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Engele LJ, González-Fernández V, Mulder BJM, Ruperti-Repilado FJ, Abia RL, van der Vlist K, Buendía F, Rueda J, Gabriel H, Schrutka L, Bouchardy J, Schwerzmann M, Possner M, Greutmann M, Gallego P, Ladouceur M, Jongbloed MRM, Tobler D, Dos L, Bouma BJ. Decreased clinical performance in TGA-ASO patients after RVOT interventions; a multicenter European collaboration. Int J Cardiol 2024; 407:132027. [PMID: 38583591 DOI: 10.1016/j.ijcard.2024.132027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Revised: 03/13/2024] [Accepted: 04/04/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND In patients with transposition of the great arteries and an arterial switch operation (TGA-ASO) right ventricular outflow tract (RVOT) obstruction is a common complication requiring one or more RVOT interventions. OBJECTIVES We aimed to assess cardiopulmonary exercise capacity and right ventricular function in patients stratified for type of RVOT intervention. METHODS TGA-ASO patients (≥16 years) were stratified by type of RVOT intervention. The following outcome parameters were included: predicted (%) peak oxygen uptake (peak VO2), tricuspid annular plane systolic excursion (TAPSE), tricuspid Lateral Annular Systolic Velocity (TV S'), right ventricle (RV)-arterial coupling (defined as TAPSE/RV systolic pressure ratio), and N-terminal proBNP (NT-proBNP). RESULTS 447 TGA patients with a mean age of 25.0 (interquartile range (IQR) 21-29) years were included. Patients without previous RVOT intervention (n = 338, 76%) had a significantly higher predicted peak VO2 (78.0 ± 17.4%) compared to patients with single approach catheter-based RVOT intervention (73.7 ± 12.7%), single approach surgical RVOT intervention (73.8 ± 28.1%), and patients with multiple approach RVOT intervention (66.2 ± 14.0%, p = 0.021). RV-arterial coupling was found to be significantly lower in patients with prior catheter-based and/or surgical RVOT intervention compared to patients without any RVOT intervention (p = 0.029). CONCLUSIONS TGA patients after a successful arterial switch repair have a decreased exercise capacity. A considerable amount of TGA patients with either catheter or surgical RVOT intervention perform significantly worse compared to patients without RVOT interventions.
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Affiliation(s)
- Leo J Engele
- CAHAL, Center for Congenital Heart Disease Amsterdam-Leiden, location Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Víctor González-Fernández
- Hospital Universitari Vall d'Hebron, CIBERCV and European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart (ERN GUARD Heart), Barcelona, Spain
| | - Barbara J M Mulder
- CAHAL, Center for Congenital Heart Disease Amsterdam-Leiden, location Amsterdam University Medical Center, Amsterdam, the Netherlands
| | | | - Raquel Ladrón Abia
- Hospital Universitario Virgen del Rocio and European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart (ERN GUARD Heart), Seville, Spain
| | - Kim van der Vlist
- CAHAL, Center for Congenital Heart Disease Amsterdam-Leiden, location Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Francisco Buendía
- Hospital Universitari i Politècnic La Fe and CIBERCV, València, Spain
| | - Joaquin Rueda
- Hospital Universitari i Politècnic La Fe and CIBERCV, València, Spain
| | | | | | - Judith Bouchardy
- University Hospital Lausanne, Switzerland; University Hospital of Geneva, Switzerland
| | - Markus Schwerzmann
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Mathias Possner
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | - Pastora Gallego
- Hospital Universitario Virgen del Rocio and European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart (ERN GUARD Heart), Seville, Spain
| | - Magalie Ladouceur
- Hôpital Européen Georges Pompidou, AP-HP, Paris Cité University, Centre de Recherche Cardiovasculaire de Paris, INSERM U970, Paris, France
| | - Monique R M Jongbloed
- CAHAL, Center for Congenital Heart Disease Amsterdam-Leiden, location Leiden University Medical Center, Department of Cardiology and Anatomy & Embryology, Leiden, the Netherlands
| | - Daniel Tobler
- University Hospital, University of Basel, Switzerland
| | - Laura Dos
- Hospital Universitari Vall d'Hebron, CIBERCV and European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart (ERN GUARD Heart), Barcelona, Spain
| | - Berto J Bouma
- CAHAL, Center for Congenital Heart Disease Amsterdam-Leiden, location Amsterdam University Medical Center, Amsterdam, the Netherlands.
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2
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Bokma JP, Geva T, Sleeper LA, Lee JH, Lu M, Sompolinsky T, Babu-Narayan SV, Wald RM, Mulder BJM, Valente AM. Improved Outcomes After Pulmonary Valve Replacement in Repaired Tetralogy of Fallot. J Am Coll Cardiol 2023; 81:2075-2085. [PMID: 37225360 DOI: 10.1016/j.jacc.2023.02.052] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 02/22/2023] [Accepted: 02/27/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND The impact of pulmonary valve replacement (PVR) on major adverse clinical outcomes in patients with repaired tetralogy of Fallot (rTOF) is unknown. OBJECTIVES The purpose of this study was to determine whether PVR is associated with improved survival and freedom from sustained ventricular tachycardia (VT) in rTOF. METHODS A PVR propensity score was created to adjust for baseline differences between PVR and non-PVR patients enrolled in INDICATOR (International Multicenter TOF Registry). The primary outcome was time to the earliest occurrence of death or sustained VT. PVR and non-PVR patients were matched 1:1 on PVR propensity score (matched cohort) and in the full cohort, modeling was performed with propensity score as a covariate adjustment. RESULTS Among 1,143 patients with rTOF (age 27 ± 14 years, 47% PVR, follow-up 8.3 ± 5.2 years), the primary outcome occurred in 82. The adjusted HR for the primary outcome for PVR vs no-PVR (matched cohort n = 524) was 0.41 (95% CI: 0.21-0.81; multivariable model P = 0.010). Full cohort analysis revealed similar results. Subgroup analysis suggested beneficial effects in patients with advanced right ventricular (RV) dilatation (interaction P = 0.046; full cohort). In patients with RV end-systolic volume index >80 mL/m2, PVR was associated with a lower primary outcome risk (HR: 0.32; 95% CI: 0.16-0.62; P < 0.001). There was no association between PVR and the primary outcome in patients with RV end-systolic volume index ≤80 mL/m2 (HR: 0.86; 95% CI: 0.38-1.92; P = 0.70). CONCLUSIONS Compared with rTOF patients who did not receive PVR, propensity score-matched individuals receiving PVR had lower risk of a composite endpoint of death or sustained VT.
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Affiliation(s)
- Jouke P Bokma
- Department of Cardiology, Amsterdam University Medical Center Amsterdam, Academic Medical Center, Amsterdam, the Netherlands
| | - Tal Geva
- Department of Cardiology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Lynn A Sleeper
- Department of Cardiology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Ji Hae Lee
- Department of Cardiology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Minmin Lu
- Department of Cardiology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Tehila Sompolinsky
- Department of Cardiology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Sonya V Babu-Narayan
- Department of Adult Congenital Heart Disease, Royal Brompton Hospital, London, United Kingdom
| | - Rachel M Wald
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, Toronto, Ontario, Canada
| | - Barbara J M Mulder
- Department of Cardiology, Amsterdam University Medical Center Amsterdam, Academic Medical Center, Amsterdam, the Netherlands
| | - Anne Marie Valente
- Department of Cardiology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA.
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3
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Engele LJ, van der Palen RLF, Egorova AD, Bartelings MM, Wisse LJ, Glashan CA, Kiès P, Vliegen HW, Hazekamp MG, Mulder BJM, Ruiter MCD, Bouma BJ, Jongbloed MRM. Cardiac Fibrosis and Innervation State in Uncorrected and Corrected Transposition of the Great Arteries: A Postmortem Histological Analysis and Systematic Review. J Cardiovasc Dev Dis 2023; 10:jcdd10040180. [PMID: 37103059 PMCID: PMC10143292 DOI: 10.3390/jcdd10040180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 03/27/2023] [Accepted: 03/28/2023] [Indexed: 04/28/2023] Open
Abstract
In the transposition of the great arteries (TGA), alterations in hemodynamics and oxygen saturation could result in fibrotic remodeling, but histological studies are scarce. We aimed to investigate fibrosis and innervation state in the full spectrum of TGA and correlate findings to clinical literature. Twenty-two human postmortem TGA hearts, including TGA without surgical correction (n = 8), after Mustard/Senning (n = 6), and arterial switch operation (ASO, n = 8), were studied. In newborn uncorrected TGA specimens (1 day-1.5 months), significantly more interstitial fibrosis (8.6% ± 3.0) was observed compared to control hearts (5.4% ± 0.8, p = 0.016). After the Mustard/Senning procedure, the amount of interstitial fibrosis was significantly higher (19.8% ± 5.1, p = 0.002), remarkably more in the subpulmonary left ventricle (LV) than in the systemic right ventricle (RV). In TGA-ASO, an increased amount of fibrosis was found in one adult specimen. The amount of innervation was diminished from 3 days after ASO (0.034% ± 0.017) compared to uncorrected TGA (0.082% ± 0.026, p = 0.036). In conclusion, in these selected postmortem TGA specimens, diffuse interstitial fibrosis was already present in newborn hearts, suggesting that altered oxygen saturations may already impact myocardial structure in the fetal phase. TGA-Mustard/Senning specimens showed diffuse myocardial fibrosis in the systemic RV and, remarkably, in the LV. Post-ASO, decreased uptake of nerve staining was observed, implicating (partial) myocardial denervation after ASO.
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Affiliation(s)
- Leo J Engele
- Center for Congenital Heart Disease Amsterdam-Leiden (CAHAL), Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Heart Centre, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Netherlands Heart Institute, 3511 EP Utrecht, The Netherlands
| | - Roel L F van der Palen
- Center for Congenital Heart Disease Amsterdam-Leiden (CAHAL), Department of Pediatric Cardiology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - Anastasia D Egorova
- Center for Congenital Heart Disease Amsterdam-Leiden (CAHAL), Department of Cardiology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - Margot M Bartelings
- Center for Congenital Heart Disease Amsterdam-Leiden (CAHAL), Department of Anatomy and Embryology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - Lambertus J Wisse
- Center for Congenital Heart Disease Amsterdam-Leiden (CAHAL), Department of Anatomy and Embryology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - Claire A Glashan
- Center for Congenital Heart Disease Amsterdam-Leiden (CAHAL), Department of Cardiology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - Philippine Kiès
- Center for Congenital Heart Disease Amsterdam-Leiden (CAHAL), Department of Cardiology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - Hubert W Vliegen
- Center for Congenital Heart Disease Amsterdam-Leiden (CAHAL), Department of Cardiology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - Mark G Hazekamp
- Center for Congenital Heart Disease Amsterdam-Leiden (CAHAL), Department of Cardiothoracic Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - Barbara J M Mulder
- Center for Congenital Heart Disease Amsterdam-Leiden (CAHAL), Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Heart Centre, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Marco C De Ruiter
- Center for Congenital Heart Disease Amsterdam-Leiden (CAHAL), Department of Anatomy and Embryology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - Berto J Bouma
- Center for Congenital Heart Disease Amsterdam-Leiden (CAHAL), Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Heart Centre, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Monique R M Jongbloed
- Center for Congenital Heart Disease Amsterdam-Leiden (CAHAL), Department of Cardiology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
- Center for Congenital Heart Disease Amsterdam-Leiden (CAHAL), Department of Anatomy and Embryology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
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4
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Woudstra OI, Skoric-Milosavljevic D, Mulder BJM, Meijboom FJ, Post MC, Jongbloed MRM, van Dijk APJ, van Melle JP, Konings TC, Postma AV, Bezzina CR, Bouma BJ, Tanck MWT. Common genetic variants improve risk stratification after the atrial switch operation for transposition of the great arteries. Int J Cardiol 2023; 371:153-159. [PMID: 36108765 DOI: 10.1016/j.ijcard.2022.09.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 09/03/2022] [Accepted: 09/08/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Clinical factors are used to estimate late complication risk in adults after atrial switch operation (AtrSO) for transposition of the great arteries (TGA), but heterogeneity in clinical course remains. We studied whether common genetic variants are associated with outcome and add value to a clinical risk score in TGA-AtrSO patients. METHODS AND RESULTS This multicenter study followed 133 TGA-AtrSO patients (aged 28 [IQR 24-35] years) for 13 (IQR 9-16) years and examined the association of genome-wide single-nucleotide polymorphisms (SNPs) with a composite endpoint of symptomatic ventricular arrhythmia, heart failure hospitalization, ventricular assist device implantation, heart transplantation, or mortality. Thirty-two patients (24%) reached the endpoint. The genome-wide association study yielded one genome-wide significant (p < 1 × 10-8) locus and 18 suggestive loci (p < 1 × 10-5). A genetic risk score constructed on the basis of independent SNPs with p < 1 × 10-5 was associated with outcome after correction for the clinical risk score (HR = 1.26/point increase [95%CI 1.17-1.35]). Risk stratification improved with a combined risk score (clinical score + genetic score) compared to the clinical score alone (p = 2 × 10-16, C-statistic 0.95 vs 0.85). In 51 patients with a clinical intermediate (5-20%) 5-year risk of events, the combined score reclassified 32 patients to low (<5%) and 5 to high (>20%) risk. Stratified by the combined score, observed 5-year event-free survival was 100%, 79% and 31% for low, intermediate, and high-risk patients, respectively. CONCLUSIONS Common genetic variants may explain some variation in the clinical course in TGA-AtrSO and improve risk stratification over clinical factors alone, especially in patients at intermediate clinical risk. These findings support the hypothesis that including genetic variants in risk assessment may be beneficial.
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Affiliation(s)
- Odilia I Woudstra
- Heart Center; Department of Clinical Cardiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Cardiovascular Sciences, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands.
| | - Doris Skoric-Milosavljevic
- Heart Center; Department of Experimental Cardiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Cardiovascular Sciences, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - Barbara J M Mulder
- Heart Center; Department of Clinical Cardiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Cardiovascular Sciences, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - Folkert J Meijboom
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands
| | - Marco C Post
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands; Department of Cardiology, St. Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, the Netherlands
| | - Monique R M Jongbloed
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, the Netherlands; Department of Anatomy & Embryology, Leiden University Medical Center, Einthovenweg 20, 2333 ZC Leiden, the Netherlands
| | - Arie P J van Dijk
- Department of Cardiology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, the Netherlands
| | - Joost P van Melle
- Department of Cardiology, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, the Netherlands
| | - Thelma C Konings
- Heart Center; Department of Clinical Cardiology, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, De Boelelaan 1117, 1081 HV Amsterdam, the Netherlands
| | - Alex V Postma
- Department of Clinical Genetics, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands; Department of Medical Biology, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - Connie R Bezzina
- Heart Center; Department of Experimental Cardiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Cardiovascular Sciences, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - Berto J Bouma
- Heart Center; Department of Clinical Cardiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Cardiovascular Sciences, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - Michael W T Tanck
- Department of Epidemiology and Data Science, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
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van Andel MM, Graaumans K, Groenink M, Zwinderman AH, van Kimmenade RRJ, Scholte AJHA, van den Berg MP, Dickinson MG, Knoop H, Bosch JA, Mulder BJM, de Waard V, Bennebroek Evertsz' F. A cross-sectional study on fatigue, anxiety, and symptoms of depression and their relation with medical status in adult patients with Marfan syndrome. Psychological consequences in Marfan syndrome. Clin Genet 2022; 102:404-413. [PMID: 36059006 PMCID: PMC9828141 DOI: 10.1111/cge.14211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 08/07/2022] [Accepted: 08/15/2022] [Indexed: 01/12/2023]
Abstract
Marfan syndrome (MFS) is a connective tissue disorder affecting the cardiovascular, ocular, and skeletal system, which may be accompanied by psychological features. This study aimed to determine the prevalence of fatigue, anxiety, and symptoms of depression in MFS patients, and to assess the degree to which sociodemographic and clinical variables are associated with fatigue and psychological aspects. The prevalence of fatigue, anxiety, and symptoms of depression were assessed in two cohorts of MFS patients and compared with healthy controls. The checklist individual strength (CIS), and hospital anxiety and depression scale (HADS) questionnaires were utilized. Medical status was assessed (family history of MFS, aortic root dilatation >40 mm, previous aortic surgery, aortic dissection, chronic pain, skeletal involvement, and scoliosis). Severe fatigue was experienced by 37% of the total MFS cohort (n = 155). MFS patients scored significantly higher on the CIS questionnaire, concerning severe fatigue, as compared with the general Dutch population (p < 0.0001). There were no differences in HADS anxiety or depression scores. In older MFS patients, with a more severe cardiovascular phenotype, chronic pain, and a higher unemployment rate, significantly more symptoms of depression were observed, when compared with the general population (p = 0.027) or compared with younger MFS patients (p = 0.026). Multivariate analysis, showed that anxiety was associated with chronic pain (p = 0.022) and symptoms of depression with unemployment (p = 0.024). MFS patients report significantly more severe fatigue as compared with the general population. Since the cause of fatigue is unclear, more research may be needed. Psychological intervention, for example, cognitive behavioral therapy, may contribute to a reduction in psychological symptoms.
