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Bu H, Gong X, Zhao T. Image diagnosis: Eisenmenger's syndrome in patients with simple congenital heart disease. BMC Cardiovasc Disord 2020; 20:194. [PMID: 32326907 PMCID: PMC7178603 DOI: 10.1186/s12872-020-01489-y] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Accepted: 04/16/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Early identification of congenital heart disease (CHD) allows detection of the pulmonary arteriopathy in an early stage, and timely shunt closure can permanently reverse pulmonary arterial hypertension (PAH). However, surgical correction is not recommended in patients with irreversible PAH. Herein we report our experience about Eisenmenger's syndrome in simple CHD. CASE PRESENTATION From January 2017 to November 2018, a total of 8 CHD patients (3 ventricular septal defects (VSD), 2 atrial septal defects (ASD), and 3 patent ductus arteriosus (PDA), median age, 15.5 years [range, 3-18 years]) with PAH were detected by chest X-ray, electrocardiogram, transthoracic echocardiography (TTE), computed tomographic angiography (CTA) and cardiac catheterization. The median defect diameter, pulmonary artery pressure (PAP), pulmonary vascular resistance (PVR) were 16.5 mm (range, 3-30 mm), 75 mmHg (range, 60-86 mmHg), and 16 Woods units (range, 12-19 Woods units), respectively. Here, we report the representative cases of three types of simple CHD with irreversible PAH. The surgical correction was not performed in all patients who had fixed PAH and were referred to medical treatment. CONCLUSIONS PAH in CHD can be reversed by early shunt closure, but this potential is lost beyond a certain point of no return. This article highlights the essence of enhancing the level of healthcare and services in Chinese rural areas. Failure to accurately and timely assess PAH will delay effective treatment past optimal treatment time, and even lead to death.
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Affiliation(s)
- Haisong Bu
- The Department of Cardiovascular Surgery, The Second Xiangya Hospital, Central South University, 139 Renmin Central Road, Changsha, Hunan 410011 People’s Republic of China
| | - Xueyang Gong
- The Department of Cardiovascular Surgery, The Second Xiangya Hospital, Central South University, 139 Renmin Central Road, Changsha, Hunan 410011 People’s Republic of China
| | - Tianli Zhao
- The Department of Cardiovascular Surgery, The Second Xiangya Hospital, Central South University, 139 Renmin Central Road, Changsha, Hunan 410011 People’s Republic of China
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Hjortshøj CS, Gilljam T, Dellgren G, Pentikäinen MO, Möller T, Jensen AS, Turanlahti M, Thilén U, Gustafsson F, Søndergaard L. Outcome after heart-lung or lung transplantation in patients with Eisenmenger syndrome. Heart 2019; 106:127-132. [PMID: 31434713 PMCID: PMC6993032 DOI: 10.1136/heartjnl-2019-315345] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 07/08/2019] [Accepted: 07/31/2019] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVE The optimal timing for transplantation is unclear in patients with Eisenmenger syndrome (ES). We investigated post-transplantation survival and transplantation-specific morbidity after heart-lung transplantation (HLTx) or lung transplantation (LTx) in a cohort of Nordic patients with ES to aid decision-making for scheduling transplantation. METHODS We performed a retrospective, descriptive, population-based study of patients with ES who underwent transplantation from 1985 to 2012. RESULTS Among 714 patients with ES in the Nordic region, 63 (9%) underwent transplantation. The median age at transplantation was 31.9 (IQR 21.1-42.3) years. Within 30 days after transplantation, seven patients (11%) died. The median survival was 12.0 (95% CI 7.6 to 16.4) years and the overall 1-year, 5-year, 10-year and 15-year survival rates were 84.1%, 69.7%, 55.8% and 40.6%, respectively. For patients alive 1 year post-transplantation, the median conditional survival was 14.8 years (95% CI 8.0 to 21.8), with 5-year, 10-year and 15-year survival rates of 83.3%, 67.2% and 50.0%, respectively. There was no difference in median survival after HLTx (n=57) and LTx (n=6) (14.9 vs 10.6 years, p=0.718). Median cardiac allograft vasculopathy, bronchiolitis obliterans syndrome and dialysis/kidney transplantation-free survival rates were 11.2 (95% CI 7.8 to 14.6), 6.9 (95% CI 2.6 to 11.1) and 11.2 (95% CI 8.8 to 13.7) years, respectively. The leading causes of death after the perioperative period were infection (36.7%), bronchiolitis obliterans syndrome (23.3%) and heart failure (13.3%). CONCLUSIONS This study shows that satisfactory post-transplantation survival, comparable with contemporary HTx and LTx data, without severe comorbidities such as cardiac allograft vasculopathy, bronchiolitis obliterans syndrome and dialysis, is achievable in patients with ES, with a conditional survival of nearly 15 years.
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Affiliation(s)
| | - Thomas Gilljam
- Department of Cardiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Göran Dellgren
- Transplant Institute, Sahlgrenska Academy, University of Gothenburg, Gothenburg, UK
| | - Markku O Pentikäinen
- Department of Paediatric Cardiology, Heart and Lung Center, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Thomas Möller
- Department of Paediatric Cardiology, Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | | | - Maila Turanlahti
- Department of Paediatric Cardiology, Heart and Lung Center, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Ulf Thilén
- Department of Cardiology, Lund University Hospital, Lund, Sweden
| | - Finn Gustafsson
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
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Zhang J, Patel S, Clavijo L, Laughrun D. Successful Implementation of Extracorporeal Membrane Oxygenation Support as a Bridge to Heart-Lung Transplantation in an Eisenmenger's Syndrome Patient With Paradoxical Coronary Embolism. J Investig Med High Impact Case Rep 2019; 7:2324709619846575. [PMID: 31053036 PMCID: PMC6505230 DOI: 10.1177/2324709619846575] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 03/29/2019] [Accepted: 04/02/2019] [Indexed: 11/24/2022] Open
Abstract
We report a case of a 23-year-old female with a history of unrepaired ventricular septal defect and pulmonary arterial hypertension with Eisenmenger's syndrome (ES) presenting with chest pain. Electrocardiography demonstrated new anterior Q waves and anterolateral ST elevations, and coronary angiography revealed a large organized thrombus in the mid-left anterior descending artery consistent with paradoxical coronary embolism. Patient was treated with percutaneous coronary intervention and aggressive anticoagulation management. Intensive care unit course was complicated by respiratory failure requiring intubation due to hospital-acquired pneumonia in the setting of severe pulmonary hypertension. Patient was emergently initiated on veno-venous extracorporeal membrane oxygenation support (ECMO) as a bridge to heart-lung transplantation. After initiation of ECMO, patient displayed significant clinical improvement and underwent successful heart-lung transplantation. This case highlights veno-venous ECMO as a bridge to heart-lung transplantation in acutely decompensated patients with ES, and is the first reported case of paradoxical coronary embolism in a patient with ES.
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Affiliation(s)
- James Zhang
- University of Southern California, Los Angeles, CA, USA
| | - Sumit Patel
- University of Southern California, Los Angeles, CA, USA
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Hong SH, Kim KH. Pulmonary artery dissection in a patient with Eisenmenger's syndrome and successful conservative medical treatment. Korean J Intern Med 2017; 32:195-196. [PMID: 27846671 PMCID: PMC5214736 DOI: 10.3904/kjim.2016.258] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Revised: 08/26/2016] [Accepted: 09/03/2016] [Indexed: 11/27/2022] Open
Affiliation(s)
- Sun Hwa Hong
- Department of Radiology, Sejong General Hospital, Bucheon, Korea
| | - Kyung-Hee Kim
- Division of Cardiology, Department of Internal Medicine, Sejong General Hospital, Bucheon, Korea
- Correspondence to Kyung-Hee Kim, M.D. Tel: +82-32-340-1443 Fax: +82-32-340-1180 E-mail:
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Skride A, Sablinskis K, Lejnieks A, Rudzitis A. Pulmonary hypertension in adults with congenital heart disease: First data from Latvian PAH registry. Eur J Intern Med 2016; 36:e20-e21. [PMID: 27637857 DOI: 10.1016/j.ejim.2016.09.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [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: 09/05/2016] [Accepted: 09/06/2016] [Indexed: 10/21/2022]
MESH Headings
- Adult
- Aged
- Echocardiography
- Eisenmenger Complex/diagnostic imaging
- Eisenmenger Complex/epidemiology
- Eisenmenger Complex/physiopathology
- Female
- Heart Defects, Congenital/diagnostic imaging
- Heart Defects, Congenital/epidemiology
- Heart Defects, Congenital/physiopathology
- Heart Septal Defects/diagnostic imaging
- Heart Septal Defects/epidemiology
- Heart Septal Defects/physiopathology
- Heart Septal Defects, Atrial/diagnostic imaging
- Heart Septal Defects, Atrial/epidemiology
- Heart Septal Defects, Atrial/physiopathology
- Heart Septal Defects, Ventricular/diagnostic imaging
- Heart Septal Defects, Ventricular/epidemiology
- Heart Septal Defects, Ventricular/physiopathology
- Humans
- Hypertension, Pulmonary/diagnostic imaging
- Hypertension, Pulmonary/epidemiology
- Hypertension, Pulmonary/physiopathology
- Latvia/epidemiology
- Male
- Middle Aged
- Prospective Studies
- Pulmonary Wedge Pressure/physiology
- Registries
- Vascular Resistance/physiology
- Walk Test
- Young Adult
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Affiliation(s)
- Andris Skride
- Riga Stradins University, 16 Dzirciema str., Riga LV-1007, Latvia; Pauls Stradins Clinical University Hospital, 13 Pilsonu str., Riga LV-1012, Latvia
| | | | - Aivars Lejnieks
- Riga Stradins University, 16 Dzirciema str., Riga LV-1007, Latvia; Riga East University Hospital, 2 Hipokrata str., Riga LV-1038, Latvia
| | - Ainars Rudzitis
- Pauls Stradins Clinical University Hospital, 13 Pilsonu str., Riga LV-1012, Latvia.
