1
|
Burchill LJ, Jain CC, Miranda WR. Advancing New Solutions for Adult Congenital Heart Disease-Related Heart Failure. J Am Coll Cardiol 2024; 83:1415-1417. [PMID: 38599717 DOI: 10.1016/j.jacc.2024.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 03/01/2024] [Indexed: 04/12/2024]
Affiliation(s)
- Luke J Burchill
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.
| | - C Charles Jain
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - William R Miranda
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| |
Collapse
|
2
|
Egbe AC, Miranda WR, Jain CC, Burchill LJ, Jokhadar M, Brown RD, Connolly HM. Low Incidence of New Intracranial Aneurysms in Adults With Coarctation of Aorta on Serial Brain Imaging. Am J Cardiol 2024; 216:46-47. [PMID: 38373680 DOI: 10.1016/j.amjcard.2024.01.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 01/26/2024] [Indexed: 02/21/2024]
Affiliation(s)
- Alexander C Egbe
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.
| | - William R Miranda
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - C Charles Jain
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Luke J Burchill
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Maan Jokhadar
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Robert D Brown
- Department of Neurology, Mayo Clinic, Rochester, Minnesota
| | - Heidi M Connolly
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
3
|
Egbe AC, Miranda WR, Abozied O, Jain CC, Burchill LJ, Karnakoti S, Ahmed MH, Francois CJ, Connolly HM. Coarctation of Aorta With Tricuspid Aortic Valve Is Not Associated With Ascending Aortic Aneurysm. J Am Coll Cardiol 2024; 83:1136-1146. [PMID: 38508846 DOI: 10.1016/j.jacc.2024.01.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 01/05/2024] [Accepted: 01/29/2024] [Indexed: 03/22/2024]
Abstract
BACKGROUND Aortic aneurysm is common in patients with coarctation of aorta (COA), but it is unclear whether the risk of aortic aneurysms is due to COA or related to the presence of other risk factors such as bicuspid aortic valve (BAV) and hypertension. OBJECTIVES The purpose of this study was to assess the relationship among COA, BAV, and thoracic aortic aneurysms. METHODS A total of 867 patients with COA (COA group) were matched 1:1:1 to 867 patients with isolated BAV (BAV group) and 867 patients without structural heart disease (SHD) (no-SHD group). The COA group was further subdivided into a COA+BAV subgroup (n = 304 [35%]), and COA with tricuspid aortic valve (TAV) (COA+TAV subgroup [n = 563 (65%)]). Aortic dimensions were assessed at baseline and at 3, 5, and 7 years. RESULTS Compared with the no-SHD group, the COA+BAV subgroup had larger aortic root diameter (37 mm [Q1-Q3: 30-43 mm] vs 32 mm [Q1-Q3: 27-35 mm]; P < 0.001) and mid ascending aorta dimeter (34 mm [Q1-Q3: 29-40 mm] vs 28 mm [Q1-Q3: 24-31 mm]; P = 0.008). Similarly, the BAV group had larger aortic root diameter (37 mm [Q1-Q3: 30-42 mm] vs 32 mm [Q1-Q3: 27-35 mm]; P < 0.001), and mid ascending aorta dimeter (35 mm [Q1-Q3: 30-40 mm] vs 28 mm [Q1-Q3: 24-31 mm]; P < 0.001). Compared with the COA+TAV subgroup, the COA+BAV subgroup and BAV group were associated with larger aortic root and mid ascending aorta diameter at baseline and follow-up. The risk of acute aortic complications was low in all groups. CONCLUSIONS These findings suggest that BAV (and not COA) was associated with ascending thoracic aorta dimensions, and that patients with COA+TAV were not at a greater risk of developing ascending aortic aneurysms as compared with patients without SHD.
Collapse
Affiliation(s)
- Alexander C Egbe
- Department of Cardiovascular Medicine Mayo Clinic, Rochester, Minnesota, USA.
| | - William R Miranda
- Department of Cardiovascular Medicine Mayo Clinic, Rochester, Minnesota, USA
| | - Omar Abozied
- Department of Cardiovascular Medicine Mayo Clinic, Rochester, Minnesota, USA
| | - C Charles Jain
- Department of Cardiovascular Medicine Mayo Clinic, Rochester, Minnesota, USA
| | - Luke J Burchill
- Department of Cardiovascular Medicine Mayo Clinic, Rochester, Minnesota, USA
| | - Snigdha Karnakoti
- Department of Cardiovascular Medicine Mayo Clinic, Rochester, Minnesota, USA
| | - Marwan H Ahmed
- Department of Cardiovascular Medicine Mayo Clinic, Rochester, Minnesota, USA
| | | | - Heidi M Connolly
- Department of Cardiovascular Medicine Mayo Clinic, Rochester, Minnesota, USA
| |
Collapse
|
4
|
Miranda WR, Egbe AC, Van De Bruaene A, Connolly HM, Burchill LJ, Jain CC. Peripheral Venous Pressure Accurately Reflects Invasively Measured Resting and Exercise Fontan Pressures. Am J Cardiol 2024; 215:62-64. [PMID: 38253306 DOI: 10.1016/j.amjcard.2024.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 12/12/2023] [Accepted: 01/04/2024] [Indexed: 01/24/2024]
Affiliation(s)
- William R Miranda
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, United States.
| | - Alexander C Egbe
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, United States
| | - Alexander Van De Bruaene
- Division of Structural and Congenital Cardiology, Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Heidi M Connolly
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, United States
| | - Luke J Burchill
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, United States
| | - C Charles Jain
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, United States
| |
Collapse
|
5
|
Ezzeddine FM, Miranda WR, Collins JD, Killu AM. Collateral coronary flow in the interventricular septum detected on intracardiac echocardiographic imaging. Heart Rhythm 2024:S1547-5271(24)00235-2. [PMID: 38458508 DOI: 10.1016/j.hrthm.2024.02.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Revised: 02/21/2024] [Accepted: 02/24/2024] [Indexed: 03/10/2024]
Affiliation(s)
- Fatima M Ezzeddine
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - William R Miranda
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Ammar M Killu
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.
| |
Collapse
|
6
|
Miranda WR, Dearani JA, Jain CC, Hagler DJ, Connolly HM, Egbe AC. Cardiac Catheterization in Adults with Ebstein Anomaly: Pathophysiologic Insights Regarding Surgical Repair and Prognosis. Pediatr Cardiol 2024; 45:591-599. [PMID: 38019300 DOI: 10.1007/s00246-023-03337-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 10/25/2023] [Indexed: 11/30/2023]
Abstract
The underlying invasive hemodynamics and physiology in Ebstein anomaly (EA) are poorly understood. Moreover, the hemodynamic impact of tricuspid valve intervention in EA has not been well studied. Retrospective cohort of 52 adults with repaired and 36 with unrepaired EA undergoing right heart catheterization at Mayo Clinic, MN between 1993 and 2021. "Repaired" EA was defined as prior tricuspid valve repair and/or replacement (83% post-tricuspid valve replacement). Repaired patients were younger than those with unrepaired EA (41.3 ± 16.0 versus 50.6 ± 15.6 years, p = 0.008) and had a lower prevalence of ≥ moderate native or prosthetic tricuspid regurgitation (67% versus 81%, p = 0.01). Right atrial (RA) pressure was higher among patients with repaired EA than in unrepaired disease [13 (11; 18) versus 10 (8; 15) mmHg; p = 0.02], but these differences were no longer present when adjusting for ≥ moderate right ventricular systolic dysfunction and ≥ moderate tricuspid regurgitation. Cardiac index (Qs) was lower among those with unrepaired EA than in repaired EA (1.9 ± 0.7 versus 2.3 ± 0.6 l/min/m2, p = 0.01), even after adjusting for similar confounders. During a follow-up of 8.6 (3.2-13.3) years, 16 (18%) patients died. Systolic pulmonary artery pressure was independently associated with all-cause mortality. In summary, higher cardiac indices were found in those with repaired EA compared to those with unrepaired disease. RA hypertension was prevalent in both groups and no differences in right filling pressures were found between groups after adjusting for potential confounders. Elevation in pulmonary pressures was independently associated with survival. The use of pulmonary vasomodulators in EA requires further investigation.
Collapse
Affiliation(s)
- William R Miranda
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA.
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - C Charles Jain
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Donald J Hagler
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
- Division of Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN, USA
| | - Heidi M Connolly
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Alexander C Egbe
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
7
|
Miranda WR, Pislaru SV. Tele-, Proto-, or Holosystolic Mitral Regurgitation . . . Time to Learn From Physical Examination and Go Beyond PISA. J Am Soc Echocardiogr 2024; 37:325-327. [PMID: 38244818 DOI: 10.1016/j.echo.2024.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 01/15/2024] [Indexed: 01/22/2024]
Affiliation(s)
- William R Miranda
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.
| | - Sorin V Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
8
|
Bhalla JS, Majmundar M, Patel KN, Deshmukh AJ, Connolly HM, Chirac A, Egbe AC, Miranda WR, Madhavan M. Trends in cardiac implantable electronic device utilization in adults with congenital heart disease: a US nationwide analysis. J Interv Card Electrophysiol 2024; 67:319-328. [PMID: 37392273 DOI: 10.1007/s10840-023-01601-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 06/20/2023] [Indexed: 07/03/2023]
Abstract
BACKGROUND Adults with congenital heart disease (ACHD) have increased risk of arrhythmias warranting implantation of cardiac implantable electronic devices (CIEDs), which may parallel the observed increase in survival of ACHD patients over the past few decades. We sought to characterize the trends and outcomes of CIED implantation in the inpatient ACHD population across US from 2005 to 2019. METHODS A retrospective analysis of the Nationwide Inpatient Sample (NIS) identified 1,599,519 unique inpatient ACHD admissions (stratified as simple (85.1%), moderate (11.5%), and complex (3.4%)) using the International Classification of Diseases 9/10-CM codes. Hospitalizations for CIED implantation (pacemaker, ICD, CRT-p/CRT-d) were identified and the trends analyzed using regression analysis (2-tailed p < 0.05 was considered significant). RESULTS A significant decrease in the hospitalizations for CIED implantation across the study period [3.3 (2.9-3.8)% in 2005 vs 2.4 (2.1-2.6)% in 2019, p < 0.001] was observed across all types of devices and CHD severities. Pacemaker implantation increased with each age decade, whereas ICD implantation rates decreased over 70 years of age. Complex ACHD patients receiving CIED were younger with a lower prevalence of age-related comorbidities, however, had a greater prevalence of atrial/ventricular tachyarrhythmias and complete heart block. The observed inpatient mortality rate was 1.2%. CONCLUSIONS In a nationwide analysis, we report a significant decline in CIED implantation between 2005 and 2019 in ACHD patients. This may either be due to a greater proportion of hospitalizations resulting from other complications of ACHD or reflect a declining need for CIED due to advances in medical/surgical therapies. Future prospective studies are needed to elucidate this trend further.
Collapse
Affiliation(s)
- Jaideep Singh Bhalla
- Department of Cardiovascular Diseases, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA.
| | - Monil Majmundar
- Department of Cardiovascular Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Kunal N Patel
- Department of Cardiovascular Medicine, West Virginia University Hospital, Morgantown, WV, USA
| | - Abhishek J Deshmukh
- Department of Cardiovascular Diseases, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Heidi M Connolly
- Department of Cardiovascular Diseases, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Anca Chirac
- Department of Cardiovascular Diseases, Mayo Clinic, Jacksonville, FL, USA
| | - Alexander C Egbe
- Department of Cardiovascular Diseases, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - William R Miranda
- Department of Cardiovascular Diseases, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Malini Madhavan
- Department of Cardiovascular Diseases, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| |
Collapse
|
9
|
Abdelrehim AA, Dearani JA, Miranda WR, Connolly HM, Stephens EH. Surgical Considerations for the Mitral Valve in Congenitally Corrected Transposition. Ann Thorac Surg 2024; 117:560-566. [PMID: 37488004 DOI: 10.1016/j.athoracsur.2023.07.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 06/20/2023] [Accepted: 07/11/2023] [Indexed: 07/26/2023]
Abstract
BACKGROUND Systemic atrioventricular valve (morphologic tricuspid valve [TV]) regurgitation has been implicated in the development of systemic ventricular failure in congenitally corrected transposition of the great arteries (ccTGA), leading to timely referral for valve replacement. However, the surgical management of subpulmonary atrioventricular valve (morphologic mitral valve [MV]) regurgitation and outcomes has not been well studied. METHODS Of 108 ccTGA patients undergoing atrioventricular valve surgery from 1979 to 2022, 22 patients (20%) underwent MV surgery. Demographics, etiology of valve regurgitation, operative details, and outcomes of these 22 patients were retrospectively reviewed. Follow-up at 1, 5, and 10 years was available for 18 (82%), 13 (59%), and 11 patients (50%), respectively. RESULTS Median age was 37 years (interquartile range, 29-57 years). Intrinsic MV pathology was present in 18 individuals (82%). Operations included repair in 16 patients (73%), replacement in 6 (27%), and concomitant replacement of TV in 16 (73%). There was 1 perioperative death (5%) in a patient undergoing an emergent operation for severe acute-on-chronic heart failure due to worsening TV regurgitation. During a median follow-up of 12 years (interquartile range, 2-19 years), 7 patients (32%) died. Among the 16 patients who underwent repair, recurrent moderate or greater regurgitation was seen in 15%, 29%, and 43% of repairs in patients with annular, leaflet, and lead-induced regurgitation, respectively. CONCLUSIONS Concomitant TV and MV disease occur much less frequently than isolated TV disease in ccTGA. Intrinsic MV disease is most commonly observed but appears less amenable to successful repair compared with mitral repair in the systemic position and suggests MV replacement may be preferred in ccTGA patients.