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Affiliation(s)
| | - Kim Graaumans
- Department of Medical PsychologyAmsterdam UMC, University of AmsterdamAmsterdamThe Netherlands
| | - Maarten Groenink
- Department of CardiologyAmsterdam UMCAmsterdamThe Netherlands,Department of RadiologyAmsterdam UMCAmsterdamThe Netherlands
| | - Aeilko H. Zwinderman
- Department of Clinical Epidemiology, Biostatistics and BioinformaticsAmsterdam UMCAmsterdamThe Netherlands
| | | | | | | | - Michael G. Dickinson
- Department of CardiologyUniversity Medical Center GroningenGroningenThe Netherlands
| | - Hans Knoop
- Department of Medical PsychologyAmsterdam UMC, University of AmsterdamAmsterdamThe Netherlands
| | - Jos A. Bosch
- Department of Medical PsychologyAmsterdam UMC, University of AmsterdamAmsterdamThe Netherlands
| | | | - Vivian de Waard
- Department of Medical Biochemistry, Amsterdam UMC, Amsterdam Cardiovascular SciencesUniversity of AmsterdamAmsterdamThe Netherlands
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Heidendael JF, Engele LJ, Bouma BJ, Dipchand AI, Thorne SA, McCrindle BW, Mulder BJM. Coagulation and Anticoagulation in Fontan Patients. Can J Cardiol 2022; 38:1024-1035. [PMID: 35122939 DOI: 10.1016/j.cjca.2022.01.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [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: 11/01/2021] [Revised: 01/17/2022] [Accepted: 01/27/2022] [Indexed: 01/22/2023] Open
Abstract
Patients with a Fontan circulation for single-ventricle physiology are at increased risk of developing thromboembolic events. Thromboembolic events can lead to failure of the Fontan circulation, chronic sequelae in case of stroke, and early mortality. Controversies exist regarding the substrates, risk factors, and optimal detection methods for thromboembolic events. Despite the major clinical implications, there is currently no consensus regarding the optimal antithrombotic therapy to prevent or treat thromboembolic events after the Fontan procedure. In this review we aimed to untangle the available literature regarding antithrombotic prophylaxis and treatment for pediatric and adult Fontan patients. A decision-tree algorithm for thromboprophylaxis in Fontan patients is proposed. Additionally, the current state of knowledge is reviewed with respect to the epidemiology, pathophysiology, and detection of thromboembolic events in Fontan patients, and important evidence gaps are highlighted.
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Affiliation(s)
- Josephine F Heidendael
- Department of Cardiology, Amsterdam University Medical Center, Amsterdam, The Netherlands.
| | - Leo J Engele
- Department of Cardiology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Berto J Bouma
- Department of Cardiology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Anne I Dipchand
- Department of Pediatrics, Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Sara A Thorne
- Department of Cardiology, Peter Munk Cardiac Center, University Health Network, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Brian W McCrindle
- Department of Pediatrics, Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Barbara J M Mulder
- Department of Cardiology, Amsterdam University Medical Center, Amsterdam, The Netherlands
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7
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Meijs TA, Muller SA, Minderhoud SCS, de Winter RJ, Mulder BJM, van Melle JP, Hoendermis ES, van Dijk APJ, Zuithoff NPA, Krings GJ, Doevendans PA, Spiering W, Witsenburg M, Roos-Hesselink JW, van den Bosch AE, Bouma BJ, Voskuil M. Hypertensive response to exercise in adult patients with repaired aortic coarctation. Heart 2022; 108:1121-1128. [PMID: 34987066 DOI: 10.1136/heartjnl-2021-320333] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 11/30/2021] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVE The clinical and prognostic implications of a hypertensive response to exercise after repair of coarctation of the aorta (CoA) remain controversial. We aimed to determine the prevalence of a hypertensive response to exercise, identify factors associated with peak exercise systolic blood pressure (SBP) and explore the association of peak exercise SBP with resting blood pressure and cardiovascular events during follow-up. METHODS From the Dutch national CONgenital CORvitia (CONCOR) registry, adults with repaired CoA who underwent exercise stress testing were included. A hypertensive response to exercise was defined as a peak exercise SBP ≥210 mm Hg in men and ≥190 mm Hg in women. Cardiovascular events consisted of coronary artery disease, stroke, aortic complications and cardiovascular death. RESULTS Of the original cohort of 920 adults with repaired CoA, 675 patients (median age 24 years (range 16-72 years)) underwent exercise stress testing. Of these, 299 patients (44%) had a hypertensive response to exercise. Mean follow-up duration was 10.1 years. Male sex, absence of a bicuspid aortic valve and elevated resting SBP were independently associated with increased peak exercise SBP. Peak exercise SBP was positively predictive of office SBP (β=0.11, p<0.001) and 24-hour SBP (β=0.05, p=0.03) at follow-up, despite correction for baseline SBP. During follow-up, 100 patients (15%) developed at least 1 cardiovascular event. Peak exercise SBP was not significantly associated with the occurrence of cardiovascular events (HR 0.994 (95% CI 0.987 to 1.001), p=0.11). CONCLUSIONS A hypertensive response to exercise was present in nearly half of the patients in this large, prospective cohort of adults with repaired CoA. Risk factors for increased peak exercise SBP were male sex, absence of a bicuspid aortic valve and elevated resting SBP. Increased peak exercise SBP independently predicted hypertension at follow-up. These results support close follow-up of patients with a hypertensive response to exercise to ensure timely diagnosis and treatment of future hypertension.
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Affiliation(s)
- Timion A Meijs
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands .,Department of Cardiology, Amsterdam UMC, location Academic Medical Center, Amsterdam, The Netherlands
| | - Steven A Muller
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | | | - Robbert J de Winter
- Department of Cardiology, Amsterdam UMC, location Academic Medical Center, Amsterdam, The Netherlands
| | - Barbara J M Mulder
- Department of Cardiology, Amsterdam UMC, location Academic Medical Center, Amsterdam, The Netherlands
| | - Joost P van Melle
- Department of Cardiology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Elke S Hoendermis
- Department of Cardiology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Arie P J van Dijk
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Nicolaas P A Zuithoff
- Department of Epidemiology and Biostatistics, Julius Center for Health Sciences and Primary Care, Utrecht, The Netherlands
| | - Gregor J Krings
- Department of Pediatric Cardiology, Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | - Pieter A Doevendans
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands.,Netherlands Heart Institute, Utrecht, The Netherlands.,Central Military Hospital, Utrecht, The Netherlands
| | - Wilko Spiering
- Department of Vascular Medicine, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Maarten Witsenburg
- Department of Cardiology, Erasmus Medical Centre, Rotterdam, The Netherlands
| | | | | | - Berto J Bouma
- Department of Cardiology, Amsterdam UMC, location Academic Medical Center, Amsterdam, The Netherlands
| | - Michiel Voskuil
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
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8
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Arvanitaki A, Gatzoulis MA, Opotowsky AR, Khairy P, Dimopoulos K, Diller GP, Giannakoulas G, Brida M, Griselli M, Grünig E, Montanaro C, Alexander PD, Ameduri R, Mulder BJM, D'Alto M. Eisenmenger Syndrome: JACC State-of-the-Art Review. J Am Coll Cardiol 2022; 79:1183-1198. [PMID: 35331414 DOI: 10.1016/j.jacc.2022.01.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 01/10/2022] [Accepted: 01/18/2022] [Indexed: 12/12/2022]
Abstract
Although major breakthroughs in the field of pediatric cardiology, cardiac surgery, intervention, and overall care improved the outlook of congenital heart disease, Eisenmenger syndrome (ES) is still encountered and remains a complex clinical entity with multisystem involvement, including secondary erythrocytosis, increased thrombotic and bleeding diathesis, high arrhythmogenic risk, progressive heart failure, and premature death. Clearly, care for ES is best delivered in multidisciplinary expert centers. In this review, we discuss the considerable recent progress in understanding the complex pathophysiology of ES, means of prognostication, and improvement in clinical outcomes achieved with pulmonary arterial hypertension-targeted therapies. Additionally, we delineate areas of uncertainty in various aspects of care, discuss gaps in current evidence, and review current status in less privileged countries and propose initiatives to reduce disease burden. Finally, we propose the application of emerging technologies to enhance the delivery and quality of health care related to ES and beyond.
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Affiliation(s)
- Alexandra Arvanitaki
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton and Harefield Hospitals, Guy's and St Thomas's NHS Foundation Trust, Imperial College, London, United Kingdom; First Department of Cardiology, AHEPA University Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece; Department of Cardiology III - Adult Congenital and Valvular Heart Disease, University Hospital Muenster, Albert-Schweitzer-Campus 1, Muenster, Germany
| | - Michael A Gatzoulis
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton and Harefield Hospitals, Guy's and St Thomas's NHS Foundation Trust, Imperial College, London, United Kingdom.
| | - Alexander R Opotowsky
- The Cincinnati Adult Congenital Heart Disease Program, Heart Institute, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Paul Khairy
- Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Konstantinos Dimopoulos
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton and Harefield Hospitals, Guy's and St Thomas's NHS Foundation Trust, Imperial College, London, United Kingdom
| | - Gerhard-Paul Diller
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton and Harefield Hospitals, Guy's and St Thomas's NHS Foundation Trust, Imperial College, London, United Kingdom; Department of Cardiology III - Adult Congenital and Valvular Heart Disease, University Hospital Muenster, Albert-Schweitzer-Campus 1, Muenster, Germany
| | - George Giannakoulas
- First Department of Cardiology, AHEPA University Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Margarita Brida
- Division of Adult Congenital Heart Disease, Department of Cardiovascular Medicine, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Massimo Griselli
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton and Harefield Hospitals, Guy's and St Thomas's NHS Foundation Trust, Imperial College, London, United Kingdom; Pediatric Cardiac Surgery and Transplantation, University of Minnesota, Minneapolis, Minnesota, USA
| | - Ekkehard Grünig
- Centre for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, and German Center of Lung Research (DZL), TLRC Heidelberg, Heidelberg, Germany
| | - Claudia Montanaro
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton and Harefield Hospitals, Guy's and St Thomas's NHS Foundation Trust, Imperial College, London, United Kingdom
| | - Peter David Alexander
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton and Harefield Hospitals, Guy's and St Thomas's NHS Foundation Trust, Imperial College, London, United Kingdom
| | - Rebecca Ameduri
- Pediatric Cardiac Surgery and Transplantation, University of Minnesota, Minneapolis, Minnesota, USA
| | - Barbara J M Mulder
- Department of Cardiology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Michele D'Alto
- Department of Cardiology, Monaldi Hospital - "L. Vanvitelli" University, Naples, Italy.
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9
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Majeed A, Geva T, Sleeper LA, Graf JA, Lu M, Babu-Narayan SV, Wald RM, Mulder BJM, Valente AM. Cardiac MRI predictors of good long-term outcomes in patients with repaired TOF. Am Heart J 2022; 245:70-77. [PMID: 34875276 DOI: 10.1016/j.ahj.2021.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 10/20/2021] [Accepted: 11/18/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Risk stratification in patients with repaired tetralogy of Fallot (rTOF) have focused on poor clinical outcomes while predictors of a benign clinical course have not been characterized. OBJECTIVE The goal of this study was to Identify cardiac magnetic resonance (CMR) markers of a good clinical course late after TOF repair. METHODS Clinical and CMR data from the International Multicenter TOF Registry (INDICATOR) were analyzed. The primary outcome was time to the earliest occurrence of a composite of death, aborted sudden death, and sustained ventricular tachycardia (VT). The secondary outcome was time to the earliest occurrence of atrial arrhythmia, nonsustained VT, and NYHA class >II. Multinomial regression was used to identify predictors of the 3-category outcome: (a) good outcome, defined as freedom from the primary AND secondary outcomes at age 50 years; (b) poor outcome, defined as presence of the primary outcome before age 50 years; and (c) intermediate outcome, defined as not fulfilling criteria for good or poor outcomes. RESULTS Among 1088 eligible patients, 96 had good outcome, 60 experienced poor outcome, and 932 had intermediate outcome. Patients were age 25.8±10.8 years at the time of the index CMR. Median follow-up was 5.8 years (IQR 3.0, 9.9) after CMR in event-free patients. By univariate analysis, smaller right ventricular (RV) end-systolic and end-diastolic volume index, smaller left ventricular end-systolic volume index, higher right and left ventricular ejection fraction, lower right and left ventricular mass index, and lower left ventricular mass/volume ratio were associated with good outcome. Multivariable modeling identified higher RV ejection fraction (OR 2.38 per 10% increase, P = .002) and lower RV mass index (OR 1.72, per 10 g/m2 decrease, P = .002) as independently associated with good outcome after adjusting for age at CMR. Classification and regression tree analysis identified important thresholds associated with good outcome that were specific to patients age ≥37 years at the time of CMR; these were RV ejection fraction ≥42% and RV mass index <39 g/m2. CONCLUSIONS Adults with rTOF and no more than mild RV dysfunction combined with no significant RV hypertrophy are likely to be free from serious adverse clinical events into their sixth decade of life and may require less frequent cardiac testing.
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Affiliation(s)
- Amara Majeed
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA.
| | - Tal Geva
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Lynn A Sleeper
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Julia A Graf
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Minmin Lu
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Sonya V Babu-Narayan
- Department of Adult Congenital Heart Disease, Royal Brompton and Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust London, United Kingdom; and National Heart Lung Institute, Imperial College London, United Kingdom
| | - Rachel M Wald
- University of Toronto, Toronto, ON, Canada; Joint Department of Medical Imaging, University of Toronto, Toronto ON, Canada
| | - Barbara J M Mulder
- Department of Cardiology, Academic Medical Center, Amsterdam, NH, The Netherlands; Academic Medical Center, Amsterdam, NH, The Netherlands
| | - Anne Marie Valente
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA; Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, MA
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10
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van Andel MM, Groenink M, van den Berg MP, Timmermans J, Scholte AJHA, Mulder BJM, Zwinderman AH, de Waard V. Genome-wide methylation patterns in Marfan syndrome. Clin Epigenetics 2021; 13:217. [PMID: 34895303 PMCID: PMC8665617 DOI: 10.1186/s13148-021-01204-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 11/27/2021] [Indexed: 12/29/2022] Open
Abstract
Background Marfan syndrome (MFS) is a connective tissue disorder caused by mutations in the Fibrillin-1 gene (FBN1). Here, we undertook the first epigenome-wide association study (EWAS) in patients with MFS aiming at identifying DNA methylation loci associated with MFS phenotypes that may shed light on the disease process. Methods The Illumina 450 k DNA-methylation array was used on stored peripheral whole-blood samples of 190 patients with MFS originally included in the COMPARE trial. An unbiased genome-wide approach was used, and methylation of CpG-sites across the entire genome was evaluated. Additionally, we investigated CpG-sites across the FBN1-locus (15q21.1) more closely, since this is the gene defective in MFS. Differentially Methylated Positions (DMPs) and Differentially Methylated Regions (DMRs) were identified through regression analysis. Associations between methylation levels and aortic diameters and presence or absence of 21 clinical features of MFS at baseline were analyzed. Moreover, associations between aortic diameter change, and the occurrence of clinical events (death any cause, type-A or -B dissection/rupture, or aortic surgery) and methylation levels were analyzed. Results We identified 28 DMPs that are significantly associated with aortic diameters in patients with MFS. Seven of these DMPs (25%) could be allocated to a gene that was previously associated with cardiovascular diseases (HDAC4, IGF2BP3, CASZ1, SDK1, PCDHGA1, DIO3, PTPRN2). Moreover, we identified seven DMPs that were significantly associated with aortic diameter change and five DMP’s that associated with clinical events. No significant associations at p < 10–8 or p < 10–6 were found with any of the non-cardiovascular phenotypic MFS features. Investigating DMRs, clusters were seen mostly on X- and Y, and chromosome 18–22. The remaining DMRs indicated involvement of a large family of protocadherins on chromosome 5, which were not reported in MFS before. Conclusion This EWAS in patients with MFS has identified a number of methylation loci significantly associated with aortic diameters, aortic dilatation rate and aortic events. Our findings add to the slowly growing literature on the regulation of gene expression in MFS patients. Supplementary Information The online version contains supplementary material available at 10.1186/s13148-021-01204-4.
