A case series describing the multidisciplinary management of pulmonary arterial hypertension in pregnancy: Time for optimism

BACKGROUND

Pulmonary arterial hypertension (PAH) is a high-risk condition during pregnancy, with recent literature describing mortality rates of up to 23%.

AIM

To describe the course and outcomes of pregnancy for women with PAH in a major Australian metropolitan referral centre over a 15-year period.

METHODS

Retrospective review of medical records of all pregnant women with PAH over the period 2005-2020.

RESULTS

We report the outcomes of nine pregnancies in six women. In five women, seven pregnancies proceeded to term with birth of a healthy neonate, five vaginal births and two caesareans. Two women opted for a termination of pregnancy in the first trimester following counselling. The planning of care and patient-centred decision-making was individually tailored by a multidisciplinary team. The pulmonary hypertension clinic provided specialist support including the management of pulmonary vasodilators. All women who delivered a live offspring received neuraxial anaesthesia.

CONCLUSIONS

Women with this condition are ideally managed in a centre with expertise in PAH; counselling regarding the risks is imperative. Regional anaesthesia, irrespective of the mode of delivery, facilitated safe delivery and improved patient experience. The option of aiming for a term vaginal birth needs to be considered in these complex women.

Management of Severe Coarctation of the Aorta and Bilateral Carotid Artery Stenosis: An Interventional Catch-22

We present a case of an adult with concurrent severe aortic coarctation, bilateral carotid artery stenosis, and anomalous right subclavian artery, posing the interventional dilemma of accepting potential cerebral hyperperfusion syndrome vs hypoperfusion ischemic injury. Transcatheter stenting of the aortic coarctation was successfully performed without any neurological deficits. (Level of Difficulty: Beginner.).

Ten Years of Percutaneous Pulmonary Valve Implantation in Australia and New Zealand

OBJECTIVE

This study sought to investigate the characteristics, morbidity (including the rate of infective endocarditis and valve replacement) and mortality of individuals undergoing percutaneous pulmonary valve implantation in Australia and New Zealand since the procedure has been performed.

BACKGROUND

The outcomes of percutaneous pulmonary valve implantation in Australia and New Zealand have not been evaluated. Recent international data, including patients from New Zealand, suggests the rate of infective endocarditis is not insignificant.

METHODS

A retrospective multi-site cohort study was undertaken via medical record review at the centres where percutaneous pulmonary valve implantation has been performed. All procedures performed from 2009-March 2018 were included. Individuals were identified from local institution databases. Data was collected and analysed including demographics, details at the time of intervention, haemodynamic outcome, post procedure morbidity and mortality. Multi-site ethics approval was obtained.

RESULTS

One hundred and seventy-nine (179) patients attended the cardiac catheter laboratory for planned percutaneous pulmonary valve implantation. Of these patients, 172 underwent successful implantation. Tetralogy of Fallot and pulmonary atresia were the most common diagnoses. The median age at procedure was 19 years (range 3-60 yrs). There was a significant improvement in the acute haemodynamics in patients undergoing percutaneous pulmonary valve implantation for stenosis. Seven (7) patients (3.9%) experienced a major procedural/early post procedure complication (death, conversion to open procedure, cardiac arrest), including two deaths. The annualised rates of infective endocarditis and valve replacement were 4.6% and 3.8% respectively. There was one death related to infective endocarditis in follow-up.

CONCLUSIONS

Percutaneous pulmonary valve replacement is a relatively safe method of rehabilitating the right ventricular outflow tract.

Platypnea-Orthodeoxia Syndrome in the Setting of Patent Foramen Ovale Without Pulmonary Hypertension or Major Lung Disease

Background

Patent foramen ovale (PFO)‐associated platypnea‐orthodeoxia syndrome is characterized by dyspnea and hypoxemia when upright. The pathogenesis is thought to involve an increase in right atrial pressure or change in degree of right to left shunting with upright posture.

