Survival of patients with congenital ventricular septal defect

AIMS

The long-term survival of patients with isolated congenital ventricular septal defect (VSD) is not well described. The aim of this study was to describe the survival of a national cohort of patients with VSD compared with the general population.

METHODS AND RESULTS

Using Danish nationwide medical registries, all patients diagnosed with congenital VSD (n = 9,136) in the period 1977-2018 were included. Patients with chromosomal abnormalities and concomitant congenital cardiac malformations other than atrial septal defect were excluded. Each patient was matched by birthyear and sex with ten controls from the general Danish population. Kaplan-Meier survival function and Cox proportional hazard regression were used to compute survival and mortality risk. Median follow-up was 22 years (interquartile range: 11-37). VSD patients displayed lower survival (P<0.001) yielding a hazard ratio (HR) for mortality of 2.7 [95% confidence interval (CI): 2.4-3.0] compared with matched controls. The adjusted HR for mortality among patients with unrepaired VSD was 2.7 (95% CI: 2.4-3.0) and 2.8 (95% CI: 2.1-3.7) for patients with surgically closed VSD. Stratified by era of VSD diagnosis, the HR for mortality was 3.2 (95% CI: 2.8-3.7) for unrepaired patients diagnosed before 1990 and 2.4 (95% CI: 2.0-2.7) for patients diagnosed later. Cardiac-related death was the commonest cause of death among unrepaired (30%) and surgically closed (65%) patients.

CONCLUSION

Patients with VSD had lower survival compared with the general population. The HR for mortality was increased over 2.5-fold in patients with unrepaired defect (Eisenmenger syndrome excluded) and over 1.5-fold in patients with surgically closed defect (excluding surgical mortality).

[Eisenmenger's syndrome in pregnancy: a case report and literature review]

OBJECTIVE

To investigate the clinical presentation, diagnosis and treatment of the Eisenmenger's syndrome in pregnancy.

METHODS

One case of Eisenmenger's syndrome in pregnancy in our hospital was retrospectively analyzed and the literature reviewed.

RESULTS

This patient who received antenatal care irregularly in other hospital was diagnosed with Eisenmenger's syndrome with the symptoms of chest distress. The other hospital suggested her to terminate pregnancy, but the patient refused. She was admitted to our hospital in her late pregnancy, received the treatment of rest, oxygen, blood gas and pulmonary artery pressure monitoring. Considering perioperative pulmonary hypertension crisis likely to occur, pulmonary artery catheter was placed preoperatively. In general anesthesia, the cesarean was performed. After operation, the patient was transferred to the intensive care unit, with the treatment of expanding blood vessels, reducing pulmonary artery pressure, administering anticoagulation and preventing infection. One week later, the patient was discharged from hospital with smooth condition.

CONCLUSION

Eisenmenger's syndrome in pregnancy is associated with extremely poor maternal and fetal outcome. Termination of pregnancy should be offered to such patients. When interruption of pregnancy is refused, the early hospital admission is needed. The patients should be managed in a high-risk pregnancy unit by a multidisciplinary team from obstetrics, cardiology, anesthesia and pediatrics for improving pregnancy outcomes.

[Paracervical block for dilatation and curettage in a parturient with Eisenmenger's syndrome]

Eisenmenger's syndrome is defined as the process in which a left-to-right shunt due to an atrial (ASD) or ventricular septal defect (VSD) in the heart causes increased pulmonary blood flow, leading to pulmonary hypertension, which in turn, ultimately results in increased pressure in the right side of the heart and reversal of the shunt to right-to-left. Therefore, anesthetic management of Eisenmenger's syndrome is often difficult. We described a case of paracervical block for dilatation and curettage in a parturient with Eisenmenger's syndrome in this report. A 29-year-old woman with Eisenmenger's syndrome due to ASD became pregnant. She had dyspnea, cyanosis, and clubbed fingers. Her activity of daily life was in a wheel chair, and she was evaluated as New York Heart Association (NYHA) class IV. Her oxygen saturation by pulse oxymeter (Sp(O2)) showed 78-82% in room air. Dilatation and curettage was scheduled in the sixth week of her pregnancy. We performed paracervical block in the direction of 4 and 8 o'clock using 1% lidocaine 12 ml under 6 l x (min(-1) oxygen inhalation through a face mask. Seven minutes after the beginning of the operation, Sp(O2) temporarily decreased to 77% due to abdominal pain by surgical procedures. The operation was finished within 8 minutes. She had no adverse events postoperatively. The anesthetic goal for Eisenmenger's syndrome is to avoid hemodynamic changes that can worsen hypoxemia through an increase in right-to-left shunt. Paracervical block is safe and effective conduction anesthesia for dilatation and curettage in a parturient with Eisenmenger's syndrome.

Eisenmenger syndrome: identifying the clues for arrhythmia

OBJECTIVE

The aim of this case-controlled, cross-sectional study is to investigate the tendency towards arrhythmia using noninvasive arrhythmia markers (QT dispersion and heart rate variability) in children with Eisenmenger syndrome.

