcome included transfer to intensive care unit (ICU) or in-hospital death.

Results

Among 2878 patients hospitalized for Covid-19, 1212 (42.1 %) were women. Women were significantly older (68.3 ± 18.0 vs. 65.4 ± 16.0 years, P < 0.001) but had less prevalent cardiovascular comorbidities than men. Among women, 276 (22.8 %) experienced the primary outcome, including 161 (13.3 %) transfer to ICU and 115 (9.5 %) deaths without transfer to ICU. The survival free from death or transfer to ICU was higher in women (HR 0.63, 95 %CI 0.53-0.73, P < 0.001), whereas the observed difference in in-hospital deaths did not reach statistical significance (P = 0.18). The proportion of women that experienced the primary outcome were 37.8 % in women with heart failure (n = 112), 30.9 % in women with coronary artery disease (n = 81), 29.1 % in women with diabetes (n = 254), 26.1 % in women with dyslipidemia (n = 315), and 26.0 % in women with hypertension (n = 632). Age (HR 1.05, 5 years increments, 95 %CI 1.01-1.10), body mass index (HR 1.06, 2 units increments, 95 %CI 1.02-1.10), chronic kidney disease (HR 1.57, 95 %CI 1.11-2.22), and heart failure (HR 1.52, 95 %CI 1.04-2.22) were independently associated with the primary outcome (Fig. 1).

Conclusions

Women hospitalized for Covid-19 were older and had less prevalent cardiovascular comorbidities than men. While female sex was associated with a lower risk of transfer to ICU or in-hospital death, Covid-19 remains associated with considerable morbi-mortality in women, especially in those with cardiovascular diseases.

3-Dimensional echocardiographic evaluation of right ventricular function in pediatric sickle cell disease population

Introduction

Sickle cell disease (SCD) is characterized by chronic hemolytic anemia and intermittent vaso-occlusive events associated with cardiac abnormalities.

Aim

To assess 3 dimensional (3D) echocardiographic of right ventricle (RV) volumes and function in a pediatric SCD population.

Methods

Eighteen patients with SCD aged 4 to 17 years old (mean age: 8.0±4 years, 56% male, body surface area (BSA) 1.0±0.35) and 18 healthy controls matched for age, gender and BSA were prospectively included and compared. Echocardiograms were performed using a commercially available ultrasound Philipps EPIQ 9 system using matrix X5–1 transducer. 3D indexed RV volumes and ejection fraction (3D- RVEF) were obtained using full volume acquisitions. RV free wall strain, tricuspid S-wave, tricuspid annular plane systolic excursion (TAPSE), indexed cardiac output, systolic pulmonary pressure (sPAP) and hemoglobin were assessed. Data were analyzed with TomtecArena© software (v2.3, Germany).

Results

Cardiac output was significantly higher in SCD children (4.5 vs 3.6 l/min/m2, p=0.025), as sPAP (24.9 vs 21.9 mmHg, p=0.015), 3D-RV diastolic volume (58.1 vs 47.5 ml/m2, p=0.025) and 3D-RV systolic volume (28.8 vs 21.4 ml/m2, p=0.005). 3D-RVEF and RV free wall strain were significantly lower in SCD compared to control population (respectively 51.9 vs 56.3%, p=0.018; −28.6 vs −32, p=0.017). There were no difference regarding TAPSE and doppler S-wave. Mean hemoglobin in SCD population was 9.6±1.7 g/dl.

Conclusions

Despite normal RV systolic function parameters, 3D-RVEF and RV free wall strain are lower in children with SCD. Chronic anemia generating volume overload and vaso-occlusive events could explain these findings.

3D sickle cell

Funding Acknowledgement

Type of funding source: None

Catheter ablation in adults with congenital heart disease: a 15-year perspective from a tertiary center

Background

With the growing population of adults with congenital heart disease (ACHD), the number of catheter ablation procedures is expected to increase over time.

Purpose

We aimed to describe temporal trends in volume and outcomes of catheter ablation procedures in ACHD patients in a large tertiary center.

Methods

Retrospective observational study including all consecutive ACHD patients undergoing catheter ablation in a tertiary reference center over a 15-year period. Acute procedural success rate (including complete success in case of non-inducibility of any arrhythmia at the end of the procedure) as well as freedom from recurrence at 12 months were analyzed.