Methods and Results

We sought to characterize patients with platypnea‐orthodeoxia syndrome related to PFO without pulmonary hypertension. We retrospectively reviewed databases at 3 tertiary referral hospitals in New South Wales, Australia from 2000 to 2019. Fourteen patients with a mean age of 69±14 years had a PFO with wide tunnel separation. Mean New York Heart Association Classification was II (±0.9) and 7 inpatients had been confined to bed (from postural symptoms). Baseline oxygen saturations supine were 93%±5% and 84%±6% upright. Two patients had a minor congenital heart defect and 4 had mild parenchymal lung disease with preserved lung function. The mean aortic root diameter was 37±6 mm and distance between aortic root and posterior atrial wall was 16±2 mm. Platypnea‐orthodeoxia syndrome was preceded by surgery in 5 patients and 1 patient had mild pneumonia. Successful closure of the PFO using an Amplatzer device was performed in 11 of 14 patients. Post‐closure, all patients had New York Heart Association Classification I (improvement 1.6±0.9, P<0.003) and semi‐recumbent oxygen saturations increased by 13%±8% (P<0.001, n=10).

Conclusions

Platypnea‐orthodeoxia syndrome is a debilitating condition, curable by PFO closure. Anatomical distortion of the atrial septum related to a dilated aortic root or shortening of the distance between the aortic root and posterior atrial wall may contribute to the syndrome.

The role of intracoronary thrombolysis in selected patients presenting with ST-elevation myocardial infarction: a case series

Background

Primary percutaneous coronary intervention (PCI) is the cornerstone of management for ST-elevation myocardial infarction (STEMI). However, large intracoronary thrombus burden complicates up to 70% of STEMI cases. Adjunct therapies described to address intracoronary thrombus include manual and mechanical thrombectomy, use of distal protection device and intracoronary anti-thrombotic therapies.

Case summary

This series demonstrates the use of intracoronary thrombolysis in the setting of large coronary thrombus, bifurcation lesions with vessel size mismatch, diffuse thrombosis without underlying plaque rupture, and improving coronary flow to allow vessel wiring and proceeding to definitive revascularization.

Discussion

Larger intracoronary thrombus burden correlates with greater infarct size, distal embolization, and the associated no-reflow phenomena, and propagates stent thrombosis, with subsequent increase in mortality and major adverse cardiac events. Intracoronary thrombolysis may provide useful adjunct therapy in highly selected STEMI cases to reduce intracoronary thrombus and facilitate revascularization.

P220 Behcet"s disease with right ventricular aneurysm

Funding Acknowledgements

Nil

Introduction

Behcet’s disease (BD) is a rare inflammatory disorder, which predominantly impacts people of Mediterranean and East Asian origin. While the aetiology is unknown, the prevailing disorder is vasculitis. Oral, skin and ocular lesions are common: cardiac involvement is rare.

Case description

A sixty-three year old male with Behcet’s disease (BD) presented for review. On clinical examination, atrial fibrillation, prominent V waves, mild pedal oedema and a ‘to and fro’ murmur were noted. Marked elevation of right ventricular (RV) end diastolic pressure was measured by cardiac catheter.

Echocardiography and magnetic resonance imaging revealed significant RV abnormalities. The mid and apical RV regions were heavily trabeculated, and an anterior aneurysm was identified (see 2D image in abstract picture). A prominent horizontal muscular ridge in the basal RV was noted, and the RV outflow tract was narrowed. While the tricuspid valve was not apically displaced, leaflet coaptation was absent with subsequent severe tricuspid regurgitation into a grossly enlarged right atrium (see colour image in abstract picture). Management included diuretics and continuing immunosuppressives.

Discussion

BD is a rare (chronic) inflammatory disorder, which mainly affects people of Mediterranean and East Asian origin, and is often first diagnosed (in the third or fourth decades of life) following recurrent oral ulcerations, skin and ocular lesions. With BD, the prevailing disorder is vasculitis. Blood vessels of all sizes, both arteries and veins, are impacted: true or false aneurysms can occur.

BD rarely affects the heart. If there is cardiac involvement, pericarditis is the most common lesion - others include myocarditis, mitral valve prolapse, intra-cardiac thrombus and myocardial infarction. We present a rare (and possibly unique) cardiac manifestation of BD, anterior RV aneurysm.