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Funaki S, Shintani Y, Minami M, Ueno T, Toda K, Sawa Y, Okumura M. [Cardiac Function after Lung Transplantation of Eisenmenger Syndrome]. Kyobu Geka 2016; 69:911-914. [PMID: 27713195] [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] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Eisenmenger syndrome(ES) could occur at the end-stage of congenital heart disease and is one of the indications for lung transplantation. Survival following heart-lung transplantation is better than that following bilateral lung transplantation (LT). However, in Japan, because of limitations in regard to the numbers of donors available, LT with cardiac repair is usually chosen. Following LT with cardiac repair, careful management of the repaired heart is necessary, though there are few reports available regarding such postoperative cardiac management. Here, we present findings from careful postoperative monitoring and management of cardiac function in a patient with ES with a ventricular septal defect, for whom LT with cardiac repair was performed. In addition, follow-up results of cardiac function are presented as well as discussion of important points related to such cases.
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Affiliation(s)
- Soichiro Funaki
- Department of Thoracic Surgery, Osaka University, Suita, Japan
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Abstract
Eisenmenger syndrome is very rare in pregnant women. Debates remain concerning the management of Eisenmenger syndrome in this patient population and the prognosis is unclear in terms of maternal and fetoneonatal outcomes. Epidural analgesia is preferred for Cesarean section as it alleviates perioperative pain and reduces the pulmonary and systemic vascular resistances. Maternal mortality in the presence of Eisenmenger syndrome is reported as 30-50% and even up to 65% in those with Cesarean section. The major causes of death could be hypovolemia, thromboembolism and preeclampsia. Pregnancy should ideally be avoided in a woman with Eisenmenger syndrome concerning the high maternal mortality rate and probable poor prognosis of the baby. A short labour and an atraumatic delivery under epidural block are preferred in the women with a strong desire of pregnancy. The purpose of this article is to discuss the debates of Eisenmenger syndrome in pregnancy and the possible resolutions.
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Affiliation(s)
- Shi-Min Yuan
- The First Hospital of Putian, Teaching Hospital, Fujian Medical University,
Fujian Province, China
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Broberg CS, Prasad SK, Carr C, Babu-Narayan SV, Dimopoulos K, Gatzoulis MA. Myocardial fibrosis in Eisenmenger syndrome: a descriptive cohort study exploring associations of late gadolinium enhancement with clinical status and survival. J Cardiovasc Magn Reson 2014; 16:32. [PMID: 24886403 PMCID: PMC4051886 DOI: 10.1186/1532-429x-16-32] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Accepted: 05/02/2014] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND A relationship between myocardial fibrosis and ventricular dysfunction has been demonstrated using late gadolinium enhancement (LGE) in the pressure-loaded right ventricle from congenital heart defects. In patients with Eisenmenger syndrome (ES), the presence of LGE has not been investigated. The aims of this study were to detect any myocardial fibrosis in ES and describe major clinical variables associated with the finding. METHODS From 45 subjects screened, 30 subjects (age 43 ± 13 years, 20 female) underwent prospective cardiovascular magnetic resonance with LGE to quantify biventricular volume and function as well as maximal and submaximal exercise during a single visit. Standard cine acquisitions were obtained for ventricular volume and function. Further imaging was performed after administration of 0.1 mmol/kg gadolinium contrast. Regions of LGE were evaluated qualitatively and quantitatively by manual contouring of identified areas, with total area expressed as a percentage of mass. Patients were followed prospectively (mean follow up 7.4 ± 0.4 years) and any deaths recorded. Patients with LGE findings were compared to those without. RESULTS LGE was present in 22/30 (73%) patients, specifically in RV myocardium (70%), RV trabeculae (60%), LV myocardium (33%) or LV papillary muscles (30%), though in small amounts (mean 1.4% of total ventricular mass, range 0.16 - 6.0%). Those with any LGE were not different in age, history of arrhythmia, desaturation, nor hemoglobin, nor ventricular size, mass, or function. Exercise capacity was low, but also not different between those with and without LGE. Similarly no significant associations were found with amount of fibrosis. There were five deaths among patients with LGE, versus two in patients without, but no difference in survival (log rank =0.03, P = 0.85). CONCLUSIONS Myocardial fibrosis by LGE is common in ES, though not extensive. The presence and quantity of LGE did not correlate with ventricular size, function, degree of cyanosis, exercise capacity, or survival in this pilot study. More data are clearly required before recommendations for routine use of LGE in these patients can be made.
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Affiliation(s)
- Craig S Broberg
- Adult Congenital Heart Program, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon, USA
- UHN 62, Knight Cardiovascular Institute, 3181 SW Sam Jackson Park Road, Portland, OR 97221, USA
| | - Sanjay K Prasad
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust, Imperial College, London, UK
| | - Chad Carr
- Adult Congenital Heart Program, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon, USA
| | - Sonya V Babu-Narayan
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust, Imperial College, London, UK
| | - Konstantinos Dimopoulos
- Adult Congenital Heart Disease Centre and National Centre for Pulmonary Hypertension, NIHR Cardiovascular BRU, and the National Heart & Lung Institute, Imperial College, London, UK
| | - Michael A Gatzoulis
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust, Imperial College, London, UK
- Adult Congenital Heart Disease Centre and National Centre for Pulmonary Hypertension, NIHR Cardiovascular BRU, and the National Heart & Lung Institute, Imperial College, London, UK
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Chen G, He JG, Liu ZH, Gu Q, Ni XH, Zhao ZH, Xiong CM. [Clinical features of adult patients with Eisenmenger syndrome associated with different types of congenital heart disease]. Zhonghua Yi Xue Za Zhi 2013; 93:1546-1549. [PMID: 24028720] [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] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
OBJECTIVE To explore the clinical features and hemodynamics of adult patients with Eisenmenger syndrome in different types of congenital heart diseases (CHD). METHODS Patients with Eisenmenger syndrome with different types of CHD diagnosed by right heart catheterization were enrolled from 31 clinical centers in China during the period from May 2007 to October 2010. Age, gender, body mass index (BMI), symptoms and signs, World Health Organization functional class (WHO-FC) of pulmonary hypertension, six-minute walk distance (6MWD) and hemodynamics were recorded. All the above indices were analyzed and compared. RESULTS A total of 224 patients with Eisenmenger syndrome with 3 kinds of CHD were enrolled, including atrial septal defect (n = 67), ventricular septal defect (n = 104) and patent ductus arteriosus (n = 53). Among them, there were 67 males (29.9%) and 157 females (70.1%) with a mean age of (29.6 ± 9.9) years (range: 15-63). Mean BMI was (19.9 ± 4.0) kg/m(2) and mean 6MWD (371 ± 75) m. The majority of patients were in WHO-FC II (n = 158, 70.5%) and III (n = 64, 28.6%). Electrocardiogram of 77.2% of them indicated hypertrophic right ventricle. Mean right atrial pressure was (8.9 ± 5.7) mm Hg (1 mm Hg = 0.133 kPa), mean pulmonary arterial pressure (mPAP) (77.2 ± 19.1) mm Hg, cardiac index (3.03 ± 1.35) L·min(-1) · m(-2) and pulmonary vascular resistance (PVR) (1621 ± 887) dyn · s · cm(-5). CONCLUSIONS The majority of patients with Eisenmenger syndrome with different types of CHD are young females and ventricular septal defect is the most frequent underlying cause. The deterioration of heart function in patients with Eisenmenger syndrome is non-parallel to mPAP and PVR in CHD.
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Affiliation(s)
- Guo Chen
- Chinese Academy of Medical Sciences, Beijing, China
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Kopeć G, Tyrka A, Miszalski-Jamka T, Mikołajczyk T, Waligóra M, Guzik T, Podolec P. Changes in exercise capacity and cardiac performance in a series of patients with Eisenmenger's syndrome transitioned from selective to dual endothelin receptor antagonist. Heart Lung Circ 2012; 21:671-8. [PMID: 22819097 DOI: 10.1016/j.hlc.2012.06.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2012] [Revised: 06/18/2012] [Accepted: 06/25/2012] [Indexed: 11/19/2022]
Abstract
BACKGROUND Differences in clinical effects between selective and dual endothelin (ET) receptor antagonists (ERA) in patients with pulmonary arterial hypertension (PAH) are currently unknown. We aimed to assess prospectively how transition from selective (sitaxsentan) to dual (bosentan) ERA affected exercise capacity and cardiocirculatory performance in patients with Eisenmenger's syndrome. METHODS A series of seven stable patients with Eisenmenger's syndrome aged 40.0 (30.0-56.0) years old treated with sitaxsentan were assessed before and three months after transition to bosentan. Six minute walk test and magnetic resonance to assess LV and RV mass, volume and ejection fraction, and pulmonary flow, and laboratory tests were performed. RESULTS We observed an increase in LV mass [96.5 (66.0-116.0) vs. 123.0 (93.0-146.0)g; p=0.03], LV ejection fraction [55.0 (44.0-63.0) vs. 65.0 (58.0-70.0)%; p=0.02)], and pulmonary flow [64 (53.0-71.0) vs. 69.0 (55.0-84.0)ml/beat; p=0.046]. This was accompanied by an increase of oxygen saturation, elongation of 6MWD [435.0 (378.0-482.3) vs. 474 (405.0-534.7); p=0.02], decrease of NTproBNP level and increase of ET-1 level. CONCLUSIONS Three month follow-up of stable patients with Eisenmenger's syndrome transitioned from sitaxsentan to bosentan revealed improvement of exercise capacity despite significant elevation of ET-1 level. Concurrent increase of LV ejection fraction and pulmonary flow might have contributed to these favourable effects.