Collapse
Affiliation(s)
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - William R Miranda
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Heidi M Connolly
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | | |
Collapse
|
10
|
Alarouri HS, Lo Russo GV, Chavez Ponce A, Akkawi AR, Mahayni A, Sularz A, Killu AM, Simard T, Singh G, Miranda WR, Alkhouli M. Association of transcatheter left atrial appendage occlusion with acute changes in left atrial pressure: An invasive hemodynamic study. Heart Rhythm 2024:S1547-5271(24)00193-0. [PMID: 38365125 DOI: 10.1016/j.hrthm.2024.02.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 01/29/2024] [Accepted: 02/11/2024] [Indexed: 02/18/2024]
Abstract
BACKGROUND The hemodynamic effects of transcatheter left atrial appendage occlusion (LAAO) remain unclear. OBJECTIVE We sought to assess the effect of LAAO on invasive hemodynamics and their correlation with clinical outcomes. METHODS We recorded mean left atrial pressure (mLAP) before and after device deployment. We assessed the prevalence and predictors of mLAP increase after deployment, the association between significant mLAP increase after deployment and 45-day peridevice leak (PDL), and the association between mLAP increase and heart failure (HF) hospitalization. A significant mLAP increase was defined as one equal to or greater than the mean percentage increase in mLAP after deployment (≥28%). RESULTS We included 302 patients (36.4% female; mean age, 75.8 ± 9.5 years). After deployment, mLAP increased in 48% of patients, 38% of whom experienced significant mLAP increase. Independent predictors of mLAP increase were baseline mLAP ≤14 mm Hg, nonparoxysmal atrial fibrillation, and age per 5 years (odds ratios: 3.66 [95% CI, 2.21-6.05], 1.81 [95% CI, 1.08-3.02], and 0.85 [95% CI, 0.73-0.99], respectively). Significant mLAP increase was an independent predictor of 45-day PDL (odds ratio, 2.55; 95% CI, 1.04-6.26). There was no association between mLAP increase and HF hospitalization. CONCLUSION After deployment, mLAP acutely rises in 48% of patients, although this is not associated with increased HF hospitalizations. PDL is more likely to develop at 45 days in patients with significant increase in mLAP after deployment, although most leaks were small (<5 mm). These findings suggest that mLAP increase after deployment is not associated with major safety concerns. Additional studies are warranted to explore the long-term hemodynamic effects of LAAO.
Collapse
Affiliation(s)
- Hasan S Alarouri
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Gerardo V Lo Russo
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Abdul-Rahman Akkawi
- Department of Internal Medicine, University of Kansas Medical Center, Wichita, Kansas
| | - Abdulah Mahayni
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Agata Sularz
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Ammar M Killu
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Trevor Simard
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Gurpreet Singh
- Department of Cardiovascular Medicine, Mayo Clinic Health System, Eau Claire, Wisconsin
| | - William R Miranda
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Mohamad Alkhouli
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.
| |
Collapse
|
11
|
El Sabbagh A, Parikh P, Ray J, Nishimura RA, Pislaru SV, Pellikka PA, Guerrero M, Hochwald A, Miranda WR. Mitral Annulus Calcium Score in Patients With Calcific Mitral Stenosis Undergoing Invasive Hemodynamic Assessment. J Am Heart Assoc 2024; 13:e030540. [PMID: 38240203 DOI: 10.1161/jaha.123.030540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 12/01/2023] [Indexed: 02/07/2024]
Abstract
BACKGROUND Aortic valve calcium score is associated with hemodynamic severity of aortic stenosis. Whether this association is present in calcific mitral stenosis remains unknown. METHODS AND RESULTS This study was a retrospective analysis of consecutive patients with mitral stenosis secondary to mitral annular calcification (MAC) undergoing transseptal catheterization. All patients underwent invasive mitral valve assessment via direct left atrial and left ventricular pressure measurement. Computed tomography within 1 year of cardiac catheterization and with adequate visualization of the mitral annulus was included. MAC calcium score quantification by Agatston method was obtained offline using dedicated software (Aquarius, TeraRecon, V.4). Median patient age was 66.9±11.2 years, 47% of patients were women, 50% had coronary artery disease, 40% had atrial fibrillation, 47% had prior cardiac surgery, and 33% had prior chest radiation. Median diastolic mitral valve gradient was 9.4±3.4 mm Hg on echocardiography and 8.5±4 mm Hg invasively. Invasive median mitral valve area using the Gorlin formula was 1.87±0.9 cm2. Median MAC calcium score for the cohort was 7280±7937 Hounsfield units. MAC calcium score correlated with the presence of atrial fibrillation (P=0.02) but was not associated with other comorbidities. There was no correlation between MAC calcium score and mitral valve area (r=0.07; P=0.6) or mitral valve gradient (r=-0.03; P=0.8). CONCLUSIONS MAC calcium score did not correlate with invasively measured mitral valve gradient and mitral valve area in patients with MAC-related mitral stenosis, suggesting that calcium score should not be used as a surrogate for invasive hemodynamic parameters.
Collapse
Affiliation(s)
| | - Pragnesh Parikh
- Department of Cardiovascular Diseases Mayo Clinic Jacksonville FL
| | - Jordan Ray
- Department of Cardiovascular Diseases Mayo Clinic Jacksonville FL
| | | | - Sorin V Pislaru
- Department of Cardiovascular Diseases Mayo Clinic Rochester MN
| | | | - Mayra Guerrero
- Department of Cardiovascular Diseases Mayo Clinic Rochester MN
| | | | | |
Collapse
|
12
|
Miranda WR, Jain CC, Borlaug BA, Connolly HM, Burchill LJ, Van De Bruaene A, Egbe AC. Exercise catheterization in adults post-Fontan with normal and abnormal haemodynamic criteria: Insights into normal Fontan physiology. Eur J Heart Fail 2024; 26:314-323. [PMID: 38155533 DOI: 10.1002/ejhf.3119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 12/10/2023] [Accepted: 12/12/2023] [Indexed: 12/30/2023] Open
Abstract
AIM The normal (i.e. expected) haemodynamics in adults post-Fontan remain poorly delineated. Moreover, the definitions of elevated exercise pulmonary artery (PA) and PA wedge pressure (PAWP) for this population have not been described. METHODS AND RESULTS Seventy-two adults post-Fontan undergoing exercise catheterization were categorized into abnormal (Group I, n = 59; defined as resting mean PA ≥14 mmHg and/or PAWP ≥12 mmHg, ΔPAWP/Δsystemic flow [Qs] >2 mmHg/L/min, and/or ΔPA/Δpulmonary flow >3 mmHg/L/min) and normal (Group II, n = 13) haemodynamics. Thirty-nine patients with non-cardiac dyspnoea (NCD) were included as controls. There was no difference in exercise arterial oxygen saturation (87% [81-92] vs. 89% [85-93], p = 0.29), while exercise PA pressure (27 [23-31] vs. 16 [14.5-19.5] mmHg, p < 0.001) and PAWP were higher (21 [18-28] vs. 12 [8-14] mmHg, p < 0.001) in Group I. At peak exercise, Group I had lower heart rate (97 [81-120] vs. 133 [112.5-147.5] bpm, p < 0.001) and Qs response (67.3 [43.8-93.1] vs. 105.9 (82-118.5) % predicted, p < 0.001) than Group II. Exercise superior vena cava pressures were higher (16 [14-22.5] vs. 5.5 [3-7.3] mmHg, p < 0.001) and arterial oxygen saturation lower (89% [85-93] vs. 97% [96-98], p < 0.001) in Group II compared to NCD, while no differences in PAWP, stroke volume index, heart rate, or Qs response were seen. If defined as two standard deviations above mean values for Group II, elevated PAWP and mean PA pressure post-Fontan would correspond to 20.6 mmHg and 25.8 mmHg, respectively. CONCLUSION PAWP >20 mmHg and mean PA pressure >25 mmHg could be used to define elevated values during exercise in adults post-Fontan. The major discrepancy in exercise haemodynamics among Group II compared to controls appears to be the degree of systemic venous hypertension and arterial desaturation.
Collapse
Affiliation(s)
- William R Miranda
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - C Charles Jain
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Heidi M Connolly
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Luke J Burchill
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Alexander Van De Bruaene
- Division of Structural and Congenital Cardiology, Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Alexander C Egbe
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
13
|
Griffeth EM, Stephens EH, Dearani JA, Francois C, Todd A, Miranda WR, Connolly HM, Bonnichsen CR, Pochettino A. Outcomes of Surgical Repair of Aberrant Subclavian Arteries in Adults. Ann Thorac Surg 2024; 117:396-402. [PMID: 37030428 PMCID: PMC10556195 DOI: 10.1016/j.athoracsur.2023.03.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 02/24/2023] [Accepted: 03/20/2023] [Indexed: 04/10/2023]
Abstract
BACKGROUND Symptoms, imaging characteristics, and early and midterm surgical outcomes for aberrant subclavian arteries (ASCA) are not well defined in the adult population. METHODS A single-institution retrospective review was conducted of adults undergoing surgical repair of ASCA and descending aorta origin/Kommerell diverticulum (KD) from January 1, 2002, to December 31, 2021. Symptom improvement and differences in imaging characteristics between anatomic groups and the number of symptoms were assessed. RESULTS Mean age was 46 ± 17 years. There were 23 of 37 left aortic arches with right ASCA (62%) and 14 of 37 right aortic arches with left ASCA (38%). Of these, 31 of 37 (84%) were symptomatic, and 19 of 37 (51%) had KD size/growth meeting criteria for surgical repair. KD aortic origin diameter was larger in more symptomatic patients: 20.60 mm (interquartile range [IQR], 16.42-30.68 mm) in patients with ≥3 symptoms vs 22.05 mm (IQR, 17.52-24.21 mm) for 2 symptoms vs 13.72 mm (IQR, 12.70-15.95 mm) for 1 symptom (P = .018). Aortic replacement was required in 22 of 37 (59%). There were no early deaths. Complications occurred in 11 of 37 (30%): vocal cord dysfunction (4 of 37 [11%]), chylothorax (3 of 37 [8%]), Horner syndrome (2 of 37 [5%]), spinal deficit (2 of 37 [5%]), stroke (1 of 37 [3%]), and temporary dialysis requirement (1 of 37 [3%]). Over a median follow-up of 2.3 years (IQR, 0.8-3.9 years), there was 1 endovascular reintervention and no reoperations. Dysphagia and shortness of breath resolved in 92% and 89%, respectively, whereas gastroesophageal reflux persisted in 47%. CONCLUSIONS The KD aortic origin diameter correlates with the number of symptoms, and surgical repair of ASCA and descending aorta origin/KD effectively relieves symptoms, with low rates of reintervention. Given the operative complexity, surgical repair should be performed in patients meeting size criteria or with significant dysphagia or shortness of breath symptoms.
Collapse
Affiliation(s)
- Elaine M Griffeth
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Austin Todd
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota
| | - William R Miranda
- Division of Structural Heart Disease, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Heidi M Connolly
- Division of Structural Heart Disease, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Crystal R Bonnichsen
- Division of Structural Heart Disease, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | | |
Collapse
|
14
|
Egbe AC, Younis A, Miranda WR, Jain CC, Connolly HM, Borlaug BA. Determinants and prognostic implications of left atrial reverse remodelling after coarctation of aorta repair in adults. Eur Heart J Cardiovasc Imaging 2024; 25:249-256. [PMID: 37585542 PMCID: PMC10824485 DOI: 10.1093/ehjci/jead203] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 06/19/2023] [Accepted: 07/12/2023] [Indexed: 08/18/2023] Open
Abstract
AIMS Left atrial (LA) dysfunction and atrial fibrillation are also relatively common in adults with coarctation of aorta (COA), and the severity of LA dysfunction is associated with a higher risk of atrial fibrillation in this population. The purpose of this study was to determine whether LA function improved after COA repair (LA reverse remodelling), and the relationship between LA reverse remodelling and atrial fibrillation. METHODS AND RESULTS Retrospective cohort study of adults undergoing COA repair (2003-20). LA reservoir strain was assessed pre intervention and 12-24 months post intervention, using speckle tracking echocardiography. Incident atrial fibrillation was assessed from COA repair to last follow-up. Of 261 adults who underwent COA repair [age 37 ± 13 years; males 148 (57%)], 124 (47%) and 137 (53%) presented with native vs. recurrent COA, respectively. Of 261 patients, 231 (82%) and 48 (18%) underwent surgical and transcatheter COA repair, respectively. The LA reservoir strain increased from 32 ± 8% (pre intervention) to 39 ± 7% (post intervention), yielding a relative increase of 21 ± 5%. Older age [β ± standard error (SE) -0.16 ± 0.09 per 5 years, P = 0.02], higher systolic blood pressure (β ± SE -0.12 ± 0.04 per 5 mmHg, P = 0.005), and higher residual COA mean gradient (β ± SE -0.17 ± 0.06 per 5 mmHg, P = 0.002) post intervention were associated with less LA reverse remodelling, after adjustment for sex, hypertension diagnosis, and left ventricular indices. LA reverse remodelling (hazard ratio 0.97, 95% confidence interval 0.96-0.98 per 1% increase from pre-intervention LA function, P = 0.006) was associated with a lower risk of atrial fibrillation after adjustment for age, sex, pre-intervention LA reservoir strain, and history of atrial fibrillation. CONCLUSION COA repair resulted in improved LA function and decreased risk for atrial fibrillation, especially in patients without residual hypertension or significant residual COA gradient.