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Affiliation(s)
- Mitzi M van Andel
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Maarten Groenink
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.,Department of Radiology, Amsterdam UMC, Amsterdam, The Netherlands
| | - Maarten P van den Berg
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Janneke Timmermans
- Department of Cardiology, Radboud University Hospital, Nijmegen, The Netherlands
| | - Arthur J H A Scholte
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Barbara J M Mulder
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Aeilko H Zwinderman
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam UMC, Amsterdam, The Netherlands
| | - Vivian de Waard
- Department of Medical Biochemistry, Amsterdam UMC, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
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11
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Meijs TA, Minderhoud SCS, Muller SA, de Winter RJ, Mulder BJM, van Melle JP, Hoendermis ES, van Dijk APJ, Zuithoff NPA, Krings GJ, Doevendans PA, Witsenburg M, Roos‐Hesselink JW, van den Bosch AE, Bouma BJ, Voskuil M. Cardiovascular Morbidity and Mortality in Adult Patients With Repaired Aortic Coarctation. J Am Heart Assoc 2021; 10:e023199. [PMID: 34755532 PMCID: PMC8751912 DOI: 10.1161/jaha.121.023199] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Background The long-term burden of cardiovascular disease after repair of coarctation of the aorta (CoA) has not been elucidated. We aimed to determine the incidence of and risk factors for cardiovascular events in adult patients with repaired CoA. Additionally, mortality rates were compared between adults with repaired CoA and the general population. Methods and Results Using the Dutch Congenital Corvitia (CONCOR) registry, patients aged ≥16 years with previous surgical or transcatheter CoA repair from 5 tertiary referral centers were included. Cardiovascular events were recorded, comprising coronary artery disease, stroke/transient ischemic attack, aortic complications, arrhythmias, heart failure hospitalizations, endocarditis, and cardiovascular death. In total, 920 patients (median age, 24 years [range 16-74 years]) were included. After a mean follow-up of 9.3±5.1 years, 191 patients (21%) experienced at least 1 cardiovascular event. A total of 270 cardiovascular events occurred, of which aortic complications and arrhythmias were most frequent. Older age at initial CoA repair (hazard ratio [HR], 1.017; 95% CI, 1.000-1.033 [P=0.048]) and elevated left ventricular mass index (HR, 1.009; 95% CI, 1.005-1.013 [P<0.001]) were independently associated with an increased risk of cardiovascular events. The mortality rate was 3.3 times higher than expected based on an age- and sex-matched cohort from the Dutch general population (standardized mortality ratio, 3.3; 95% CI, 2.3-4.4 [P<0.001]). Conclusions This large, prospective cohort of adults with repaired CoA showed a high burden of cardiovascular events, particularly aortic complications and arrhythmias, during long-term follow-up. Older age at initial CoA repair and elevated left ventricular mass index were independent risk factors for the occurrence of cardiovascular events. Mortality was 3.3-fold higher compared with the general population. These results advocate stringent follow-up after CoA repair and emphasize the need for improved preventive strategies.
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Affiliation(s)
- Timion A. Meijs
- Department of CardiologyUniversity Medical Center UtrechtUtrechtThe Netherlands
| | | | - Steven A. Muller
- Department of CardiologyUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Robbert J. de Winter
- Department of CardiologyAmsterdam UMC, Location Academic Medical CenterAmsterdamThe Netherlands
| | - Barbara J. M. Mulder
- Department of CardiologyAmsterdam UMC, Location Academic Medical CenterAmsterdamThe Netherlands
| | - Joost P. van Melle
- Department of CardiologyUniversity Medical Center GroningenGroningenThe Netherlands
| | - Elke S. Hoendermis
- Department of CardiologyUniversity Medical Center GroningenGroningenThe Netherlands
| | - Arie P. J. van Dijk
- Department of CardiologyRadboud University Medical CenterNijmegenThe Netherlands
| | - Nicolaas P. A. Zuithoff
- Department of Epidemiology and BiostatisticsJulius Center for Health Sciences and Primary CareUtrechtThe Netherlands
| | - Gregor J. Krings
- Department of Pediatric CardiologyWilhelmina Children’s HospitalUtrechtThe Netherlands
| | - Pieter A. Doevendans
- Department of CardiologyUniversity Medical Center UtrechtUtrechtThe Netherlands,Department of CardiologyCentral Military HospitalUtrechtThe Netherlands,Netherlands Heart InstituteUtrechtThe Netherlands
| | | | | | | | - Berto J. Bouma
- Department of CardiologyAmsterdam UMC, Location Academic Medical CenterAmsterdamThe Netherlands
| | - Michiel Voskuil
- Department of CardiologyUniversity Medical Center UtrechtUtrechtThe Netherlands
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12
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van Andel MM, de Waard V, Timmermans J, Scholte AJHA, van den Berg MP, Zwinderman AH, Mulder BJM, Groenink M. Aortic distensibility in Marfan syndrome: a potential predictor of aortic events? Open Heart 2021; 8:openhrt-2021-001775. [PMID: 34702778 PMCID: PMC8549677 DOI: 10.1136/openhrt-2021-001775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 09/23/2021] [Indexed: 11/29/2022] Open
Abstract
Objectives Patients with Marfan syndrome (MFS) are prone to develop aortic aneurysms due to fragmentation of elastic fibres, resulting in reduced distensibility of the aorta. Reduced distensibility was previously shown to predict progressive descending aorta dilatation. Here, we investigated longitudinal changes in distensibility, as a potential predictor of aortic events. Methods This retrospective study included all patients with MFS with at least four cardiac magnetic resonance examinations performed between 1996 and 2012. Aortic distensibility was assessed, in the ascending (level 1), proximal descending (level 2) and distal descending (level 3) aorta. Changes in distensibility were studied using linear mixed-effects regression models. Results In total, 35 patients with MFS (age at inclusion 28 (IQR 23–32) years, 54% men) were included. Mean aortic distensibility was already low (between 2.9×10–3/mm Hg/year and 6.4×10–3/mm Hg/year) at all levels at baseline, and significantly decreased over time at levels 2 and 3 (respectively, p=0.012 and p=0.002). The rate of distensibility loss per year (×10-3/mm Hg/year) was 0.01, 0.03 and 0.06×10–3/mm Hg at levels 1, 2 and 3, respectively. At inclusion, men exhibited very low distensibility, whereas women showed moderately reduced distensibility, gradually decreasing with age. Aortic dilatation rate at level 2 was associated with reduced aortic distensibility. However, we could not demonstrate a direct correlation between distensibility and clinical events during a follow-up of 22 years. Conclusion Patients with MFS display reduced aortic distensibility already at an early age, inversely relating to aortic dilatation rate. However, in this selected patient group, distensibility seems less suitable as an individual predictor of aortic events.
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Affiliation(s)
- Mitzi M van Andel
- Cardiology, Amsterdam UMC - Location AMC, Amsterdam, The Netherlands
| | - Vivian de Waard
- Medical Biochemistry, Amsterdam UMC - Locatie AMC, Amsterdam, The Netherlands
| | | | | | | | - Aeilko H Zwinderman
- Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam UMC - Locatie AMC, Amsterdam, The Netherlands
| | | | - Maarten Groenink
- Cardiology, Amsterdam UMC - Location AMC, Amsterdam, The Netherlands .,Radiology, Amsterdam UMC - Location AMC, Amsterdam, The Netherlands
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13
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Woudstra O, Skoric-Milosavljevic D, Post MC, Meijboom FJ, Jongbloed MRM, Van Dijk APJ, Konings TC, Bezzina CR, Mulder BJM, Bouma BJ, Tanck MWT. Common genetic variants improve risk stratification after atrial switch operation for transposition of the great arteries. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.1855] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Current clinical risk scores are able to predict late complication risk in adults after atrial switch operation (AtrSO) for transposition of the great arteries (TGA), but a large heterogeneity in clinical course remains.
Purpose
To study whether common genetic factors are predictive of outcome and provide added value to an existing clinical risk score in TGA-AtrSO patients.
Methods
This multicenter study examined the association of genome-wide single-nucleotide polymorphisms (SNPs) in TGA-AtrSO patients with a combined clinical endpoint: time to symptomatic ventricular arrhythmia, heart failure hospitalization, ventricular assist device implantation, heart transplantation, or mortality. Furthermore, we evaluated whether a polygenic risk score (PRS) constructed of independent single-nucleotide polymorphisms (SNPs) with a p<1x10–5 could be of added value to a recently published clinical risk score (included clinical factors: age >30 years, prior ventricular arrhythmia, age >1 year at repair, ≥moderate right ventricular dysfunction, severe tricuspid regurgitation, and ≥mild left ventricular dysfunction).
Results
We followed 133 patients (age at inclusion 28 [IQR 24–35] years, 59% male) for 13 [IQR 8–16] years. Thirty-two patients (24%) reached the endpoint. The genome-wide association study yielded one locus that reached genome-wide significance (p<1x10–8) and 18 loci marked by 20 SNPs that reached the suggestive threshold (p<1x10–5). The constructed PRS remained an independent predictor after correction for the clinical score (HR=1.21/point increase [95% CI 1.13–1.29], p=3x10–10). While the clinical risk score indicated intermediate (5–20%) 5-year risk of events in 52 patients (39%), the combined risk score (clinical score + PRS) reclassified 35 patients to low (<5%) and 6 to high (>20%) risk. Observed 5-year event-free survival based on the combined score remained 100% for low-risk patients, compared to 23% and 64% in intermediate and high-risk patients, respectively. This resulted in improved risk stratification with the combined risk score vs the clinical risk score alone (p=2x10–16, C-statistic 0.95 vs 0.85).
Conclusions
Genetic factors explain some of the variation in clinical course of TGA-AtrSO patients and improve risk stratification. In the heterogeneous group of patients with a clinical score indicating intermediate risk, the combined model could classify 67% of patients more accurately to <5% or >20% risk. These data argue for more research into the impact of genetics on clinical outcome in adult congenital heart disease.
Funding Acknowledgement
Type of funding sources: Foundation. Main funding source(s): Dutch Heart Foundation Figure 1. Risk stratification of predicted 5-year risk of events based on the clinical model versus the combined model (clinical risk score + polygenic risk score).
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Affiliation(s)
- O Woudstra
- Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands (The)
| | | | - M C Post
- St Antonius Hospital, Nieuwegein, Netherlands (The)
| | - F J Meijboom
- University Medical Center Utrecht, Utrecht, Netherlands (The)
| | | | - A P J Van Dijk
- University Medical Center St Radboud (UMCN), Nijmegen, Netherlands (The)
| | - T C Konings
- Amsterdam UMC - Location VUmc, Amsterdam, Netherlands (The)
| | - C R Bezzina
- Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands (The)
| | - B J M Mulder
- Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands (The)
| | - B J Bouma
- Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands (The)
| | - M W T Tanck
- Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands (The)
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14
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Engele LJ, Mulder BJM, Schoones JW, Kies P, Egorova AD, Vliegen HW, Hazekamp MG, Bouma BJ, Jongbloed MRM. The coronary arteries in adults after arterial switch: a systematic review. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.1845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Coronary artery status in adults longterm after the arterial switch operation (ASO) is unclear. As a consequence, current follow-up strategies for coronary assessment remain controversial. We conducted a systemic review to provide an overview of coronary complications during adulthood and to evaluate the value of coronary imaging in adults after ASO, in light of current guidelines.
Material and method
Studies describing coronary complications or coronary imaging after ASO in adults were considered eligible for review and analysis. Articles were screened for the inclusion of adult ASO patients and data on coronary complications and findings of coronary imaging were collected. In cohort studies with both adults (≥18 years) and non-adults (<18 years) only outcomes in identifiable adults were analyzed.
Results
A total of 993 adults were followed with a median follow-up of 2.0 years after reaching adulthood. Myocardial ischemia was suspected in 16/192 patients (6.8%). The number of coronary interventions was 4 (0.4%) and coronary death was reported in 4 (0.4%) patients. The following coronary abnormalities were found by routine coronary computer tomography CT (cCT): stenosis (4%), acute angle (40%), kinking (24%) and interaterial course (11%). No coronary events were reported during pregnancy (n=45).
Conclusion
The reported number of coronary interventions (0.4%) and of coronary death (0.4%) during a median follow-up of 2 years in 993 ASO adults is low. Coronary abnormalities including acute angle, kinking and interarterial course were commonly found by cCT. The 2020 European Society of Cardiology (ESC) guidelines state that routine screening for coronary pathologies is questionable. However, based on current findings and in line with the 2018 American ACC/AHA guidelines we suggest a baseline assessment of the coronary arteries in all adult ASO patients. Thereafter, an individualized coronary follow-up strategy, based upon coronary findings, is advisable.
Funding Acknowledgement
Type of funding sources: Foundation. Main funding source(s): Hartstichting Freedom from coronary complications
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Affiliation(s)
- L J Engele
- Academic Medical Center, Cardiology, Amsterdam, Netherlands (The)
| | - B J M Mulder
- Academic Medical Center, Cardiology, Amsterdam, Netherlands (The)
| | - J W Schoones
- Leiden University Medical Center, Directorate of Research Policy, Leiden, Netherlands (The)
| | - P Kies
- Leiden University Medical Center, Cardiology, Leiden, Netherlands (The)
| | - A D Egorova
- Leiden University Medical Center, Cardiology, Leiden, Netherlands (The)
| | - H W Vliegen
- Leiden University Medical Center, Cardiology, Leiden, Netherlands (The)
| | - M G Hazekamp
- Leiden University Medical Center, Cardiothoracic Surgery, Leiden, Netherlands (The)
| | - B J Bouma
- Academic Medical Center, Cardiology, Amsterdam, Netherlands (The)
| | - M R M Jongbloed
- Leiden University Medical Center, Departments of Cardiology and Anatomy and Embryology, Leiden, Netherlands (The)
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15
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Van Andel MM, De Waard V, Timmermans J, Scholte AJHA, Van Den Berg MP, Zwinderman AH, Mulder BJM, Groenink M. Longitudinal changes in aortic distensibility in patients with Marfan syndrome. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.1994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Patients with Marfan syndrome (MFS) may develop aortic dissection due to progressive dilatation in the entire aorta. Increased aortic stiffness, i.e.a. decreased distensibility has been shown to often precede these dismal sequelae. Therefore, we investigated longitudinal changes in aortic distensibility throughout the entire aorta by means of Cardiac Magnetic Resonance (CMR) imaging in patients with MFS.
Methods
This retrospective study included all MFS patients with four CMR examinations performed between 1996 and 2012. Aortic distensibility was measured and calculated by a single analyst, in the ascending, proximal- and distal descending, and abdominal aorta. Changes in distensibility were studied using linear mixed-effects regression models. Furthermore, we investigated the association between distensibility and age, sex, blood pressure, medication use, FBN1 mutation type, and previous aortic root surgery.
Results
In total, 35 MFS patients (age at inclusion 28 [IQR 23–32] years, 54% male) were included. Mean aortic distensibility was low in the ascending and proximal descending aorta (resp. 3.25±1.87, 3.91±1.73x10–3 mmHg–1) at the first scan. Distensibility decreased significantly over time at level 2, 3, and 4 (resp. p=0.021, p=0.002, p=0.038) (Figure 1). The rate of distensibility loss per year (x10–3 mmHg–1/year) was respectively 0.04 and 0.06 in the proximal- and distal descending aorta.
Men seemed to have a lower but more stable distensibility, whereas women showed a higher distensibility at younger age, but a faster deterioration rate over time (difference in distensibility loss per year between men and women: 0.08, p=0.038). Distensibility did not correlate significantly with medication use, FBN1 mutation type or previous aortic root surgery.
Conclusion
Patients with MFS have low distensibility at all levels of the aorta at young age, which keeps decreasing over time. Men had lower distensibility at younger age than women. Distensibility was stably low in men, while still deteriorating over time in women.
Funding Acknowledgement
Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): AMC FoundationHorstingstuit Foundation
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Affiliation(s)
- M M Van Andel
- Amsterdam UMC - Location Academic Medical Center, Cardiology, Amsterdam, Netherlands (The)
| | - V De Waard
- Amsterdam UMC - Location Academic Medical Center, Medical Biochemistry, Amsterdam, Netherlands (The)
| | - J Timmermans
- Radboud University Hospital, Cardiology, Nijmegen, Netherlands (The)
| | - A J H A Scholte
- Leiden University Medical Center, Cardiology, Leiden, Netherlands (The)
| | - M P Van Den Berg
- University Medical Center Groningen, Cardiology, Groningen, Netherlands (The)
| | - A H Zwinderman
- Amsterdam UMC - Location Academic Medical Center, Clinical Epidemiology, Amsterdam, Netherlands (The)
| | - B J M Mulder
- Amsterdam UMC - Location Academic Medical Center, Cardiology, Amsterdam, Netherlands (The)
| | - M Groenink
- Amsterdam UMC - Location Academic Medical Center, Cardiology, Amsterdam, Netherlands (The)
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16
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Heidendael JF, Van Engele LJ, Bouma BJ, Mulder BJM. Patients with mild congenital heart defects and atrial arrhythmias: anticoagulate all or follow the CHA2DS2-VASc score? Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.1852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Purpose
Clinical practice used to anticoagulated all patients with mild congenital heart defects (CHD) and atrial arrhythmias (AA) because of the presence of structural abnormalities. Current guidelines on adult congenital heart disease indicate that in these patients, as per general, the CHA2DS2-VASc score should be followed when deciding upon thromboprophylaxis in case AA. To validate this recommendation, we aimed to assess the incidence of thromboembolism in patients with mild CHD according to CHA2DS2-VASc score using non-vitamin K oral anticoagulants (NOACs) for AA.
Methods
Data are retrieved from the multinational NOTE-registry, which follows ACHD patients on NOACs for several indications since 2014. Patients in whom NOAC was prescribed for atrial arrhythmias were included in this study. The primary endpoint was the incidence of thromboembolism (TE) and major bleeding (MB). Secondary outcomes were minor bleeding and mortality. Risk stratification was performed using CHA2DS2-VASc score at baseline.
Results
The NOTE registry has up to date engaged leading ACHD-centers of up to 14 different countries throughout the world, thereby demonstrating a significant effort to fill the gap in science regarding the efficacy and safety of NOACs in the ACHD population. Out of a total of 638 patients, 72 patients had mild congenital defects and NOACs prescribed for AA. The mean age at baseline was 57 (±12) years and 56% was female. Patients were followed up to a maximum of 7 years (202 patient-years; median 2.5, IQR 1.2–4.0). In all patients with a CHA2DS2-VASc score of 0 (n=24), no TE occurred (annualized TE-rate 0%), while 2 patients suffered a MB (annualized MB-rate 3.3%; Figure 1). In patients with a CHA2DS2-VASc score of 1 (n=8) or ≥2 (n=40) the annualized eventrates were 0% and 0.8% for TE, and 0% and 1.7% for MB, respectively.