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Affiliation(s)
- Grzegorz Kopeć
- John Paul II Hospital in Krakow, Department of Cardiac and Vascular Diseases, Pradnicka 80, 31-202 Krakow, Poland.
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Galbraith EM, Weiss SH, Fisher MR, Book WM. Twin pregnancy in a woman with pulmonary atresia, ventricular septal defect, and aortopulmonary collaterals complicated by Eisenmenger physiology. Int J Cardiol 2011; 152:e14-5. [PMID: 20961640 DOI: 10.1016/j.ijcard.2010.09.072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2010] [Accepted: 09/26/2010] [Indexed: 11/18/2022]
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Tay ELW, Peset A, Papaphylactou M, Inuzuka R, Alonso-Gonzalez R, Giannakoulas G, Tzifa A, Goletto S, Broberg C, Dimopoulos K, Gatzoulis MA. Replacement therapy for iron deficiency improves exercise capacity and quality of life in patients with cyanotic congenital heart disease and/or the Eisenmenger syndrome. Int J Cardiol 2011; 151:307-12. [PMID: 20580108 DOI: 10.1016/j.ijcard.2010.05.066] [Citation(s) in RCA: 98] [Impact Index Per Article: 7.5] [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: 03/24/2010] [Revised: 05/26/2010] [Accepted: 05/30/2010] [Indexed: 11/17/2022]
Affiliation(s)
- Edgar L W Tay
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK.
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Ramakrishnan S, Vyas C, Kothari SS, Bhargava B, Kukreti BB, Kalaivani M, Juneja R, Seth S, Saxena A, Bahl VK. Acute and short-term hemodynamic effects of metoprolol in Eisenmenger syndrome: a preliminary observational study. Am Heart J 2011; 161:938-43. [PMID: 21570526 DOI: 10.1016/j.ahj.2011.02.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [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: 11/25/2010] [Accepted: 02/09/2011] [Indexed: 01/09/2023]
Abstract
BACKGROUND Progressive heart failure and sudden cardiac death are the common causes of death in Eisenmenger syndrome. β-Bockers may be useful in Eisenmenger syndrome, but the safety and efficacy are not proven. The objective of the study was to evaluate the hemodynamic effects and safety of metoprolol in Eisenmenger syndrome. METHODS Fifteen patients of Eisenmenger syndrome with a mean age of 22.6 (±8.9) years were studied. Hemodynamic parameters were measured at baseline, after 15 mg of intravenous metoprolol and 6 weeks after oral metoprolol (25 mg/d for 2 weeks and 50 mg/d for 4 weeks). RESULTS Intravenous metoprolol was well tolerated, although there was a significant decrease in pulmonary and systemic blood flows. The calculated pulmonary vascular resistance index (23.3 ± 8.6 to 27.4 ± 10.6 Wood U, P = .005) and systemic vascular resistance index (34.9 ± 9.9 to 41.9 ± 13.5 Wood U, P = .005) increased significantly. After 6 weeks of oral metoprolol, the pulmonary artery mean pressure declined significantly (79.9 ± 12.9 to 73.4 ± 14.0 mm Hg, P = .04), which was associated with a slight decrease in mean aortic pressures as compared with baseline. The 6-minutes walk distance increased (401.2 ± 99.9 to 462.5 ± 81.7 m, P = .005). CONCLUSIONS Preliminary observations suggest that metoprolol is safe and well tolerated in selected patients with Eisenmenger syndrome. Acute hemodynamic worsening recovers in the short term, and the exercise capacity improves in most patients. Larger studies are warranted.
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Belohlavek J, Rohn V, Jansa P, Tosovsky J, Kunstyr J, Semrad M, Horak J, Lips M, Mlejnsky F, Balik M, Klein A, Linhart A, Lindner J. Veno-arterial ECMO in severe acute right ventricular failure with pulmonary obstructive hemodynamic pattern. J Invasive Cardiol 2010; 22:365-369. [PMID: 20679672] [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] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
Extracorporeal membrane oxygenation (ECMO) is an effective rescue method for severe respiratory and cardiac failure. Right ventricular (RV) failure with cardiogenic shock is a critical condition with generally poor prognosis unless aggressive therapeutical measures are undertaken. Authors report on their initial experience with ECMO support in severe RV failure with cardiogenic shock caused by an obstructive hemodynamic pattern. Four patients with cardiogenic shock due to severe RV failure related to pulmonary arterial hypertension (2 patients), congenital heart disease with Eisenmenger physiology (1 subject) and massive pulmonary embolism (1 patient) were supported with emergency veno-arterial ECMO. ECMO circuit was instituted using peripheral cannulation in all subjects. Immediate hemodynamic and ventilatory improvement was observed in all patients. The mean support duration was 11 days (range 5-16 days), 2 (50%) patients were successfully weaned off ECMO and survived to hospital discharge. The other 2 patients were considered by mutual consensus to have irreversible organ damage, the ECMO support was withdrawn and the patients died. Bleeding complications were the main complications observed. As per initial experience, veno-arterial ECMO allows bypassing of the pulmonary bed, therefore, relieves the RV pressure overload and does not cause further elevation of the pulmonary pressures in contrary to RV assist devices. This aggressive management approach requires further clinical evaluation in order to establish its definite role in critical RV failure.
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Affiliation(s)
- Jan Belohlavek
- 2nd Department of Internal Medicine, Cardiology and Angiology, General Teaching Hospital, 1st Medical School, Charles University, Prague, Czech Republic.
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Pandey R, Garg R, Nath MP, Rajan S, Punj J, Darlong V, Chandralekha. Eisenmenger's syndrome in pregnancy: use of Proseal laryngeal mask airway (PLMA) and epidural analgesia for elective cesarean section. Acta Anaesthesiol Taiwan 2009; 47:204-7. [PMID: 20015822 DOI: 10.1016/s1875-4597(09)60056-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
We describe the successful anesthetic management of cesarean section in a patient with Eisenmenger's syndrome secondary to an atrial septal defect. Although conception is discouraged in women with Eisenmenger's syndrome, in inevitable circumstances, careful and meticulous planning of anesthesia can help the parturient survive the ordeal of a cesarean section. The cardiac output must be maintained and systemic vascular resistance must not be allowed to fall. This should ensure that there is minimal change in the right to left shunt. In our patient, the scenario of Eisenmenger's syndrome was complicated by biventricular hypertrophy. We achieved the goals in our patient by using general anesthesia with the Proseal laryngeal mask airway, a combination of ketamine and propofol, and epidural analgesia.
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Affiliation(s)
- Ravindra Pandey
- Department of Anesthesiology and Intensive Care, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India.
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16
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Iveta S. Eisenmenger syndrome--a unique form of pulmonary arterial hypertension. BRATISL MED J 2009; 110:757-764. [PMID: 20196469] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
In 5-10% of adults with congenital heart disease (left-to-right shunt defects), pulmonary arterial hypertension (PAH) can develop with variable severity. An extreme manifestation of PAH in this setting is known as the Eisenmenger syndrome. It represents not only PAH associated with congenital heart disease, but also a multi-systemic disorder, presented by variety of complications (cyanosis, bleeding, thrombotic diathesis, high risk of bacterial endocarditis or cerebral abscess, ischemic complications, hepatic and renal involvement, congestive heart failure and sudden death). Authors concisely identify the underlying pathophysiological and hemodynamic aspects of Eisenmenger syndrome and focus on the clinical presentation. Eisenmenger syndrome represents a unique form of PAH with many differences. The preserved right ventricular function seems to play the key role in a better survival of these patients compared to other forms of PAH. To achieve a satisfactory prognosis and life-quality in patients with Eisenmenger syndrome it is necessary not only to treat their hemodynamic features (PAH and/or ventricular dysfunction) but also to adequately manage and prevent all the multi-systemic complications resulting from this disease. This often needs a care in specialized centers with multi-disciplinary approach (Tab. 2, Fig. 6, Ref. 17).
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Affiliation(s)
- Simkova Iveta
- Department of Cardiology, National Institute of Cardiovascular Diseases, Slovak Medical University, Bratislava, Slovakia.
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17
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Stathopoulos I, Nissirios T, Ostfeld R, Gordon G, Spevack D. A-dip of the aortic valve by M-mode echocardiography. Cardiol J 2009; 16:273-275. [PMID: 19437405] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023] Open
Abstract
We present a case with the previously unreported finding of an a-dip in the M-mode tracing of the aortic valve. An a-dip is commonly seen in the M-mode tracing of the pulmonic valve motion, and represents near equalization of pulmonary artery and right ventricular end- -diastolic pressures during atrial contraction. M-mode echocardiography has become an ancillary study to the basic two-dimensional examination, but can often convey important features of cardiac hemodynamics quite elegantly, as the present case demonstrates.
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Affiliation(s)
- Ioannis Stathopoulos
- Montefiore Medical Center, Albert Einstein School of Medicine Cardiology Bronx, NY, USA.
