Effect of phosphodiesterase-5 inhibition on SystEmic Right VEntricular size and function. A multicentre, double-blind, randomized, placebo-controlled trial: SERVE

AIMS

In adults with congenital heart disease and systemic right ventricles, progressive right ventricular systolic dysfunction is common and is associated with adverse outcomes. Our aim was to assess the impact of the phosphodiesterase-5-inhibitor tadalafil on right ventricular systolic function.

METHODS AND RESULTS

This was a double-blind, randomized, placebo-controlled, multicentre superiority trial (NCT03049540) involving 100 adults with systemic right ventricles (33 women, mean age: 40.7 ± 10.7 years), comparing tadalafil 20 mg once daily versus placebo (1:1 ratio). The primary endpoint was the change in right ventricular end-systolic volume after 3 years of therapy. Secondary endpoints were changes in right ventricular ejection fraction, exercise capacity and N-terminal pro-B-type natriuretic peptide concentration. Primary endpoint assessment by intention to treat analysis at 3 years of follow-up was possible in 83 patients (42 patients in the tadalafil group and 41 patients in the placebo group). No significant changes over time in right ventricular end-systolic volumes were observed in the tadalafil and the placebo group, and no significant differences between treatment groups (3.4 ml, 95% confidence interval -4.3 to 11.0, p = 0.39). No significant changes over time were observed for the pre-specified secondary endpoints for the entire study population, without differences between the tadalafil and the placebo group.

CONCLUSIONS

In this trial in adults with systemic right ventricles, right ventricular systolic function, exercise capacity and neuro-hormonal activation remained stable over a 3-year follow-up period. No significant treatment effect of tadalafil was observed. Further research is needed to find effective treatment for improvement of ventricular function in adults with systemic right ventricles.

Medication in adults after atrial switch for transposition of the great arteries: clinical practice and recommendations

Aims

Heart failure is the main threat to long-term health in adults with transposition of the great arteries (TGA) corrected by an atrial switch operation (AtrSO). Current guidelines refrain from recommending heart failure medication in TGA-AtrSO, as there is insufficient data to support the hypothesis that it is beneficial. Medication is therefore prescribed based on personal judgements. We aimed to evaluate medication use in TGA-AtrSO patients and examine the association of use of renin–angiotensin–aldosterone system (RAAS) inhibitors and β-blockers with long-term survival.

Methods and results

We identified 150 TGA-AtrSO patients [median age 30 years (interquartile range 25–35), 63% male] included in the CONCOR registry from five tertiary medical centres with subsequent linkage to the Dutch Dispensed Drug Register for the years 2006–2014. Use of RAAS inhibitors, β-blockers, and diuretics increased with age, from, respectively, 21% [95% confidence interval (CI) 14–40], 12% (95% CI 7–21), and 3% (95% CI 2–7) at age 25, to 49% (95% CI 38–60), 51% (95% CI 38–63), and 41% (95% CI 29–54) at age 45. Time-varying Cox marginal structural models that adjusted for confounding medication showed a lower mortality risk with use of RAAS inhibitors and β-blockers in symptomatic patients [hazard ratio (HR) = 0.13 (95% CI 0.03–0.73); P = 0.020 and HR = 0.12 (95% CI 0.02–0.17); P = 0.019, respectively]. However, in the overall cohort, no benefit of RAAS inhibitors and β-blockers was seen [HR = 0.93 (95% CI 0.24–3.63); P = 0.92 and HR = 0.98 (0.23–4.17); P = 0.98, respectively].

Conclusion

The use of heart failure medication is high in TGA-AtrSO patients, although evidence of its benefit is limited. This study showed lower risk of mortality with use of RAAS inhibitors and β-blockers in symptomatic patients only. These findings can direct future guidelines, supporting use of RAAS inhibitors and β-blockers in symptomatic, but not asymptomatic patients.

Inhaled iloprost as a rescue therapy for transposition of the great arteries with persistent pulmonary hypertension of the newborn

Transposition of the great arteries (TGA) in the newborn combined with persistent pulmonary hypertension was reported previously to occur in 3-12 % of full-term neonates with TGA. Right-to-left shunting at the ductal level causes severe hypoxemia despite prostaglandin infusion and balloon atrial septostomy. Although the introduction of inhaled nitric oxide (iNO) has improved the prognosis, this condition still is associated with high preoperative mortality. This report describes the case of a newborn with TGA and persistent pulmonary hypertension, which was managed successfully with oral sildenafil, iNO, and inhaled iloprost during life-threatening acute pulmonary hypertension, thus preventing the use of extracorporeal membrane oxygenation.