Collapse
Affiliation(s)
- Alexander C Egbe
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Ahmed Younis
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - William R Miranda
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - C Charles Jain
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Heidi M Connolly
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| |
Collapse
|
15
|
Egbe AC, Salama AA, Miranda WR, Karnakoti S, Anderson JH, Jain CC, Burchill LJ, Connolly HM. Right Heart Reverse Remodeling and Prosthetic Valve Function After Transcatheter vs Surgical Pulmonary Valve Replacement. JACC Cardiovasc Interv 2024; 17:248-258. [PMID: 38267139 DOI: 10.1016/j.jcin.2023.11.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 11/15/2023] [Accepted: 11/16/2023] [Indexed: 01/26/2024]
Abstract
BACKGROUND There are limited data about postprocedural right heart reverse remodeling and long-term prosthesis durability after transcatheter pulmonary valve replacement (TPVR) and how these compare to surgical pulmonary valve replacement (SPVR). OBJECTIVES This study sought to compare right heart reverse remodeling, pulmonary valve gradients, and prosthetic valve dysfunction after TPVR vs SPVR. METHODS Patients with TPVR were matched 1:2 to patients with SPVR based on age, sex, body surface area, congenital heart lesion, and procedure year. Right heart indexes (right atrial [RA] reservoir strain, RA volume index, RA pressure, right ventricular [RV] global longitudinal strain, RV end-diastolic area, and RV systolic pressure) were assessed at baseline (preintervention), 1 year postintervention, and 3 years postintervention. Pulmonary valve gradients were assessed at 1, 3, 5, 7, and 9 years postintervention. RESULTS There were 64 and 128 patients in the TPVR and SPVR groups, respectively. Among patients with TPVR, 46 (72%) and 18 (28%) received Melody (Medtronic) vs SAPIEN (Edwards Lifesciences) valves, respectively. The TPVR group had greater postprocedural improvement in RA reservoir strain and RV global longitudinal strain at 1 and 3 years. The TPVR group had a higher risk of prosthetic valve dysfunction mostly because of a higher incidence of prosthetic valve endocarditis compared to SPVR but a similar risk of pulmonary valve reintervention because some of the patients with endocarditis received medical therapy only. Both groups had similar pulmonary valve mean gradients at 9 years postintervention. CONCLUSIONS These data suggest a more favorable right heart outcome after TPVR. However, the risk of prosthetic valve endocarditis and prosthetic valve dysfunction remains a major concern.
Collapse
Affiliation(s)
- Alexander C Egbe
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, Minnesota, USA.
| | - Abdalla A Salama
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, Minnesota, USA; Department of Cardiovascular Diseases, Suez Canal University, Ismailia, Egypt
| | - William R Miranda
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, Minnesota, USA
| | - Snigdha Karnakoti
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, Minnesota, USA
| | - Jason H Anderson
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, Minnesota, USA
| | - C Charles Jain
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, Minnesota, USA
| | - Luke J Burchill
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, Minnesota, USA
| | - Heidi M Connolly
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, Minnesota, USA
| |
Collapse
|
16
|
Miranda WR, Jain CC, Egbe AC, Reddy YN, Dearani JA, Hagler DJ, Connolly HM. Hemodynamics in Adults with Systemic Right Ventricles: Differences Between Congenitally Corrected and Complete Transposition of the Great Arteries. Pediatr Cardiol 2024:10.1007/s00246-023-03381-w. [PMID: 38231238 DOI: 10.1007/s00246-023-03381-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Accepted: 12/07/2023] [Indexed: 01/18/2024]
Abstract
Despite their anatomical differences, congenitally corrected (ccTGA) and complete transposition of the great arteries (d-TGA) post-atrial switch are frequently studied together and managed similarly from a medical standpoint due to the shared systemic right ventricle (sRV). The aim was to assess differences in their underlying hemodynamics. The study is a retrospective review of 138 adults with ccTGA or d-TGA post-atrial switch undergoing cardiac catheterization at Mayo Clinic, MN between 2000 and 2021. ccTGA was categorized into isolated or complex ccTGA depending on concomitant ventricular septal defect and/or left ventricular outflow obstruction. There were 53 patients with d-TGA (91% post-Mustard procedure), 51 with complex and 34 with isolated ccTGA. Isolated ccTGA patients were older (51.8 ± 13.1 years) than those with d-TGA (37.5 ± 8.3 years) or complex ccTGA (40.8 ± 13.4 years). There were no differences in sRV or left ventricular size and function across groups. The ccTGA group more commonly had ≥ moderate tricuspid regurgitation than those with d-TGA; ≥ moderate mitral and ≥ moderate pulmonary regurgitation were most prevalent in complex ccTGA. There were no differences in sRV end-diastolic pressure (sRVEDP) or PAWP between groups. However, the ratio of PAWP:sRVEDP was higher in those with d-TGA compared to those with ccTGA. Cardiac index was higher in the d-TGA group than both groups of ccTGA patients with the latter showing higher indices of ventricular afterload. In conclusion, despite sharing a sRV, adults with d-TGA and ccTGA have substantial differences in hemodynamics and structural/valvular abnormalities. Further investigation regarding disease-specific responses to heart failure therapy in those with d-TGA and ccTGA is warranted.
Collapse
Affiliation(s)
- William R Miranda
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA.
| | - C Charles Jain
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Alexander C Egbe
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Yogesh N Reddy
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Donald J Hagler
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
- Division of Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN, USA
| | - Heidi M Connolly
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| |
Collapse
|
17
|
Egbe AC, Miranda WR, Ahmed M, Burchill LJ, Jain CC, Karnakoti S, Kandlakunta S, Connolly HM. Diagnostic and Prognostic Role of Left Ventricular Strain Imaging in Adults with Coarctation of aorta. Am J Cardiol 2024; 211:98-105. [PMID: 37940012 DOI: 10.1016/j.amjcard.2023.10.082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 10/03/2023] [Accepted: 10/28/2023] [Indexed: 11/10/2023]
Abstract
The relative diagnostic and prognostic performance of left ventricular (LV) global longitudinal strain (LVGLS) compared with LV ejection fraction (LVEF) and the role of LVGLS for detecting the early stages of LV systolic dysfunction in adults with repaired coarctation of the aorta are unknown. This study aimed to address these knowledge gaps. We used a retrospective cohort study of adults with repaired coarctation of the aorta who underwent transthoracic echocardiogram (2003 to 2020). LV systolic function was assessed using LVEF (derived from volumetric analysis) and LVGLS (derived from speckle-tracking echocardiography). Of the 795 patients (age 36 ± 14 years), the mean LVEF and LVGLS were 62 ± 11% and 21 ± 4%, respectively. The prevalence of LV systolic dysfunction was higher when assessed using LVGLS than using LVEF (20% vs 6%, p <0.001). Of 795 patients, 94 (12%) patients died, of which 75 (9%) died from cardiovascular causes. LVGLS provided more robust prognostic power in predicting the all-cause mortality than LVEF, as evidenced by a higher C-statistic (0.743, 95% confidence interval 0.730 to 0.755 vs 0.782, 95% confidence interval 0.771 to 0.792, p <0.001). Furthermore, patients with normal LVEF in the setting of reduced LVGLS had a higher risk of all-cause mortality (than patients with normal LVGLS and LVEF) and were at risk for a temporal decrease in LVEF during follow-up. These findings suggest that the use of LVGLS for risk stratification can help identify high-risk patients and provide opportunities for interventions, which would, in turn, improve clinical outcomes. Further studies are required to empirically test these postulates.
Collapse
Affiliation(s)
- Alexander C Egbe
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, Rochester, Minnesota.
| | - William R Miranda
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, Rochester, Minnesota
| | - Marwan Ahmed
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, Rochester, Minnesota
| | - Luke J Burchill
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, Rochester, Minnesota
| | - C Charles Jain
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, Rochester, Minnesota
| | - Snigdha Karnakoti
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, Rochester, Minnesota
| | | | - Heidi M Connolly
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, Rochester, Minnesota
| |
Collapse
|
18
|
Lee E, Ito S, Miranda WR, Lopez-Jimenez F, Kane GC, Asirvatham SJ, Noseworthy PA, Friedman PA, Carter RE, Borlaug BA, Attia ZI, Oh JK. Artificial intelligence-enabled ECG for left ventricular diastolic function and filling pressure. NPJ Digit Med 2024; 7:4. [PMID: 38182738 PMCID: PMC10770308 DOI: 10.1038/s41746-023-00993-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 12/11/2023] [Indexed: 01/07/2024] Open
Abstract
Assessment of left ventricular diastolic function plays a major role in the diagnosis and prognosis of cardiac diseases, including heart failure with preserved ejection fraction. We aimed to develop an artificial intelligence (AI)-enabled electrocardiogram (ECG) model to identify echocardiographically determined diastolic dysfunction and increased filling pressure. We trained, validated, and tested an AI-enabled ECG in 98,736, 21,963, and 98,763 patients, respectively, who had an ECG and echocardiographic diastolic function assessment within 14 days with no exclusion criteria. It was also tested in 55,248 patients with indeterminate diastolic function by echocardiography. The model was evaluated using the area under the curve (AUC) of the receiver operating characteristic curve, and its prognostic performance was compared to echocardiography. The AUC for detecting increased filling pressure was 0.911. The AUCs to identify diastolic dysfunction grades ≥1, ≥2, and 3 were 0.847, 0.911, and 0.943, respectively. During a median follow-up of 5.9 years, 20,223 (20.5%) died. Patients with increased filling pressure predicted by AI-ECG had higher mortality than those with normal filling pressure, after adjusting for age, sex, and comorbidities in the test group (hazard ratio (HR) 1.7, 95% CI 1.645-1.757) similar to echocardiography and in the indeterminate group (HR 1.34, 95% CI 1.298-1.383). An AI-enabled ECG identifies increased filling pressure and diastolic function grades with a good prognostic value similar to echocardiography. AI-ECG is a simple and promising tool to enhance the detection of diseases associated with diastolic dysfunction and increased diastolic filling pressure.
Collapse
Affiliation(s)
- Eunjung Lee
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Saki Ito
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - William R Miranda
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Garvan C Kane
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | | | | | - Paul A Friedman
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Rickey E Carter
- Health Sciences Research, Mayo Clinic, Jacksonville, FL, USA
| | - Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Zachi I Attia
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jae K Oh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA.
| |
Collapse
|
19
|
Salama AA, Abozied OA, Anderson JH, Miranda WR, Connolly HM, Jain C, Cabalka A, Egbe AC. Cardiac Reverse Remodeling and Changes in Heart Failure Indices After Transcatheter Tricuspid Valve Replacement in Adults With Congenital Heart Disease. Circ Cardiovasc Interv 2024; 17:e013334. [PMID: 37942627 PMCID: PMC10841471 DOI: 10.1161/circinterventions.123.013334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 09/11/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND There are limited data about changes in cardiac function (cardiac reverse remodeling) and heart failure indices after transcatheter tricuspid valve-in-valve replacement (TT-VIVR). The purpose of this study was to evaluate cardiac reverse remodeling and temporal changes in heart failure indices after TT-VIVR in adults with congenital heart disease. METHODS Retrospective cohort study of adults with congenital heart disease that underwent TT-VIVR and had >6 months of follow-up (January 1, 2011, to April 30, 2023). Echocardiographic indices of cardiac remodeling and heart failure indices (New York Heart Association class, NT-proBNP (N-terminal pro-brain natriuretic peptide), glomerular filtration rate, and model for end-stage liver disease excluding international normalized ratio score) were assessed preintervention and at 1-, 3-, and 5-year postintervention. RESULTS Of 39 patients (age 39 [32-46] years), 14 (36%) and 25 (64%) received Melody valve and Sapien valve prosthesis, respectively. At 1-year post-TT-VIVR, there was a temporal improvement in right atrial reservoir strain (17±8% versus 22±8%, P<0.001), right atrial volume (81 [59-108] versus 63 [48-82] mL/m2, P<0.001), right atrial pressure (12±4% versus 6±4%, P<0.001), and right ventricular global longitudinal strain (-15±7% versus -20±7%, P<0.001). Similarly, there was a temporal improvement in NT-proBNP, glomerular filtration rate, model for end-stage liver disease excluding international normalized ratio score, and New York Heart Association class. The temporal improvements in heart failure indices and valve function were maintained at 3- and 5-year post-TT-VIVR. CONCLUSIONS Considering the significant mortality risk associated with reoperations for tricuspid valve replacement, these data suggest favorable outcomes after TT-VIVR, and support TT-VIVR as a viable alternative to surgical tricuspid valve replacement, especially in high-risk patients.
Collapse
Affiliation(s)
- Abdalla A Salama
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, MN (A.A.S., O.A.A., J.H.A., W.R.M., H.M.C., C.J., A.C., A.C.E.)
- Department of Cardiovascular Diseases, Suez Canal University, Ismailia, Egypt (A.A.S.)
| | - Omar A Abozied
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, MN (A.A.S., O.A.A., J.H.A., W.R.M., H.M.C., C.J., A.C., A.C.E.)
| | - Jason H Anderson
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, MN (A.A.S., O.A.A., J.H.A., W.R.M., H.M.C., C.J., A.C., A.C.E.)
| | - William R Miranda
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, MN (A.A.S., O.A.A., J.H.A., W.R.M., H.M.C., C.J., A.C., A.C.E.)
| | - Heidi M Connolly
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, MN (A.A.S., O.A.A., J.H.A., W.R.M., H.M.C., C.J., A.C., A.C.E.)
| | - Charles Jain
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, MN (A.A.S., O.A.A., J.H.A., W.R.M., H.M.C., C.J., A.C., A.C.E.)
| | - Allison Cabalka
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, MN (A.A.S., O.A.A., J.H.A., W.R.M., H.M.C., C.J., A.C., A.C.E.)
| | - Alexander C Egbe
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, MN (A.A.S., O.A.A., J.H.A., W.R.M., H.M.C., C.J., A.C., A.C.E.)
| |
Collapse
|
20
|
Egbe AC, Abozied O, Miranda WR, Younis A, Burchill L, Kandlakunta S, Ahmed MH, Karnakoti S, Connolly HM. Prognostic role of inferior vena collapsibility index in congenital heart disease: A validation study. Int J Cardiol 2024; 394:131399. [PMID: 37774925 DOI: 10.1016/j.ijcard.2023.131399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 08/28/2023] [Accepted: 09/24/2023] [Indexed: 10/01/2023]
Abstract
BACKGROUND A recent study showed that inferior vena cava collapsibility index (IVCCI) <60% had better prognostic performance as compared to the American Society of Echocardiogram (ASE) criteria for estimating right atrial pressure (RAP). However, this study was based on a selected cohort of adults with congenital heart disease (CHD) that underwent right heart catheterization and limiting the generalizability of the results. The purpose of this study was, therefore, to validate the prognostic performance of IVCCI in a more representative sample of adults with CHD, which would in turn, improve generalizability of the results. METHODS Retrospective cohort study of adults with CHD that underwent echocardiogram at Mayo Clinic (2003-2021). Elevated RAP was defined as RAP >10 mmHg, and was estimated using IVCCI <60% or the ASE criteria (maximum IVC diameter < 2.1 cm and IVCCI <50%). Cardiovascular event was defined as heart failure hospitalization, heart transplant or cardiovascular death. RESULTS Of the 4029 patients, 754 (19%) and 601 (15%) had elevated RAP (RAP >10 mmHg) based on IVCCI <60%, and the ASE criteria, respectively. Of the 4029 patients, 374 (9%) had cardiovascular events during 7.6 (4.4-10.5) years of follow-up. IVCCI <60% was independently associated with cardiovascular events (adjusted HR 2.08, 95% CI 1.75-2.42; C-statistic 0.708, 95%CI 0.688-0.728), and provided improved prognostic performance as compared to the ASE criteria (C-statistic difference 0.036, 95%CI 0.017-0.055, P = 0.008). CONCLUSIONS IVCCI had superior prognostic performance as compared to the ASE criteria.