Conclusion

In this case report we present a rare cardiac manifestation of BD, anterior RV aneurysm.

Abstract P220 Figure. Echocardiography Images

Management errors in adults with congenital heart disease: prevalence, sources, and consequences

Aims

Improved survival has resulted in increasing numbers and complexity of adults with congenital heart disease (ACHD). International guidelines recommend specialized care but many patients are still not managed at dedicated ACHD centres. This study analysed referral sources and appropriateness of management for patients referred to our tertiary ACHD Centre over the past 3 years.

Methods and results

We compared differences in care between patients referred from paediatric/ACHD-trained vs. general adult cardiologists, according to Adherence (A) or Non-Adherence (NA) with published guidelines. Non-Adherent cases were graded according to the severity of adverse outcome or risk of adverse outcome. Of 309 consecutively referred patients (28 ± 14 years, 51% male), 134 (43%) were from general cardiologists (19% highly complex CHD) and 115 (37%) were from paediatric cardiology or ACHD specialists (33% highly complex CHD). Sixty referrals (20%) were from other medical teams and of those, 31 had been lost to follow-up. Guideline deviations were more common in referrals from general compared to CHD-trained cardiologists (P < 0.001). Of general cardiology referrals, 49 (37%) were NA; 18 had catastrophic or major complications (n = 2, 16 respectively). In contrast, only 12 (10%) of the paediatric/ACHD referrals were NA, but none of these were catastrophic and only 3 were major. Simple, moderate, and highly complex CHD patients were at increased risk of adverse outcome when not under specialized CHD cardiology care (P = 0.04, 0.009, and 0.002, respectively).

Conclusion

Non-adherence with guidelines was common in the ACHD population, and this frequently resulted in important adverse clinical consequences. These problems were more likely in patients who had not been receiving specialized CHD care. Configuring healthcare systems to optimize 'whole of life' care for this growing population is essential.

Coronary artery vasospasm in a patient with Churg-Strauss syndrome

Patients with Churg-Strauss syndrome often suffer from unusual cardiac manifestations and sudden cardiac death. This differs from patients with other autoimmune disorders, who typically present with premature ischaemic heart disease. We report the case of a 56-year-old man with recurrent coronary vasospasm, including an inferoposterior ST-elevation myocardial infarction, complicated by bradycardic arrest. There was only minor coronary artery disease on coronary angiography. An elevated eosinophil count was noted. His medical history included allergic rhinitis with polyposis, adult-onset asthma and biopsy-proven eosinophilic oesophagitis. Review of his sinus biopsies demonstrated blood vessels with marked accumulation of eosinophils in extravascular areas. The patient, therefore, met the American College of Rheumatology criteria for Churg-Strauss syndrome. The patient was commenced on immunosuppression, with the return of the eosinophil count to within normal limits, and remains free of cardiovascular events over 24 months.

Sudden cardiac death in adults with congenitally corrected transposition of the great arteries

Background

Congenitally corrected transposition of the great arteries (ccTGA) is a rare congenital heart disease. There have been only few reports of sudden cardiac death (SCD) in patients with ccTGA and reasonable ventricular function.

Methods

A retrospective review of the medical records of all patients attending our adult congenital heart centre, with known ccTGA.

Results

From a database of over 3500 adult patients with congenital heart disease, we identified 39 (∼1%) with ccTGA and ‘two-ventricle’ circulations. 65% were male. The mean age at diagnosis was 12.4±11.4 years and the mean age at last time of review was 34.3±11.3 years. 24 patients (56%) had a history of surgical intervention. 8 (19%) had had pacemaker implantation and 2 had had a defibrillator implanted for non-sustained ventricular tachycardia (NSVT). In 544 years of patient follow-up, there had been five cases of SCD in our population; 1 death per 109 patient-years. Two of these patients had had previously documented supraventricular or NSVT. However, they were all classified as New York Heart Association (NYHA) class I or II, and systemic (right) ventricular function had been recorded as normal, mildly or mildly–moderately impaired, at most recent follow-up.