Multiple brain abscesses in a child with congenital cyanotic heart disease

We report multiple and diffuse supratentorial and infratentorial brain abscesses in a ten months old girl with D- transposition of great arteries. The child was managed medically with intravenous antibiotics for 4 weeks. Her fever settled, however, weakness of right half of the body persisted despite remarkable improvement. Multiple abscesses (about 40 in number), in a child less than 2 years age, associated neutrophilia with toxic granulations and successful therapy with antibiotics alone makes this an unusual case.

Angiotensin Receptor Blockade and Exercise Capacity in Adults With Systemic Right Ventricles

Background— Pharmacological blockade of the renin-angiotensin system improves exercise tolerance in patients with left ventricular dysfunction, yet its impact on patients with systemic right ventricles (RVs) remains unknown.

Methods and Results— A multicenter, randomized, double-blind, placebo-controlled, crossover clinical trial was performed to assess the effects of losartan on exercise capacity and neurohormonal levels in patients with systemic RVs. Of 29 patients studied (age, 30.3±10.9 years), 21 had transposition of the great arteries with a Mustard baffle, and 8 had congenitally corrected transposition of the great arteries. Baseline values were as follows: V̇ o 2 max, 29.8±5.6 mL · kg −1 · min −1 (73.5±12.9% predicted value); RV ejection fraction, 41.6±9.3%; N-terminal pro brain natriuretic peptide (NT-proBNP), 257.7±243.4 pg/mL (normal <125 pg/mL); and angiotensin II, 5.7±4.9 pg/mL (normal <5.0 pg/mL). Comparing losartan to placebo showed no differences in V̇ o 2 max (29.9±5.4 versus 29.4±6.2 mL · kg −1 · min −1 ; P =0.43), exercise duration (632.3±123.0 versus 629.9±140.7 seconds; P =0.76), and NT-proBNP levels (201.2±267.8 versus 229.7±291.5 pg/mL; P =0.10), despite a trend toward increased angiotensin II levels (15.2±13.8 versus 8.8±12.5 pg/mL; P =0.08).

Conclusions— In adults with systemic RVs, losartan did not improve exercise capacity or reduce NT-proBNP levels. Minimal baseline activation of the renin-angiotensin system may explain this lack of benefit and imply an alternative pathophysiological mechanism for the progressive ventricular dysfunction and impaired exercise capacity observed in such patients.

Phentolamine as a treatment for poor mixing in transposition of the great arteries with adequate intraatrial communication

Patients with transposition of the great arteries often show poor mixing for different reasons, even after adequate balloon atrial septostomy. We present a patient with such a lesion whose clinical status improved dramatically after phentolamine was applied. We believe this improvement is due to reduction in afterload caused by the alpha(2) blocker and also possibly as a response to a presumptive effect of the drug on the diastolic function of the right ventricle, allowing more left-to-right shunt across the atrial septal defect. Both phenomena can improve cardiac output in such a situation.

The harlequin color change and association with prostaglandin E1

The harlequin color change is an unusual cutaneous phenomenon observed in newborn infants as transient, benign episodes of a sharply demarcated erythema on half of the infant, with simultaneous contralateral blanching. In this report, two newborns with congenital heart anomalies demonstrated the harlequin color change, one whose skin findings showed a course related to the dose of systemic prostaglandin E1, suggesting a possible association. The benign, self-limited nature of the color change mandates that prostaglandin E1 not be discontinued for this reason. The entity is likely more common than the paucity of reports in the world literature suggests, and all physicians should recognize its graphic appearance to avoid unnecessary exposure to agents in an effort to treat it.

Pseudo-Bartter syndrome in a neonate on prostaglandin infusion

We describe a case of iatrogenic pseudo-Bartter syndrome caused by administration of prostaglandin E1 (PGE1 alprostadil). Although the use of i.v. PGE1 is a well-established pharmacological therapy in neonates with a ductus-dependent congenital cardiopathy to ensure ductus-dependent flow, we could only find one other report on pseudo-Bartter syndrome related to PGE1 infusion.