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18
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Trojnarska O, Plaskota K. Therapeutic methods used in patients with Eisenmenger syndrome. Cardiol J 2009; 16:500-506. [PMID: 19950085] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023] Open
Abstract
Patients with Eisenmenger syndrome form a small percentage of congenital heart disease patients. The rarity of this syndrome, combined with its complex pathophysiology, account for the insufficient understanding of the principles underlying its proper treatment. The main clinical symptoms are: cyanosis due to secondary erythrocytosis, resulting in increased blood viscosity, iron deficiency anemia (enhanced by unnecessary phlebotomies), blood clotting disturbances, heart failure and serious supraventricular and ventricular arrhythmias. Recent decades have seen developments in pulmonary hypertension pathophysiology which have led to the introduction of new groups of drugs: prostacycline analogs (Epoprostenol, Treprostinil, Beraprost, Illoprost), phosphodiesterase inhibitors (Sildenafil, Tadalafil), endothelin receptor antagonists (Bosentan, Sitaxantan, Ambrisentan) and nitric oxide. These drugs should be administered to patients in III-IV NYHA class. Despite successful early results, the therapeutic effect on patients with Eisenmenger syndrome has not been conclusively established. Our therapeutic efforts should be directed mainly towards preventing complications. As a rule, we should avoid agents with no established therapeutic efficacy and try to alleviate symptoms without any additional risk, so as not to disrupt the existing clinical balance.
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MESH Headings
- Anemia, Iron-Deficiency/etiology
- Anemia, Iron-Deficiency/prevention & control
- Antihypertensive Agents/therapeutic use
- Arrhythmias, Cardiac/etiology
- Arrhythmias, Cardiac/prevention & control
- Blood Coagulation Disorders/etiology
- Blood Coagulation Disorders/prevention & control
- Blood Viscosity
- Cyanosis/etiology
- Cyanosis/prevention & control
- Eisenmenger Complex/complications
- Eisenmenger Complex/diagnosis
- Eisenmenger Complex/drug therapy
- Eisenmenger Complex/etiology
- Eisenmenger Complex/physiopathology
- Eisenmenger Complex/therapy
- Endothelin Receptor Antagonists
- Female
- Heart Defects, Congenital/complications
- Heart Defects, Congenital/physiopathology
- Humans
- Hypertension, Pulmonary/etiology
- Hypertension, Pulmonary/prevention & control
- Male
- Nitric Oxide/therapeutic use
- Phosphodiesterase Inhibitors/therapeutic use
- Polycythemia/etiology
- Polycythemia/prevention & control
- Pregnancy
- Pregnancy Complications, Cardiovascular/etiology
- Pregnancy Complications, Cardiovascular/prevention & control
- Prostaglandins I/therapeutic use
- Risk Reduction Behavior
- Treatment Outcome
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Affiliation(s)
- Olga Trojnarska
- 1st Cardiology Department, University of Medical Sciences, Poznań, Poland.
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19
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Simkova I, Tavacova M, Kanalikova K, Pacak J, Kaldararova M. Clinical and hemodynamic picture of Eisenmenger syndrome. BRATISL MED J 2009; 110:788-794. [PMID: 20196474] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Eisenmenger syndrome represents a very specific form of pulmonary arterial hypertension (PAH). Unlike patients with idiopathic PAH, in Eisenmenger syndrome the clinical and cardiac status is often relatively stable for a long time. On the other hand, due to cyanosis and due to maladaptive body reactions many noncardiac complications may occur. Fourteen patients (pts) with Eisenmenger syndrome were analyzed, with the mean age 41 years. Invasively measured pre-capillary pulmonary hypertension was severe (mean pulmonary arterial pressure 79 mmHg) and a statistically significant difference according to the site of defect was found (pre-tricuspid shunts vs post-tricuspid shunts = 57,5 mmHg vs 88 mmHg; p = 0.01). It is neccessary to keep in mind that non-cardiac events and complications may lead to death sooner then the right ventricular dysfunction or PAH (Tab. 7, Fig. 21, Ref. 16).
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Affiliation(s)
- I Simkova
- Department of Cardiology, National Institute of Cardiovascular Diseases, Slovak Medical University, Bratislava, Slovakia.
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20
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Santos-Martínez LE, Martínez-Guerra ML, Bautista E, Castillo F, Castañón A, Pulido T, Hernández JL, Sandoval J. [Impact of the deep breathing maneuver in the gas exchange in the subject with severe obesity and pulmonary arterial hypertension associated to Eisenmenger's syndrome]. Arch Cardiol Mex 2008; 78:265-272. [PMID: 18959013] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023] Open
Abstract
UNLABELLED Obesity and Eisenmenger's syndrome are entities widely studied. However, its association is unusual and has not been reported. A wide range of gas exchange abnormalities have been describe in both groups. In the severe obese patients this abnormalities are attributed to a ventilation/perfusion mismatch and to an increase pulmonary venous-arterial shunt, that correlates with the lung volume. In severe obese patients with the Eisenmenger's syndrome, this correlation is unknown. METHODS We studied 28 obese subjects paired by body mass index > 30 kg/m2. Assigned to two groups, obese with Eisenmenger's syndrome and obese without the syndrome. Clinical variables, respiratory function, echocardiography and gas exchange pre and post-deep breathing maneuver were obtained. STATISTICAL ANALYSIS The variables are expressed with mean+/-standard deviation. Student t test for paired groups and Pearson correlation coefficient were gathered for the differences and associations between groups. A p-value <0.05 was considered significant. RESULT Age was 48.57 +/- 10.32 vs 60.86 +/- 10.47 y.o. respectively, p < 0.004. Systolic pulmonary arterial pressure 104.36 +/- 37 vs 50.1 +/- 12 mm Hg, p < 0.001. The arterial oxygen pressure at rest and during the deep breathing maneuver in each group was: 51.64 +/- 6.38 vs 57.14 +/- 11, p < 0.188 and 56.29 +/- 11.15 vs 72 +/- 11.83, p < 0.001; venous-arterial shunt 12.79 +/- 3.66 vs 13.07 +/- 4.84, p < 0.767 and 9.21 +/- 3.77 vs 6.5 +/- 2.28, p < 0.001; alveolar arterial oxygen difference 271.14 +/- 79.92 vs 243.79 +/- 92.07, p < 0.001, respectively. CONCLUSION Obese subjects with Eisenmenger's syndrome, did not have significant improvement of gas exchange with the deep breathing maneuver.
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Gatzoulis MA, Beghetti M, Galiè N, Granton J, Berger RMF, Lauer A, Chiossi E, Landzberg M. Longer-term bosentan therapy improves functional capacity in Eisenmenger syndrome: Results of the BREATHE-5 open-label extension study. Int J Cardiol 2008; 127:27-32. [PMID: 17658633 DOI: 10.1016/j.ijcard.2007.04.078] [Citation(s) in RCA: 170] [Impact Index Per Article: 10.6] [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: 02/26/2007] [Accepted: 04/26/2007] [Indexed: 11/26/2022]
Abstract
BACKGROUND Bosentan, an oral endothelin ET(A)/ET(B) receptor antagonist, improves hemodynamics and exercise capacity in patients with Eisenmenger syndrome but longer-term effects are unknown. This study investigated the efficacy and safety of bosentan up to 40 weeks in these patients. METHODS Following the 16-week, double blind, placebo-controlled BREATHE-5 study of bosentan in patients with Eisenmenger syndrome, an open-label extension (OLE) was performed. Patients who completed BREATHE-5 received bosentan for an additional 24 weeks (62.5 mg b.i.d. for 4 weeks, then 125 mg b.i.d.) and were analyzed in two groups; ex-placebo and ex-bosentan, according to BREATHE-5 treatment. RESULTS Thirty-seven patients with Eisenmenger syndrome who participated in BREATHE-5 were included in the OLE. At week 24, the 6-minute walk distance (mean+/-SE) increased from OLE baseline for the ex-placebo (+33.2+/-23.9 m) and ex-bosentan group (+6.7+/-10.0 m). The overall improvement from baseline of BREATHE-5 was +61.3+/-8.1 m (95% confidence interval: [44.7, 78.0]) for the ex-bosentan group. WHO functional class was improved in both groups. Bosentan did not reduce systemic arterial blood oxygen saturation; safety profile was comparable to previous trials. CONCLUSIONS In conclusion, these longer follow-up data support the efficacy and safety profile reported in the preceding BREATHE-5 study of bosentan treatment of Eisenmenger syndrome, challenging the notion that pulmonary vascular disease and severe functional impairment in these patients are not amenable to therapy.
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Affiliation(s)
- Michael A Gatzoulis
- Royal Brompton Hospital and the National Heart and Lung Institute, Imperial College, London, UK.
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22
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Moodie DS. Proceedings of the American Heart Association, Chicago, Illinois, October 2006. CONGENIT HEART DIS 2008; 2:143-6. [PMID: 18377493 DOI: 10.1111/j.1747-0803.2007.00089.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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23
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Toyono M, Harada K, Tamura M, Aoki-Okazaki M, Shimada S, Oyamada J, Takada G. Paradoxical relationship between B-type natriuretic peptide and pulmonary vascular resistance in patients with ventricular septal defect and concomitant severe pulmonary hypertension. Pediatr Cardiol 2008; 29:65-9. [PMID: 17786380 DOI: 10.1007/s00246-007-9037-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [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: 12/22/2006] [Accepted: 06/18/2007] [Indexed: 10/22/2022]
Abstract
B-type natriuretic peptide (BNP) reflects volume overload on left ventricle and pulmonary hypertension (PH) in patients with ventricular septal defect (VSD). Pulmonary vascular resistance (PVR) has been reported to correlate positively with BNP in VSD patients with various degrees of PH. We aimed to investigate the relationship between PVR and BNP in VSD patients with severe PH. We examined 24 subjects with VSD concomitant severe PH aged from 2 months to 17 years (median: 4 months). The ratio of pulmonary to systemic pressure (Pp/Ps), the ratio of pulmonary to systemic flow (Qp/Qs), the ratio of pulmonary to systemic resistance (Rp/Rs), and PVR were determined by cardiac catheterization. PVR and Rp/Rs ranged from 1.6 to 15.5 (mean: 5.7 +/- 3.9) Wood unit . m(2) and 0.1 to 0.8 (mean: 0.4 +/- 0.2), respectively. BNP ranged from 5.5 to 69 (mean: 31 +/- 19) pg/ml. Negative correlations were observed between BNP and PVR (r = -0.56, p = 0.004) and BNP and Rp/Rs (r = -0.51, p = 0.01). BNP was significantly lower (<10 pg/ml) in VSD patients with Eisenmenger physiology as compared with the others (p = 0.003). We should draw attention to evaluate BNP values in VSD patients with severe PH.