Collapse
Affiliation(s)
- Alexander C Egbe
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, United States of America.
| | - Omar Abozied
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, United States of America
| | - William R Miranda
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, United States of America
| | - Ahmed Younis
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, United States of America
| | - Luke Burchill
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, United States of America
| | - Sriharsha Kandlakunta
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, United States of America
| | - Marwan H Ahmed
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, United States of America
| | - Snigdha Karnakoti
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, United States of America
| | - Heidi M Connolly
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, United States of America
| |
Collapse
|
21
|
Lyle M, Miranda WR, Vaidya VR, Rose CH, Melduni RM, Connolly HM, Young KA. Pregnancy Outcomes in Left Ventricular Noncompaction. Am J Cardiol 2023; 209:154-155. [PMID: 37848172 DOI: 10.1016/j.amjcard.2023.09.080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 09/20/2023] [Indexed: 10/19/2023]
Affiliation(s)
- Melissa Lyle
- Division of Advanced Heart Failure and Transplantation, Department of Transplant, Mayo Clinic, Jacksonville, Florida
| | - William R Miranda
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota.
| | - Vaibhav R Vaidya
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Carl H Rose
- Department of Obstetrics & Gynecology, Mayo Clinic, Rochester, Minnesota
| | - Rowlens M Melduni
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Heidi M Connolly
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Katie A Young
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
22
|
Agasthi P, Van Houten HK, Yao X, Jain CC, Egbe A, Warnes CA, Miranda WR, Dunlay SM, Stephens EH, Johnson JN, Connolly HM, Burchill LJ. Mortality and Morbidity of Heart Failure Hospitalization in Adult Patients With Congenital Heart Disease. J Am Heart Assoc 2023; 12:e030649. [PMID: 38018491 PMCID: PMC10727341 DOI: 10.1161/jaha.123.030649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 10/04/2023] [Indexed: 11/30/2023]
Abstract
BACKGROUND Little is known about outcomes following heart failure (HF) hospitalization among adults with congenital heart disease (CHD) in the United States. We aim to compare the outcomes of HF versus non-HF hospitalizations in adults with CHD. METHODS AND RESULTS Using a national deidentified administrative claims data set, patients with adult congenital heart disease (ACHD) hospitalized with and without HF (ACHDHF+, ACHDHF-) were characterized to determine the predictors of 90-day and 1-year mortality and quantify the risk of mortality, major adverse cardiac and cerebrovascular events, and health resource use. Cox proportional hazard regression was used to compare ACHDHF+ versus ACHDHF- for risk of events and health resource use. Of 26 454 unique ACHD admissions between January 1, 2010 and December 31, 2020, 5826 (22%) were ACHDHF+ and 20 628 (78%) were ACHDHF-. The ACHD HF+ hospitalizations increased from 6.6% to 14.0% (P<0.0001). Over a mean follow-up period of 2.23 ± 2.19 years, patients with ACHDHF+ had a higher risk of mortality (hazard ratio [HR], 1.86 [95% CI, 1.67-2.07], P<0.001), major adverse cardiac and cerebrovascular events (HR, 1.73 [95% CI, 1.63-1.83], P<0.001) and health resource use including rehospitalization (HR, 1.09 [95% CI, 1.05-1.14], P<0.001) and increased postacute care service use (HR, 1.56 [95% CI, 1.32-1.85], P<0.001). Cardiology clinic visits within 30 days of hospital admission were associated with lower 90-day and 1-year all-cause mortality (odds ratio [OR], 0.62 [95% CI, 0.49-0.78], P<0.001; OR, 0.69 [95% CI, 0.58-0.83], P<0.001, respectively). CONCLUSIONS HF hospitalization is associated with increased risk of mortality and morbidity with high health resource use in patients with ACHD. Recent cardiology clinic attendance appears to mitigate these risks.
Collapse
Affiliation(s)
| | - Holly K. Van Houten
- Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo ClinicRochesterMNUSA
- OptumLabsMinnetonkaMNUSA
| | - Xiaoxi Yao
- Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo ClinicRochesterMNUSA
- OptumLabsMinnetonkaMNUSA
| | - C. Charles Jain
- Department of Cardiovascular Medicine, Mayo ClinicRochesterMNUSA
| | - Alexander Egbe
- Department of Cardiovascular Medicine, Mayo ClinicRochesterMNUSA
| | - Carole A. Warnes
- Department of Cardiovascular Medicine, Mayo ClinicRochesterMNUSA
| | | | - Shannon M. Dunlay
- Department of Cardiovascular Medicine, Mayo ClinicRochesterMNUSA
- Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo ClinicRochesterMNUSA
| | | | - Jonathan N. Johnson
- Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic Children’s CenterRochesterMNUSA
| | | | - Luke J. Burchill
- Department of Cardiovascular Medicine, Mayo ClinicRochesterMNUSA
| |
Collapse
|
23
|
Abdelrehim AA, Stephens EH, Miranda WR, Todd AL, Connolly HM, Egbe AC, Burchill LJ, Ashikhmina EA, Dearani JA. Systemic Atrioventricular Valve Surgery in Patients With Congenitally Corrected Transposition of the Great Vessels. J Am Coll Cardiol 2023; 82:2197-2208. [PMID: 38030349 DOI: 10.1016/j.jacc.2023.09.822] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 08/08/2023] [Accepted: 09/26/2023] [Indexed: 12/01/2023]
Abstract
BACKGROUND Limited data exist regarding the long-term outcomes of systemic atrioventricular valve (SAVV) intervention (morphologic tricuspid valve) in congenitally corrected transposition (ccTGA). OBJECTIVES The goal of this study was to evaluate the mid- and long-term outcomes of SAVV surgery in ccTGA. METHODS We performed a retrospective review of 108 ccTGA patients undergoing SAVV surgery from 1979 to 2022. The primary outcome was a composite endpoint of mortality, cardiac transplantation, or ventricular assist device implantation. The secondary outcome was long-term systemic right ventricular ejection fraction (SVEF). Cox proportional hazard and linear regression models were used to analyze survival and late SVEF data. RESULTS The median age at surgery was 39.5 years (Q1-Q3: 28.8-51.0 years), and the median preoperative SVEF was 39% (Q1-Q3: 33.2%-45.0%). Intrinsic valve abnormality was the most common mechanism of SAVV regurgitation (76.9%). There was 1 early postoperative mortality (0.9%). Postoperative complete heart block occurred in 20 patients (18.5%). The actuarial 5-, 10-, and 20-year freedom from death or transplantation was 92.4%, 79.1%, and 62.9%. The 10- and 20-year freedom from valve reoperation was 100% and 93% for mechanical prosthesis compared with 56.6% and 15.7% for bioprosthesis (P < 0.0001). Predictors of postoperative mortality were age at operation (P = 0.01) and preoperative SVEF (P = 0.04). Preoperative SVEF (P < 0.001), complex ccTGA (P = 0.02), severe SAVV regurgitation (P = 0.04), and preoperative creatinine (P = 0.003) were predictors of late postoperative SVEF. CONCLUSIONS SAVV surgery remains a valuable option for the treatment of patients with ccTGA, with low early mortality and satisfactory long-term outcomes, particularly in those with SVEF ≥40%. Timely referral and accurate patient selection are the keys to better long-term outcomes.
Collapse
Affiliation(s)
- Ahmed A Abdelrehim
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | - William R Miranda
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Austin L Todd
- Department of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minnesota, USA
| | - Heidi M Connolly
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Alexander C Egbe
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Luke J Burchill
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Elena A Ashikhmina
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA.
| |
Collapse
|
24
|
Ergi DG, Schaff HV, Connolly HM, Miranda WR, Majdalany DS, Dearani JM. Left ventricular outflow tract obstruction in patients with Ebstein anomaly. JTCVS Open 2023; 16:641-647. [PMID: 38204684 PMCID: PMC10775129 DOI: 10.1016/j.xjon.2023.10.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 10/04/2023] [Accepted: 10/10/2023] [Indexed: 01/12/2024]
Abstract
Objective In this study, we investigated the clinical characteristics of patients with Ebstein anomaly and left ventricular outflow tract (LVOT) obstruction as well as possible mechanisms of obstruction as assessed by 2-dimensional echocardiography. Methods We queried our institutional echocardiography and surgical databases for patients with the diagnosis of Ebstein anomaly seen from 1985 through 2022. Fourteen patients had the additional diagnosis of LVOT obstruction identified from transthoracic echocardiography. Results The mean age of the 14 patients at the time that LVOT obstruction was identified was 51.9 ± 9.9 years, and 11 (78%) were female. LVOT obstruction (mean gradient 61.0 ± 25.7 mm Hg) was documented at the time of initial diagnosis of Ebstein anomaly for 8, and in the remaining, was recognized on follow-up imaging. Dynamic LVOT obstruction with systolic anterior motion (SAM) was the most common mechanism and was mostly accompanied by leftward septal movement and septal hypertrophy. Seven of the 9 patients with SAM had the diagnosis of hypertrophic cardiomyopathy. Leftward bowing of the septum appeared to be the sole cause of LVOT obstruction in 3 and a contributing factor to SAM in 4. Among the 13 patients who underwent an operation for Ebstein anomaly, 7 had concomitant septal myectomy and 3 had a subsequent procedure. Conclusions There are multiple mechanisms of LVOT obstruction in patients with Ebstein anomaly, including SAM and leftward bowing of the interventricular septum, which may exist alone or in combination. Septal myectomy at the time of tricuspid valvuloplasty is safe and effectively reduces gradients in the outflow tract and may prevent the need for subsequent reintervention.
Collapse
Affiliation(s)
- Defne Gunes Ergi
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | | | | | | | | | | |
Collapse
|
25
|
Lloyd JW, Anavekar NS, Oh JK, Miranda WR. Multimodality Imaging in Differentiating Constrictive Pericarditis From Restrictive Cardiomyopathy: A Comprehensive Overview for Clinicians and Imagers. J Am Soc Echocardiogr 2023; 36:1254-1265. [PMID: 37619909 DOI: 10.1016/j.echo.2023.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 07/27/2023] [Accepted: 08/14/2023] [Indexed: 08/26/2023]
Abstract
In the evaluation of heart failure, 2 differential diagnostic considerations include constrictive pericarditis and restrictive cardiomyopathy. The often outwardly similar clinical presentation of these 2 pathologic entities routinely renders their clinical distinction difficult. Consequently, initial assessment requires a keen understanding of their separate pathophysiology, epidemiology, and hemodynamic effects. Following a detailed clinical evaluation, further assessment initially rests on comprehensive echocardiographic investigation, including detailed Doppler evaluation. With the combination of mitral inflow characterization, tissue Doppler assessment, and hepatic vein interrogation, initial differentiation of constrictive pericarditis and restrictive cardiomyopathy is often possible with high sensitivity and specificity. In conjunction with a compatible clinical presentation, successful differentiation enables both an accurate diagnosis and subsequent targeted management. In certain cases, however, the diagnosis remains unclear despite echocardiographic assessment, and additional evaluation is required. With advances in noninvasive tools, such evaluation can often continue in a stepwise, algorithmic fashion noninvasively, including both cross-sectional and nuclear imaging. Should this additional evaluation itself prove insufficient, invasive assessment with appropriate expertise may ultimately be necessary.
Collapse
Affiliation(s)
- James W Lloyd
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Nandan S Anavekar
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Jae K Oh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - William R Miranda
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.
| |
Collapse
|
26
|
Abdelrehim AA, Dearani JA, Holst KA, Miranda WR, Connolly HM, Todd AL, Burchill LJ, Schaff HV, Pochettino A, Stephens EH. Risk factors and early outcomes of repeat sternotomy in 1960 adults with congenital heart disease: A 30-year, single-center study. J Thorac Cardiovasc Surg 2023:S0022-5223(23)01090-5. [PMID: 37981102 DOI: 10.1016/j.jtcvs.2023.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 10/06/2023] [Accepted: 11/05/2023] [Indexed: 11/21/2023]
Abstract
OBJECTIVE Patients with congenital heart disease (CHD) increasingly live into adulthood, often requiring cardiac reoperation. We aimed to assess the outcomes of adults with CHD (ACHD) undergoing repeat sternotomy at our institution. METHODS Review of our institution's cardiac surgery database identified 1960 ACHD patients undergoing repeat median sternotomy from 1993 to 2023. The primary outcome was early mortality, and the secondary outcome was a composite end point of mortality and significant morbidity. Univariable and multivariable logistic regression models were used to determine factors independently associated with outcomes. RESULTS Of the 1960 ACHDs patient undergoing repeat sternotomy, 1183 (60.3%) underwent a second, third (n = 506, 25.8%), fourth (n = 168, 8.5%), fifth (n = 70, 3.5%), and sixth sternotomy or greater (n = 33, 1.6%). CHD diagnoses were minor complexity (n = 145, 7.4%), moderate complexity (n = 1380, 70.4%), and major complexity (n = 435, 22.1%). Distribution of procedures included valve (n = 549, 28%), congenital (n = 625, 32%), aortic (n = 104, 5.3%), and major procedural combinations (n = 682, 34.7%). Overall early mortality was 3.1%. Factors independently associated with early mortality were older age at surgery, CHD of major complexity, preoperative renal failure, preoperative ejection fraction, urgent operation, and postoperative blood transfusion. In addition, sternotomy number and bypass time were independently associated with the composite outcome. CONCLUSIONS Despite the increase in early mortality with sternotomy number, sternotomy number was not independently associated with early mortality but with increased morbidity. Improvement strategies should target factors leading to urgent operations, early referral, along with operative efficiency including bypass time and blood conservation.