Results

From November 2004 to November 2019, 302 catheter ablations in 221 ACHD patients (43.6±15.0 years, 58.9% males) were performed. The annual number of catheter ablation increased progressively from 4 to 60 by year (p&lt;0.001). Intra-atrial reentrant tachycardia/focal atrial tachycardia was the most common targeted arrhythmia (n=217, 71.9%). Over the study period, acute procedural success rate increased from 45.0% to 93.3% (p&lt;0.001), including complete acute procedural success from 45.0% to 88.1% (p&lt;0.001) (Figure 1). The use of irrigated catheters (30.0% to 94.8%, p&lt;0.001), 3D-mapping systems (60.0% to 96.3%, p&lt;0.001), contact force catheters (0.0% to 91.9%, &lt;0.001), and high-density mapping (0.0% to 71.9%, p&lt;0.01) increased significantly. Use of irrigated catheters (OR=3.96, 95% CI: 1.79–8.55), 3D-mapping system (OR=3.55, 95% CI: 1.62–7.55), contact force catheters (OR=3.46, 95% CI: 1.71–7.25), and high-density mapping (OR=3.85, 95% CI: 1.60–7.26) were associated with acute procedural success. The rate of freedom from any recurrence at 12 months increased from 29.4% to 66.2% (p=0.001). Seven (2.3%) non-fatal complications occurred.

Conclusions

The number of catheter ablation procedures in ACHD patients has considerably increased over the last 15 years. Advances in ablative technologies appear to be associated with a low rate of complications and a significant improvement in acute and midterm outcomes.

Evolution of acute procedural success

Funding Acknowledgement

Type of funding source: None

P4165Influence of restrictive right ventricular physiology in outcomes after transcatheter pulmonary valve implantation in adult patients

Background

A restrictive right ventricular (RV) physiology (r-RVP) is present in almost half of the patients with repaired tetralogy of Fallot (ToF), but its effect on later patients' clinical status is controversial.

Purpose

Evaluate the outcomes after transcatheter pulmonary valve implantation (TPVI) in patients with restrictive versus non-restrictive RV.

Methods

Single-center retrospective study of patients who underwent TPVI for pulmonary regurgitation between 2008 and 2017. Electrocardiogram, transthoracic echocardiogram, cardiac magnetic resonance and cardio-pulmonary exercise test were performed previous to TPVI and repeated 12 months after. For statistical analysis restrictive physiology was defined as the presence of end-diastolic forward flow (EDFF) and RVEDVi <150ml/m2.

Results

Fifty-nine patients, 55 with tetralogy of Fallot, were included. R-RVP was present in 23 patients (39.0%). At the baseline, the majority of the patients were symptomatic, in NYHA functional class II–III (n=48, 81.4%) and with reduced cardiopulmonary performance (VO2max = 20.5mL/min/kg), both worse among patients with r-RVP (p=0.018 and p=0.018). During a mean follow-up of 446.4±226.1 days after TPVI one patient died. BNP levels were not significantly different from baseline. Despite self-reported functional capacity and exercise capacity improvement after TPVI (p<0.001), all parameters remained lower in r-RVP group. One year after TPVI, pulmonary and tricuspid regurgitation decrease significantly, as well as RVEDV, in both groups. However, RV systolic function remained unchanged in both groups. Regarding to the dysrhythmic profile, all patients with need for an implantable cardiac defibrillator and seven of the eight patients requiring radiofrequency ablation for sustained supraventricular arrhythmias during follow-up were in the group without r-RVP (p=0.038).

Kaplan-Meier survival curve

Conclusion

TPVI had a positive impact in clinical status in a cohort of patients with predominant PR regardless the presence of restrictive physiology. Moreover, besides higher VO2max and anaerobic threshold in the non-restrictive group, the magnitude of the improvement was not statistically different between the two groups. Nevertheless, in patients without r-RVP, a peculiar caution has to be focused regarding rhythmic issue during follow-up, despite the TPVI.

[Severe hydrogen sulfide intoxication: a pediatric case of survival]

We report a paediatric case of survival following severe hydrogen sulfide (H2S) gas intoxication. A 13-year-old boy was found submerged to the neck in a manure tank. He was hypothermic, unresponsive with bilateral mydriasis, and had poor oxygen saturation. After intubation, he was transferred to the paediatric intensive care unit of a tertiary care children's hospital. He developed acute respiratory distress syndrome (ARDS) requiring high frequency percussive ventilation. Cardiac evaluation was significant for myocardial infarction and left ventricular function impairment. He completely recovered from the respiratory and cardiac failure. Neurological examinations showed abnormal signals on MRI in the semi-oval center and in the frontal cortex. Follow-up detected partial impairment of axonal fibers of the right external popliteal sciatic nerve. Paediatric cases of survival after H2S intoxication have been rarely reported. Such exposures can evolve to severe ARDS and benefit from high frequency percussive ventilation. Hypothermia and other metabolic abnormalities are now better explained thanks to actual knowledge about endogenous H2S function. Lessons learned from paediatric accidents should result in better information about this threat for farmers and families living in houses with septic tanks, reducing the risk to their own and their children's safety.