Conclusion
These reassuring results demonstrated that the annualized eventrate for TE in patients with mild CHD and a CHA2DS2-VASc score of 0 under treatment with NOACs is very low, at the cost of major bleedings. Following the guidelines seems justified: similar to patients with acquired heart disease the prescription of oral anticoagulant therapy can be refrained from in patients with CHA2DS2-VASc score of 0 and in those with CHA2DS2-VASc score 1 it can be debated weighing the risks and benefits.
Funding Acknowledgement
Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Netherlands Heart Institute Figure 1. Eventrates of TE and MB
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Affiliation(s)
- J F Heidendael
- Amsterdam University Medical Center, Amsterdam, Netherlands (The)
| | - L J Van Engele
- Amsterdam University Medical Center, Amsterdam, Netherlands (The)
| | - B J Bouma
- Amsterdam University Medical Center, Amsterdam, Netherlands (The)
| | - B J M Mulder
- Amsterdam University Medical Center, Amsterdam, Netherlands (The)
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17
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Cozijnsen L, Braam RL, Bakker-de Boo M, Otten AM, Post JG, Schermer T, Bouma BJ, Mulder BJM. Family screening in patients with isolated bicuspid aortic valve : Restriction to those with aortic dilatation is not justified. Neth Heart J 2021; 30:207-211. [PMID: 34476731 PMCID: PMC8941042 DOI: 10.1007/s12471-021-01621-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2021] [Indexed: 11/26/2022] Open
Abstract
Aim To determine the prevalence of undiagnosed bicuspid aortic valve (BAV) and isolated aortic dilatation in first-degree relatives (FDRs) of patients with isolated BAV and to explore the recurrence risk of BAV in different subgroups of probands with BAV. Recent American College of Cardiology (ACC)/American Heart Association (AHA) Guidelines recommend family screening in patients with associated aortopathy only. Methods During follow-up visits, patients with isolated BAV received a printed invitation for their FDRs advising cardiac screening. Results From 2012–2019, 257 FDRs of 118 adult BAV patients were screened, among whom 63 (53%) index patients had undergone aortic valve surgery (AVS), including concomitant aortic replacement in 25 (21%). Of the non-operated index patients, 31 (26%) had aortic dilatation (> 40 mm). Mean age of the FDRs was 48 years (range 4–83) and 42% were male. The FDR group comprised 20 parents, 103 siblings and 134 offspring. Among these FDRs, 12 (4.7%) had a previously undiagnosed BAV and 23 (8.9%) had an isolated aortic dilatation. FDRs of the probands with previous AVS (n = 147) had a risk ratio for BAV of 2.25 (95% confidence interval (CI) 0.62–8.10). FDRs of the probands with BAV and repaired or unrepaired aortic dilatation (n = 127) had a risk ratio for BAV of 0.51 (95% CI 0.16–1.66). Conclusion Screening FDRs of patients with isolated BAV resulted in a reasonable yield of 14% new cases of BAV or isolated aortic dilatation. A trend towards an increased risk of BAV in FDRs was observed in the probands with previous AVS, whereas this risk seemed to be diminished in the probands with associated aortic dilatation. This latter finding does not support the restrictive ACC/AHA recommendation.
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Affiliation(s)
- L Cozijnsen
- Department of Cardiology, Gelre Hospital, Apeldoorn, The Netherlands.
| | - R L Braam
- Department of Cardiology, Gelre Hospital, Apeldoorn, The Netherlands
| | - M Bakker-de Boo
- Department of Cardiology, Gelre Hospital, Apeldoorn, The Netherlands
| | - A M Otten
- Department of Cardiology, Gelre Hospital, Apeldoorn, The Netherlands
| | - J G Post
- Department of Genetics, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - T Schermer
- Department of Clinical Epidemiology, Gelre Hospital, Apeldoorn, The Netherlands
| | - B J Bouma
- Department of Cardiology, Amsterdam University Medical Centres, location AMC, Amsterdam, The Netherlands
| | - B J M Mulder
- Department of Cardiology, Amsterdam University Medical Centres, location AMC, Amsterdam, The Netherlands
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18
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Girnius A, Zentner D, Valente AM, Pieper PG, Economy KE, Ladouceur M, Roos-Hesselink JW, Warshak C, Partington SL, Gao Z, Ollberding N, Faust M, Girnius S, Kaemmerer H, Nagdyman N, Cohen S, Canobbio M, Akagi T, Grewal J, Bradley E, Buber Y, Palumbo J, Walker N, Aboulhosn J, Oechslin E, Baumgartner H, Kurdi W, Book WM, Mulder BJM, Veldtman GR. Bleeding and thrombotic risk in pregnant women with Fontan physiology. Heart 2021; 107:1390-1397. [PMID: 33234672 PMCID: PMC10367127 DOI: 10.1136/heartjnl-2020-317397] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 10/16/2020] [Accepted: 10/21/2020] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND/OBJECTIVES Pregnancy may potentiate the inherent hypercoagulability of the Fontan circulation, thereby amplifying adverse events. This study sought to evaluate thrombosis and bleeding risk in pregnant women with a Fontan. METHODS We performed a retrospective observational cohort study across 13 international centres and recorded data on thrombotic and bleeding events, antithrombotic therapies and pre-pregnancy thrombotic risk factors. RESULTS We analysed 84 women with Fontan physiology undergoing 108 pregnancies, average gestation 33±5 weeks. The most common antithrombotic therapy in pregnancy was aspirin (ASA, 47 pregnancies (43.5%)). Heparin (unfractionated (UFH) or low molecular weight (LMWH)) was prescribed in 32 pregnancies (30%) and vitamin K antagonist (VKA) in 10 pregnancies (9%). Three pregnancies were complicated by thrombotic events (2.8%). Thirty-eight pregnancies (35%) were complicated by bleeding, of which 5 (13%) were severe. Most bleeds were obstetric, occurring antepartum (45%) and postpartum (42%). The use of therapeutic heparin (OR 15.6, 95% CI 1.88 to 129, p=0.006), VKA (OR 11.7, 95% CI 1.06 to 130, p=0.032) or any combination of anticoagulation medication (OR 13.0, 95% CI 1.13 to 150, p=0.032) were significantly associated with bleeding events, while ASA (OR 5.41, 95% CI 0.73 to 40.4, p=0.067) and prophylactic heparin were not (OR 4.68, 95% CI 0.488 to 44.9, p=0.096). CONCLUSIONS Current antithrombotic strategies appear effective at attenuating thrombotic risk in pregnant women with a Fontan. However, this comes with high (>30%) bleeding risk, of which 13% are life threatening. Achieving haemostatic balance is challenging in pregnant women with a Fontan, necessitating individualised risk-adjusted counselling and therapeutic approaches that are monitored during the course of pregnancy.
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Affiliation(s)
- Andrea Girnius
- Anesthesiology, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Dominica Zentner
- Department of Cardiology and Department of Genomic Medicine, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Anne Marie Valente
- Brigham and Women's Hospital, Department of Medicine, Division of Cardiovascular Disease, Department of Cardiology Harvard Medical School, Boston, Massachusetts, USA
| | - Petronella G Pieper
- Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Katherine E Economy
- Brigham and Women's Hospital, Department of Obstetrics and Gynecology, Division Maternal Fetal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Magalie Ladouceur
- Cardiology, Hopital Europeen Georges Pompidou, Paris, France.,Pediatric Cardiology, Hopital Universitaire Necker-Enfants Malades, Paris, France
| | | | - Carri Warshak
- Obstetrics and Gynecology, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Sara L Partington
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Zhiqian Gao
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Nicholas Ollberding
- Department of Pediatrics, Cincinnati Children's Hospital Medical Centre, Cincinnati, Ohio, USA.,Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Michelle Faust
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Saulius Girnius
- Department of Hematology, Trihealth Cancer Institute, Cincinnati, Ohio, USA
| | | | | | - Scott Cohen
- Department of Cardiology, The Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Mary Canobbio
- School of Nursing, University of California Los Angeles, Los Angeles, California, USA
| | - Teiji Akagi
- Cardiovascular Medicine, Okayama University, Okayama, Japan
| | - Jasmine Grewal
- Cardiology, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Elisa Bradley
- Adult Congenital Heart Disease, The Ohio State University & Nationwide Children's Hospital, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Yonathan Buber
- Department of Medicine, Division of Cardiology, University of Washington School of Medicine, Seattle, Washington, USA
| | - Joseph Palumbo
- Haematology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | | | - Jamil Aboulhosn
- Ahmanson/UCLA ACHD Center, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Erwin Oechslin
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, University Heatlh Network and University of Toronto, Toronto, Ontario, Canada.,Bitove Family Professorship of Adult Congenital Heart Disease, Toronto General Hospital, Toronto, Ontario, Canada
| | - Helmut Baumgartner
- Department of Cardiology III: Adult Congenital and Valvular Heart Disease, University Hospital Muenster, Muenster, Albert Schweitzer Campus 1, Building A1, 48149 Muenster, Germany
| | - Wesam Kurdi
- King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Wendy M Book
- Internal Medicine, Division of Cardiology, Emory University, Atlanta, Georgia, USA
| | | | - Gruschen R Veldtman
- Adult Congenital Heart Disease, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
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19
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Engele LJ, Mulder BJM, Schoones JW, Kiès P, Egorova AD, Vliegen HW, Hazekamp MG, Bouma BJ, Jongbloed MRM. The Coronary Arteries in Adults after the Arterial Switch Operation: A Systematic Review. J Cardiovasc Dev Dis 2021; 8:jcdd8090102. [PMID: 34564120 PMCID: PMC8468869 DOI: 10.3390/jcdd8090102] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 08/19/2021] [Accepted: 08/21/2021] [Indexed: 01/11/2023] Open
Abstract
Coronary artery status in adults long after the arterial switch operation (ASO) is unclear. We conducted a systematic review to provide an overview of coronary complications during adulthood and to evaluate the value of routine coronary imaging in adults after ASO, in light of current guidelines. Articles were screened for the inclusion of adult ASO patients and data on coronary complications and findings of coronary imaging were collected. A total of 993 adults were followed with a median available follow-up of only 2.0 years after reaching adulthood. Myocardial ischemia was suspected in 17/192 patients (8.9%). The number of coronary interventions was four (0.4%), and coronary death was reported in four (0.4%) patients. A lack of ischemia-related symptoms cannot be excluded because innervation studies indicated deficient cardiac innervation after ASO, although data is limited. Anatomical high-risk features found by routine coronary computed tomography (cCT) included stenosis (4%), acute angle (40%), kinking (24%) and inter-arterial course (11%). No coronary complications were reported during pregnancy (n = 45), although, remarkably, four (9%) patients developed heart failure. The 2020 European Society of Cardiology (ESC) guidelines state that routine screening for coronary pathologies is questionable. Based on current findings and in line with the 2018 American ACC/AHA guidelines a baseline assessment of the coronary arteries in all ASO adults seems justifiable. Thereafter, an individualized coronary follow-up strategy is advisable at least until significant duration of follow-up is available.
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Affiliation(s)
- Leo J Engele
- Center for Congenital Heart Disease Amsterdam-Leiden (CAHAL), Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Heart Centre, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Netherlands Heart Institute, 3511 EP Utrecht, The Netherlands
| | - Barbara J M Mulder
- Center for Congenital Heart Disease Amsterdam-Leiden (CAHAL), Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Heart Centre, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Netherlands Heart Institute, 3511 EP Utrecht, The Netherlands
| | - Jan W Schoones
- Directorate of Research Policy, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - Philippine Kiès
- Center for Congenital Heart Disease Amsterdam-Leiden (CAHAL), Department of Cardiology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - Anastasia D Egorova
- Center for Congenital Heart Disease Amsterdam-Leiden (CAHAL), Department of Cardiology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - Hubert W Vliegen
- Center for Congenital Heart Disease Amsterdam-Leiden (CAHAL), Department of Cardiology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - Mark G Hazekamp
- Center for Congenital Heart Disease Amsterdam-Leiden (CAHAL), Department of Cardiothoracic Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - Berto J Bouma
- Center for Congenital Heart Disease Amsterdam-Leiden (CAHAL), Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Heart Centre, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Netherlands Heart Institute, 3511 EP Utrecht, The Netherlands
| | - Monique R M Jongbloed
- Center for Congenital Heart Disease Amsterdam-Leiden (CAHAL), Department of Cardiology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
- Center for Congenital Heart Disease Amsterdam-Leiden (CAHAL), Department of Anatomy and Embryology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
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20
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Van Andel MM, Van Ooij P, Gottwald L, De Waard V, Zwinderman AH, Mulder BJM, Nederveen AJ, Groenink M. Abnormal aortic hemodynamics at predilection sites for dissection in patients with Marfan Syndrome: a 4D flow study. Eur Heart J Cardiovasc Imaging 2021. [DOI: 10.1093/ehjci/jeab090.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): AMC Foundation Horstingstuit Foundation
Introduction
Patients with Marfan syndrome (MFS) may develop aneurysmatic dilatation and dissection of the aorta with a consequence of sudden death at relatively young age. We performed an aortic 4D flow MRI analysis, providing a comprehensive quantification and visualization of abnormal aortic velocity and wall shear stress (WSS) magnitude and direction with recently developed techniques (1,2). We hypothesize that abnormal hemodynamics are found at predilection sites for aortic dissection in MFS patients.
Methods
This prospective study included 56 MFS patients and 25 healthy subjects as controls. Aortic 4D flow MRI was performed on a 3T Philips Ingenia system (Best, Netherlands). The aorta was manually segmented on time-averaged phase contrast MR angiogram images (phase contrast images multiplied by absolute velocity) by thresholding, watershed, and manual voxel in-/exclusion. The segmentations were used to mask the velocities, calculate WSS, and co-registration for quantification of abnormal hemodynamics (3).
Abnormally elevated velocity and WSS were defined as higher than the three-dimensional 95% confidence interval as determined in the control group. Abnormally directed velocity and WSS were defined as vector angle differences higher than 120°. The aorta was subdivided in six regions of interest (ROIs) for total multiple linear regression with age, aortic diameter, and blood pressure characteristics. Independent predictors were defined as characteristics that were significant in the total model. Significance was defined as p < 0.05 with Bonferonni correction. The 3D-maps with abnormal hemodynamics were co-registered and added to create 3D-maps that show the incidence of abnormal hemodynamics.
Results
Figure 1 shows examples of maps with abnormal velocity and WSS magnitude and direction respectively. Ascending elevated velocity was associated with age, aortic diameter and blood pressure characteristics, whereas elevated WSS was associated with blood pressure characteristics only. No independent predictors were found for abnormally directed hemodynamics. Figure 2 shows the incidence maps for abnormally elevated velocity and abnormally directed WSS in two patients. The maximum incidence for elevated velocity and WSS were 32% and 20%, respectively, and found in the ascending aorta. The maxima for abnormally directed velocity and WSS were 18% and 39%, respectively, and found in the inner proximal descending aorta.
Conclusion
Altered aortic geometry and wall properties in MFS patients cause detectable hemodynamic effects in 30% of our cohort at known predilection sites for aortic dissection in MFS patients: the ascending aorta and proximal descending aorta. Independent measures of altered hemodynamics could possibly indicate individual patients at risk for aortic dissection.