Collapse
Affiliation(s)
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn.
| | - Kimberly A Holst
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | | | - Heidi M Connolly
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minn
| | - Austin L Todd
- Department of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minn
| | - Luke J Burchill
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minn
| | | | | | | |
Collapse
|
27
|
Abozied O, Miranda WR, Connolly HM, Younis A, Ahmed M, Kamath PS, Egbe AC. Temporal Change in Hepatic and Renal Function After Pulmonary Valve Replacement in Adults With Tetralogy of Fallot. Am J Cardiol 2023; 206:40-41. [PMID: 37677883 PMCID: PMC10827362 DOI: 10.1016/j.amjcard.2023.08.074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 08/05/2023] [Accepted: 08/12/2023] [Indexed: 09/09/2023]
Affiliation(s)
| | | | | | | | | | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | | |
Collapse
|
28
|
Egbe AC, Anderson JH, Karnakoti S, Jain CC, Ahmed MH, Burchill LJ, Connolly HM, Miranda WR. Assessment of Coarctation of Aorta Gradient: Echocardiogram-Catheterization Correlation. Am J Cardiol 2023; 205:420-421. [PMID: 37660667 PMCID: PMC10805228 DOI: 10.1016/j.amjcard.2023.08.083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 08/16/2023] [Indexed: 09/05/2023]
Affiliation(s)
- Alexander C Egbe
- The Department of Cardiovascular Medicine, Mayo Clinic Rochester, Minnesota.
| | - Jason H Anderson
- The Department of Cardiovascular Medicine, Mayo Clinic Rochester, Minnesota
| | - Snigdha Karnakoti
- The Department of Cardiovascular Medicine, Mayo Clinic Rochester, Minnesota
| | - C Charles Jain
- The Department of Cardiovascular Medicine, Mayo Clinic Rochester, Minnesota
| | - Marwan H Ahmed
- The Department of Cardiovascular Medicine, Mayo Clinic Rochester, Minnesota
| | - Luke J Burchill
- The Department of Cardiovascular Medicine, Mayo Clinic Rochester, Minnesota
| | - Heidi M Connolly
- The Department of Cardiovascular Medicine, Mayo Clinic Rochester, Minnesota
| | - William R Miranda
- The Department of Cardiovascular Medicine, Mayo Clinic Rochester, Minnesota
| |
Collapse
|
29
|
Egbe AC, Younis A, Miranda WR, Jain CC, Burchill LJ, Dearani JA, Stephens EH, Connolly HM. Relation Between Preoperative Hypoxia and Postoperative Oxygen Saturation in Patients Post-Fontan Palliation Who Undergo Heart Transplant. Am J Cardiol 2023; 205:325-326. [PMID: 37633068 PMCID: PMC10798178 DOI: 10.1016/j.amjcard.2023.08.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Accepted: 08/07/2023] [Indexed: 08/28/2023]
Affiliation(s)
- Alexander C Egbe
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.
| | - Ahmed Younis
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - William R Miranda
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - C Charles Jain
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Luke J Burchill
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Heidi M Connolly
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
30
|
Miranda WR, Kamath PS, Jain CC, Connolly HC, Egbe AC. Liver Fibrosis Scores Are Associated With Resting and Exercise Fontan and Pulmonary Artery Wedge Pressures: Insights Into FALD. Can J Cardiol 2023; 39:1349-1357. [PMID: 37150355 DOI: 10.1016/j.cjca.2023.04.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 04/03/2023] [Accepted: 04/27/2023] [Indexed: 05/09/2023] Open
Abstract
BACKGROUND Alterations in liver perfusion and venous hypertension have been implicated in the pathophysiology of Fontan-associated liver disease (FALD). However, the correlation between exercise hemodynamics and markers of FALD have not been studied. METHODS We performed a retrospective review of 32 consecutive adults undergoing exercise catheterisation at the Mayo Clinic, Minnesota. Invasive hemodynamics were correlated with aspartate transaminase to platelet ratio index (APRI) and the Fibrosis-4 (Fib-4) score, well validated surrogates of liver fibrosis. RESULTS The mean age was 30.9 ± 7 years. The mean APRI was 0.5 ± 0.2 and the mean Fib-4 score 1.3 ± 0.8. Fib-4 scores correlated with spleen size on abdominal imaging (r = 0.40; P = 0.03). Resting Fontan pressure was 13.9 ± 3.9 mm Hg and pulmonary artery wedge pressure (PAWP) 10.0 ± 3.5 mm Hg. At peak exercise (69.4 ± 23.2 W), Fontan pressures increased to 26.5 ± 6.2 mm Hg and PAWP to 22.4 ± 7.1 mm Hg. APRI and Fib-4 score were directly related to Fontan pressure and PAWP at rest and during exercise, and inversely related to exercise arterial O2 saturation. Fib-4 inversely correlated with O2 delivery indices. Similarly, when categorising patients according to high APRI (> 0.5 vs ≤ 0.5) or Fib-4 score (≥ 1.45 vs < 1.45) according to previously proposed cutoffs for diagnosis of liver fibrosis, those with elevated scores had higher resting and exercise Fontan and PAWP pressure with lower O2 arterial saturation. CONCLUSIONS APRI and Fib-4 score correlated with resting and exercise Fontan pressure and PAWP. In addition, Fib-4 scores were inversely related to O2 delivery indices. These findings support a role played by hepatic venous hypertension and reduced O2 supply in patients with FALD.
Collapse
Affiliation(s)
- William R Miranda
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - C Charles Jain
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Heidi C Connolly
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Alexander C Egbe
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| |
Collapse
|
31
|
Agasthi P, Jain CC, Egbe AC, Hagler DJ, Cabalka AK, Taggart NW, Anderson JH, Cetta F, Connolly HM, Burchill LJ, Kamath PS, Miranda WR. Clinical Outcomes of Percutaneous Fontan Stenting in Adults. Can J Cardiol 2023; 39:1358-1365. [PMID: 37141988 DOI: 10.1016/j.cjca.2023.04.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 04/20/2023] [Accepted: 04/26/2023] [Indexed: 05/06/2023] Open
Abstract
BACKGROUND Fontan pathway stenosis is a well-known complication after palliation. Percutaneous stenting is effective for angiographic/hemodynamic relief of Fontan obstruction, but its clinical impact in adults remains unknown. METHODS This was a retrospective cohort of 26 adults undergoing percutaneous stenting for Fontan obstruction from 2014 to 2022. Procedural details, functional capacity, and liver parameters were reviewed at baseline and during follow-up. RESULTS Median age was 22.5 years (interquartile range [IQR] 19-28.8 y); 69% were male. After stenting, Fontan gradient significantly decreased (2.0 ± 1.9 vs 0 [IQR 0-1] mm Hg; P < 0.005), and minimal Fontan diameter increased (11.3 ± 2.9 vs 19.3 [IQR 17-20] mm; P < 0.001). One patient developed acute kidney injury periprocedurally. During a follow-up of 2.1 years (IQR 0.6-3.7 y), 1 patient had thrombosis of the Fontan stent and 2 underwent elective Fontan re-stenting. New York Heart Association functional class improved in 50% of symptomatic patients. Changes in functional aerobic capacity on exercise testing were directly related to pre-stenting Fontan gradient (n = 7; r = 0.80; P = 0.03) and inversely related to pre-stenting minimal Fontan diameter (r = -0.79; P = 0.02). Thrombocytopenia (platelet count < 150 109/L) was present in 42.3% of patients before and in 32% after the procedure (P = 0.08); splenomegaly (spleen size > 13 cm) was present in 58.3% and 58.8% (P = 0.57), respectively. Liver fibrosis (aspartate transaminase to platelet ratio index and Fibrosis-4) scores were unchanged after the procedure compared with baseline. CONCLUSIONS Percutaneous stenting in adults is safe and effective in relieving Fontan obstruction, resulting in subjective improvement in functional capacity in some. A subset of patients demonstrated improvement in markers of portal hypertension, suggesting that Fontan stenting could improve Fontan-associated liver disease in select individuals.
Collapse
Affiliation(s)
- Pradyumna Agasthi
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - C Charles Jain
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Alexander C Egbe
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Donald J Hagler
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA; Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Allison K Cabalka
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA; Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Nathaniel W Taggart
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA; Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jason H Anderson
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA; Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Frank Cetta
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA; Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Heidi M Connolly
- Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Luke J Burchill
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - William R Miranda
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA.
| |
Collapse
|
32
|
Miranda WR, Charles Jain C, Frantz RP, DuBrock HM, Connolly HM, Burchill LJ, Egbe AC. Effects of inhaled nitric oxide on Fontan hemodynamics in adults. J Heart Lung Transplant 2023; 42:1349-1352. [PMID: 37127071 DOI: 10.1016/j.healun.2023.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 04/24/2023] [Accepted: 04/27/2023] [Indexed: 05/03/2023] Open
Abstract
The pulmonary vasculature plays a pivotal role in the nonpulsatile systemic venous return post-Fontan palliation. Elevated pulmonary vascular resistance index (PVRi) carries a worse prognosis post-Fontan, but the benefits of pulmonary vasodilators remain controversial. Moreover, the potential for worsening ventricular filling pressures with pulmonary vasodilation has been highlighted. We reviewed our experience with inhaled nitric oxide (iNO) administration during cardiac catheterization in 30 adults (age 32.7 ± 8.5 years) post-Fontan. The main findings of the study are: (1) iNO decreased pulmonary artery pressures, transpulmonary gradient, and PVRi without increasing pulmonary artery wedge pressure, (2) cardiac index was unchanged with iNO, and (3) different from acquired left heart disease, iNO did not result in further elevations in pulmonary artery wedge pressure in those with elevated ventricular filling pressures. iNO administration in adults post-Fontan was safe; whether baseline PVRi and response to iNO could be used to predict response to pulmonary vasodilators post-Fontan requires further investigation.
Collapse
Affiliation(s)
| | - C Charles Jain
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Robert P Frantz
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Hilary M DuBrock
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Heidi M Connolly
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Luke J Burchill
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Alexander C Egbe
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| |
Collapse
|
33
|
Egbe AC, Miranda WR, Jain CC, Stephens EH, Andi K, Abozied O, Connolly HM. Temporal Changes in Clinical Characteristics and Outcomes of Adults With Congenital Heart Disease. Am Heart J 2023; 264:1-9. [PMID: 37301316 PMCID: PMC10823874 DOI: 10.1016/j.ahj.2023.05.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 05/03/2023] [Accepted: 05/27/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND The purpose of this study was to assess differences in the clinical characteristics (defined by congenital heart disease [CHD] anatomic and physiologic classification scheme) of adults with CHD across different eras, and how these differences influence outcomes (heart failure hospitalization and all-cause mortality). METHOD Patients were divided into depending on year of baseline encounter: cohort #1 (1991-2000, n = 1,984 [27%]), cohort #2 (2001-2010, n = 2,448 [34%]), and cohort #3 (2011-2020, n = 2,847 [39%]). Patients were classified into 3 anatomic groups (simple, moderate, and complex CHD) and 4 physiologic stages (stage A-D). RESULTS There was a temporal increase in the proportion of patients in physiologic stage C (17% vs 21% vs 24%, P < .001), and stage D (7% vs 8% vs 10%, P = .09), with a corresponding decrease in physiologic stage A (39% vs 35% vs 28%, P < .001). No temporal change in anatomic groups. There was a temporal decrease in the incidence of all-cause mortality (12.7 vs 10.6 vs 9.5 per 1,000 patient-years, P < .001). However, there was a temporal increase in the incidence of heart failure hospitalization (6.8 vs 8.4 vs 11.2 per 1,000 patient-years, P < .001). CHD physiologic stage (but not anatomic groups) was associated with heart failure hospitalization and all-cause mortality. CONCLUSIONS There is a need for better strategies to identify and treat heart failure, and to modify the risk factors associated with heart failure and all-cause mortality.