[Guillain-Barré syndrome in a child with normal tendon reflexes]

We describe the case of a 10-year-old child with the acute motor axonal neuropathy (AMAN) form of Guillain-Barré syndrome (GBS) with preserved tendon reflexes, 6 days after a bout of gastroenteritis. The child quickly showed weakness of the distal muscles of his four limbs, with preserved tendon reflexes and a raised CSF protein concentration with no cells. Nerve conduction studies showing motor axonal degeneration confirmed the diagnosis of GBS in spite of preserved tendon reflexes. The serum was positive for IgG antibodies to gangliosides GM1 and GD1b. The child received intravenous immunoglobulins, which resulted in a favorable progression. This case proves that GBS with normal tendon reflexes exists. The other cases of SGB with preserved tendon reflexes already described in the literature were the AMANs form with antibodies to gangliosides in the serum and only adults were affected.

[Chronic meningococcemia: 3 cases in the immunocompetent child]

Chronic meningococcemia is a part of extra meningeal manifestations of meningococcal disease. Its diagnosis can be difficult because of lack of sensitivity of blood cultures.

CASE REPORT

Three cases, concerning immunocompetent children, respectively aged of 14, 10 and 4 years are reported. The clinical course was characterized by recurrent fever, inflammatory joint manifestations and diffuse maculopapules secondary centered by petechiae. Microbiological findings revealed in one case a positive throat culture and presence of meningococcal soluble antigens in blood and urine. In the other two cases, diagnosis was done after done after positive blood culture at the 7th, and 13th days of course.

CONCLUSION

The diagnosis should be considered in any children with a prolonged, recurrent fever and cutaneous and joint manifestations even if blood cultures remain negative. The response to therapy by usual antimeningococcal antibiotics is dramatic and curative while a prolonged untreated course may be complicated by metastatic infection.

[Clear cell meningioma: recurrent intraspinal tumor in a child]

BACKGROUND

Meningiomas represent 1.5% to 4.3% of cerebral and medullar primary tumors in children.

CASE REPORT

A 9-year-old girl had a history of thoracolumbar scoliosis. An intracanalar and extramedullar tumor was confined to the lumbar region. Resection identified a clear cell meningioma. A symptomatic and tumoral recurrence occurred 5 months later in the same region. After a second resection, the patient received radiotherapy. At 8 months follow-up, no recurrence was documented.

CONCLUSIONS

A stiff and painful scoliosis can be predictive of expansive intracanalar tumor. The recurrent or multifocal evolution of clear cell meningioma show the "aggressive behavior" of this histological type. A preventive radiotherapy could be proposed, depending on the age of the patient and the localization of the tumor.

Influence of chronic ethanol intake on obesity, liver steatosis and hyperlipidaemia in the Zucker fa/fa rat

The effect of chronic alcohol intoxication on metabolic disturbances and fatty infiltration and degeneration was studied in genetically obese, hyperlipoproteinaemic, fa/fa Zucker rats. Sixteen obese Zucker (fa/fa) rats, sixteen lean Zucker rats (Fa/-) and sixteen Wistar rats, all male rats aged 7-8 weeks, were given either a control (C) diet (13% of energy from protein, 37% from fat, 50% from carbohydrate) or an ethanol (E) diet (13% of energy from protein, 37% from fat, 14% from carbohydrate, 36% from ethanol) for 4 weeks. The fa/fa rats given diet E consumed more energy than those given diet C, but after 4 weeks the weight gains and degrees of obesity were similar for both groups. With both diets, the developed hyperlipidaemia could be explained by the hyperinsulinaemia. Both hypertriglyceridaemia and hypercholesterolaemia were lower in fa/fa rats eating diet E than in those given diet C. Fatty infiltration of the liver, as assessed by hepatic triacyglycerol and cholesterol contents, was observed with both diets, but for fa/fa rats it was less extreme in those given diet E.

Paradoxical effect of ethanol on liver lipogenesis in the genetically-obese Zucker rat

Sixteen obese (fa/fa) Zucker rats, sixteen lean (Fa/-) Zucker rats and sixteen Wistar rats, all male rats aged 7-8 weeks, were given either a control (C) diet containing no ethanol or an ethanol (E) diet in which 36% of the energy was supplied by ethanol, for a period of 4 weeks. The activities of glucose-6-phosphate dehydrogenase (EC 1.1.1.49), glucose-6-phosphatase (EC 3.1.3.9) and glycerol kinase (EC 2.7.1.30) and the glycogen content in the livers of obese (fa/fa) rats were lower in animals given diet E than in those given diet C. As a result, hepatic lipogenesis and fatty degeneration of the liver were reduced in obese (fa/fa) rats given diet E.