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Affiliation(s)
- MM Van Andel
- Amsterdam UMC - Location Academic Medical Center, Cardiology, Amsterdam, Netherlands (The)
| | - P Van Ooij
- Amsterdam UMC - Location Academic Medical Center, Radiology & Nuclear Medicine, Amsterdam, Netherlands (The)
| | - L Gottwald
- Philips Healthcare, Best, Netherlands (The)
| | - V De Waard
- Amsterdam UMC - Location Academic Medical Center, Medical Biochemistry, Amsterdam, Netherlands (The)
| | - AH Zwinderman
- Amsterdam UMC - Location Academic Medical Center, Clinical Epidemiology, Amsterdam, Netherlands (The)
| | - BJM Mulder
- Amsterdam UMC - Location Academic Medical Center, Cardiology, Amsterdam, Netherlands (The)
| | - AJ Nederveen
- Amsterdam UMC - Location Academic Medical Center, Radiology & Nuclear Medicine, Amsterdam, Netherlands (The)
| | - M Groenink
- Amsterdam UMC - Location Academic Medical Center, Cardiology, Amsterdam, Netherlands (The)
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21
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van Andel MM, Indrakusuma R, Jalalzadeh H, Balm R, Timmermans J, Scholte AJ, van den Berg MP, Zwinderman AH, Mulder BJM, de Waard V, Groenink M. Long-term clinical outcomes of losartan in patients with Marfan syndrome: follow-up of the multicentre randomized controlled COMPARE trial. Eur Heart J 2021; 41:4181-4187. [PMID: 32548624 PMCID: PMC7711887 DOI: 10.1093/eurheartj/ehaa377] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 02/07/2020] [Accepted: 04/24/2020] [Indexed: 01/09/2023] Open
Abstract
AIMS The COMPARE trial showed a small but significant beneficial effect of 3-year losartan treatment on aortic root dilatation rate in adults with Marfan syndrome (MFS). However, no significant effect was found on clinical endpoints, possibly due to a short follow-up period. The aim of the current study was therefore to investigate the long-term clinical outcomes after losartan treatment. METHODS AND RESULTS In the original COMPARE study (inclusion 2008-2009), adult patients with MFS (n = 233) were randomly allocated to either the angiotensin-II receptor blocker losartan® on top of regular treatment (β-blockers in 71% of the patients) or no additional medication. After the COMPARE trial period of 3 years, study subjects chose to continue their losartan medication or not. In a median follow-up period of 8 years, 75 patients continued losartan medication, whereas 78 patients, originally allocated to the control group, never used losartan after inclusion. No differences existed between baseline characteristics of the two groups except for age at inclusion [losartan 34 (interquartile range, IQR 26-43) years, control 41 (IQR 30-52) years; P = 0.031], and β-blocker use (losartan 81%, control 64%; P = 0.022). A pathological FBN1 mutation was present in 76% of patients and 58% of the patients were male. Clinical endpoints, defined as all-cause mortality, aortic dissection/rupture, elective aortic root replacement, reoperation, and vascular graft implantation beyond the aortic root, were compared between the two groups. A per-patient composite endpoint was also analysed. Five deaths, 14 aortic dissections, 23 aortic root replacements, 3 reoperations, and 3 vascular graft implantations beyond the aortic root occurred during follow-up. Except for aortic root replacement, all endpoints occurred in patients with an operated aortic root. Patients who used losartan during the entire follow-up period showed a reduced number of events compared to the control group (death: 0 vs. 5, P = 0.014; aortic dissection: 3 vs. 11, P = 0.013; elective aortic root replacement: 10 vs. 13, P = 0.264; reoperation: 1 vs. 2, P = 0.463; vascular graft implantations beyond the aortic root 0 vs. 3, P = 0.071; and composite endpoint: 14 vs. 26, P = 0.019). These results remained similar when corrected for age and β-blocker use in a multivariate analysis. CONCLUSION These results suggest a clinical benefit of combined losartan and β-blocker treatment in patients with MFS.
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Affiliation(s)
- Mitzi M van Andel
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Reza Indrakusuma
- Department of Vascular Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Hamid Jalalzadeh
- Department of Vascular Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Ron Balm
- Department of Vascular Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Janneke Timmermans
- Department of Cardiology, St. Radboud University Medical Center, Geert grooteplein 10, 6525 GA, Nijmegen, The Netherlands
| | - Arthur J Scholte
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 AZ, Leiden, The Netherlands
| | - Maarten P van den Berg
- Department of Cardiology, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Aeilko H Zwinderman
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Barbara J M Mulder
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Vivian de Waard
- Department of Medical Biochemistry, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Maarten Groenink
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.,Department of Radiology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
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22
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Etnel JRG, Bons LR, De Heer F, Robbers-Visser D, Van Beynum IM, Straver B, Jongbloed MR, Kiès P, Slieker MG, Van Dijk APJ, Kluin J, Bertels RA, Utens EMWJ, The R, Van Galen E, Mulder BJM, Blom NA, Hazekamp MG, Roos-Hesselink JW, Helbing WA, Bogers AJJC, Takkenberg JJM. Patient information portal for congenital aortic and pulmonary valve disease: a stepped-wedge cluster randomised trial. Open Heart 2021; 8:openhrt-2020-001252. [PMID: 33757975 PMCID: PMC7993296 DOI: 10.1136/openhrt-2020-001252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 09/29/2020] [Accepted: 09/29/2020] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND In response to an increased need for patient information in congenital heart disease, we previously developed an online, evidence-based information portal for patients with congenital aortic and pulmonary valve disease. To assess its effectiveness, a stepped-wedge cluster randomised trial was conducted. METHODS Adult patients and caregivers of paediatric patients with congenital aortic and/or pulmonary valve disease and/or tetralogy of Fallot who visited the outpatient clinic at any of the four participating centres in the Netherlands between 1 March 2016-1 July 2017 were prospectively included. The intervention (information portal) was introduced in the outpatient clinic according to a stepped-wedge randomised design. One month after outpatient clinic visit, each participant completed a questionnaire on disease-specific knowledge, anxiety, depression, mental quality of life, involvement and opinion/attitude concerning patient information and involvement. RESULTS 343 participants were included (221 control, 122 intervention). Cardiac diagnosis (p=0.873), educational level (p=0.153) and sex (p=0.603) were comparable between the two groups. All outcomes were comparable between groups in the intention-to-treat analyses. However, only 51.6% of subjects in the intervention group (n=63) reported actually visiting the portal. Among these subjects (as-treated), disease-specific knowledge (p=0.041) and mental health (p=0.039) were significantly better than in control subjects, while other baseline and outcome variables were comparable. CONCLUSION Even after being invited by their cardiologists, only half of the participants actually visited the information portal. Only in those participants that actually visited the portal, knowledge of disease and mental health were significantly better. This underlines the importance of effective implementation of online evidence-based patient information portals in clinical practice.
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Affiliation(s)
- Jonathan R G Etnel
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Lidia R Bons
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Frederiek De Heer
- Department of Cardiothoracic Surgery, Academic Medical Center, Amsterdam, Netherlands
| | | | - Ingrid M Van Beynum
- Department of Pediatric Cardiology, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Bart Straver
- Department of Pediatric Cardiology, Academic Medical Center, Amsterdam, Netherlands
| | | | - Philippine Kiès
- Department of Cardiology, Leiden University Medical Center, Leiden, Netherlands
| | - Martijn G Slieker
- Department of Pediatric Cardiology, Radboudumc, Nijmegen, Netherlands
| | | | - Jolanda Kluin
- Department of Cardiothoracic Surgery, Academic Medical Center, Amsterdam, Netherlands.,Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands
| | - Robin A Bertels
- Department of Pediatric Cardiology, Leiden University Medical Center, Leiden, Netherlands
| | - Elisabeth M W J Utens
- Department of Child and Adolescent Psychiatry/Psychology, Erasmus University Medical Center, Rotterdam, Netherlands.,Research Institute of Child Development and Education, University of Amsterdam, Amsterdam, Netherlands.,De Bascule, Academic Center for Child Psychiatry, Amsterdam, Netherlands
| | | | - Eugene Van Galen
- Patient Association 'Patiëntenvereniging Aangeboren Hartafwijkingen', Maarssen, Netherlands
| | - Barbara J M Mulder
- Department of Cardiology, Academic Medical Center, Amsterdam, Netherlands
| | - Nico A Blom
- Department of Pediatric Cardiology, Leiden University Medical Center, Leiden, Netherlands
| | - Mark G Hazekamp
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands
| | | | - Willem A Helbing
- Department of Pediatric Cardiology, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Ad J J C Bogers
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Johanna J M Takkenberg
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
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23
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Woudstra OI, Zandstra TE, Vogel RF, van Dijk APJ, Vliegen HW, Kiès P, Jongbloed MRM, Egorova AD, Doevendans PAFM, Konings TC, Mulder BJM, Tanck MWT, Meijboom FJ, Bouma BJ. Clinical Course Long After Atrial Switch: A Novel Risk Score for Major Clinical Events. J Am Heart Assoc 2021; 10:e018565. [PMID: 33615824 PMCID: PMC8174274 DOI: 10.1161/jaha.120.018565] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background Patients with transposition of the great arteries corrected by an atrial switch operation experience major clinical events during adulthood, mainly heart failure (HF) and arrhythmias, but data on the emerging risks remain scarce. We assessed the risk for events during the clinical course in adulthood, and provided a novel risk score for event‐free survival. Methods and Results This multicenter study observed 167 patients with transposition of the great arteries corrected by an atrial switch operation (61% Mustard procedure; age, 28 [interquartile range, 24–36] years) for 13 (interquartile range, 9–16) years, during which 16 (10%) patients died, 33 (20%) had HF events, defined as HF hospitalizations, heart transplantation, ventricular assist device implantation, or HF‐related death, and 15 (9%) had symptomatic ventricular arrhythmias. Five‐year risk of mortality, first HF event, and first ventricular arrhythmia increased from 1% each at age 25 years, to 6% (95% CI, 4%–9%), 23% (95% CI, 17%–28%), and 5% (95% CI, 2%–8%), respectively, at age 50 years. Predictors for event‐free survival were examined to construct a prediction model using bootstrapping techniques. A prediction model combining age >30 years, prior ventricular arrhythmia, age >1 year at repair, moderate or greater right ventricular dysfunction, severe tricuspid regurgitation, and mild or greater left ventricular dysfunction discriminated well between patients at low (<5%), intermediate (5%–20%), and high (>20%) 5‐year risk (optimism‐corrected C‐statistic, 0.86 [95% CI, 0.82–0.90]). Observed 5‐ and 10‐year event‐free survival rates in low‐risk patients were 100% and 97%, respectively, compared with only 31% and 8%, respectively, in high‐risk patients. Conclusions The clinical course of patients undergoing atrial switch increasingly consists of major clinical events, especially HF. A novel risk score stratifying patients as low, intermediate, and high risk for event‐free survival provides information on absolute individual risks, which may support decisions for pharmacological and interventional management.
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Affiliation(s)
- Odilia I Woudstra
- Department of Clinical and Experimental Cardiology Heart Center Amsterdam Cardiovascular SciencesAmsterdam University Medical CenterUniversity of Amsterdam the Netherlands.,Department of Cardiology University Medical Center Utrecht Utrecht the Netherlands
| | - Tjitske E Zandstra
- Department of Cardiology Leiden University Medical Center Leiden the Netherlands
| | - Rosanne F Vogel
- Department of Clinical and Experimental Cardiology Heart Center Amsterdam Cardiovascular SciencesAmsterdam University Medical CenterUniversity of Amsterdam the Netherlands
| | - Arie P J van Dijk
- Department of Cardiology Radboud University Medical Center Nijmegen the Netherlands
| | - Hubert W Vliegen
- Department of Cardiology Leiden University Medical Center Leiden the Netherlands
| | - Philippine Kiès
- Department of Cardiology Leiden University Medical Center Leiden the Netherlands
| | - Monique R M Jongbloed
- Department of Cardiology Leiden University Medical Center Leiden the Netherlands.,Department of Anatomy and Embryology Leiden University Medical Center Leiden the Netherlands
| | - Anastasia D Egorova
- Department of Cardiology Leiden University Medical Center Leiden the Netherlands
| | | | - Thelma C Konings
- Department of Clinical and Experimental Cardiology Heart Center Amsterdam Cardiovascular SciencesAmsterdam University Medical CenterVrije Universiteit Amsterdam Amsterdam the Netherlands
| | - Barbara J M Mulder
- Department of Clinical and Experimental Cardiology Heart Center Amsterdam Cardiovascular SciencesAmsterdam University Medical CenterUniversity of Amsterdam the Netherlands
| | - Michael W T Tanck
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics Amsterdam University Medical CenterUniversity of Amsterdam the Netherlands
| | - Folkert J Meijboom
- Department of Cardiology University Medical Center Utrecht Utrecht the Netherlands
| | - Berto J Bouma
- Department of Clinical and Experimental Cardiology Heart Center Amsterdam Cardiovascular SciencesAmsterdam University Medical CenterUniversity of Amsterdam the Netherlands
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24
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Baumgartner H, De Backer J, Babu-Narayan SV, Budts W, Chessa M, Diller GP, Lung B, Kluin J, Lang IM, Meijboom F, Moons P, Mulder BJM, Oechslin E, Roos-Hesselink JW, Schwerzmann M, Sondergaard L, Zeppenfeld K. 2020 ESC Guidelines for the management of adult congenital heart disease. Eur Heart J 2021; 42:563-645. [PMID: 32860028 DOI: 10.1093/eurheartj/ehaa554] [Citation(s) in RCA: 790] [Impact Index Per Article: 263.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
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25
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Oudkerk Pool MD, Hooglugt JLQ, Schijven MP, Mulder BJM, Bouma BJ, de Winter RJ, Pinto Y, Winter MM. Review of Digitalized Patient Education in Cardiology: A Future Ahead? Cardiology 2021; 146:263-271. [PMID: 33550295 DOI: 10.1159/000512778] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 10/11/2020] [Indexed: 01/21/2023]
Abstract
INTRODUCTION An increased focus on shared decision-making and patient empowerment in cardiology and on patient outcomes such as quality of life (QoL), depression, and anxiety underline the importance of high-quality patient education. Studies focusing on digital means of patient education performed in other disciplines of medicine demonstrated its positive effect in these areas. Therefore, a review of the current literature was performed to (i) evaluate the status of innovative, digitalized means of patient education in cardiology and (ii) assess the impact of digital patient education on outcome parameters (i.e., patient knowledge (or health literacy), QoL, depression, anxiety, and patient satisfaction). METHOD A review of the current literature was performed to evaluate the effect of digitalized patient education for any purpose in the field of cardiology. Medline and EMBASE were searched for articles reporting any digital educational platform used for patient education up to May 2020. The articles were compared on their effect on patient knowledge or health literacy, QoL, depression or anxiety, and patient satisfaction. RESULTS The initial search yielded 279 articles, 34 of which were retained after applying in, and exclusion criteria. After full-text analysis, the total number of articles remaining was 16. Of these, 6 articles discussed the use of smartphone or tablet applications as a means of patient education, whereas 3 reviewed web-based content, and 7 evaluated the use of video (2 three-dimensional videos, from which one on a virtual reality headset). CONCLUSION This review demonstrates that digital patient education increases patient knowledge. Overall, digital education increases QoL and lowers feelings of depression and anxiety. The majority of patients express satisfaction with digital platforms. It remains important that developers of digital patient education platforms remain focused on clear, structured, and comprehensible information presentation.
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Affiliation(s)
- Marinka D Oudkerk Pool
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands, .,Netherlands Heart Institute, Utrecht, The Netherlands,
| | - Jean-Luc Q Hooglugt
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Marlies P Schijven
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Barbara J M Mulder
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Berto J Bouma
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Robbert J de Winter
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Yigal Pinto
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Michiel M Winter
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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26
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Vehmeijer JT, Koyak Z, Leerink JM, Zwinderman AH, Harris L, Peinado R, Oechslin EN, Robbers-Visser D, Groenink M, Boekholdt SM, de Winter RJ, Oliver JM, Bouma BJ, Budts W, Van Gelder IC, Mulder BJM, de Groot JR. Identification of patients at risk of sudden cardiac death in congenital heart disease: The PRospEctiVE study on implaNTable cardIOverter defibrillator therapy and suddeN cardiac death in Adults with Congenital Heart Disease (PREVENTION-ACHD). Heart Rhythm 2021; 18:785-792. [PMID: 33465514 DOI: 10.1016/j.hrthm.2021.01.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 12/27/2020] [Accepted: 01/10/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Sudden cardiac death (SCD) is the main preventable cause of death in patients with adult congenital heart disease (ACHD). Since robust risk stratification methods are lacking, we developed a risk score model to predict SCD in patients with ACHD: the PRospEctiVE study on implaNTable cardIOverter defibrillator therapy and suddeN cardiac death in Adults with Congenital Heart Disease (PREVENTION-ACHD) risk score model. OBJECTIVE The purpose of this study was to prospectively study predicted SCD risk using the PREVENTION-ACHD risk score model and actual SCD and sustained ventricular tachycardia/ventricular fibrillation (VT/VF) rates in patients with ACHD. METHODS The PREVENTION-ACHD risk score model assigns 1 point each to coronary artery disease, New York Heart Association class II/III heart failure, supraventricular tachycardia, systemic ejection fraction < 40%, subpulmonary ejection fraction < 40%, QRS duration ≥ 120 ms, and QT dispersion ≥ 70 ms. SCD risk was calculated for each patient. An annual predicted risk of ≥3% constituted high risk. The primary outcome was SCD or VT/VF after 2 years. The secondary outcome was SCD. RESULTS The study included 783 consecutive patients with ACHD (n=239 (31%) left-sided lesions; n=138 (18%) tetralogy of Fallot; n=108 (14%) closed atrial septal defect; median age 36 years; interquartile range 28-47 years; n=401 (51%) men). The PREVENTION-ACHD risk score model identified 58 high-risk patients. Eight patients (4 at high risk) experienced the primary outcome. The Kaplan-Meier estimates were 7% (95% confidence interval [CI] 0.1%-13.3%) in the high-risk group and 0.6% (95% CI 0.0%-1.1%) in the low-risk group (hazard ratio 12.5; 95% CI 3.1-50.9; P < .001). The risk score model's sensitivity was 0.5 and specificity 0.93, resulting in a C-statistic of 0.75 (95% CI 0.57-0.90). The hazard ratio for SCD was 12.4 (95% CI 1.8-88.1) (P = .01); the sensitivity and specificity were 0.5 and 0.92, and the C-statistic was 0.81 (95% CI 0.67-0.95). CONCLUSION The PREVENTION-ACHD risk score model provides greater accuracy in SCD or VT/VF risk stratification as compared with current guideline indications and identifies patients with ACHD who may benefit from preventive implantable cardioverter-defibrillator implantation.