Conclusions

Our experience suggests the need for improved risk stratification and/or surveillance for malignant arrhythmia in adults with ccTGA, even in those with reasonable functional class on ventricular function.

Late outcomes in adults with coarctation of the aorta

AIMS

Previous cohort studies of patients with coarctation of the aorta (CoA) demonstrate reduced long-term survival. Improved surgical outcomes in children and evolution of adult congenital heart disease (ACHD) services have resulted in improved survival in patients with other CHDs. We hypothesise that for young adult patients with CoA long-term outcomes have improved in the contemporary era.

METHODS

151 patients (58% men) with simple CoA followed up at a tertiary ACHD service in Sydney, Australia, from 1993 to 2013 were included. We documented mortality and major morbidity such as the need for re-intervention for re-coarctation or aneurysms.

RESULTS

140 patients (mean age 35±15 years) underwent CoA repair at median age of 5 (IQR 0-10) years. Initial surgical strategy included end-to-end repair in 43, subclavian flap aortoplasty in 28 and patch aortoplasty in 31 patients (and was not documented in 28 cases). 6 patients had endovascular repair, 4 had interposition tube grafts and 11 were unrepaired. There were a total of seven deaths at a median age of 60 years. Actuarial survival was 98% at 40, 98% at 50 and 89% at 60 years of age. Re-coarctation occurred in 34% and descending aortic aneurysms were noted in 18%. Patients with end-to-end repair had lower rates of significant re-coarctation or descending aortic aneurysms (p=0.026 and <0.001, respectively). 66% had bicuspid aortic valve and 44% were hypertensive.

CONCLUSIONS

Patients with CoA who reach adolescence demonstrate very good long-term survival up to age 60 years. Long-term morbidity is common, however, related largely to aortic complications and late hypertension.

The role of cardiac MRI in the diagnosis and management of sinus venosus atrial septal defect

Sinus venosus atrial septal defects (SV-ASDs) are inter-atrial communications caused by a deficiency of the common wall between the superior or inferior vena cava and the right-sided pulmonary veins. The diagnosis can be challenging, especially in adults with delayed presentation. We present images that illustrate an example of the role of cardiac magnetic resonance imaging (CMRI) in the diagnosis and follow-up of a patient with SV-ASD.

Trastuzumab-induced cardiotoxicity: the role of two-dimensional myocardial strain imaging in diagnosis and management

A 45-year-old female breast cancer patient developed heart failure during adjuvant trastuzumab therapy. Her initial left ventricular ejection fraction (LVEF) was 39% and corresponding global longitudinal and circumferential systolic strain measurements were also significantly reduced. Trastuzumab was ceased and supportive cardiac therapy commenced. The ensuing LVEF and systolic strain measurements showed consistent improvement so that trastuzumab was recommenced (while supportive cardiac therapy continued). At this point, reduced circumferential systolic strain with preserved LVEF was observed. Subsequent echocardiograms revealed further reductions in circumferential and longitudinal systolic strain without reductions in LVEF.

Creation of a functional tricuspid valve: novel use of percutaneously implanted valve in right atrial to right ventricular conduit in a patient with tricuspid atresia

We report the first use of a stented pulmonic valve within the right atrial to right ventricular conduit of a patient who underwent a Björk modification Fontan for tricuspid atresia. In effect, a functional tricuspid valve was created. This case report demonstrates the feasibility of transcatheter valve replacement in positions other than the pulmonic or aortic valve and that future revision of conduits in the Björk modification Fontan can be performed percutaneously.

Exercise capacity and biventricular function in adult patients with repaired tetralogy of Fallot

BACKGROUND

Adult patients with repaired tetralogy of Fallot (rTOF) often have diminished exercise capacity. The primary objective of this study was to examine whether abnormalities of biventricular function play a role in exercise limitation in patients with rTOF.