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Affiliation(s)
- Manatomo Toyono
- Pediatrics, Reproductive and Developmental Medicine, Akita University, 1-1-1 Hondo, Akita 010-8543, Japan.
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Diller GP, Dimopoulos K, Kaya MG, Harries C, Uebing A, Li W, Koltsida E, Gibbs JSR, Gatzoulis MA. Long-term safety, tolerability and efficacy of bosentan in adults with pulmonary arterial hypertension associated with congenital heart disease. Heart 2007; 93:974-6. [PMID: 17639112 PMCID: PMC1994431 DOI: 10.1136/hrt.2006.089185] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.1] [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] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To examine long-term safety and efficacy of bosentan--an oral dual endothelin receptor antagonist--in patients with pulmonary hypertension associated with congenital heart disease or Eisenmenger's syndrome. DESIGN Retrospective study. SETTING Tertiary cardiology referral centre. PATIENTS All adult patients with pulmonary arterial hypertension associated with congenital heart disease treated with bosentan at the Royal Brompton Adult Congenital Heart Centre were included. MAIN OUTCOME MEASURES Oxygen saturation, functional (WHO) class, 6-minute walk test distance and liver enzymes were analysed. RESULTS Eighteen patients (14 female) with pulmonary arterial hypertension associated with congenital heart disease (15 patients with Eisenmenger's syndrome) with a mean (SD) age of 41 (9) years (range 23-69) were included. Median follow-up was 29 months (range 1-39). One patient died during follow-up. Patients tolerated bosentan well and no significant rise in liver transaminases was seen. Arterial oxygen saturation remained stable throughout follow-up. Mean (SD) functional class (p = 0.001) and the 6-minute walk test distance improved compared with baseline (284 (144) vs 363 (124) m, 380 (91) m and 408 (114) m at baseline, 0-6 months, 6-12 months and 1-2 years of treatment, respectively; p<0.05 for each). CONCLUSIONS Bosentan appears to be safe and well tolerated in adults with pulmonary arterial hypertension associated with congenital heart disease or Eisenmenger's syndrome during mid- to long-term follow-up. In addition, functional class and the 6-minute walk test distance improved and this effect was maintained for up to 2 years of bosentan treatment.
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Affiliation(s)
- Gerhard-Paul Diller
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Royal Brompton Hospital, and the National Heart and Lung Institute, Imperial College of Science and Medicine, London, UK
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25
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Broberg CS, Ujita M, Prasad S, Li W, Rubens M, Bax BE, Davidson SJ, Bouzas B, Gibbs JSR, Burman J, Gatzoulis MA. Pulmonary arterial thrombosis in eisenmenger syndrome is associated with biventricular dysfunction and decreased pulmonary flow velocity. J Am Coll Cardiol 2007; 50:634-42. [PMID: 17692749 DOI: 10.1016/j.jacc.2007.04.056] [Citation(s) in RCA: 100] [Impact Index Per Article: 5.9] [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: 01/03/2007] [Revised: 04/10/2007] [Accepted: 04/15/2007] [Indexed: 02/08/2023]
Abstract
OBJECTIVES This study sought to determine what factors are associated with pulmonary artery thrombi in Eisenmenger patients. BACKGROUND Pulmonary artery thrombosis is common in Eisenmenger syndrome, although its underlying pathophysiology is poorly understood. METHODS Adult patients with Eisenmenger syndrome underwent computed tomography pulmonary angiography, cardiac magnetic resonance imaging, and echocardiography. Measurement of ventricular function, pulmonary artery size, and pulmonary artery blood flow were obtained. Hypercoagulability screening and platelet function assays were performed. RESULTS Of 55 consecutive patients, 11 (20%) had a detectable thrombus. These patients were older (p = 0.032), but did not differ in oxygen saturation, hemoglobin, or hematocrit from those without thrombus. Right ventricular ejection fraction by magnetic resonance imaging was lower in those with thrombus (0.41 +/- 0.15 vs. 0.53 +/- 0.13, p = 0.017), as was left ventricular ejection fraction (0.48 +/- 0.12 vs. 0.60 +/- 0.09, p = 0.002), a finding corroborated by tissue Doppler and increased brain natriuretic peptide. Those with thrombus also had a larger main pulmonary artery diameter (48 +/- 14 mm vs. 38 +/- 9 mm, p = 0.007) and a lower peak systolic velocity in the pulmonary artery (p = 0.003). There were no differences in clotting factors, platelet function, or bronchial arteries between groups. Logistic regression showed pulmonary artery velocity to be independently associated with thrombosis. CONCLUSIONS Pulmonary arterial thrombosis among adults with Eisenmenger syndrome is common and relates to older age, biventricular dysfunction, and slow pulmonary artery blood flow rather than degree of cyanosis or coagulation abnormalities. Further work to define treatment efficacy is needed.
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Affiliation(s)
- Craig S Broberg
- Adult Congenital Heart Disease Centre, Royal Brompton Hospital and National Heart Lung Institute, Imperial College School of Medicine, London, England.
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Griffin N, Allen D, Wort J, Rubens M, Padley S. Eisenmenger syndrome and idiopathic pulmonary arterial hypertension: do parenchymal lung changes reflect aetiology? Clin Radiol 2007; 62:587-95. [PMID: 17467397 DOI: 10.1016/j.crad.2007.01.013] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2006] [Revised: 12/30/2006] [Accepted: 01/05/2007] [Indexed: 01/15/2023]
Abstract
AIM To document the pulmonary vascular changes on thin-section computed tomography (CT) in patients with Eisenmenger syndrome and idiopathic pulmonary arterial hypertension, and to determine whether there is any correlation with pulmonary arterial pressures or the aetiology of pulmonary hypertension. MATERIAL AND METHODS From the National Pulmonary Hypertension Database, we identified eight patients with idiopathic pulmonary arterial hypertension and 20 patients with Eisenmenger syndrome (secondary to a ventriculoseptal defect) who had also undergone contrast-enhanced thin-section CT. CT studies were reviewed for the presence of centrilobular nodules, mosaicism, neovascularity, and bronchial artery hypertrophy. Haemodynamic data were also reviewed. RESULTS Centrilobular nodules, mosaicism, and neovascularity were seen in both patient groups (p>0.05). A significantly higher number of enlarged bronchial arteries were seen in patients with Eisenmenger syndrome. There was no correlation with pulmonary arterial pressures. CONCLUSION Patients with idiopathic pulmonary arterial hypertension and Eisenmenger syndrome demonstrated similar pulmonary vascular changes on CT. These changes did not predict the underlying cause of pulmonary hypertension or its severity.
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Affiliation(s)
- N Griffin
- Royal Brompton and Harefield NHS Trust, London, UK.
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Abstract
We treated prospectively 14 patients with Eisenmenger's syndrome, with a mean age of 10 years, ranging from 3 to 18 years. Treatment continued for 12 months, and demonstrated a lasting symptomatic improvement, but no improvement in terms of mean saturation of oxygen over 24 hours. Exercise capacity, as judged by peak uptake of oxygen, worsened in the six patients able to perform a treadmill test. The symptomatic benefit from dual blockage of endothelin receptors in these patients may be due to mechanisms other than selective pulmonary vasodilatation alone.
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Affiliation(s)
- Henrik Brun
- Paediatric Cardiology Unit, Rikshospitalet, Oslo, Norway.
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Abstract
Pulmonary arterial hypertension associated with congenital heart disease, although common (15%-30%) in all-comers with congenital heart disease, is variable in terms of clinical manifestations, severity of associated pulmonary arterial hypertension, and response to therapy and outcomes (depending on lesion anatomy, pulmonary circulation flows and pressures, and presence and timings of surgeries). Evaluation includes imaging and catheterization. Surgical or another anatomic correction may be desirable after rigorous preinterventional assessment. Patients who are not surgical candidates or who fail to improve early or late after surgery may have the potential to respond to idiopathic pulmonary arterial hypertension therapies. Lung or heart/lung transplantation remains an option for selected recalcitrant patients.
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Affiliation(s)
- Michael J Landzberg
- Boston Adult Congenital Heart and Pulmonary Hypertension Group, Children's Hospital, Brigham and Women's Hospital, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA 02115-5724, USA.
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Abstract
BACKGROUND It has long been debated whether patients with atrial septal defect (ASD) Eisenmenger syndrome have idiopathic pulmonary arterial hypertension with an incidental ASD or severe pulmonary hypertension on the basis of their ASD shunt magnitude alone. HYPOTHESIS It was hypothesized that if ASD Eisenmenger patients had idiopathic pulmonary arterial hypertension with an incidental ASD, a mutation in the bone morphogenetic protein receptor-2 (BMPR2) would be found in some of these patients. PATIENTS AND METHODS All adult patients with ASD Eisenmenger syndrome were identified from the databases of two adult congenital cardiac units, and were matched to a control group with similar types of ASDs and no pulmonary hypertension. Gene coding for BMPR2 was examined for mutation using denaturing high-performance liquid chromatography of the entire coding sequence. RESULTS Eighteen adult patients with ASD Eisenmenger syndrome and 18 control patients were identified. ASD Eisenmenger patients had significantly larger ASDs than the control patients (3.7+/-1.2 cm versus 1.9+/-0.7 cm, P<0.01). A mutation in BMPR2 was not detected in either group. CONCLUSION ASD Eisenmenger syndrome may occur without BMPR2 mutation. Whether shunt magnitude alone or in combination with yet another genetic mutation is responsible for the development of pulmonary hypertension in these patients remains to be determined.