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Affiliation(s)
- Jim T Vehmeijer
- Department of Cardiology, Heart Center, Amsterdam University Medical Centers/University of Amsterdam, Amsterdam, The Netherlands
| | - Zeliha Koyak
- Department of Cardiology, Heart Center, Amsterdam University Medical Centers/University of Amsterdam, Amsterdam, The Netherlands
| | - Jan M Leerink
- Department of Cardiology, Heart Center, Amsterdam University Medical Centers/University of Amsterdam, Amsterdam, The Netherlands
| | - Aeilko H Zwinderman
- Department of Clinical Epidemiology and Biostatistics, Amsterdam University Medical Centers/University of Amsterdam, The Netherlands
| | - Louise Harris
- Division of Cardiology, Peter Munk Cardiac Center, Toronto Congenital Cardiac Center of Adults/University of Toronto, Toronto, Ontario, Canada
| | - Rafael Peinado
- Department of Cardiology, La Paz University Hospital/Autonomous University of Madrid, Madrid, Spain
| | - Erwin N Oechslin
- Division of Cardiology, Peter Munk Cardiac Center, Toronto Congenital Cardiac Center of Adults/University of Toronto, Toronto, Ontario, Canada
| | - Daniëlle Robbers-Visser
- Department of Cardiology, Heart Center, Amsterdam University Medical Centers/University of Amsterdam, Amsterdam, The Netherlands
| | - Maarten Groenink
- Department of Cardiology, Heart Center, Amsterdam University Medical Centers/University of Amsterdam, Amsterdam, The Netherlands
| | - S Matthijs Boekholdt
- Department of Cardiology, Heart Center, Amsterdam University Medical Centers/University of Amsterdam, Amsterdam, The Netherlands
| | - Robbert J de Winter
- Department of Cardiology, Heart Center, Amsterdam University Medical Centers/University of Amsterdam, Amsterdam, The Netherlands
| | - José M Oliver
- Department of Cardiology, Gregorio Marañon University Hospital, CIBERCV, Madrid, Spain
| | - Berto J Bouma
- Department of Cardiology, Heart Center, Amsterdam University Medical Centers/University of Amsterdam, Amsterdam, The Netherlands
| | - Werner Budts
- Department of Cardiology, Universitair Ziekenhuis Leuven/Department of Cardiovascular Sciences, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Isabelle C Van Gelder
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Barbara J M Mulder
- Department of Cardiology, Heart Center, Amsterdam University Medical Centers/University of Amsterdam, Amsterdam, The Netherlands; Netherlands Heart Institute, Utrecht, The Netherlands
| | - Joris R de Groot
- Department of Cardiology, Heart Center, Amsterdam University Medical Centers/University of Amsterdam, Amsterdam, The Netherlands.
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27
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Woudstra OI, Ghanam A, Vliegen HW, van Dijk APJ, van Melle JP, Groenink M, Meijboom FJ, Post MC, Mulder BJM, Bouma BJ, Bokma JP. The aortic root in repaired tetralogy of Fallot: Serial measurements and impact of losartan treatment. Int J Cardiol 2020; 326:88-91. [PMID: 33098953 DOI: 10.1016/j.ijcard.2020.10.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 09/01/2020] [Accepted: 10/07/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Aortic root dilatation is common in adults with repaired tetralogy of Fallot (rTOF) and might lead to aortic dissection. However, little is known on progression of aortic dilatation and the effect of pharmaceutical treatment. This study aims to determine factors associated with aortic growth and investigate effects of losartan. METHODS AND RESULTS We performed a prespecified analysis from the 1:1 randomized, double-blind REDEFINE trial. Aortic root diameters were measured at baseline and after 2.0 ± 0.3 years of follow-up using cardiovascular magnetic resonance (CMR) imaging. A total of 66 patients were included (68% men, age 40 ± 12 years, baseline aortic root 37 ± 6 mm, 32% aortic dilatation (>40 mm)). There was a trend towards slow aortic root growth (+0.6 ± 2.3 mm after two years, p = 0.06) (n = 60). LV stroke volume was the only factor associated with both a larger baseline aortic root (β: 0.09 mm/ml (95% C.I.:0.02, 0.15), p = 0.010) and with aortic growth during follow-up (β: 0.04 mm/ml (95% C.I.:0.005, 0.066), p = 0.024), after correction for age, sex, and body surface area using linear regression analysis. No treatment effect of losartan was found (p = 0.17). CONCLUSIONS Aortic root dilatation was present in about one-third of rTOF patients. A larger LV stroke volume was associated with both a larger baseline aortic root and ongoing growth. Our findings provide no arguments for lower aortic diameter thresholds for prophylactic surgery compared to the general population.
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Affiliation(s)
- O I Woudstra
- Heart Center; Department of Clinical and Experimental Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands; Department of Cardiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - A Ghanam
- Heart Center; Department of Clinical and Experimental Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - H W Vliegen
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - A P J van Dijk
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - J P van Melle
- Department of Cardiology, Groningen University Medical Center, Groningen, the Netherlands
| | - M Groenink
- Heart Center; Department of Clinical and Experimental Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - F J Meijboom
- Department of Cardiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - M C Post
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - B J M Mulder
- Heart Center; Department of Clinical and Experimental Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands; Netherlands Heart Institute, Utrecht, the Netherlands
| | - B J Bouma
- Heart Center; Department of Clinical and Experimental Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - J P Bokma
- Heart Center; Department of Clinical and Experimental Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands.
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28
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Woudstra OI, Kuijpers JM, Jongbloed MRM, van Dijk APJ, Sieswerda GT, Vliegen HW, Egorova AD, Kiès P, Duijnhouwer AL, Robbers-Visser D, Konings TC, Zwinderman AH, Meijboom FJ, Mulder BJM, Bouma BJ. Medication in adults after atrial switch for transposition of the great arteries: clinical practice and recommendations. European Heart Journal - Cardiovascular Pharmacotherapy 2020; 8:77-84. [PMID: 32976560 PMCID: PMC8728040 DOI: 10.1093/ehjcvp/pvaa111] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 08/27/2020] [Accepted: 09/11/2020] [Indexed: 01/14/2023]
Abstract
Abstract
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.
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Affiliation(s)
| | - Joey M Kuijpers
- Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Monique R M Jongbloed
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
- Department of Anatomy & Embryology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Arie P J van Dijk
- Department of Cardiology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Gertjan T Sieswerda
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Hubert W Vliegen
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Anastasia D Egorova
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Philippine Kiès
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Anthonie L Duijnhouwer
- Department of Cardiology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Daniëlle Robbers-Visser
- Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Thelma C Konings
- Department of Cardiology, Amsterdam UMC, VU University, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Aeilko H Zwinderman
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Folkert J Meijboom
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Barbara J M Mulder
- Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Berto J Bouma
- Corresponding author. Tel: +31 020 566 9111, Fax: +31 020 696 2609,
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29
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Scognamiglio G, Fusco F, Hankel TC, Bouma BJ, Greutmann M, Khairy P, Ladouceur M, Dimopoulos K, Niwa K, Broberg CS, Miranda B, Budts W, Bouchardy J, Schwerzmann M, Lipczyńska M, Tobler D, Tsai SF, Egbe AC, Aboulhosn J, Fernandes SM, Garr B, Rutz T, Mizuno A, Proietti A, Alonso-Gonzalez R, Mulder BJM, Sarubbi B. Safety and efficacy of non-vitamin K antagonist oral anticoagulants for prevention of thromboembolism in adults with systemic right ventricle: Results from the NOTE international registry. Int J Cardiol 2020; 322:129-134. [PMID: 32805330 DOI: 10.1016/j.ijcard.2020.08.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 07/07/2020] [Accepted: 08/07/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Patients with systemic right ventricle (sRV), including transposition of great arteries (TGA) after atrial switch procedure and congenitally corrected transposition of great arteries (ccTGA), may require anticoagulation for thromboembolism (TE) prevention. In the absence of data on non-vitamin K antagonist oral anticoagulants (NOACs), vitamin K antagonists (VKAs) remain the agent of choice. We investigated the safety, efficacy and feasibility of NOACs treatment in adults with sRV in a worldwide study. METHODS This is an international multicentre prospective study, using data from the NOTE registry on adults with sRV taking NOACs between 2014 and 2019. The primary endpoints were TE and major bleeding (MB). The secondary endpoint was minor bleeding. RESULTS A total of 76 patients (42.5 ± 10.0 years, 76% male) with sRV (74% TGA, 26% ccTGA) on NOACs were included in the study. During a median follow-up of 2.5 years (IQR1.5-3.9), TE events occurred in 3 patients (4%), while no MB episodes were reported. Minor bleeding occurred in 9 patients (12%). NOAC treatment cessation rate was 1.4% (95%CI:0.3-4%) during the first year of follow-up. All the patients with TE events had a CHA2DS2-VASc score ≥ 2 and impaired sRV systolic function at baseline. The total incidence of major events during follow-up was significantly lower compared to historical use of VKAs or aspirin before study inclusion (1.4% (95%CI:0.29-4%) vs 6,9% (95%CI:2.5-15.2%); p = .01). CONCLUSIONS In this prospective study, NOACs appear to be well-tolerated, with excellent efficacy and safety at mid-term in patients with sRV.
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Affiliation(s)
- Giancarlo Scognamiglio
- Adult Congenital Heart Disease Unit, Department of Cardiology, Monaldi Hospital, Naples, Italy.
| | - Flavia Fusco
- Adult Congenital Heart Disease Unit, Department of Cardiology, Monaldi Hospital, Naples, Italy
| | - Tara C Hankel
- Department of Cardiology, Academic Medical Centre, Amsterdam, the Netherlands
| | - Berto J Bouma
- Department of Cardiology, Academic Medical Centre, Amsterdam, the Netherlands
| | - Matthias Greutmann
- Department of Cardiology, University Hospital Zurich, Zurich, Switzerland
| | - Paul Khairy
- Electrophysiology Service and Adult Congenital Heart Disease Centre, Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | - Magalie Ladouceur
- Adult Congenital Heart Disease Unit, Centre de Référence M3C, Hôpital Européen Georges Pompidou, Université Paris Descartes, Paris, France
| | - Konstantinos Dimopoulos
- Adult Congenital Heart Disease Centre, Royal Brompton Hospital and Imperial College of London, London, United Kingdom
| | - Koichiro Niwa
- Department of Cardiology, St. Luke's International Hospital, Tokyo, Japan
| | - Craig S Broberg
- Department of Cardiology, Oregon Health & Science University Hospital, Portland, United States of America
| | - Berta Miranda
- Integrated Adult Congenital Heart Disease Unit of Vall d' Hebron-Sant Pau University Hospitals, Division of Cardiology, Vall d'Hebron Hospital, Barcelona, Spain
| | - Werner Budts
- Congenital and Structural Cardiology, University Hospitals Leuven, Department of Cardiovascular Sciences, Catholic University Leuven, Leuven, Belgium
| | - Judith Bouchardy
- Service of Cardiology, University Hospital of Lausanne and University of Lausanne, Lausanne, Switzerland; Department of Cardiology, University Hospital Geneva, Genève, Switzerland
| | - Markus Schwerzmann
- Center for Congenital Heart Disease, University Hospital Inselspital, University of Bern, Bern, Switzerland
| | - Magdalena Lipczyńska
- Adult Congenital Heart Center, Cardinal Wyszynski National Institute of Cardiology, Warsaw, Poland
| | - Daniel Tobler
- Department of Cardiology, University Hospital Basel, Basel, Switzerland
| | - Shane F Tsai
- Department of Cardiology, University of Nebraska Medical Centre, NE, United States of America
| | - Alexander C Egbe
- Department of Cardiology, Mayo Clinic, Rochester, United States of America
| | - Jamil Aboulhosn
- Ahmanson/UCLA Adult Congenital Heart Disease Center, University of California, LosAngeles, United States of America
| | - Susan M Fernandes
- Adult Congenital Heart Disease Program at Stanford, Lucile Packard Children's Hospital, Stanford Health Care, Stanford School of Medicine, Palo Alto, CA, United States of America
| | - BreAnn Garr
- Department of Cardiology, Cincinnati Children's Hospital Medical Centre, Cincinnati, United States of America
| | - Tobias Rutz
- Service of Cardiology, University Hospital of Lausanne and University of Lausanne, Lausanne, Switzerland
| | - Atsushi Mizuno
- Department of Cardiology, St. Luke's International Hospital, Tokyo, Japan
| | - Anna Proietti
- Electrophysiology Service and Adult Congenital Heart Disease Centre, Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | - Rafael Alonso-Gonzalez
- Adult Congenital Heart Disease Centre, Royal Brompton Hospital and Imperial College of London, London, United Kingdom
| | - Barbara J M Mulder
- Department of Cardiology, Academic Medical Centre, Amsterdam, the Netherlands; Interuniversity Cardiology Institute of the Netherlands, Netherlands Heart Institute, Utrecht, the Netherlands
| | - Berardo Sarubbi
- Adult Congenital Heart Disease Unit, Department of Cardiology, Monaldi Hospital, Naples, Italy
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Siegmund AS, Pieper PG, Mulder BJM, Sieswerda GT, van Dijk APJ, Roos-Hesselink JW, Jongbloed MRM, Konings TC, Bouma BJ, Groen H, Sollie-Szarynska KM, Kampman MAM, Bilardo CM, van Veldhuisen DJ, Aalberts JJJ. Doppler gradients, valve area and ventricular function in pregnant women with aortic or pulmonary valve disease: Left versus right. Int J Cardiol 2020; 306:152-157. [PMID: 31785953 DOI: 10.1016/j.ijcard.2019.11.118] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 09/12/2019] [Accepted: 11/15/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Little is known about the course of echocardiographic parameters used for the evaluation of valvular heart disease (VHD) during pregnancy, hampering interpretation of possible changes (physiological vs. pathophysiological). Therefore we studied the course of these parameters and ventricular function in pregnant women with aortic and pulmonary VHD. METHODS The cohort comprised 66 pregnant women enrolled in the prospective ZAHARA studies or evaluated by an identical protocol who had pulmonary VHD or aortic VHD (stenosis/prosthetic valve). The control group comprised 46 healthy pregnant women. Echocardiography was performed preconception, during pregnancy and 1 year postpartum. Peak gradient, mean gradient, aortic valve area (AVA)/effective orifice area (EOA), left ventricular ejection fraction (LVEF) and right ventricular function (RVF; TAPSE) were assessed. RESULTS Peak and mean gradients increased during pregnancy compared to preconception in women with aortic VHD and controls (p < 0.0125), but not in women with pulmonary VHD. AVA/EOA remained unchanged. Preconception and postpartum gradients were comparable in all groups. Mean LVEF was normal in pregnant women with VHD and controls. Mean TAPSE was lower (p < 0.001) in women with pulmonary VHD compared to women with aortic VHD and controls (<20 mm vs. ≥23 mm; p < 0.001). In women with pulmonary VHD a decrease of TAPSE was observed during pregnancy (p = 0.005). CONCLUSION Physiological changes during pregnancy lead to increased Doppler gradients in women with aortic VHD. This increase was not found in women with pulmonary VHD, probably caused by impaired RVF. Therefore, evaluation of RVF during pregnancy might be important to prevent underestimation of the degree of stenosis.
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Affiliation(s)
- Anne S Siegmund
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Petronella G Pieper
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Barbara J M Mulder
- Department of Cardiology, Amsterdam University Medical Center, location Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Gertjan Tj Sieswerda
- Department of Cardiology, University Medical Center Utrecht, University of Utrecht, Utrecht, the Netherlands
| | - Arie P J van Dijk
- Department of Cardiology, Radboud University Medical Center, Radboud University, Nijmegen, the Netherlands
| | - Jolien W Roos-Hesselink
- Department of Cardiology, Erasmus Medical Center, University of Rotterdam, Rotterdam, the Netherlands
| | - Monique R M Jongbloed
- Department of Cardiology, Leiden University Medical Center, Leiden University, Leiden, the Netherlands
| | - Thelma C Konings
- Department of Cardiology, Amsterdam University Medical Center, location VU University Medical Center, VU University Amsterdam, Amsterdam, the Netherlands
| | - Berto J Bouma
- Department of Cardiology, Amsterdam University Medical Center, location Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Henk Groen
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Krystyna M Sollie-Szarynska
- Department of Obstetrics, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Marlies A M Kampman
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Caterina M Bilardo
- Department of Obstetrics, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Dirk J van Veldhuisen
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Jan J J Aalberts
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.
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Kauw D, Woudstra OI, van Engelen K, Meijboom FJ, Mulder BJM, Schuuring MJ, Bouma BJ. 22q11.2 deletion syndrome is associated with increased mortality in adults with tetralogy of Fallot and pulmonary atresia with ventricular septal defect. Int J Cardiol 2020; 306:56-60. [PMID: 32145937 DOI: 10.1016/j.ijcard.2020.02.064] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 01/15/2020] [Accepted: 02/26/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND 22q11.2 Deletion syndrome (22q11.2DS) is common in patients with tetralogy of Fallot (TOF) or pulmonary atresia with ventricular septal defect (PA/VSD) and is associated with worse outcomes in children. Whether this impaired prognosis is also translated into adulthood is unknown, as data in adult patients are limited. We aimed to compare long-term outcomes in adults with TOF or PA/VSD both with and without 22q11.2DS. METHODS This study prospectively followed a nationwide multicenter cohort of TOF or PA/VSD patients with genetically confirmed presence or absence of 22q11.2DS, from inclusion in the Dutch national CONCOR registry for adults with congenital heart disease (CHD) onward. Outcome measures included all-cause mortality, cardiac mortality, need for pulmonary valve replacement (PVR), ventricular arrhythmias (VA), pacemaker implantation, and ICD implantation. RESULTS In total, 479 patients were included (277 (58%) male, median age 28 [IQR; 21-37] years, 62 (13%) with PA/VSD, 34 (7%) with 22q11.2DS). During a median follow-up of 11 [IQR; 6-13] years, 52 (11%) patients died (8 with 22q11.2DS and 44 without 22q11.2DS). Patients with 22q11.2DS had significant decreased survival after 12 years (76% [95% CI; 62-93]) compared to patients without 22q11.2DS (89% [95% CI; 86-92], p = 0.008). 22q11.2DS was associated with increased risk of all-cause mortality and cardiac-mortality, independent of age, sex, and PA/VSD. No association was found between 22q11.2DS and late complications i.e. PVR, VA, pacemaker, or ICD implantation. CONCLUSIONS Adults with TOF or PA/VSD with 22q11.2DS have a significantly worse survival than adults without this deletion. In patients with TOF or PA/VSD, genetic analysis for the presence of 22q11.2DS is important for risk stratification and genetic counseling.