METHODS

This was a retrospective review of 99 adult patients with rTOF. Right ventricular (RV) and left ventricular (LV) function were assessed echocardiographically using the myocardial performance index (MPI). Maximal oxygen consumption (VO(2) Max) was measured during a level 1 cardiopulmonary exercise test.

RESULTS

The mean age of the cohort was 34 +/- 11 years (50% females). Although most of the patients reported good functional capacity, the peak Vo(2)max was decreased at 22 +/- 6 mL/kg per minute (66% +/- 13% predicted Vo(2)max for age and sex). The mean RV and LV MPI were 0.30 +/- 0.07 and 0.42 +/- 0.09, respectively. In the multivariate model, higher RV MPI (P = .04) and LV MPI (P = .005) values, representing impaired ventricular function, were associated with diminished Vo(2)max. There was a significant correlation between the RV and LV MPI (r = 0.54, P = .001).

CONCLUSIONS

Impairment of RV and LV function, as measured by MPI, is associated with diminished exercise capacity in patients with repaired tetralogy of Fallot. Furthermore, there is a linear relationship between the RV and LV function suggesting that ventricular interactions are contributing to the limited exercise capacity in this group of patients. Strategies aimed at preserving biventricular function or improving adverse ventricular interactions could help to improve functional capacity in these patients.

Probucol inhibits in-stent thrombosis and neointimal hyperplasia by promoting re-endothelialization

BACKGROUND

Evidence suggests that delayed re-endothelialization is responsible for in-stent thrombosis. Probucol inhibits neointimal thickening in animals via enhanced re-endothelialization and is the only oral drug that consistently inhibits restenosis after coronary angioplasty in humans. Here, we examined the effects of probucol on re-endothelialization and neointimal formation in a stent model.

METHODS AND RESULTS

New Zealand White rabbits were fed a hypercholesterolemic diet with probucol (1%) or without (control) (n=11 each) for 6 weeks. At 2 weeks, endothelial denudation and stenting of the iliac artery was performed. Iliac arteries were harvested at week 6, and stented segments sectioned and analyzed. Compared with control, probucol increased in-stent re-endothelialization (74+/-6% in controls versus 93+/-3% in probucol-treated; P=0.008), and decreased average luminal stenosis (58+/-27 versus 31+/-16%; P=0.01) and stent depth (619+/-310 versus 314+/-158 microm; P=0.009). Compared with control, probucol also decreased accumulation of macrophages in the neointima. Furthermore, none of the probucol-treated rabbits had in-stent thrombosis, whereas four of eleven control rabbits showed thrombosis (P=0.04).

CONCLUSIONS

Probucol demonstrates anti-restenotic and appears to have anti-thrombotic properties that are likely related to its ability to promote in-stent re-endothelialization.

Antioxidants protect from atherosclerosis by a heme oxygenase-1 pathway that is independent of free radical scavenging

Oxidative stress is implicated in atherogenesis, yet most clinical trials with antioxidants, particularly vitamin E, have failed to protect against atherosclerotic diseases. A striking exception is probucol, which retards atherosclerosis in carotid arteries and restenosis of coronary arteries after angioplasty. Because probucol has in vitro cellular-protective effects independent of inhibiting lipid oxidation, we investigated the mode of action of probucol in vivo. We used three models of vascular disease: apolipoprotein E–deficient mice, a model of atherosclerosis; rabbit aortic balloon injury, a model of restenosis; and carotid injury in obese Zucker rats, a model of type 2 diabetes. Unexpectedly, we observed that the phenol moieties of probucol were insufficient, whereas its sulphur atoms were required for protection. Probucol and its sulphur-containing metabolite, but not a sulphur-free phenolic analogue, protected via cell-specific effects on inhibiting macrophage accumulation, stimulating reendothelialization, and inhibiting vascular smooth muscle cell proliferation. These processes were mediated via induction of heme oxygenase-1 (HO-1), an activity not shared by vitamin E. Our findings identify HO-1 as the molecular target of probucol. They indicate 2-electron rather than radical (1-electron) oxidants as important contributors to atherogenesis, and point to novel lead compounds for therapeutic intervention against atherosclerotic diseases.