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Affiliation(s)
- Judith Therrien
- Toronto Congenital Cardiac Centre for Adults, Toronto General Hospital, Canada.
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30
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Abstract
The prevalence of pulmonary arterial hypertension (PAH) in congenital heart anomalies is rising, because an increasing proportion of these patients now reach adulthood. However, morbidity and mortality rates in these patients are modified by the existing cardiac anomaly and thus differ from idiopathic pulmonary hypertension (IPAH). There are, in addition to Eisenmenger's syndrome, special forms such as local PAH or hemodynamically relevant increased pulmonary vascular resistance associated with a dysfunctional or absent right ventricle. In all these forms of PAH it is the therapeutic aim to achieve pulmonary vascular dilatation to reduce symptoms of right ventricular stress and to increase pulmonary blood flow and raise systemic oxygen supply. Just as in IPAH, intravenous, inhaled or oral medications--prostanoids, endothelin-receptor inhibitors, phosphodiesterase-5 inhibitors--are being used with increasing success.
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Affiliation(s)
- I Schulze-Neick
- Klinik für Angeborene Herzfehler/Kinderkardiologie, Deutsches Herzzentrum Berlin, Augustenburger Platz, 13353 Berlin
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MESH Headings
- Abnormalities, Multiple
- Adult
- Aneurysm/etiology
- Child
- Diagnostic Techniques, Cardiovascular
- Dinoprostone/physiology
- Ductus Arteriosus/embryology
- Ductus Arteriosus/physiology
- Ductus Arteriosus, Patent/diagnosis
- Ductus Arteriosus, Patent/embryology
- Ductus Arteriosus, Patent/epidemiology
- Ductus Arteriosus, Patent/physiopathology
- Ductus Arteriosus, Patent/surgery
- Ductus Arteriosus, Patent/therapy
- Eisenmenger Complex/etiology
- Eisenmenger Complex/physiopathology
- Epoprostenol/physiology
- Heart Failure/etiology
- Humans
- Hypertension, Pulmonary/etiology
- Incidence
- Infant
- Infant, Newborn
- Oxygen/blood
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Affiliation(s)
- Douglas J Schneider
- University of Illinois College of Medicine at Peoria, and Cardiac Catheterization Laboratory, Children's Hospital of Illinois, 420 NE Glen Oak Ave, Suite 304, Peoria, IL 61603, USA.
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32
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Affiliation(s)
- Henryk Kafka
- Royal Brompton Hospital and the National Heart and Lung Institute, Imperial College, London, UK.
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33
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Makaryus AN, Forouzesh A, Johnson M. Pregnancy in the patient with Eisenmenger's syndrome. Mt Sinai J Med 2006; 73:1033-6. [PMID: 17195894] [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] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Eisenmenger's syndrome occurs when a large congenital or surgically created shunt between the left and right sides of the heart causes an increase in pulmonary vascular resistance that equals or surpasses systemic resistance, resulting in a reversal of the shunt from a left-to-right shunt to a right-to-left or bi-directional shunt. The maternal mortality rate of pregnancy in the presence of Eisenmenger's syndrome is reported to be as high as 50-65% with cesarean section. We present the case of a 32-year-old woman with Eisenmenger's syndrome who gave birth at 29 weeks of gestation via C-section to a healthy baby boy, and we review the literature regarding the management of such patients.
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Affiliation(s)
- Amgad N Makaryus
- Department of Medicine, North Shore University Hospital, Manhasset, NY, USA
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Abstract
Background—
Phosphodiesterase-5 inhibitors produce a significant decrease in pulmonary vascular resistance in patients with idiopathic pulmonary arterial hypertension. We studied the effects of tadalafil, a phosphodiesterase-5 inhibitor, on short-term hemodynamics, tolerability, and efficacy over a 12-week period in patients of Eisenmenger syndrome having a pulmonary vascular pathology similar to idiopathic pulmonary arterial hypertension.
Methods and Results—
Sixteen symptomatic Eisenmenger syndrome patients (mean age, 25±8.9 years) were assessed hemodynamically at baseline and 90 minutes after a single dose of tadalafil (1 mg/kg body weight up to a maximum of 40 mg). The same dose was then continued daily for 12 weeks, and the patients were restudied. There was a significant decrease in mean pulmonary vascular resistance immediately (24.75±8.49 to 19.22±8.23 Woods units;
P
<0.005) and at 12 weeks (19.22±8.23 to 17.02±6.19 Woods units;
P
=0.03 versus 90 minutes). Thirteen of 16 patients (81.25%) showed a ≥20% decrease in pulmonary vascular resistance and were defined as responders. The mean systemic oxygen saturation improved significantly both immediately (84.34±5.47% to 87.39±4.34%;
P
<0.005) and at 12 weeks (87.39±4.34% to 89.16±3.8%;
P
<0.02 versus 90 minutes) without a significant change in systemic vascular resistance. None of the patients had a fall in systemic arterial pressure, worsening of systemic oxygen saturation, or any adverse reactions to the drug. The mean World Health Organization functional class improved from 2.31±0.47 to 1.25±0.44 (
P
<0.0001), and the 6-minute walk distance improved from 344.56±119.06 to 387.56±117.18 m (
P
<0.001).
Conclusions—
Preliminary evaluation of tadalafil has shown efficacy and safety in selected patients with Eisenmenger syndrome, warranting further investigation in this subgroup of patients.
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35
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Voelkel NF, Quaife RA, Leinwand LA, Barst RJ, McGoon MD, Meldrum DR, Dupuis J, Long CS, Rubin LJ, Smart FW, Suzuki YJ, Gladwin M, Denholm EM, Gail DB. Right Ventricular Function and Failure. Circulation 2006; 114:1883-91. [PMID: 17060398 DOI: 10.1161/circulationaha.106.632208] [Citation(s) in RCA: 864] [Impact Index Per Article: 48.0] [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] [Indexed: 01/23/2023]
MESH Headings
- Basic Helix-Loop-Helix Transcription Factors/genetics
- Basic Helix-Loop-Helix Transcription Factors/physiology
- Eisenmenger Complex/etiology
- Eisenmenger Complex/physiopathology
- Epoprostenol/therapeutic use
- Forecasting
- Genetic Predisposition to Disease
- Humans
- Hypertension, Pulmonary/etiology
- Hypertension, Pulmonary/physiopathology
- Myocardial Infarction/complications
- Peptidyl-Dipeptidase A/genetics
- Polymorphism, Genetic
- Pressure
- Pulmonary Heart Disease/etiology
- Pulmonary Heart Disease/physiopathology
- Transcription, Genetic
- Tricuspid Valve Insufficiency/complications
- Tricuspid Valve Insufficiency/physiopathology
- Vasodilator Agents/therapeutic use
- Ventricular Dysfunction, Left/complications
- Ventricular Dysfunction, Left/physiopathology
- Ventricular Dysfunction, Right/drug therapy
- Ventricular Dysfunction, Right/etiology
- Ventricular Dysfunction, Right/genetics
- Ventricular Dysfunction, Right/physiopathology
- Ventricular Function
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Affiliation(s)
- Norbert F Voelkel
- Pulmonary Hypertension Center, University of Colorado at Denver and Health Sciences Center, 4200 E Ninth Ave, MC: C272, Denver, CO 80262, USA.
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36
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Bouch DC, Allsager CM, Moore N. Peri-operative trans-oesophageal echocardiography and nitric oxide during general anaesthesia in a patient with Eisenmenger's syndrome. Anaesthesia 2006; 61:996-1000. [PMID: 16978316 DOI: 10.1111/j.1365-2044.2006.04758.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
We describe the peri-operative care of a patient with Eisenmenger's syndrome presenting for laparotomy. These patients require techniques to prevent the potential increase in intracardiac shunt caused by anaesthesia, by minimising increases in pulmonary artery pressure and reductions in systemic vascular resistance. The successful use of combined epidural and general anaesthesia with elective use of inhaled nitric oxide as a pulmonary vasodilator, and intra-operative trans-oesophageal echocardiography is described.
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Affiliation(s)
- D C Bouch
- Department of Anaesthetics and Critical Care Medicine, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, UK.
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37
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Abstract
BACKGROUND Bosentan, a dual endothelin receptor antagonist, has been used for symptomatic improvement of patients with idiopathic pulmonary arterial hypertension (PAH) and specific types of secondary (e.g. scleroderma and human immunodeficiency virus infection) PAH, but its efficacy in patients with congenital heart disease and chronic thromboembolic pulmonary hypertension is still under evaluation. In this study two patients are presented, one with common atrioventricular canal and pulmonary hypertension and the other with recurrent pulmonary thromboembolism; both improved significantly after bosentan administration. MATERIALS AND METHODS The first patient was a 38-year-old female with trisomy 21, common atrioventricular canal and pulmonary hypertension (Eisenmenger syndrome). The second patient was a 57-year-old male, who was on anticoagulant therapy owing to an episode of pulmonary embolism that had been diagnosed 3 years earlier. Recurrent pulmonary thromboembolism was considered the most probable diagnosis. Chest spiral computed tomography examination excluded pulmonary endarterectomy as a therapeutic approach. At admission, the two patients were on New York Heart Association class IV, diagnosed by progressive rest dyspnea. Bosentan was administered to patients 1 and 2 for 6 and 9 months, respectively (62.5 mg b.i.d. for 4 weeks, then 125 mg b.i.d.). RESULTS Bosentan therapy resulted in significant clinical improvement in both patients. No hepatic dysfunction nor any other side-effect was observed. CONCLUSIONS Bosentan could be an effective therapy for pulmonary hypertension owing to congenital heart disease and chronic thromboembolic disease.