Collapse
Affiliation(s)
- Alexander C Egbe
- Department of Cardiovascular Medicine, Mayo Clinic and Foundation, Rochester, MN.
| | - William R Miranda
- Department of Cardiovascular Medicine, Mayo Clinic and Foundation, Rochester, MN
| | - C Charles Jain
- Department of Cardiovascular Medicine, Mayo Clinic and Foundation, Rochester, MN
| | | | - Kartik Andi
- Department of Cardiovascular Medicine, Mayo Clinic and Foundation, Rochester, MN
| | - Omar Abozied
- Department of Cardiovascular Medicine, Mayo Clinic and Foundation, Rochester, MN
| | - Heidi M Connolly
- Department of Cardiovascular Medicine, Mayo Clinic and Foundation, Rochester, MN
| |
Collapse
|
34
|
Andi K, Abozied O, Miranda WR, Anderson JH, Connolly HM, Jain CC, Burchill LJ, Egbe AC. Clinical benefits of angiotensin receptor-Neprilysin inhibitor in adults with congenital heart disease. Int J Cardiol 2023; 387:131152. [PMID: 37429446 DOI: 10.1016/j.ijcard.2023.131152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 06/19/2023] [Accepted: 07/05/2023] [Indexed: 07/12/2023]
Abstract
BACKGROUND There are limited data about the clinical benefits of angiotensin receptor-neprilysin inhibitor (ARNI) in adults with congenital heart disease (CHD). The purpose of the study was to assess the clinical benefits (chamber function and heart failure indices) of ARNI in adults with CHD. METHOD In this retrospective cohort study, we compared the temporal change in chamber function and heart failure indices between 35 patients that received ARNI for >6 months, and a propensity matched control group (n = 70) of patients that received angiotensin converting enzyme inhibitor or angiotensin-II receptor blocker (ACEI/ARB) within the same period. RESULTS Of the 35 patients in the ARNI group, 21 (60%) had systemic left ventricle (LV) while 14 (40%) had systemic right ventricle (RV). Compared to the ACEI/ARB group, the ARNI group had greater relative improvement in LV global longitudinal strain (GLS) (28% versus 11% increase from baseline, p < 0.001) and RV-GLS (11% versus 4% increase from baseline, p < 0.001), and greater relative improvement in New York Heart Association functional class (-14 versus -2% change from baseline, p = 0.006) and N-terminal pro-brain natriuretic peptide levels (-29% versus -13% change from baseline, p < 0.001). These results were consistent across different systemic ventricular morphologies. CONCLUSIONS ARNI was associated with improvement in biventricular systolic function, functional status, and neurohormonal activation, suggesting prognostic benefit. These results provide a foundation for a randomized clinical trial to empirically test the prognostic benefits of ARNI in adults with CHD, as the next step towards evidence-based recommendations for heart failure management in this population.
Collapse
Affiliation(s)
- Kartik Andi
- From the Department of Cardiovascular Medicine, Mayo Clinic Rochester, MN 55905, USA
| | - Omar Abozied
- From the Department of Cardiovascular Medicine, Mayo Clinic Rochester, MN 55905, USA
| | - William R Miranda
- From the Department of Cardiovascular Medicine, Mayo Clinic Rochester, MN 55905, USA
| | - Jason H Anderson
- From the Department of Cardiovascular Medicine, Mayo Clinic Rochester, MN 55905, USA
| | - Heidi M Connolly
- From the Department of Cardiovascular Medicine, Mayo Clinic Rochester, MN 55905, USA
| | - C Charles Jain
- From the Department of Cardiovascular Medicine, Mayo Clinic Rochester, MN 55905, USA
| | - Luke J Burchill
- From the Department of Cardiovascular Medicine, Mayo Clinic Rochester, MN 55905, USA
| | - Alexander C Egbe
- From the Department of Cardiovascular Medicine, Mayo Clinic Rochester, MN 55905, USA.
| |
Collapse
|
35
|
Egbe AC, Miranda WR, Jain CC, Anderson JH, Younis A, Abozied O, Connolly HM. Prognostic Value of the Anatomic-Physiologic Classification in Adults With Congenital Heart Disease. Circ Heart Fail 2023; 16:e010404. [PMID: 37476989 PMCID: PMC10526749 DOI: 10.1161/circheartfailure.122.010404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 06/01/2023] [Indexed: 07/22/2023]
Abstract
BACKGROUND The prognostic role of the congenital heart disease (CHD) anatomic/physiologic classification has not been systematically studied. The purpose of this study was to determine whether CHD physiologic stage provided improvement in prognostic power (to predict all-cause mortality) beyond conventional clinical risk models. METHODS Retrospective study of adults with CHD at the Mayo Clinic (2003-2019). The CHD physiologic stage was assessed at baseline and 36 (24-48) months, and patients were classified into stages A to D at these time points. Clinical stability (remaining in the same stage), clinical improvement (moving to less advanced stage), and clinical deterioration (moving to more advanced stage) were determined at 36 months. We defined conventional clinical risk indices as age/sex, functional class, comorbidities, cardiac procedures, hepatorenal dysfunction, and ventricular/valvular dysfunction. RESULTS Of 5321 patients, 1649 (31%), 1968 (37%), 1224 (23%), and 480 (9%) were in stages A, B, C, and D at baseline. Of 5321 patients, 4588 (86%) also had assessments at 36 months, and of these patients, 3347 (73%), 386 (8%), and 855 (19%) had clinical stability, deterioration, and improvement, respectively. Patients with clinical improvement were more likely to have undergone cardiac procedures between both assessments. Both baseline CHD physiologic stage (hazard ratio, 1.13 [95% CI, 1.09-1.17]; P<0.001, per unit increase in stage) and change in CHD physiologic stage (hazard ratio, 1.46 [95% CI, 1.32-1.61]; P=0.007, per unit increase in stage) were associated with mortality after adjustments for conventional risk indices and provided incremental improvement in prognostic power beyond conventional clinical risk models as evidence by an increase in C statistic from 0.702 (0.681-0.724) to 0.769 (0.754-0.787). CONCLUSIONS The CHD physiologic stage can potentially be used for risk stratification, as well as to monitor disease progression and response to therapy.
Collapse
Affiliation(s)
- Alexander C Egbe
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, MN
| | | | - C Charles Jain
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, MN
| | - Jason H Anderson
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, MN
| | - Ahmed Younis
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, MN
| | - Omar Abozied
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, MN
| | - Heidi M Connolly
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, MN
| |
Collapse
|
36
|
Egbe AC, Miranda WR, Madhavan M, Abozied O, Younis AK, Ahmed MH, Connolly HM, Deshmukh AJ. Right atrial dysfunction is associated with atrial arrhythmias in adults with repaired tetralogy of fallot. Am Heart J 2023; 263:141-150. [PMID: 37271358 DOI: 10.1016/j.ahj.2023.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 05/26/2023] [Accepted: 05/30/2023] [Indexed: 06/06/2023]
Abstract
BACKGROUND Adults with repaired tetralogy of Fallot (TOF) have right atrial (RA) remodeling and dysfunction, and RA function can be measured using speckle tracking echocardiography. There are limited data about the role of RA strain imaging for risk stratification in this population. We hypothesized that RA reservoir strain can identify TOF patients at risk of developing atrial arrhythmia. To test this hypothesis, we assessed the relationship between RA reservoir strain and atrial arrhythmias in adults with repaired TOF. METHOD Retrospective cohort study of adults with repaired TOF, and no prior history of atrial arrhythmias. Atrial arrhythmia was defined as atrial fibrillation, atrial flutter/atrial tachycardia, and categorized as new-onset versus recurrent atrial arrhythmias. RESULTS We identified 426 patients (age 33 ± 12 years; males 208 (49%)) that met the inclusion criteria. The mean RA reservoir strain, conduit strain, and booster strain were 34 ± 11%, 20 ± 9%, and 15 ± 12%, respectively. Of 426 patients, 73 (17%) developed new-onset atrial arrhythmias (atrial flutter/tachycardia n = 42; atrial fibrillation n = 31); annual incidence 1.9%. RA reservoir strain was associated with new-onset atrial arrhythmias (adjusted HR 0.95, 95% CI 0.93-0.97) after multivariable adjustment. Of 73 patients with new-onset atrial arrhythmia, 41 (56%) had recurrent atrial arrhythmia (atrial flutter/tachycardia n = 18; atrial fibrillation n = 23); annual incidence 11.2%. Similarly, RA reservoir strain was associated with recurrent atrial arrhythmias (adjusted HR 0.92, 95% CI 0.88-0.96) after multivariable adjustment. CONCLUSIONS RA strain indices can identify patients at risk for atrial arrhythmias, and this can in turn, be used to guide the type/intensity of therapy in such patients.
Collapse
Affiliation(s)
- Alexander C Egbe
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, Rochester, MN.
| | - William R Miranda
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, Rochester, MN
| | - Malini Madhavan
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, Rochester, MN
| | - Omar Abozied
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, Rochester, MN
| | - Ahmed K Younis
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, Rochester, MN
| | - Marwan H Ahmed
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, Rochester, MN
| | - Heidi M Connolly
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, Rochester, MN
| | | |
Collapse
|
37
|
Egbe AC, Miranda WR, Jain CC, Andi K, Abozied O, Younis AK, Kandlakunta S, Salama AA, Stephens EH, Connolly HM. Prognostic Performance of Right Ventricular Global Longitudinal Strain Measurements in Patients With Ebstein Anomaly. J Am Coll Cardiol 2023; 82:503-513. [PMID: 37532420 DOI: 10.1016/j.jacc.2023.05.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 05/03/2023] [Accepted: 05/11/2023] [Indexed: 08/04/2023]
Abstract
BACKGROUND There are limited data on the prognostic role of right ventricular global longitudinal strain (RVGLS) in patients with Ebstein anomaly. OBJECTIVES This study sought to assess the relationship between RVGLS and mortality and to compare prognostic performance of RVGLS with conventional echocardiographic indices of right ventricular (RV) systolic function. METHODS This study identified adults with Ebstein anomaly with echocardiographic assessment of RV systolic function (RVGLS, RV fractional area change [RVFAC], RV tissue Doppler systolic velocity [RV s'], and tricuspid annular plane systolic excursion [TAPSE]) from 2003 to 2020. For ease of presentation, RVGLS was modeled as absolute values (ie, without the negative sign). RESULTS Of 620 patients (median age 37 years; men 261 [42%]), the mean absolute RVGLS, RVFAC, RV s', and TAPSE were 18% ± 5%, 32% ± 9%, 14 ± 6 cm/s, and 22 ± 8 mm, respectively. There were correlations between absolute RVGLS and RVFAC (r = 0.71; P < 0.001), between absolute RVGLS and RV s' (r = 0.41; P = 0.03), and between absolute RVGLS and TAPSE (r = 0.44; P = 0.002). Of 620 patients, 47 (8%) died during follow-up, and 34 of these deaths were cardiovascular. Absolute RVGLS was independently associated with all-cause mortality (adjusted HR: 0.94; 95% CI: 0.92-0.96 per unit increase) and cardiovascular mortality (adjusted HR: 0.92; 95% CI: 0.90-0.94 per unit increase). Absolute RVGLS had superior prognostic power (ie, ability to predict mortality) as compared with RVFAC, RV s', or TAPSE. CONCLUSIONS These data support the use of RVGLS for risk stratification in Ebstein anomaly, and further studies are required to assess how interventions may affect different patients according to risk stratification.
Collapse
Affiliation(s)
- Alexander C Egbe
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.
| | - William R Miranda
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - C Charles Jain
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Kartik Andi
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Omar Abozied
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Ahmed K Younis
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Abdalla A Salama
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA; Department of Cardiovascular Diseases, Suez Canal University, Ismailia, Egypt
| | | | - Heidi M Connolly
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| |
Collapse
|
38
|
Hu TY, Janga C, Amin M, Tan NY, Hodge DO, Mehta RA, McLeod CJ, Chiriac A, Miranda WR, Connolly HM, Asirvatham SJ, Deshmukh AJ, Egbe AC, Madhavan M. Catheter Ablation of Atrial Fibrillation in Adult Congenital Heart Disease: Procedural Characteristics and Outcomes. Circ Arrhythm Electrophysiol 2023; 16:437-446. [PMID: 37485717 DOI: 10.1161/circep.122.011392] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 06/27/2023] [Indexed: 07/25/2023]
Abstract
BACKGROUND The outcomes of catheter ablation for atrial fibrillation in adults with congenital heart disease are not well described. METHODS In a retrospective study of adult patients with congenital heart disease who underwent catheter ablation for atrial fibrillation between 2000 and 2020 at Mayo Clinic, procedural characteristics and outcomes were collected. The primary outcomes were atrial arrhythmia (AA) recurrence following a 3-month blanking period and repeat ablation. An arrhythmia clinical severity score was assessed pre- and post-ablation based on the duration of arrhythmia episodes, symptoms, cardioversion frequency, and antiarrhythmic drug use. RESULTS One hundred forty-five patients (age, 57±12 years; 28% female; 63% paroxysmal atrial fibrillation) underwent 198 ablations with a median follow-up of 26 months (interquartile range, 14-69). One hundred ten, 26, and 9 patients had simple, moderate, and complex congenital heart disease, respectively. All patients underwent pulmonary vein isolation, and non-pulmonary vein targets were ablated in 79 (54%). AA recurrence at 12 months was 37% (95% CI, 29%-45%). On univariate analysis, increasing left atrial volume index was associated with higher odds of AA recurrence (odds ratio, 1.03 [1.00-1.06] per 1 mL/m2 increment; P=0.05). Noninducibility of atrial flutter was predictive of decreased odds of AA recurrence (odds ratio, 0.43 [0.21-0.90]; P=0.03). A second ablation was performed in 43 patients after a median of 20 (interquartile range, 8-37) months. Arrhythmia clinical severity scores improved following ablation, reflecting a decrease in symptoms, cardioversions, and antiarrhythmic drugs. CONCLUSIONS Catheter ablation of atrial fibrillation is feasible and effective in patients with adult congenital heart disease and reduces symptoms. Recurrence of AA frequently requires repeat ablation.