CONCLUSION

Primary Bartter syndrome is associated with endogenous increased levels of prostaglandins. Therefore, we postulate that the dose of prostaglandin E1 administered, immaturity and the genetic background are all relevant factors involved in the phenotypic presentation of iatrogenic pseudo-Bartter syndrome in this preterm infant.

Improved systemic ventricular function after carvedilol administration in a patient with congenitally corrected transposition of the great arteries

Congenitally corrected transposition of the great arteries (CCTGA) is associated with shortened survival due, at least in part, to progressive systolic dysfunction of the systemic ventricle. We report a substantial improvement in systemic ventricular function with carvedilol in a 63-year-old man with CCTGA.

[Congenitally corrected transposition of the great vessels in adulthood. The value of noninvasive study methods]

A 57-year-old man with a cough and increasing exertional dyspnoea for the past 6 weeks was found on examination to have a loud systolic murmur and cardiomegaly with pulmonary congestion. Echocardiography revealed congenitally corrected transposition of the great arteries (cTGA: atrioventricular and ventriculoarterial discordance): a morphologically right ventricle with a tricuspid valve on the left, a morphologically left ventricle with bicuspid a-v valve on the right, the aorta arising ventrally from the left-sided (morphologically right) ventricle. The tricuspid valve showed an Ebstein-like anomaly with obvious regurgitation. Transoesophageal and contrast echocardiography defined valvar anatomy, attachment of the great arteries and cardiac chambers to the venous and arterial circulations, as well as absence of a left to right shunt. Angiography revealed a coronary anatomy typical for cTGA. The exertional dyspnoea responded to diuretics and low doses of ACE inhibitor. Follow-up monitoring of the valvar regurgitation and appropriate endocarditis prophylaxis were recommended. As the haemodynamics in cTGA is normal, in the absence of additional anomalies, it is a congenital cardiac defect which can, though rarely, present first in adulthood. Life expectancy depends on the nature of any additional defects and the degree of commonly associated tricuspid valve regurgitation. As this case demonstrates, echocardiography can largely define the anomalies.

Prostaglandin-induced foveolar hyperplasia simulating pyloric stenosis in an infant with cyanotic heart disease

Prostaglandin infusion is used to maintain patency of the ductus arteriosus in infants with cyanotic congenital heart disease. Recently, gastric outlet obstruction as a result of prostaglandin infusion has been described. In our case, an upper gastrointestinal contrast study seemed to depict the typical appearance of pyloric stenosis in an infant who had received an infusion of prostaglandin for a prolonged period. Serial ultrasonograms, however, disclosed progressive elongation of the antropyloric channel without wall thickening. This report is the second to illustrate prostaglandin-induced gastric outlet obstruction in a vomiting infant with a gastrointestinal series diagnosis of pyloric stenosis.

Prostaglandin E2 administration in infants with ductus-dependent cyanotic congenital heart disease

Prostaglandin E2 was administered to 22 newborns with ductus-dependent cyanotic congenital heart disease. Twelve patients had pulmonary atresia and ten simple dextrotransposition of the great arteries. Patients were classified into two groups: group 1 (n = 11) received prostaglandin E2 by the intravenous route (dose: 0.01-0.05 microgram/kg per min); group 2 (n = 11) received prostaglandin E2 by the oral route (dose: 35-65 micrograms/kg per 1-4 h). Treatment lasted for 1-90 days. All infants except one of group 2 showed a significant (greater than 10 Torr) increase in PaO2 following PGE2 administration. The mean increase in PaO2 was higher (P less than 0.01) in group 1 (21.8 +/- 1.7, Torr) than in group 2 (15.8 +/- 1.5, Torr). PaO2 fell significantly (P less than 0.01) in five patients of group 1 who continued treatment orally with satisfactory (greater than 30 Torr) levels in four of them. Severe side effects were observed only in group 1. The data show that similarly to prostaglandin E1 infusions, prostaglandin E2, given i.v. or orally, is useful in the management of infants with ductus-dependent cyanotic congenital heart disease. Oral prostaglandin E2, administration is less effective than i.v. infusions, but can be used for long-term, therapy being more convenient and causing minimal morbidity.