METHODS

We studied 23 patients, whose pulmonary-to-systemic resistance ratio was calculated to be greater than 0.75, and who were diagnosed as Eisenmenger syndrome between 1990 and 2001. Twenty healthy children were studied as the control group. Electrocardiographic recordings with calculation of QT dispersion, Holter monitoring, echocardiographic studies and heart rate variability (HRV) analysis were performed in both groups. Catheterization records were analyzed in all the patients.

RESULTS

QT and QTc dispersion were higher (p=0.007 and p=0.006, respectively) and PR interval was longer (p=0.009) in the patients with Eisenmenger syndrome, than those in the control group. In addition, low frequency component, high frequency component, very low frequency component, and total power, obtained from HRV analysis were significantly lower in the patients with Eisenmenger syndrome (p=0.001, p=0.006, p=0.009 and p=0.011, respectively). Evaluation of Holter recordings revealed pathologic findings in 21.7% of the patients with Eisenmenger syndrome. Pulmonary-to-systemic resistance ratio of the patients with pathologic Holter findings were higher than in the patients with normal Holter recordings (p=0.011). It was also shown that there was a positive correlation between OT dispersion and pulmonary-to-systemic resistance ratio (p=0.048, r=0.416) and between QT dispersion and PR interval (p=0.009, r=0.532) in the patients with Eisenmenger syndrome.

CONCLUSION

Dispersion of repolarization, being associated with high pulmonary-to-systemic resistance ratio, is increased and autonomic modulation of heart rate is impaired in patients with Eisenmenger syndrome. These findings suggest that arrhythmia risk for patients with Eisenmenger syndrome is higher than in normal controls.

A retrospective study of bosentan in pulmonary arterial hypertension associated with congenital heart disease

BACKGROUND

Pulmonary Arterial Hypertension (PAH) plays a significant role in morbidity and mortality of patients with congenital heart disease (CHD). Bosentan, a dual endothelin receptor antagonist has been approved for PAH patients with Eisenmenger physiology (EP). The authors retrospectively reviewed the efficacy and safety of bosentan in Thai PAH patients associated with CHD.

MATERIAL AND METHOD

The study population was obtained from the databases of the CHD patients at Siriraj Hospital from October 2004 to April 2007 who received 6 months of bosentan treatment. Inclusion criteria are: CHD with Eisenmenger physiology (EP) or those with severe PAH after surgical repair or interventional cardiac catheterization. Clinical characteristics including the 6-- minute walk test (6MWT) distances, oxygen saturation (O2 sat), New York Heart Association (NYHA) functional class, and right ventricular systolic pressure (RVSP) at baseline were compared with those at 1, 3, and 6 months post bosentan treatment. Signs and symptoms of adverse events were also recorded.

RESULTS

There were 11 patients from among those who fitted the inclusion criteria and whose records were examined. Their average age was 51.1 +/- 10.1 years old (13-61 years old). Patients were divided into 2 groups; Group A (6 patients) was PAH with EP and Group B (5 patients) was PAH post intervention. In group A, the 6MWT increased from 151 +/- 69 meters to 293 +/- 61 meters (p = 0.001) with the average increase of 38 +/- 61 meters. The 2O sat increased from 83 +/- 12.7% to 91.8 +/- 5.6% (p = 0.038) with an average increase of 1.4 +/- 0.07%. There was no significant change in right ventricular systolic pressure (RVSP). In group B, there was a trend in 6MWT improvement from 274 +/- 69 meters to 312 +/- 38 meters but this was not statistically different. There were improvements in the NYHA functional class in both groups. There was no significant increase in serum aminotransferase at the end of 6 months in each patient.

CONCLUSION

There are benefits of bosentan for treatment of severe PAH in CHD, especially in patients with Eisenmenger physiology. Obvious benefits are an improvement of 6MWT and O2 sat.

Continuous spinal anesthesia and postoperative analgesia for elective cesarean section in a parturient with Eisenmenger's syndrome

We describe the use of continuous spinal anesthesia (CSA) for an elective cesarean section in a 29-year-old parturient with Eisenmenger's syndrome at 30 weeks of gestation. It is essential in patients with Eisenmenger's syndrome to prevent significant increases in right-to-left shunt following the reduction in systemic vascular resistance. In this case, the patient hoped to be awake during the operation because of her fear of death. We therefore applied CSA to this patient because single-shot spinal anesthesia and epidural anesthesia might cause sudden cardiovascular depression. In fact, sudden cardiovascular changes were avoided by the titration of local anesthetics and the operation was uneventful, although prompt treatment of hypotension was essential and adjustment of the anesthetic levels was difficult. Postoperative patient-controlled spinal analgesia provided satisfactory pain relief with hemodynamic stability and no significant side effects. However, thorough experience with the requisite techniques is critical in CSA because of the technical difficulty of the procedure, and anesthesiologists must gain such experience in less-demanding cases before attempting to administer it in patients presenting extreme challenges as described in this case report.