Collapse
Affiliation(s)
- Tiffany Y Hu
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (T.Y.H., C.J., N.Y.T., W.R.M., H.M.C., S.J.A., A.J.D., A.C.E., M.M.)
| | - Chaitra Janga
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (T.Y.H., C.J., N.Y.T., W.R.M., H.M.C., S.J.A., A.J.D., A.C.E., M.M.)
| | - Mustapha Amin
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH (M.A.)
| | - Nicholas Y Tan
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (T.Y.H., C.J., N.Y.T., W.R.M., H.M.C., S.J.A., A.J.D., A.C.E., M.M.)
| | - David O Hodge
- Department of Quantitative Health Sciences, Mayo College of Medicine, Jacksonville, FL (D.O.H.)
| | - Ramila A Mehta
- Department of Quantitative Health Sciences, Mayo College of Medicine, Rochester, MN (R.A.M.)
| | - Christopher J McLeod
- Department of Cardiovascular Diseases, Mayo Clinic in Jacksonville, FL (C.J.M., A.C.)
| | - Anca Chiriac
- Department of Cardiovascular Diseases, Mayo Clinic in Jacksonville, FL (C.J.M., A.C.)
| | - William R Miranda
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (T.Y.H., C.J., N.Y.T., W.R.M., H.M.C., S.J.A., A.J.D., A.C.E., M.M.)
| | - Heidi M Connolly
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (T.Y.H., C.J., N.Y.T., W.R.M., H.M.C., S.J.A., A.J.D., A.C.E., M.M.)
| | - Samuel J Asirvatham
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (T.Y.H., C.J., N.Y.T., W.R.M., H.M.C., S.J.A., A.J.D., A.C.E., M.M.)
| | - Abhishek J Deshmukh
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (T.Y.H., C.J., N.Y.T., W.R.M., H.M.C., S.J.A., A.J.D., A.C.E., M.M.)
| | - Alexander C Egbe
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (T.Y.H., C.J., N.Y.T., W.R.M., H.M.C., S.J.A., A.J.D., A.C.E., M.M.)
| | - Malini Madhavan
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (T.Y.H., C.J., N.Y.T., W.R.M., H.M.C., S.J.A., A.J.D., A.C.E., M.M.)
| |
Collapse
|
39
|
Egbe AC, Miranda WR, Connolly HM, Kullo IJ, Borlaug BA. Daytime Versus Nighttime Ambulatory Blood Pressure Monitoring in Coarctation of Aorta. Hypertension 2023; 80:e134-e136. [PMID: 37161822 PMCID: PMC10523865 DOI: 10.1161/hypertensionaha.123.21124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Affiliation(s)
- Alexander C Egbe
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, MN
| | | | - Heidi M Connolly
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, MN
| | - Iftikhar J Kullo
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, MN
| | - Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, MN
| |
Collapse
|
40
|
Alabdaljabar MS, Cendrowski EE, Nishimura RA, Miranda WR, Geske JB, Rihal CS, Eleid MF. Hemodynamic Predictors of Outcome Following Alcohol Septal Ablation for Hypertrophic Obstructive Cardiomyopathy. Circ Cardiovasc Interv 2023; 16:e013068. [PMID: 37582173 PMCID: PMC10424819 DOI: 10.1161/circinterventions.123.013068] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 07/11/2023] [Indexed: 08/17/2023]
Abstract
BACKGROUND Alcohol septal ablation (ASA) is a minimally invasive treatment for drug-refractory obstructive hypertrophic cardiomyopathy. Detailed assessment of pressure changes and predictors of mortality and procedure success are not well defined. METHODS This is a single-center study evaluating pressure changes and predictors of mortality and procedure success in transseptal ASA. Survival analysis and predictors of mortality were assessed using the Kaplan-Meier analysis and Cox regression, respectively. RESULTS A total of 156 patients were included (mean age, 67.3 years; 46.8% women). Left atrial (LA) pressure and left ventricular outflow tract (LVOT) gradient decreased, whereas aortic pulse pressure (PP) increased post-ASA. Patients with lower baseline mean LA pressure ( 82% (gradient change median), and PP increase >19% (PP change median) had superior survival. On Cox univariable regression, baseline mean LA pressure >median (19 mm Hg; hazard ratio [HR], 2.09 [95% CI, 1.05-4.18]; P=0.036), residual LVOT gradient (HR, 1.02 [95% CI, 1.01-1.03]; P=0.003), and LVOT gradient percent reduction median (28 mm Hg; HR, 2.36 [95% CI, 1.17-4.76]; P=0.016), baseline mean LA pressure >median (19 mm Hg; HR, 2.70 [95% CI, 1.33-5.50]; P=0.006), percentage reduction in gradient CONCLUSIONS ASA is associated with an acute decrease in the LVOT gradient and LA pressures and increase in aortic PP. Mean LA pressure, percentage decrease in LVOT gradient, and increase in PP are strong predictors of survival free of all-cause mortality following ASA and are important variables for procedural guidance.
Collapse
Affiliation(s)
| | - Emily E. Cendrowski
- Cardiovascular Medicine (E.E.C., R.A.N., W.R.M., J.B.G., C.S.R., M.F.E.), Mayo Clinic, Rochester, MN
| | - Rick A. Nishimura
- Cardiovascular Medicine (E.E.C., R.A.N., W.R.M., J.B.G., C.S.R., M.F.E.), Mayo Clinic, Rochester, MN
| | - William R. Miranda
- Cardiovascular Medicine (E.E.C., R.A.N., W.R.M., J.B.G., C.S.R., M.F.E.), Mayo Clinic, Rochester, MN
| | - Jeffrey B. Geske
- Cardiovascular Medicine (E.E.C., R.A.N., W.R.M., J.B.G., C.S.R., M.F.E.), Mayo Clinic, Rochester, MN
| | - Charanjit S. Rihal
- Cardiovascular Medicine (E.E.C., R.A.N., W.R.M., J.B.G., C.S.R., M.F.E.), Mayo Clinic, Rochester, MN
| | - Mackram F. Eleid
- Cardiovascular Medicine (E.E.C., R.A.N., W.R.M., J.B.G., C.S.R., M.F.E.), Mayo Clinic, Rochester, MN
| |
Collapse
|
41
|
Griffeth EM, Dearani JA, Hassler KR, Todd A, Johnson JN, Miranda WR, Stephens EH. Late Outcomes of Konno-Rastan and Modified Konno for Left Ventricular Outflow Tract Obstruction. Ann Thorac Surg 2023:S0003-4975(23)00711-7. [PMID: 37479125 PMCID: PMC10799181 DOI: 10.1016/j.athoracsur.2023.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 06/20/2023] [Accepted: 07/11/2023] [Indexed: 07/23/2023]
Abstract
BACKGROUND While early outcomes of the Konno-Rastan and modified Konno procedures are known, long-term outcomes remain undetermined. Our objective was to examine long-term clinical and echocardiographic outcomes. METHODS Retrospective review was performed of patients undergoing Konno-Rastan and modified Konno for complex left ventricular outflow tract (LVOT) obstruction from January 1980 to January 2021. The Ross-Konno procedure was excluded due to its often limited ventriculotomy. RESULTS A total of 92 patients were identified: 73 Konno-Rastan and 19 modified Konno. The modified Konno group was significantly younger (median [interquartile range, IQR]: 6, [2-12] years vs 16 [9-32] years, P = .001). LVOT obstruction was multilevel (39 of 92 [42.4%]), tunnel subaortic (35 of 92 [38.0%]), or aortic valve stenosis/annular hypoplasia (18 of 92 [19.6%]). Shone syndrome was present in 20 of 92 (21.7%) patients. Operative mortality was 7 of 92 (7.6%); 4 of 86 (4.7%) in elective vs 3 of 6 (50.0%) in urgent cases (P = .005). Median follow-up was 12 (IQR, 5-22) years. Aortic valve/LVOT mean gradient was 13 (IQR, 10-18) mm Hg at 1 year but gradually increased to 25 (IQR, 13-46) mm Hg at 10 years. Ejection fraction remained normal. Freedom from reoperation at 5 and 10 years was 77.2% and 58.4% among Konno-Rastan and 57.7% and 41.7% among modified Konno patients (P = .28), respectively. Overall survival at 5, 10, and 15 years was 82.9%, 76.3%, and 65.5%. Risk factors for mortality included older age, New York Heart Association class III/IV, longer cardiopulmonary bypass time, and multilevel LVOT obstruction. CONCLUSIONS While LVOT obstruction is alleviated early, recurrent LVOT obstruction occurs over time after Konno-Rastan and modified Konno procedures. Additionally, despite preserved left ventricular systolic function, late overall survival is poor in this young population.
Collapse
Affiliation(s)
- Elaine M Griffeth
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Kenneth R Hassler
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Austin Todd
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota
| | - Jonathan N Johnson
- Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota
| | - William R Miranda
- Division of Structural Heart Disease, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | | |
Collapse
|
42
|
Connolly HM, Dearani JA, Miranda WR. Ebstein Anomaly: We Should Do Better. J Am Coll Cardiol 2023; 81:2431-2433. [PMID: 37344045 DOI: 10.1016/j.jacc.2023.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 05/08/2023] [Indexed: 06/23/2023]
Affiliation(s)
- Heidi M Connolly
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, Minnesota, USA.
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic Rochester, Minnesota, USA
| | - William R Miranda
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, Minnesota, USA
| |
Collapse
|
43
|
Simard T, Sarma D, Miranda WR, Jain CC, Anderson JH, Collins JD, El Sabbagh A, Jhand A, Peikert T, Reeder GS, Munger TM, Packer DL, Holmes DR. Pathogenesis, Evaluation, and Management of Pulmonary Vein Stenosis: JACC Review Topic of the Week. J Am Coll Cardiol 2023; 81:2361-2373. [PMID: 37316116 DOI: 10.1016/j.jacc.2023.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 04/06/2023] [Indexed: 06/16/2023]
Abstract
Pulmonary vein stenosis (PVS) can arise from several etiologies, including congenital, acquired, and iatrogenic sources. PVS presents insidiously, leading to significant delays in diagnosis. A high index of suspicion and dedicated noninvasive evaluation are key to diagnosis. Once diagnosed, both noninvasive and invasive evaluation may afford further insights into the relative contribution of PVS to symptoms. Treatment of underlying reversible pathologies coupled with transcatheter balloon angioplasty and stenting for persistent severe stenoses are established approaches. Ongoing refinements in diagnostic modalities, interventional approaches, postintervention monitoring, and medical therapies hold promise to further improve patient outcomes.
Collapse
Affiliation(s)
- Trevor Simard
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA. https://twitter.com/tjsimard
| | - Dhruv Sarma
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA. https://twitter.com/SarmaDhruv
| | - William R Miranda
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - C Charles Jain
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jason H Anderson
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Abdallah El Sabbagh
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Aravdeep Jhand
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Tobias Peikert
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Guy S Reeder
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Thomas M Munger
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Douglas L Packer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - David R Holmes
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.
| |
Collapse
|
44
|
Egbe AC, Miranda WR, Anderson JH, Pellikka PA, Stephens EH, Andi K, Abozied O, Connolly HM. Left ventricular adaptation to aortic regurgitation in adults with repaired coarctation of aorta. Int J Cardiol 2023:S0167-5273(23)00650-2. [PMID: 37149005 DOI: 10.1016/j.ijcard.2023.04.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 04/05/2023] [Accepted: 04/30/2023] [Indexed: 05/08/2023]
Abstract
BACKGROUND Aortic regurgitation (AR) can develop in adults with repaired coarctation of aorta (COA), but there are limited data about left ventricular (LV) remodeling and clinical outcomes in this population. The purpose of the study was to compare LV remodeling (LV mass index [LVMI], LV ejection fraction [LVEF], and septal E/e') and onset of symptoms before aortic valve replacement, and LV reverse remodeling (%-change in LVMI, LVEF and E/e') after aortic valve replacement in patients with versus without repaired COA presenting with AR. METHODS Asymptomatic adults with repaired COA presenting with moderate/severe AR (AR-COA group) were matched 1:2 to asymptomatic adults without COA and similar severity of AR (control group). RESULTS Although both groups (AR-COA n = 52, and control n = 104) had similar age, sex, body mass index, aortic valve gradient, and AR severity, the AR-COA group had higher LVMI (124 ± 28 versus 102 ± 25 g/m2, p < 0.001) and E/e' (12.3 ± 2.3 versus 9.5 ± 2.1, p = 0.02) but similar LVEF (63 ± 9% versus 67 ± 10%, p = 0.4). COA diagnosis (adjusted HR 1.95, 95%CI 1.49-2.37, p < 0.001), older age, E/e', and LV hypertrophy were associated with onset of symptoms. Of 89 patients (AR-COA n = 41, and control n = 48) with echocardiographic data at 1-year post- aortic valve replacement, the AR-COA group had less regression of LVMI (-8% [95%CI -5 to -11] versus -17% [95%CI -15 to -21], p < 0.001) and E/e' (-5% [95% CI -3 to -7] versus -16% [95% CI -13 to -19], p < 0.001). CONCLUSIONS Patients with COA and AR had a more aggressive clinical course, and perhaps may require a different threshold for surgical intervention.