[Prostaglandin therapy in newborn infants with a Botalli duct-dependent circulation]

21 patients are described with either the pulmonary or the systemic circulation dependent on the patency of the ductus arteriosus. Treatment with Prostaglandin type E (PGE) was instituted to improve tissue oxygenation. Special PGE 2. It is concluded that PGE can be life-saving in critically ill newborns but that complications, especially episodes of apnoea, are frequent. Little is known about the possible sequelae of long-term oral PGE 2-treatment.

Long-term prostaglandin E1 therapy in congenital heart defects

Seventeen neonates received an intravenous infusion of prostaglandin E1 for an average of 39 days (range 8 to 104). Seven (group 1) had transposition of the great arteries with no ventricular septal defect or a small one; eight (group 2) had ductus-dependent pulmonary flow (pulmonary atresia or stenosis in six and tricuspid atresia in two); and two (group 3) had aortic coarctation, one with no ventricular septal defect, the other with ventricular septal defect, isthmus hypoplasia and descending aortic flow supplied mainly by the ductus. An increase in the arterial partial pressure of oxygen (PO2) was seen in groups 1 and 2. Six patients from group 1 and two from group 2 developed heart failure; cortical hyperostosis of long bones was seen in three patients from group 1 and three from group 2; one from group 1 had refractory diarrhea. Other side effects seen at the beginning improved as the rate of infusion diminished. In group 3, the patient with complex coarctation had a decrease in blood pressure in the arms, an increase in pressure in the legs and restoration of renal function; in the patient with no ventricular septal defect, heart failure worsened during therapy. Histologic changes seen in three ductus were attributed to the closing process. When delaying surgery in selected ill infants with heart defects is deemed advantageous, long-term infusions of prostaglandin E1 are feasible.

Use of prostaglandin E2 in management of transposition of great arteries before balloon atrial septostomy

Fifteen infants with transposition of the great arteries and severe hypoxaemia were treated with prostaglandin E2 infusions before atrial septostomy was performed. Twelve patients had simple transposition and three had small ventricular septal defects. The infusion resulted in a highly significant increase of PaO2 from 22 +/- 3 mmHg to 37 +/- 5 mmHg within one to two hours. Only one patient did not respond to treatment. PaO2 remained constantly above 30 mmHg throughout prostaglandin infusion. After balloon atrial septostomy prostaglandin administration was stopped. Only two patients required reinfusion within 24 hours after septostomy because of a decrease of PaO2 below 25 mmHg. At angiocardiography before balloon septostomy the ductus was of aortic size in eight, and of about half the aortic diameter in six patients. In one infant the ductus was closed. One infant had to undergo early ductus ligation because of heart failure. In 10 of 11 infants who have undergone total correction the initially large ductus had closed spontaneously.

Evaluation of alprostadil (prostaglandin E1) in the management of congenital heart disease in infancy

Prostaglandins have been shown to relax the smooth muscle of the ductus arteriosus in the fetus in utero. This physiologic action has been applied to the management of newborn infants with certain types of congenital malformations. Infants with lesions producing right ventricular outflow obstruction have a compromised pulmonary circulation and require a patent ductus arteriosus for adequate pulmonary blood flow. Infusion of alprostadil (PGE1) dilates the ductus, increases pulmonary blood flow, and thereby improves oxygenation. Likewise, infants with aortic arch interruption or coarctation of the aorta are dependent on an open ductus to maintain lower body perfusion. Alprostadil is of great benefit in this situation as well. The side effects of alprostadil include peripheral vasodilation and hypotension and, most importantly, apnea. Hyperpyrexia and jitteriness may also occur. Side effects occur only in about 20% of infants and usually are easily reversed. The benefits therefore greatly outweigh the risks, but careful monitoring is essential.

[Prostaglandin E-2 in cyanotic heart defects in newborn (author's transl)]

14 newborn babies with pulmonary atresia (4) or transposition (TGA) (8) received Prostaglandin E2 infusions to correct their hypoxia and acidosis. 12 out of 10 patients were infused before diagnostic catheterization and creation of an interatrial communication by balloon atrioseptostomy. Infusions were stopped after septostomy in patients with transposition and prolonged up to palliative surgery in pulmonary atresia patients. All patients whose treatment was started in the first four days of life had a highly significant rise of their paO2. The only non-responder was a patient with TGA after septostomy who was a non-mixer and seven days old. Typical side effects of PGE2 were seen in two-thirds of all cases. One patient with TGA needed ductus ligation after PGE2 withdrawal because of congestive heart failure due to prolonged ductus patency. We conclude that prostaglandins of the E-type can safely be used in all cases of TGA with hypoxia and acidosis who are awaiting catheterization. Even when an adequate interatrial communication does not yet exist PGE2 seems to bring good oxygenation by opening the ductus. Used up to a maximum of 32 hours infusion-time heart failure was not seen.