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Affiliation(s)
- S Kourouklis
- 2nd Department of Cardiology, Hellenic Red Cross General Hospital, Athens, Greece
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38
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Abstract
Background—
Despite an appreciable increase in basal coronary blood flow in cyanotic congenital heart disease, flow reserve remains normal. We hypothesized that preservation of flow reserve resides in remodeling of the coronary microcirculation. Microcirculatory morphometric analyses were performed to test this hypothesis.
Methods and Results—
Necropsy specimens from 4 sources were studied: (1) hearts from patients with Eisenmenger’s syndrome (A; n=5), (2) structurally abnormal hearts with ventricular hypertrophy (B; n=8), (3) structurally normal hearts with ventricular hypertrophy (C; n=6), and (4) normal hearts (D; n=5). To compare responses of the microcirculation to hypoxia versus hypertrophy, sections were taken from the left ventricular free wall, which in group A, was hypoxemic but not hypertrophied; in groups B and C, was hypertrophied but not hypoxemic; and in group D, was neither hypertrophied nor hypoxemic. Coronary arterioles were immunolabeled for smooth muscle α-actin. Measured morphometric parameters included long and short axes, area, and perimeter. Arteriolar length, volume and surface densities were calculated. There was a significant intergroup difference for arteriolar length density (
P
=0.03) and diameter (
P
=0.03). Total length density in group A hearts was markedly lower, but mean arteriolar diameter was significantly greater (34%) compared with group B (
P
=0.03). Arteriolar volume density was similar to that in the other groups.
Conclusions—
Remodeling of the coronary microcirculation is the key mechanism for preservation of flow reserve in cyanotic congenital heart disease. The increase in short axis (diameter) compensated for lower arteriolar length density and was the principal anatomic basis for maintenance of normal flow reserve.
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Affiliation(s)
- Eduard I Dedkov
- Department of Anatomy and Cell Biology and Cardiovascular Center, University of Iowa Carver College of Medicine, Iowa City, USA
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39
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Abstract
Background—
Eisenmenger syndrome is characterized by the development of pulmonary arterial hypertension with consequent intracardiac right-to-left shunt and hypoxemia in patients with preexisting congenital heart disease. Because Eisenmenger syndrome is associated with increased endothelin expression, patients may benefit from endothelin receptor antagonism. Theoretically, interventions that have some effect on the systemic vascular bed could worsen the shunt and increase hypoxemia.
Methods and Results—
The Bosentan Randomized Trial of Endothelin Antagonist Therapy-5 (BREATHE-5) was a 16-week, multicenter, randomized, double-blind, placebo-controlled study evaluating the effect of bosentan, a dual endothelin receptor antagonist, on systemic pulse oximetry (primary safety end point) and pulmonary vascular resistance (primary efficacy end point) in patients with World Health Organization functional class III Eisenmenger syndrome. Hemodynamics were assessed by right- and left-heart catheterization. Secondary end points included exercise capacity assessed by 6-minute walk distance, additional hemodynamic parameters, functional capacity, and safety. Fifty-four patients were randomized 2:1 to bosentan (n=37) or placebo (n=17) for 16 weeks. The placebo-corrected effect on systemic pulse oximetry was 1.0% (95% confidence interval, −0.7 to 2.8), demonstrating that bosentan did not worsen oxygen saturation. Compared with placebo, bosentan reduced pulmonary vascular resistance index (−472.0 dyne · s · cm
−5
;
P
=0.0383). The mean pulmonary arterial pressure decreased (−5.5 mm Hg;
P
=0.0363), and the exercise capacity increased (53.1 m;
P
=0.0079). Four patients discontinued as a result of adverse events, 2 (5%) in the bosentan group and 2 (12%) in the placebo group.
Conclusions—
In this first placebo-controlled trial in patients with Eisenmenger syndrome, bosentan was well tolerated and improved exercise capacity and hemodynamics without compromising peripheral oxygen saturation.
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Affiliation(s)
- Nazzareno Galiè
- Istituto di Cardiologia, Università di Bologna, Via Massarenti, 9 IT-40138, Bologna, Italy.
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40
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Adhyapak SM, Pujar SV, Mahala BK, Shetty PK. Echocardiographic evaluation of the morphology and function of the right ventricle in Eisenmenger's syndrome and idiopathic pulmonary hypertension. Indian Heart J 2006; 58:341-344. [PMID: 19039152] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023] Open
Abstract
AIM The aim of this study was to investigate the reasons for better prognosis in adults with Eisenmenger's syndrome than those suffering from idiopathic pulmonary hypertension. Our hypothesis was that right ventricular function is better preserved in the former case than in the latter. METHODS We used two-dimensional echocardiography and tissue Doppler imaging to compare right ventricular morphology and function in 24 subjects with Eisenmenger's syndrome and 23 age- and sex-matched subjects with idiopathic pulmonary hypertension. RESULTS The mean age was 27.4+/-12.2 years for both groups. There were more patients from the idiopathic pulmonary hypertension group in the New York Heart Association Class III than those from the Eisenmenger's syndrome group (48.4% vs 36.3%; p<0.01). Measurements of the right and left ventricular free wall thickness, as well as the internal diameter of the right ventricle were taken, and tissue Doppler imaging was used to assess the function of both ventricles. In the Eisenmenger's group, the mean right ventricular and left ventricular free wall thickness was 10.4+/-2.78 mm and 9.7+/-1.98 mm, respectively. The mean right ventricular internal diameter in diastole and in systole were 20+/-8.64 mm and 18.1+/-9.24 mm, respectively. The mean right ventricular S1 was 10.4+/-3.4 cm/sec and S2, 10.3+/-2.6 cm/sec, while the left ventricular S1 was 7.4+/-1.87 cm/s and S2, 7.5+/-1.05 cm/sec, with a normal biventricular function. In the idiopathic pulmonary hypertension group, the mean right ventricular and left ventricular free wall thickness was 11.3+/-3.24 mm and 9.8+/-1.94 mm, respectively. The mean right ventricular internal diameter in diastole and systole was 36+/-8.9 mm and 30.1+/-9.8 mm, respectively. The mean right ventricular S1 was 6.9+/-3.4 cm/sec and S2, 6.8+/-2.8 cm/sec, while the left ventricular S1 was 7.4+/-1.8 cm/sec and S2, 7.5+/-1.05 cm/sec, reflecting right ventricular systolic dysfunction. CONCLUSIONS Right ventricular function was better preserved among subjects with Eisenmenger's syndrome than those with idiopathic pulmonary hypertension in a study in which the two groups were matched for age and sex.
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41
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Affiliation(s)
- Michael J Landzberg
- Division of Cardiothoracic Surgery, Oregon Health and Science University, Portland, Oregon, USA.
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42
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García Ruiz N, Farré Pinilla M, Sistac Ballarín JM, Martínez Salavera T. [General anesthesia in an adult with Eisenmenger syndrome]. Rev Esp Anestesiol Reanim 2006; 53:387-8. [PMID: 16910148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
MESH Headings
- Acetaminophen/therapeutic use
- Adult
- Androstanols/administration & dosage
- Anesthesia, Dental/methods
- Anesthesia, General/methods
- Anesthetics, Dissociative/administration & dosage
- Anesthetics, Inhalation/administration & dosage
- Anesthetics, Intravenous/administration & dosage
- Anti-Inflammatory Agents, Non-Steroidal
- Antibiotic Prophylaxis
- Contraindications
- Down Syndrome/complications
- Dyspnea/etiology
- Eisenmenger Complex/complications
- Eisenmenger Complex/physiopathology
- Fentanyl/administration & dosage
- Heart Defects, Congenital/complications
- Hemodynamics
- Humans
- Hypertension, Pulmonary/etiology
- Hypertrophy, Left Ventricular/complications
- Hypoxia/etiology
- Ketamine/administration & dosage
- Male
- Methyl Ethers/administration & dosage
- Neuromuscular Nondepolarizing Agents/administration & dosage
- Pain, Postoperative/drug therapy
- Phenylephrine/administration & dosage
- Rocuronium
- Sevoflurane
- Tooth Extraction
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43
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Abstract
The original definition of Eisenmenger syndrome refers to an unrestrictive post-tricuspid valve congenital systemic-to-pulmonary shunt. When the pulmonary arterial systolic pressure becomes equal to the systemic arterial systolic pressure, the direction of the shunt becomes pulmonary-to-systemic. The latter leads to progressive cyanosis, and exercise intolerance is initially proportional to the degree of hypoxaemia. Later, congestive heart failure may occur . The management principle is to avoid any factors that destabilise this delicately balanced physiology. Until recently, this could only be achieved by symptomatic therapy; however, when patients are severely incapacitated, transplantation is needed. At present, new drugs, which are more selective pulmonary vasodilators, are available to interfere with the ongoing disease process to improve functional capacity and delay the decision for transplantation.
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Affiliation(s)
- Werner Budts
- Department of Cardiology, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium.