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Affiliation(s)
- Dirkjan Kauw
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, the Netherlands; Netherlands Heart Institute, Moreelsepark 1, 3351, EP, Utrecht, the Netherlands
| | - Odilia I Woudstra
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, the Netherlands; Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584, CX, Utrecht, the Netherlands
| | - Klaartje van Engelen
- Department of Clinical Genetics, Amsterdam UMC, VU University Medical Centre, De Boelelaan 1117, 1081, HV, Amsterdam, the Netherlands
| | - Folkert J Meijboom
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584, CX, Utrecht, the Netherlands
| | - Barbara J M Mulder
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, the Netherlands
| | - Mark J Schuuring
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, the Netherlands; Department of Cardiology, Haga Teaching Hospital, Els-Borst-Eilersplein 275, 2545 AA the Hague, the Netherlands
| | - Berto J Bouma
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, the Netherlands.
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Woudstra OI, van Dissel AC, van der Bom T, de Bruin-Bon RHACM, van Melle JP, van Dijk APJ, Vliegen HW, Mulder BJM, Tanck MWT, Meijboom FJ, Bouma BJ. Myocardial Deformation in the Systemic Right Ventricle: Strain Imaging Improves Prediction of the Failing Heart. Can J Cardiol 2019; 36:1525-1533. [PMID: 32553818 DOI: 10.1016/j.cjca.2019.12.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 11/28/2019] [Accepted: 12/10/2019] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Predicting heart failure events in patients with a systemic right ventricle (sRV) due to transposition of the great arteries (TGA) is important for timely intensification of follow-up. This study assessed the value of strain compared with currently used parameters as predictor for heart failure-free survival in patients with sRV. METHODS In participants of a multicentre trial, speckle-tracking echocardiography (STE) was performed to assess global longitudinal strain (GLS), mechanical dispersion (MD), and postsystolic shortening (PSS). Cox regression was used to determine the association of STE parameters with the combined end point of progression of heart failure and death, compared with cardiovascular magnetic resonance (CMR) and computed tomography (CT) derived parameters. RESULTS Echocardiograms of 60 patients were analyzed (mean age 34 ± 11 years, 65% male, 35% congenitally corrected TGA). Mean GLS was -13.5 ± 2.9%, median MD was 49 (interquartile range [IQR] 30-76) ms, and 14 patients (23%) had PSS. During a median 8 (IQR 7-9) years, 15 patients (25%) met the end point. GLS, MD, and PSS were all associated with heart failure-free survival in univariable analysis. After correction for age, only GLS (optimal cutoff > -10.5%) and CMR/CT-derived sRV ejection fraction (optimal cutoff < 30%) remained associated with heart failure-free survival: hazard ratio (HR) 8.27, 95% confidence interval (CI) 2.50-27.41 (P < 0.001), and HR 4.34, 95% CI 1.48-12.74 (P = 0.007), respectively). Combining GLS and ejection fraction improved prediction, with patients with both GLS > -10.5% and sRV ejection fraction < 30% at highest risk (HR 19.69, 95% CI 4.90-79.13; P < 0.001). CONCLUSIONS The predictive value of GLS was similar to that of CMR/CT-derived ejection fraction. The combination of GLS and ejection fraction identified patients at highest risk of heart failure and death. Easily available STE parameters can be used to guide follow-up intensity and can be integrated into future risk prediction scores.
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Affiliation(s)
- Odilia I Woudstra
- Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands; Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Alexandra C van Dissel
- Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands; Netherlands Heart Institute, Utrecht, The Netherlands
| | - Teun van der Bom
- Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Rianne H A C M de Bruin-Bon
- Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Joost P van Melle
- Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Arie P J van Dijk
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Hubert W Vliegen
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Barbara J M Mulder
- Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands; Netherlands Heart Institute, Utrecht, The Netherlands
| | - Michael W T Tanck
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Folkert J Meijboom
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Berto J Bouma
- Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands.
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Page DJ, Miossec MJ, Williams SG, Monaghan RM, Fotiou E, Cordell HJ, Sutcliffe L, Topf A, Bourgey M, Bourque G, Eveleigh R, Dunwoodie SL, Winlaw DS, Bhattacharya S, Breckpot J, Devriendt K, Gewillig M, Brook JD, Setchfield KJ, Bu'Lock FA, O'Sullivan J, Stuart G, Bezzina CR, Mulder BJM, Postma AV, Bentham JR, Baron M, Bhaskar SS, Black GC, Newman WG, Hentges KE, Lathrop GM, Santibanez-Koref M, Keavney BD. Whole Exome Sequencing Reveals the Major Genetic Contributors to Nonsyndromic Tetralogy of Fallot. Circ Res 2019; 124:553-563. [PMID: 30582441 DOI: 10.1161/circresaha.118.313250] [Citation(s) in RCA: 98] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
RATIONALE Familial recurrence studies provide strong evidence for a genetic component to the predisposition to sporadic, nonsyndromic Tetralogy of Fallot (TOF), the most common cyanotic congenital heart disease phenotype. Rare genetic variants have been identified as important contributors to the risk of congenital heart disease, but relatively small numbers of TOF cases have been studied to date. OBJECTIVE We used whole exome sequencing to assess the prevalence of unique, deleterious variants in the largest cohort of nonsyndromic TOF patients reported to date. METHODS AND RESULTS Eight hundred twenty-nine TOF patients underwent whole exome sequencing. The presence of unique, deleterious variants was determined; defined by their absence in the Genome Aggregation Database and a scaled combined annotation-dependent depletion score of ≥20. The clustering of variants in 2 genes, NOTCH1 and FLT4, surpassed thresholds for genome-wide significance (assigned as P<5×10-8) after correction for multiple comparisons. NOTCH1 was most frequently found to harbor unique, deleterious variants. Thirty-one changes were observed in 37 probands (4.5%; 95% CI, 3.2%-6.1%) and included 7 loss-of-function variants 22 missense variants and 2 in-frame indels. Sanger sequencing of the unaffected parents of 7 cases identified 5 de novo variants. Three NOTCH1 variants (p.G200R, p.C607Y, and p.N1875S) were subjected to functional evaluation, and 2 showed a reduction in Jagged1-induced NOTCH signaling. FLT4 variants were found in 2.4% (95% CI, 1.6%-3.8%) of TOF patients, with 21 patients harboring 22 unique, deleterious variants. The variants identified were distinct to those that cause the congenital lymphoedema syndrome Milroy disease. In addition to NOTCH1, FLT4 and the well-established TOF gene, TBX1, we identified potential association with variants in several other candidates, including RYR1, ZFPM1, CAMTA2, DLX6, and PCM1. CONCLUSIONS The NOTCH1 locus is the most frequent site of genetic variants predisposing to nonsyndromic TOF, followed by FLT4. Together, variants in these genes are found in almost 7% of TOF patients.
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Affiliation(s)
- Donna J Page
- From the Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine, and Health, Manchester Academic Health Science Centre, University of Manchester, United Kingdom (D.J.P., S.G.W., R.M.M., E.F., B.D.K.)
| | - Matthieu J Miossec
- Institute of Genetic Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom (M.J.M., H.J.C., L.S., A.T., M.S.-K.).,Center for Bioinformatics and Integrative Biology, Faculty of Biological Sciences, Universidad Andrés Bello, Santiago, Chile (M.J.M.)
| | - Simon G Williams
- From the Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine, and Health, Manchester Academic Health Science Centre, University of Manchester, United Kingdom (D.J.P., S.G.W., R.M.M., E.F., B.D.K.)
| | - Richard M Monaghan
- From the Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine, and Health, Manchester Academic Health Science Centre, University of Manchester, United Kingdom (D.J.P., S.G.W., R.M.M., E.F., B.D.K.)
| | - Elisavet Fotiou
- From the Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine, and Health, Manchester Academic Health Science Centre, University of Manchester, United Kingdom (D.J.P., S.G.W., R.M.M., E.F., B.D.K.)
| | - Heather J Cordell
- Institute of Genetic Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom (M.J.M., H.J.C., L.S., A.T., M.S.-K.)
| | | | - Ana Topf
- Institute of Genetic Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom (M.J.M., H.J.C., L.S., A.T., M.S.-K.)
| | - Mathieu Bourgey
- Canadian Centre for Computational Genomics, Montréal, QC, Canada (M.B.).,McGill Genome Center, Montréal, QC, Canada (M.B., G.B., R.E., G.M.L.)
| | - Guillaume Bourque
- McGill Genome Center, Montréal, QC, Canada (M.B., G.B., R.E., G.M.L.)
| | - Robert Eveleigh
- McGill Genome Center, Montréal, QC, Canada (M.B., G.B., R.E., G.M.L.)
| | - Sally L Dunwoodie
- Chain Reaction Program in Congenital Heart Disease Research, Victor Chang Cardiac Research Institute, Sydney, NSW, Australia (S.L.D.).,Faculties of Medicine and Science, University of New South Wales, Sydney (S.L.D.).,Heart Centre for Children, The Children's Hospital at Westmead, Sydney, NSW (S.L.D.)
| | - David S Winlaw
- School of Child and Adolescent Health, Sydney Medical School, University of Sydney (D.S.W.).,Victor Chang Cardiac Research Institute, NSW, Australia (D.S.W.).,RDM Cardiovascular Medicine, Wellcome Centre for Human Genetics, University of Oxford (D.S.W., S.B.)
| | - Shoumo Bhattacharya
- RDM Cardiovascular Medicine, Wellcome Centre for Human Genetics, University of Oxford (D.S.W., S.B.).,Center for Human Genetics, Catholic University Leuven, Belgium (S.B., J.B., K.D.)
| | - Jeroen Breckpot
- Center for Human Genetics, Catholic University Leuven, Belgium (S.B., J.B., K.D.).,Pediatric and Congenital Cardiology, UZ Leuven (J.B., M.G.)
| | - Koenraad Devriendt
- Center for Human Genetics, Catholic University Leuven, Belgium (S.B., J.B., K.D.)
| | - Marc Gewillig
- Pediatric and Congenital Cardiology, UZ Leuven (J.B., M.G.)
| | - J David Brook
- School of Life Sciences, University of Nottingham, Queen's Medical Centre (J.D.B., K.J.S.)
| | - Kerry J Setchfield
- School of Life Sciences, University of Nottingham, Queen's Medical Centre (J.D.B., K.J.S.)
| | - Frances A Bu'Lock
- Congenital and Paediatric Cardiology, East Midlands Congenital Heart Centre and University of Leicester, Glenfield Hospital (F.A.B.)
| | - John O'Sullivan
- Adult Congenital and Paediatric Cardiac Unit, Freeman Hospital, Newcastle upon Tyne (J.O.)
| | - Graham Stuart
- University Hospitals Bristol NHS Foundation Trust, Bristol (G.S.)
| | - Connie R Bezzina
- Heart Center, Department of Clinical and Experimental Cardiology (C.R.B.), Academic Medical Center, Amsterdam, the Netherlands
| | - Barbara J M Mulder
- Department of Medical Biology (B.J.M.M.), Academic Medical Center, Amsterdam, the Netherlands
| | - Alex V Postma
- Department of Clinical Genetics (A.V.P.), Academic Medical Center, Amsterdam, the Netherlands
| | - James R Bentham
- Department of Paediatric Cardiology, Yorkshire Heart Centre, Leeds (J.R.B.)
| | - Martin Baron
- Division of Molecular and Cellular Function, School of Biological Sciences, Faculty of Biology Medicine and Health, University of Manchester (M.B.)
| | - Sanjeev S Bhaskar
- Manchester Centre for Genomic Medicine, Saint Mary's Hospital, Oxford, Manchester (S.S.B., G.C.B.)
| | - Graeme C Black
- Manchester Centre for Genomic Medicine, Saint Mary's Hospital, Oxford, Manchester (S.S.B., G.C.B.)
| | - William G Newman
- Division of Evolution and Genomic Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Oxford (W.G.N.); and Division of Evolution and Genomic Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, UK
| | | | - G Mark Lathrop
- McGill Genome Center, Montréal, QC, Canada (M.B., G.B., R.E., G.M.L.)
| | - Mauro Santibanez-Koref
- Institute of Genetic Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom (M.J.M., H.J.C., L.S., A.T., M.S.-K.)
| | - Bernard D Keavney
- From the Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine, and Health, Manchester Academic Health Science Centre, University of Manchester, United Kingdom (D.J.P., S.G.W., R.M.M., E.F., B.D.K.)
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Yang H, Nassif M, Khairy P, de Groot JR, Roos YBWEM, de Winter RJ, Mulder BJM, Bouma BJ. Cardiac diagnostic work-up of ischaemic stroke. Eur Heart J 2019; 39:1851-1860. [PMID: 29788298 DOI: 10.1093/eurheartj/ehy043] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Accepted: 08/17/2016] [Indexed: 12/20/2022] Open
Abstract
Cardioembolic sources account for 20-30% of ischaemic strokes and are important to identify considering their prognostic and therapeutic implications. During the past years, new developments have been made in the cardiac diagnostic evaluation and management of patients with ischaemic stroke, especially regarding strokes of unknown aetiology. These recent advances have had a major impact on our understanding of embolic strokes, their diagnostic work-up, and clinical management. Herein, we propose a cardiac diagnostic work-up scheme for patients with ischaemic stroke from definite cardioembolic sources and embolic strokes of undetermined source.
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Affiliation(s)
- Hayang Yang
- Department of Cardiology, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.,Interuniversity Cardiology Institute of the Netherlands-Netherlands Heart Institute, Moreelsepark 1, 3511 EP, Utrecht, The Netherlands
| | - Martina Nassif
- Department of Cardiology, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Paul Khairy
- Department of Cardiology, Montreal Heart Institute, Université de Montréal, 5000 Rue Bélanger, QC H1T 1C8, Montreal, Canada
| | - Joris R de Groot
- Department of Cardiology, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Yvo B W E M Roos
- Department of Neurology, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Robbert J de Winter
- Department of Cardiology, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Barbara J M Mulder
- Department of Cardiology, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.,Interuniversity Cardiology Institute of the Netherlands-Netherlands Heart Institute, Moreelsepark 1, 3511 EP, Utrecht, The Netherlands
| | - Berto J Bouma
- Department of Cardiology, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
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35
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Kuijpers JM, Vaartjes I, Bokma JP, van Melle JP, Sieswerda GT, Konings TC, Bakker-de Boo M, van der Bilt I, Voogel B, Zwinderman AH, Mulder BJM, Bouma BJ. Risk of coronary artery disease in adults with congenital heart disease: A comparison with the general population. Int J Cardiol 2019; 304:39-42. [PMID: 31767384 DOI: 10.1016/j.ijcard.2019.11.114] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 09/28/2019] [Accepted: 11/15/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Coronary artery disease (CAD) will increasingly determine outcome in the aging adult congenital heart disease (CHD) population. We aimed to determine sex-specific incidence of CAD in adult CHD patients throughout adulthood, compared to the general population. METHODS AND RESULTS We followed 11,723 adult CHD patients (median age 33 years; 49% male; 57% mild, 34% moderate, 9% severe CHD) from the Dutch CONCOR registry, and two age-sex-matched persons per patient from the general population for first CAD event in national registers (period 2002-2012). Incidence rates were estimated using smoothed hazard functions. CAD risk during follow-up, stratified by CHD severity, was compared using proportional subdistribution hazards regression. In ACHD patients, 103 CAD events (43 women) occurred over 60,456 person-years. Rates per 1000person-years increased from 0.3(95% confidence interval: 0.1-0.6) at age 20 to 5.8(3.7-8.9) at 70 years in female, and from 0.5(0.3-1.0) to 7.8(5.1-11.8) in male patients. Compared to the general population, relative risk was 12.0(2.5-56.3) in women and 4.6(1.7-12.1) in men aged 20 years. Relative risk declined with age, remaining significant up to age ~65 years in women and ~50 years in men. In patients with mild, moderate and severe CHD, CAD risk was 1.3(0.9-1.9), 1.6(1.0-2.5) and 2.9(1.3-6.9) times increased compared to the general population, respectively. CONCLUSIONS We found increased CAD risk in adult CHD patients, with greater relative risk at younger age, in women and those with more severe CHD. These results underline the importance of screening for and treatment of CAD risk factors in these patients.