[Prostaglandins E1 in the treatment of neonatal cardiopathies related to ductus arteriosus. 19 cases]

A series of 19 neonates with persistent ductus arteriosus associated with right heart pathology such as pulmonary or tricuspid atresia (13 cases), left heart and aortic arch pathology (3 cases) and simple transposition of the great arteries (3 cases) is presented. The efficacity of an infusion of prostaglandins (PG E1, 0,05 /kg/min) in improving the clinical condition of the patients before surgery was confirmed. A rapid improvement in the blood gases (02 saturation) was obtained in right heart pathology. In children with the second group, the efficacity of PG depended mainly on the clinical state and degree of peripheral hypoperfusion before therapy. For this reason, the infusion should be instituted as soon as possible, even before confirmation of the diagnosis. PG were used in a newborn with simple transposition of the great arteries in association with balloon septostomy in order to obtain an earlier result with the latter procedure. The incidence of side effects was higher in this than in other reported series. The protocol of infusion and its surveillance are discussed. Prolonged infusion of PG is not advised as it was probably responsible for oedematous infiltration of the vessel wall in one child.

Use of prostaglandin E1 in infants with d-transposition of the great arteries and intact ventricular septum

Prostaglandin E1 was used to treat five infants with d-transposition of the great arteries and intact ventricular septum who had persistent severe hypoxemia after the creation of an interatrial communication. Three infants had a dramatic improvement in systemic arterial oxygen saturation associated with dilation of the ductus arteriosus; in two of the three cases urgent surgery was avoided. Two infants had no clinical evidence of increased ductal shunting and no improvement in oxygen saturation. A trial of prostaglandin E1 is recommended for treatment of severe hypoxemia in infants with d-transposition of the great arteries with intact ventricular septum if the presence of a large atrial septal defect is established.

Pharmacologic dilatation of the ductus arteriosus with prostaglandin E1 in infants with congenital heart disease

Prostaglandin E1 (PGE1) has been used for successful palliation in nine infants with congenital heart disease. Seven patients had pulmonary atresia with ductal-dependent pulmonary blood flow. In this group, systemic O2 saturation increased from a mean value of 45% to 79% after infusion of PGE1, and surgical palliation was successfully done with the infants in stable condition, without hypoxemia or acidemia. An additional patient with coarctation of the aorta had marked ductal dilatation after PGE1 infusion as indicated by umbilical artery pulse pressure. The coarctation was repaired, with the infant in stable condition. The final patient had neonatal tricuspid insufficiency with right to left atrial shunting. Systemic O2 saturation was improved after PGE1 infusion, though the ductus was closed. The improved oxygenation was believed to be due to a reduction in pulmonary vascular resistance by PGE1. Prostaglandin E1 provides a powerful new tool for palliation of critical congenital heart disease in infants whose ductal constriction can markedly influence their clinical status.

Palliation of cyanotic congenital heart disease in infancy with E-type prostaglandins

Prostaglandin-E (PGE) infusions have been used in an attempt to increase ductal patency in 11 infants aged one to 99 days with cyanotic heart disease. PGE1 was used in nine infants and PGE2 in two. Five patients had pulmonary atresia, four extreme pulmonary stenosis, one Ebstein's anomaly and one simple transposition of the great arteries. All but the oldest infant showed a satisfactory increase in oxygen saturation (average 36%) attributed to dilatation of the ductus. The failure in one infant may have been due largely to hypoplasia of the left pulmonary artery. The only important side effect was apnea in one infant receiving PGE2. The efficacy of this form of treatment is confirmed in infants dependent on ductal patency for survival. PGE is an important asset in saving the lives of neonates requiring an aorticopulmonary shunt operation. The recommended starting dose is 0.1 mug/kg/min of PGE1 given by constant infusion.