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44
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Joyce JA. Update for nurse anesthetists. Eisenmenger syndrome: an anesthetic conundrum. AANA J 2006; 74:233-9. [PMID: 16786918] [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] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
Eisenmenger syndrome is an insidious disease entity. This disease is characterized by an unrepaired congenital heart defect and left-to-right cardiac shunting. After many years of increased blood flow through the pulmonary system as a result of the shunting, damage to the pulmonary vessels occurs, culminating in severe pulmonary hypertension. The pulmonary hypertension eventually causes the cardiac shunt to reverse direction. The right-to-left shunt results in a very debilitated patient. There is no known medical cure for this disease; the only curative option is heart-lung transplantation or bilateral lung transplantation with repair of the patent heart defect. Because of the great strides in medical care, more patients with Eisenmenger syndrome require anesthesia. Maintaining the patient's systemic vascular resistance at the preoperative level is of paramount importance. Choosing the best anesthesia technique is difficult, at best.
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Affiliation(s)
- Joseph A Joyce
- Moses Cone Health System, Wesley Long Community Hospital Division, Greensboro, NC, USA
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45
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Poindron D, Godart F, Duhamel A, Richard A, Francart C, Brevière GM, Rey C. [The effect of an endothelin receptor antagonist in Eisenmenger syndrome: a single-center experience of 11 patients]. Arch Mal Coeur Vaiss 2006; 99:457-62. [PMID: 16802735] [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] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
The Eisenmenger syndrome is a complication of congenital heart disease with significant left-to-right shunts, such as large ventricular septal defects, and corresponds to fixed pulmonary hypertension with shunt reversal. Bosentan, an inhibitor of endothelin A and B receptors, is a new molecule previously validated in the treatment of primary pulmonary hypertension. The authors report their monocentric experience of bosentan in 11 consecutive patients with the Eisenmenger syndrome treated for at least one year. This retrospective study comprised 7 females and 4 males with an average age of 34 years (range 17 to 51 years). The underlying lesion was ventricular septal defect (n = 4), atrial septal defect (n = 3), pulmonary atresia with septal defect (n = 4 of which 2 were treated palliatively). Before treatment, the patients were classified according to the NHYA functional class (I, II, IIIa and IIIb, IV or, respectively from 1 to 5) with a distribution in this series between Classes IIIa and IV (average 3.81 +/- 0.75) and from 3 to 10 on Borg's dyspnoea scale (average 6.54 +/- 2.29). The ambient oxygen saturation (SaO2) at rest was, on average 77 +/- 9%, the haemoglobin concentration 16.6 +/- 2.4 g/dl; hepatic transaminase levels were normal. The 6 minute walk test before treatment was 216 +/- 111 m with marked desaturation on exercise (49 +/- 18%). With Bosentan, patients were globally much better clinically with a decrease in dyspnoea, improvement in NHYA class and increased 6 minute walking perimeter. Improvement in NYHA class was observed from 3 months' treatment (3.0 +/- 0.8, p = 0.0002) and was sustained to one year (2.54 +/- 0.7, p< 0.001). An improvement of dyspnoea on Borg's scale was observed from the second month's treatment (5.56 +/- 1.65, p = 0.0201) and persisted throughout follow up to one year (3.81 +/- 1.32, p < 0.0001). Similarly, the 6 minute walking perimeter increased from the first control at 6 months (323 +/- 82 m, p < 0.0001) and at one year (322 +/- 62 m, p <0.0004). Finally, although a significant increase in SaO2 was observed at 6 months (p = 0.0032), this was hardly significant at one year (82 +/- 10 %, p = 0.0512). Transaminase levels did not rise significantly at the follow up visits (p = ns) and the haemoglobin concentration was unchanged. No patient died during the study period. This study showed a clear functional improvement in patients with Eisenmenger's syndrome treated with bosentan. The drug was well tolerated clinically with few adverse effects and a good safety margin of usage.
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Affiliation(s)
- D Poindron
- Service des malades cardiovasculaires infantiles et congénitales, Hôpital cardiologique, Université de Lille 2, CHRU Lille
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46
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Affiliation(s)
- Clive Lewis
- Cardiology Department, The Heart Hospital, University College London, London W1M 8PH
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47
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Chuang ML, Chang HC, Lim KE, Vintch JRE. Gas exchange detection of right-to-left shunt in dyspneic patients: Report of three cases. Int J Cardiol 2006; 108:117-9. [PMID: 16516706 DOI: 10.1016/j.ijcard.2005.02.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2005] [Accepted: 02/05/2005] [Indexed: 10/25/2022]
Abstract
We evaluated three patients with undiagnosed complaints of progressive dyspnea. Based on gas-exchange findings as the initial diagnostic tool, the high ventilatory equivalents for CO2, low sustained end-tidal PCO2, hypoxemia, and central cardiovascular dysfunction during cardiopulmonary exercise testing (CPET) suggested that each had significant pulmonary vasculopathy with right-to-left shunting. The diagnoses of Osler-Rendu-Weber syndrome, ventricular septal defect with Eisenmenger's complex, and hepatopulmonary syndrome were later confirmed by pulmonary angiography, cardiac catheterization, and contrast enhanced echocardiography respectively. We suggest that CPET is an appropriate noninvasive tool to begin and guide the evaluation of undiagnosed dyspnea.
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48
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Guye ML, Schoeffler M, Chouquer R, Muchada R. [Anaesthesia for a non cardiac surgery in a patient with an Eisenmenger syndrome. Interest of a non invasive haemodynamic monitoring]. Ann Fr Anesth Reanim 2005; 25:197-200. [PMID: 16269233 DOI: 10.1016/j.annfar.2005.09.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/07/2004] [Accepted: 08/29/2005] [Indexed: 11/25/2022]
Abstract
Patients with an Eisenmenger syndrome have an instuble hemodynamic status. During a general anaesthesia, the intracardiac shunt has to maintain the correct orientation and volume, adapted to each patient, in such a condition, to avoid the risk of hypoxemia and cardiac failure. The haemodynamic monitoring with a Swan Ganz catheter could be useful. But it is necessary to evaluate the advantage and the risks when the technique is used in these pathological circumstances. Moreover, when the cardiac output is measured with the thermodilution technique, the right-left intra cardiac shunt volume, is not taking into account. The continuous haemodynamic monitoring, with a simplified transoesophageal echo-Doppler system, as it was done in this case, allows appreciate the real quantitative variations of the shunt. In this way the more adequate calculation of some others haemodynamic parameters, over all the total systemic vascular resistances, allows a more precise therapeutic approach.
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Affiliation(s)
- M L Guye
- Département d'Anesthésie-Réanimation, Clinique Mutualiste Eugène-André, 107, rue Trarieux, 69424 Lyon, France
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49
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Abstract
Patients with Eisenmenger syndrome do much better than patients with all other etiologies of severe pulmonary hypertension. The primary reason, and a major focus of this review, is the right ventricle, a remarkable chamber with preserved systolic function despite a lifetime of systemic level pulmonary hypertension.
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Affiliation(s)
- William E Hopkins
- Cardiology Unit, University of Vermont College of Medicine, Cardiology Unit, McClure 1, 111 Colchester Av., Burlington, VT 05401, USA.
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50
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Gatzoulis MA, Rogers P, Li W, Harries C, Cramer D, Ward S, Mikhail GW, Gibbs JSR. Safety and tolerability of bosentan in adults with Eisenmenger physiology. Int J Cardiol 2005; 98:147-51. [PMID: 15676179 DOI: 10.1016/j.ijcard.2004.08.025] [Citation(s) in RCA: 85] [Impact Index Per Article: 4.5] [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: 05/27/2004] [Revised: 07/27/2004] [Accepted: 08/07/2004] [Indexed: 11/22/2022]
Abstract
BACKGROUND Bosentan, a dual-endothelin receptor antagonist, is an established treatment for pulmonary arterial hypertension. We hypothesized that bosentan is safe and well tolerated in patients with Eisenmenger physiology. METHODS In this pilot open-label study, we primarily examined safety and tolerability of oral bosentan. Patients were recruited from our adult congenital heart clinic following informed consent. Baseline and 3-month assessment included WHO functional class, resting oxygen saturations, 6-min walk test, transthoracic echocardiography and respiratory mass spectrometry. Patient clinical status and liver enzymes were closely monitored throughout. RESULTS All 10 study patients (42+/-4 years; eight female) tolerated bosentan well. No major adverse events or significant liver enzyme elevations were observed. All but one patient felt better; none felt worse. Four patients experienced transient leg oedema. Resting oxygen saturations (83+/-5 versus 80+/-5%; P=0.011) and the distance travelled in the 6-min walk test (348+/-112 versus 249+/-117 m; P=0.004) increased relative to baseline. Changes in echocardiographic parameters (maximum aortic forward flow velocity 1.3+/-0.1 versus 1.1+/-0.2 ms, P=0.013; pulmonary arterial acceleration time 66+/-10 versus 58+/-12 m/s, P=0.02) and pulmonary blood flow (3.45+/-1.2 versus 2.58+/-1.0 L/min, P=0.008) suggested improved pulmonary haemodynamics by study end. Other echocardiographic changes suggested improved right ventricular systolic function (septal amplitude 1.0 versus 1.1 cm, P=0.048; systolic tissue Doppler velocity 4.8 versus 2.3 cm s(-1), P=0.002) by study end. CONCLUSIONS Bosentan was safe and well tolerated in adults with Eisenmenger physiology both at initiation and after 3 months of oral therapy. Clinical status of patients and pulmonary haemodynamics appeared to improve, and this warrants further investigation.
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Affiliation(s)
- Michael A Gatzoulis
- Adult Congenital Heart Program, Royal Brompton Hospital, Sydney Street, London, SW3 6NP, UK.
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