Collapse
Affiliation(s)
- Alexander C Egbe
- Cardiovascular Medicine, and Department of Cardiovascular Surgery, Mayo Clinic Rochester, MN 55905, United States of America.
| | - William R Miranda
- Cardiovascular Medicine, and Department of Cardiovascular Surgery, Mayo Clinic Rochester, MN 55905, United States of America
| | - Jason H Anderson
- Cardiovascular Medicine, and Department of Cardiovascular Surgery, Mayo Clinic Rochester, MN 55905, United States of America
| | - Patricia A Pellikka
- Cardiovascular Medicine, and Department of Cardiovascular Surgery, Mayo Clinic Rochester, MN 55905, United States of America
| | - Elizabeth H Stephens
- Cardiovascular Medicine, and Department of Cardiovascular Surgery, Mayo Clinic Rochester, MN 55905, United States of America
| | - Kartik Andi
- Cardiovascular Medicine, and Department of Cardiovascular Surgery, Mayo Clinic Rochester, MN 55905, United States of America
| | - Omar Abozied
- Cardiovascular Medicine, and Department of Cardiovascular Surgery, Mayo Clinic Rochester, MN 55905, United States of America
| | - Heidi M Connolly
- Cardiovascular Medicine, and Department of Cardiovascular Surgery, Mayo Clinic Rochester, MN 55905, United States of America
| |
Collapse
|
45
|
Miranda WR, Jain CC, Burchill LJ, Cabalka AK, Hagler DJ, Francois CJ, Connolly HM, Egbe AC. Correlation Between Fontan Pathway Diameter and Inferior-Superior Vena Cava Gradients in Adults Undergoing Exercise Catheterization. Circ Cardiovasc Interv 2023; 16:e012493. [PMID: 37192313 DOI: 10.1161/circinterventions.122.012493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Affiliation(s)
- William R Miranda
- Department of Cardiovascular Medicine (W.R.M., C.C.J., L.J.B., D.J.H., H.M.C., A.C.E.), Mayo Clinic, Rochester, MN
| | - C Charles Jain
- Department of Cardiovascular Medicine (W.R.M., C.C.J., L.J.B., D.J.H., H.M.C., A.C.E.), Mayo Clinic, Rochester, MN
| | - Luke J Burchill
- Department of Cardiovascular Medicine (W.R.M., C.C.J., L.J.B., D.J.H., H.M.C., A.C.E.), Mayo Clinic, Rochester, MN
| | - Allison K Cabalka
- Division of Cardiology, Department of Pediatric and Adolescent Medicine (A.K.C., D.J.H.), Mayo Clinic, Rochester, MN
| | - Donald J Hagler
- Department of Cardiovascular Medicine (W.R.M., C.C.J., L.J.B., D.J.H., H.M.C., A.C.E.), Mayo Clinic, Rochester, MN
- Division of Cardiology, Department of Pediatric and Adolescent Medicine (A.K.C., D.J.H.), Mayo Clinic, Rochester, MN
| | | | - Heidi M Connolly
- Department of Cardiovascular Medicine (W.R.M., C.C.J., L.J.B., D.J.H., H.M.C., A.C.E.), Mayo Clinic, Rochester, MN
| | - Alexander C Egbe
- Department of Cardiovascular Medicine (W.R.M., C.C.J., L.J.B., D.J.H., H.M.C., A.C.E.), Mayo Clinic, Rochester, MN
| |
Collapse
|
46
|
Miranda WR, Jain CC, Borlaug BA, Jaffe AS, Connolly HM, Burchill LJ, Egbe AC. Exercise Capacity, NT-proBNP, and Exercise Hemodynamics in Adults Post-Fontan. J Am Coll Cardiol 2023; 81:1590-1600. [PMID: 37076213 DOI: 10.1016/j.jacc.2023.02.031] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 02/08/2023] [Accepted: 02/10/2023] [Indexed: 04/21/2023]
Abstract
BACKGROUND Cardiopulmonary exercise testing (CPET) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) measurement are frequently performed in adults post-Fontan, but their correlations with exercise invasive hemodynamics are poorly understood. Moreover, whether exercise cardiac catheterization provides incremental prognostic information is unknown. OBJECTIVES The authors sought to correlate resting and exercise Fontan pressures (FP) and pulmonary artery wedge pressure (PAWP) with peak oxygen consumption (VO2) on CPET, NT-proBNP, and clinical outcomes. METHODS This was a retrospective cohort of 50 adults (age ≥18 years) post-Fontan undergoing supine exercise venous catheterization between 2018 and 2022. RESULTS Median age was 31.5 years (IQR: 23.7-36.5 years). Ventricular ejection fraction was 48.5% ± 13.0%. Exercise FP and PAWP were related to peak VO2 and ln NT-proBNP levels. Patients with peak VO2 <50% predicted had higher exercise FP (30.0 ± 6.8 mm Hg vs 19 mm Hg [IQR: 16-24 mm Hg]; P < 0.001) and PAWP (25.9 ± 6.3 mm Hg vs 15.1 ± 7.0 mm Hg; P <0.001) compared with those with more preserved exercise capacity. Exercise FP (30.0 ± 7.1 mm Hg vs 23.2 ± 7.2 mm Hg; P = 0.003) and PAWP (25.1 ± 6.7 mm Hg vs 18.8 ± 7.9 mm Hg; P = 0.006) were higher in those with NT-proBNP levels ≥300 pg/mL. During a follow-up of 0.9 years (IQR: 0.6-2.9 years), exercise FP and PAWP remained independently associated with a composite of death, cardiac transplantation, or hospitalization due to heart failure/refractory arrhythmias after adjusting for confounders. CONCLUSIONS In adults post-Fontan, resting and exercise FP and PAWP were inversely related to exercise capacity on noninvasive CPET, and exercise hemodynamics were directly related to NT-proBNP levels. Exercise FP and PAWP were independently associated with clinical outcomes and might be more sensitive than resting values to predict clinical outcomes.
Collapse
Affiliation(s)
- William R Miranda
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.
| | - C Charles Jain
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Allan S Jaffe
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Heidi M Connolly
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Luke J Burchill
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Alexander C Egbe
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| |
Collapse
|
47
|
Egbe AC, Miranda WR, Stephens EH, Anderson JH, Andi K, Goda A, Abozied O, Ramachandran D, Connolly HM. Right Ventricular Systolic Dysfunction in Adults With Anatomic Repair of d-Transposition of Great Arteries. Am J Cardiol 2023; 192:101-108. [PMID: 36764091 PMCID: PMC10402278 DOI: 10.1016/j.amjcard.2023.01.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 12/19/2022] [Accepted: 01/13/2023] [Indexed: 02/10/2023]
Abstract
The purpose of this study was to assess the prevalence of right ventricular (RV) systolic dysfunction in adults with anatomic repair of dextro-transposition of great arteries (d-TGAs), and to determine its relation to clinical outcomes across multiple domains (functional status, peak oxygen consumption, N-terminal pro-brain natriuretic peptide, and heart failure hospitalization). Adults with anatomic repair for d-TGA and with echocardiographic images for strain analysis were divided into 2 groups: (1) d-TGA status after an arterial switch operation (d-TGA-ASO group) and (2) d-TGA status after a Rastelli operation (d-TGA-Rastelli group). RV systolic function was assessed using RV global longitudinal strain (RVGLS), and RV systolic dysfunction was defined as RVGLS >-18%. We identified 151 patients (median age 21 years [19 to 28]; d-TGA-ASO group 89 [59%], and d-TGA-Rastelli group 62 [41%]). The mean RVGLS was -22 ± 4%, and 47 patients (31%) had RV systolic dysfunction. The d-TGA-Rastelli group had lower (less negative) RVGLS than that of the d-TGA-ASO group (-19 ± 3% vs -25 ± 3%, p <0.001) and higher prevalence of RV systolic dysfunction (48% vs 19%, p <0.001). RVGLS (absolute value) was associated with peak oxygen consumption (r = 0.58, p <0.001; adjusted R2 = 0.28), log-N-terminal pro-brain natriuretic peptide (r = -0.41, p = 0.004; adjusted R2 = 0.21), New York Heart Association class III/IV (odds ratio 2.29, 1.56 to 3.19, p = 0.01), and heart failure hospitalization (hazard ratio 0.93, 0.88 to 0.98, p = 0.009). RV systolic dysfunction was common in adults with d-TGA and anatomic repair and was associated with clinical outcomes. Longitudinal studies are required to determine the risk factors for progressive RV systolic dysfunction and to identify strategies for preventing RV systolic dysfunction in this population.
Collapse
|
48
|
Rizzo SA, Yalamuri SM, Rosenbaum AN, Anavekar NS, Miranda WR, Daly R, Dearani JA, Villavicencio M, Behfar A. Percutaneous Mechanical Circulatory Support as a Bridge to Transplantation in Ebstein Anomaly. Mayo Clin Proc 2023; 98:626-630. [PMID: 37019516 DOI: 10.1016/j.mayocp.2023.01.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 10/26/2022] [Accepted: 01/03/2023] [Indexed: 04/07/2023]
Abstract
Ebstein anomaly is a rare congenital heart defect occurring in 0.0005% of the population because of mispositioning and malformation of the tricuspid valve. Here, we present the first description and associated imaging of percutaneous mechanical circulatory support in the setting of cardiogenic shock secondary to Ebstein anomaly.
Collapse
Affiliation(s)
- Skylar A Rizzo
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN; Department of Molecular Pharmacology and Therapeutics, Mayo Clinic, Rochester, MN; Mayo Clinic Medical Scientist Training Program, Mayo Clinic, Rochester, MN; Van Cleve Cardiac Regenerative Medicine Program, Mayo Clinic, Rochester, MN
| | | | - Andrew N Rosenbaum
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN; Van Cleve Cardiac Regenerative Medicine Program, Mayo Clinic, Rochester, MN; William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN
| | | | | | - Richard Daly
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | | | - Atta Behfar
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN; Department of Molecular Pharmacology and Therapeutics, Mayo Clinic, Rochester, MN; Van Cleve Cardiac Regenerative Medicine Program, Mayo Clinic, Rochester, MN; William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN.
| |
Collapse
|
49
|
Martin de Miguel I, Kamath PS, Egbe AC, Jain CC, Cetta F, Connolly HM, Miranda WR. Haemodynamic and prognostic associations of liver fibrosis scores in Fontan-associated liver disease. Heart 2023; 109:619-625. [PMID: 36581444 DOI: 10.1136/heartjnl-2022-321435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 11/17/2022] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVES Fontan-associated liver disease (FALD) is universal post-Fontan palliation; however, its impact on survival remains controversial and current diagnostic tools have limitations. We aimed to assess the prognostic role of liver fibrosis scores (aminotransferase to platelet ratio [APRI] and fibrosis-4 [FIB-4]) and their association with haemodynamics and other markers of liver disease. METHODS 159 adults (age ≥18 years) post-Fontan undergoing catheterisation at Mayo Clinic, Minnesota, between 1999 and 2017 were included. Invasive haemodynamics and FALD-related laboratory, imaging and pathology data were documented. RESULTS Mean age was 31.5±9.3 years, while median age at Fontan procedure was 7.5 years (4-14). Median APRI score (n=159) was 0.49 (0.33-0.61) and median FIB-4 score (n=94) was 1.12 (0.71-1.65). Correlations between APRI and FIB-4 scores and Fontan pressures (r=0.30, p=0.0002; r=0.34, p=0.0008, respectively) and pulmonary arterial wedge pressure (r=0.25, p=0.002; r=0.30, p=0.005, respectively) were weak. Median average hepatic stiffness by magnetic resonance elastography was 4.9 kPa (4.3-6.0; n=26) and 24 (77.4%) showed stage 3 or 4 liver fibrosis on biopsy; these variables were not associated with APRI/FIB-4 scores. On multivariable analyses, APRI and FIB-4 scores were independently associated with overall mortality (HR 1.31 [1.07-1.55] per unit increase, p=0.003; HR 2.15 [1.31-3.54] per unit increase, p=0.003, respectively). CONCLUSIONS APRI and FIB-4 scores were associated with long-term all-cause mortality in Fontan patients independent of other prognostic markers. Correlations between haemodynamic status and liver scores were weak; furthermore, most markers of liver fibrosis failed to correlate with non-invasive indices, underscoring the complexity of FALD.
Collapse
Affiliation(s)
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Alexander C Egbe
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - C Charles Jain
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Frank Cetta
- Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Heidi M Connolly
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - William R Miranda
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| |
Collapse
|
50
|
Penfold MP, Haq IU, Connolly HM, Dearani JA, Schaff HV, Miranda WR, Asirvatham SJ, Killu AM, Arghami A, Stephens EH. Atrial Appendage Aneurysms: Natural History and Outcomes. World J Pediatr Congenit Heart Surg 2023:21501351231162909. [PMID: 36972504 DOI: 10.1177/21501351231162909] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
BACKGROUND Left (LAAA) and right atrial appendage aneurysms (RAAA) are rare entities, and their natural history, management, and long-term outcomes are not well studied. METHODS This retrospective review includes all patients from 2000 to 2021 with atrial appendage aneurysms at our institution identified using an electronic search tool. LAAA and RAAA were confirmed using multimodality imaging and intraoperative findings. RESULTS We identified 13 (87%) patients with LAAA and 2 (13%) with RAAA. At diagnosis, 11 (73%) were female, mean age was 51.4 ± 18.8 years, and ejection fraction 56.5 ± 13.1%. Three (20%) patients had congenital heart disease including 2 (13%) with atrioventricular septal defects and 1 (7%) with congenitally corrected transposition. LAAA/RAAA was diagnosed due to new-onset atrial fibrillation (AF) in 6 (40%) patients and embolic stroke in 2 (13%). Ten patients had preexisting AF diagnosed 2.9 ± 1.4 years earlier at a mean age of 50.2 ± 15.5 years. Thrombus within the aneurysm was identified in 2 (15%) LAAA patients. All patients were on anticoagulation and follow-up of the cohort from diagnosis was 7.1 ± 6.2 years. Eleven (73%) patients were surgically managed with 7 (64%) lesions excised, 1 (9%) stapled, and 3 (27%) ligated. Postoperative complications occurred in 2 (18%) patients with 1 (7%) developing tricuspid regurgitation and another with pericardial effusion and tamponade. CONCLUSIONS Atrial appendage aneurysm is a rare disease and nearly half of patients present with AF. Surgical treatment with concomitant AF ablation is a reasonable and safe management option.
Collapse
Affiliation(s)
| | - Ikram-Ul Haq
- Department of Internal Medicine, 6915Mayo Clinic, Rochester, MN, USA
| | - Heidi M Connolly
- Department of Cardiovascular Medicine, 6915Mayo Clinic, Rochester, MN, USA
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, 6915Mayo Clinic, Rochester, MN, USA
| | - Hartzell V Schaff
- Department of Cardiovascular Surgery, 6915Mayo Clinic, Rochester, MN, USA
| | - William R Miranda
- Department of Internal Medicine, 6915Mayo Clinic, Rochester, MN, USA
| | - Samuel J Asirvatham
- Department of Pediatrics, 6915Mayo Clinic, Rochester, MN, USA
- Department of Cardiovascular Medicine, 6915Mayo Clinic, Rochester, MN, USA
| | - Ammar M Killu
- Department of Cardiovascular Medicine, 6915Mayo Clinic, Rochester, MN, USA
| | - Arman Arghami
- Department of Cardiovascular Surgery, 6915Mayo Clinic, Rochester, MN, USA
| | | |
Collapse
|