Unusual post-extraction hemorrhage in a cardiac patient: a case report

In patients with cyanotic congenital heart disease (CCHD), the need for antibiotic prophylaxis for infective endocarditis is well known among dentists, but not many dentists are aware of the associated hemorrhagic tendencies in such patients. We report a case of post-extraction hemorrhage in a patient with Eisenmenger's syndrome and discuss the importance of more elaborate hematologic evaluation in patients with CCHD before oral surgery.

A comparison of the intrapulmonary arteries in the Eisenmenger complex and in stenosis of ostium infundibuli associated with biventricular origin of the aorta

The case to be reported is characterized by stenosis of the ostium infundibuli of the right ventricle and biventricular origin of the aorta. Certain of the anatomic features of the heart in this case are similar to those of the Eisenmenger complex. One difference between the two conditions is that in the case herewith reported subpulmonary (infundibular) stenosis existed, while in the Eisenmenger complex there is no anatomic barrier to pulmonary blood flow, either in the heart or great vessels. On these gross anatomic differences seem to depend the differences in structure of the intrapulmonary arteries in the two conditions.

Sterilization of women with Eisenmenger syndrome: report of 4 cases

Maternal mortality exceeding 50% and perinatal loss of more than 45% contraindicate pregnancy in females with Eisenmenger syndrome. Sterilization is the contraceptive method of choice. Any operation carries a very significant risk in persons with Eisenmenger syndrome; the anaesthetic mortality has been reported to be 19%. This paper details the successful sterilization of 4 women with Eisenmenger syndrome at our institution.

Laparoscopic tubal sterilization under local anesthesia in women with cyanotic heart disease

Laparoscopic tubal sterilization under local anesthesia with intravenous sedation has been shown to be a safe procedure. However, the use of laparoscopy in patients with cyanotic cardiovascular disease is controversial and is generally contraindicated. Five women were referred with uncorrectable cyanotic heart disease and pulmonary hypertension. The mean preoperative arterial oxygen pressure was 56.2 +/- 5 mmHg (N = 5). After cardiology and cardiovascular anesthesia consultation and clearance, the patients underwent laparoscopic sterilization with Silastic rings under local anesthesia using direct trocar entry. Continuous hemodynamic monitoring and pulse oximetry were employed. The patients were kept in the intensive care unit or the hospital for 24 hours for monitoring, and all did well. This hospital for 24 hours for monitoring, and all did well. This small retrospective series demonstrates that laparoscopic sterilization under local anesthesia is a sterilization technique that may be suitable and safe for such patients when appropriate monitoring is performed. Tubal sterilization may be the contraceptive method of choice in women with heart disease when pregnancy is contraindicated.

Superselective angiography with digital subtraction and embolization of a maxillary hemangioma in a patient with Eisenmenger's syndrome

Central maxillofacial hemangiomas can represent diagnostic and therapeutic problems. The concurrent existence of Eisenmenger's complex in the presented case added an anesthetic challenge. The development of superselective arterial catheterization and digital subtraction angiography has been instrumental in improving the ability of clinicians to diagnose and effectively manage vascular lesions, especially in the maxillofacial region. Embolization remains an excellent adjunctive therapy for vascular processes.

[Eisenmenger's syndrome in pregnancy. Controlled segmental epidural block for cesarean section]

We present a case of Eisenmenger's Syndrome in which an elective Caesarean Section was carried out successfully under lumbar epidural anaesthesia, following adequate physiological and psychological preparation of the patient.

[Eisenmenger's syndrome and pregnancy]

Eisenmenger's syndrome is one of the congenital heart defects which deteriorates in the course of pregnancy. For this reason, it is tried to discourage the patient from becoming pregnant, or to strictly interrupt pregnancy up to the 10th gestation week, or -- if the former proves impossible -- to introduce intensive medical supervision until the end of gravidity. A delivery is described of a 23-year old woman, in whom, when 19 years old, Eisenmenger's syndrome -- developed secondarily on the atrial septal defect -- was diagnosed by catheterization. She was admitted to the Department in the 26th week of pregnancy and as successfully confined in the 38th week by using vacuum extraction. Peripartal antibiotic prophylaxis was applied during labour, although she was given oxygen. No derivatives of ergotamine were administered in order to avoid undesirable effects. The loss of blood was controlled and replaced. She was discharged with a healthy girl on the 9th postpartal day without any complications.

Eisenmenger syndrome in pregnancy: a possible cause of neonatal polycythemia and persistent fetal circulation

A 23-year-old white primigravid woman with Eisenmenger syndrome and hypoxemia was delivered of a male infant at 34 weeks' gestation after spontaneous onset of labor. The infant was small for gestational age, weighing 1670 g. He subsequently developed respiratory distress and was found to have a high hematocrit with clinical and echocardiographic evidence of persistent fetal circulation. After partial exchange transfusion with plasma, the hematocrit, pulmonary vascular resistance, and arterial oxygen tension became normal. The authors suggest that chronic maternal hypoxemia during pregnancy may cause polycythemia and increased pulmonary vascular resistance in the newborn, leading to persistent fetal circulation.

The second heart sound in pulmonary embolism and pulmonary hypertension

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