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Affiliation(s)
- Joey M Kuijpers
- Department of Cardiology, Academic Medical Center, Amsterdam, the Netherlands; Netherlands Heart Institute, Utrecht, the Netherlands
| | - Ilonca Vaartjes
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Jouke P Bokma
- Department of Cardiology, Academic Medical Center, Amsterdam, the Netherlands; Netherlands Heart Institute, Utrecht, the Netherlands
| | - Joost P van Melle
- Department of Cardiology, University Medical Center Groningen, Groningen, the Netherlands
| | - Gertjan Tj Sieswerda
- Department of Cardiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Thelma C Konings
- Department of Cardiology, VU University Medical Center, Amsterdam, the Netherlands
| | | | - Ivo van der Bilt
- Department of Cardiology, HagaZiekenhuis, Den Haag, the Netherlands
| | - Bart Voogel
- Department of Cardiology, Spaarne Gasthuis, Haarlem/Hoofddorp, the Netherlands
| | - Aeilko H Zwinderman
- Department of Clinical Epidemiology and Biostatistics, Academic Medical Center, Amsterdam, the Netherlands
| | - Barbara J M Mulder
- Department of Cardiology, Academic Medical Center, Amsterdam, the Netherlands; Netherlands Heart Institute, Utrecht, the Netherlands
| | - Berto J Bouma
- Department of Cardiology, Academic Medical Center, Amsterdam, the Netherlands.
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36
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Ellesøe SG, Workman CT, Bouvagnet P, Loffredo CA, McBride KL, Hinton RB, van Engelen K, Gertsen EC, Mulder BJM, Postma AV, Anderson RH, Hjortdal VE, Brunak S, Larsen LA. Familial co-occurrence of congenital heart defects follows distinct patterns. Eur Heart J 2019; 39:1015-1022. [PMID: 29106500 PMCID: PMC6018923 DOI: 10.1093/eurheartj/ehx314] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Accepted: 06/01/2017] [Indexed: 12/16/2022] Open
Abstract
Aims Congenital heart defects (CHD) affect almost 1% of all live born children and the number of adults with CHD is increasing. In families where CHD has occurred previously, estimates of recurrence risk, and the type of recurring malformation are important for counselling and clinical decision-making, but the recurrence patterns in families are poorly understood. We aimed to determine recurrence patterns, by investigating the co-occurrences of CHD in 1163 families with known malformations, comprising 3080 individuals with clinically confirmed diagnosis. Methods and results We calculated rates of concordance and discordance for 41 specific types of malformations, observing a high variability in the rates of concordance and discordance. By calculating odds ratios for each of 1640 pairs of discordant lesions observed between affected family members, we were able to identify 178 pairs of malformations that co-occurred significantly more or less often than expected in families. The data show that distinct groups of cardiac malformations co-occur in families, suggesting influence from underlying developmental mechanisms. Analysis of human and mouse susceptibility genes showed that they were shared in 19% and 20% of pairs of co-occurring discordant malformations, respectively, but none of malformations that rarely co-occur, suggesting that a significant proportion of co-occurring lesions in families is caused by overlapping susceptibility genes. Conclusion Familial CHD follow specific patterns of recurrence, suggesting a strong influence from genetically regulated developmental mechanisms. Co-occurrence of malformations in families is caused by shared susceptibility genes.
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Affiliation(s)
- Sabrina G Ellesøe
- Programme for Disease Systems Biology, Novo Nordisk Foundation Center for Protein Research, University of Copenhagen, Blegdamsvej 3, DK-2200 Copenhagen, Denmark
| | - Christopher T Workman
- Department of Biotechnology and Biomedicine, Technical University of Denmark, Lyngby, Denmark
| | - Patrice Bouvagnet
- Laboratoire Cardiogénétique, Hospices Civils de Lyon, Groupe Hospitalier Est, 59 boulevard Pinel, CBPE, 69677, Bron, France
| | - Christopher A Loffredo
- Department of Oncology, Georgetown University Medical Center, 3970 Reservoir Road, Washington, DC 20057-1472, USA
| | - Kim L McBride
- Center for Cardiovascular Research, Nationwide Children's Hospital, and Department of Pediatrics, Ohio State University, 700 Children's Drive Columbus, OH 43205, Columbus, OH, USA
| | - Robert B Hinton
- Division of Cardiology, The Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 2003, Cincinnati, OH, 45229, USA
| | - Klaartje van Engelen
- Department of Clinical Genetics, Academic Medical Centre, Meibergdreef 15, Amsterdam 1105 AZ, The Netherlands.,Department of Clinical Genetics, VU University, De Boelelaan 1117, NL-1081 HV Amsterdam, The Netherlands
| | - Emma C Gertsen
- Department of Clinical Genetics, Academic Medical Centre, Meibergdreef 15, Amsterdam 1105 AZ, The Netherlands
| | - Barbara J M Mulder
- Department of Cardiology, Academic Medical Centre, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - Alex V Postma
- Department of Clinical Genetics, Academic Medical Centre, Meibergdreef 15, Amsterdam 1105 AZ, The Netherlands.,Department of Anatomy, Embryology & Physiology, Academic Medical Centre, Meibergdreef 15, Amsterdam 1105 AZ, The Netherlands
| | - Robert H Anderson
- Institute of Genetic Medicine, Newcastle University, Central Pkwy, Newcastle upon Tyne NE1 3BZ, UK
| | - Vibeke E Hjortdal
- Department of Cardiothoracic Surgery, Aarhus University Hospital, Skejby, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
| | - Søren Brunak
- Programme for Disease Systems Biology, Novo Nordisk Foundation Center for Protein Research, University of Copenhagen, Blegdamsvej 3, DK-2200 Copenhagen, Denmark
| | - Lars A Larsen
- Wilhelm Johannsen Centre for Functional Genome Research, Department of Cellular and Molecular Medicine, University of Copenhagen, Blegdamsvej 3, DK-2200 Copenhagen, Denmark
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37
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Kauw D, Koole MAC, Winter MM, Dohmen DAJ, Tulevski II, Blok S, Somsen GA, Schijven MP, Vriend JWJ, Robbers-Visser D, Mulder BJM, Bouma BJ, Schuuring MJ. Advantages of mobile health in the management of adult patients with congenital heart disease. Int J Med Inform 2019; 132:104011. [PMID: 31654966 DOI: 10.1016/j.ijmedinf.2019.104011] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 08/22/2019] [Accepted: 10/14/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND Adults with congenital heart disease (ACHD) often suffer from deterioration related to cardiac arrhythmias, hypertension (HT) or heart failure (HF), frequently occurring between planned visits. Mobile health (mHealth) could improve management through remote monitoring by enabling swift therapeutic response and detecting new diagnoses. METHODS We performed a prospective study employing mHealth in ACHD patients, weekly monitoring heart rhythm, weight and blood pressure. In case of consecutive threshold exceeding measurements or in case of new diagnosis, patients were contacted and if needed the treating physician was consulted. Inclusion criteria were: palpitations within the last three years (with or without arrhythmia diagnosis) or HF NYHA class ≥ II. We evaluated the detection of recurrences and new diagnosis of arrhythmias, HT and HF, adherence and patient experience (Net Promotor Score (NPS)). RESULTS In total, 109 of the 268 invited ACHD patients were enrolled, 80 with palpitations, 13 with HF, 16 experienced both, mean age 45 (±13) years, 33% male. Median follow-up was 12 (Q1-Q3;9-14) months, 91 patients initiated all measurements (heart rhythm, weight and blood pressure). In 25% of the patients with diagnosed arrhythmias (14/56) recurrences of arrhythmias were detected; 13% of the patients with undiagnosed palpitations (4/32) were diagnosed with novel arrhythmias. In 38% of the patients with HT at baseline (6/16), treatment adjustment was necessary, 4% of the patients without HT (4/76) received novel HT diagnosis. Diuretics were adjusted in 7% of the patients with HF (2/29). Adherence was > 70% in 77% of the patients that started weekly measurements (70/91). Patients that were female, older of age and experienced palpitations at inclusion were more likely to acquire an adherence of > 70%. NPS was completed by 68 patients, 57 patients (84%) were promotors or neutral, and 11 patients (16%) were critics. CONCLUSIONS mHealth offers advantages in the management of selected ACHD patients; it enabled early detection of recurrences and new diagnosis of arrhythmias, hypertension and heart failure, which lead to swift therapeutic response or remote reassurance. Furthermore, mHealth was well accepted with high adherence and positive patient experience.
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Affiliation(s)
- Dirkjan Kauw
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Netherlands Heart Institute, Utrecht, the Netherlands
| | - Maarten A C Koole
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Cardiology Centers of the Netherlands, Amsterdam, the Netherlands; Department of Cardiology, Rode Kruis Ziekenhuis, Beverwijk, the Netherlands
| | - Michiel M Winter
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Cardiology Centers of the Netherlands, Amsterdam, the Netherlands
| | | | - Igor I Tulevski
- Cardiology Centers of the Netherlands, Amsterdam, the Netherlands
| | - Sebastiaan Blok
- Cardiology Centers of the Netherlands, Amsterdam, the Netherlands; Department of Vascular medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - G Aernout Somsen
- Cardiology Centers of the Netherlands, Amsterdam, the Netherlands
| | - Marlies P Schijven
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Joris W J Vriend
- Department of Cardiology, Haga Teaching Hospital, the Hague, the Netherlands
| | - Daniëlle Robbers-Visser
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Barbara J M Mulder
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Berto J Bouma
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Mark J Schuuring
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Department of Cardiology, Haga Teaching Hospital, the Hague, the Netherlands.
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38
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Van Andel MM, Wanga S, Yin X, Skroblin P, Koolbergen DR, Groenink M, Zwinderman AH, De Vries CJ, Mulder BJM, Mayr M, De Waard V. 444Plasma levels of microfibrillar associated protein type 4 (MFAP4) are predictive for aortic dissection in patients with Marfan Syndrome. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz747.0110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Aim
Marfan syndrome is a disorder with mutations in the fibrillin-1 gene, leading to elastic fiber degradation and increased TGF-beta signaling. The life-threatening feature of Marfan is aneurysm formation with a risk of fatal aortic dissections. In a proteomics screen, we identified MFAP4, a protein involved in fibrillin-1 and elastic fiber formation, to be increased in the Marfan aorta. We aim to study the role of MFAP4 in Marfan aortic disease.
Methods and results
MFAP4 co-localizes in the aorta with elastin and collagen fibers.
In vitro experiments show that MFAP4 expression is upregulated by TGF-beta, which could explain the increased MFAP4 protein levels in the Marfan aorta.
In a substudy of 96 Marfan patients from the COMPARE trial, MFAP4 levels correlate with aortic root diameter (r=0.30, p=0.01). Patients previously enrolled in the COMPARE trial were retrospectively analyzed. Cardiovascular events, including aortic dissection, were assessed. Plasma samples were prospectively collected at time of inclusion in the study and analyzed retrospectively on MFAP4. In the 7 years of follow up, 5 Type B dissections occurred, all of them in patients in the upper tertile of plasma MFAP4. High plasma MFAP4 associates with poor dissection-free survival (Figure 1).
Moreover, the aortic distensibility as measure for aortic stiffness and damage, was calculated throughout the aorta from available MRI images of these patients. Interestingly, in the descending thoracic aorta where type B dissections occur, the aortic distensibility is significantly lower (indicating decreased aortic elasticity) in Marfan patients with high plasma MFAP4, thus associating with aortic damage.
Figure 1
Conclusion
MFAP4, a protein involved in extracellular matrix assembly, is elevated in the Marfan aorta. High plasma MFAP4 seems to reflect aortic damage and predicted type B aortic dissections in up to 7 years follow up.
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Affiliation(s)
- M M Van Andel
- Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, Netherlands (The)
| | - S Wanga
- Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, Netherlands (The)
| | - X Yin
- Kings College Hospital, Cardiovascular Proteomics, London, United Kingdom
| | - P Skroblin
- Kings College Hospital, Cardiovascular Proteomics, London, United Kingdom
| | - D R Koolbergen
- Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, Netherlands (The)
| | - M Groenink
- Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, Netherlands (The)
| | - A H Zwinderman
- Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, Netherlands (The)
| | - C J De Vries
- Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, Netherlands (The)
| | - B J M Mulder
- Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, Netherlands (The)
| | - M Mayr
- Kings College Hospital, Cardiovascular Proteomics, London, United Kingdom
| | - V De Waard
- Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, Netherlands (The)
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Van Andel MM, Jalalzadeh J, Indrakusuma R, Balm R, Timmermans J, Van Den Berg MP, Scholte AJHA, De Waard V, Zwinderman AH, Mulder BJM, Groenink M. 445Effects of losartan and beta-blockers on aortic root dilatation in patients with Marfan Syndrome - results of the extended COMPARE trial. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz747.0111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
Despite several randomized trials, beneficial effects of Losartan and β-blockers in adults with Marfan syndrome (MFS) are not entirely clear. The COMPARE trial previously showed a small but significant beneficial effect of Losartan on top of β-blocker use on aortic root dilatation rate. Yet, this effect was not reproduced by other trials, although in general a favourable effect of Losartan could be demonstrated. All trials in adults with MFS showed lower than expected aortic root dilatation rates, suggesting mildly affected study populations. Therefore we extended the follow-up period of the COMPARE trial up to 10 years and aimed to assess the clinical outcomes of the study cohort, as well as the effect of medication regimes on aortic root dilatation rates in the subgroup of patients with a native aortic root at initial randomization.
Methods
Patients previously enrolled in the COMPARE trial were retrospectively analyzed. Cardiovascular events (aortic dissections, ruptures and operations) and all-cause mortality were assessed. Individual aortic root dilatation rates were estimated in patients with a native aortic root at time of randomization on the basis of linear regression analysis of multiple transthoracic echocardiogram (TTE) results. Correlations between aortic root dilatation rates and cumulative Losartan or β-blocker treatment days were assessed with Spearman's rho (ρ).
Results
During a median follow-up of 8.0 years, two dissections and three deaths occurred in the 151 patients with a native aortic root at time of randomization. The 122 patients that were eligible for aortic root dilatation analysis, underwent a median of 6 TTEs. The median aortic root dilatation rate in these patients was 0.28 (interquartile range 0.09 - 0.59) mm/y. These patients were further classified as either patients with a stable aortic root (n=102) or with aortic root growth (n=20), based on the threshold of 0.9 mm per year. Patients with aortic root growth had significantly more aortic root replacements during follow-up (17/20 vs 18/102, P=0.001).
Furthermore, aortic root dilatation rate was negatively correlated with the number of Losartan treatment days (ρ=−0.272, P=0.003), β-blocker treatment days (ρ=−0.217, P=0.017) and with the duration of follow-up (ρ=−0.437, P<0.001).
Conclusions
Our results support previous findings that Losartan and β-blockers appear to be equally effective on aortic root dilatation rate in Marfan Syndrome patients. The low event rate in the long term follow-up of this subgroup of the COMPARE trial represent a relatively mildly affected study population and an aggressive prophylactic surgical regime.
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Affiliation(s)
- M M Van Andel
- Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, Netherlands (The)
| | - J Jalalzadeh
- Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, Netherlands (The)
| | - R Indrakusuma
- Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, Netherlands (The)
| | - R Balm
- Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, Netherlands (The)
| | - J Timmermans
- Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, Netherlands (The)
| | - M P Van Den Berg
- University Medical Center Groningen, Groningen, Netherlands (The)
| | | | - V De Waard
- Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, Netherlands (The)
| | - A H Zwinderman
- Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, Netherlands (The)
| | - B J M Mulder
- Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, Netherlands (The)
| | - M Groenink
- Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, Netherlands (The)
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Woudstra OI, Kuijpers JM, Meijboom FJ, Post MC, Jongbloed MRM, Duijnhouwer AL, van Dijk APJ, van Melle JP, Konings TC, Zwinderman AH, Mulder BJM, Bouma BJ. High burden of drug therapy in adult congenital heart disease: polypharmacy as marker of morbidity and mortality. Eur Heart J Cardiovasc Pharmacother 2019; 5:216-225. [PMID: 30903133 PMCID: PMC6749841 DOI: 10.1093/ehjcvp/pvz014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 02/11/2019] [Accepted: 03/20/2019] [Indexed: 11/13/2022]
Abstract
Aims To assess medication use in adult congenital heart disease (ACHD) patients compared to the age- and sex-matched general population, identify patterns of pharmacotherapy, and analyse associations between pharmacotherapy and adverse outcomes in ACHD. Methods and results Data of 14 138 ACHD patients from the CONCOR registry [35 (24–48) years, 49% male] and age- and sex-matched referents (1:10 ratio) were extracted from the Dutch Dispensed Drug Register for the years 2006–14. Adult congenital heart disease patients had more cardiovascular and non-cardiovascular drugs than referents (median 3 vs. 1, P < 0.001). Polypharmacy, defined as ≥5 dispensed drug types yearly, was present in 30% of ACHD and 15% of referents {odds ratio [OR] = 2.47 [95% confidence interval (CI) 2.39–2.54]}. Polypharmacy was independently associated with female sex [OR = 1.92 (95% CI 1.88–1.96)], older age [for men: OR = 2.3/10 years (95% CI 2.2–2.4) and for women: OR = 1.6/10 years (95% CI 1.5–1.6); Pinteraction < 0.001], and ACHD severity [mild: OR = 2.51 (95% CI 2.40–2.61), moderate: OR = 3.22 (95% CI 3.06–3.40), severe: OR = 4.87 (95% CI 4.41–5.38)]. Cluster analysis identified three subgroups with distinct medication patterns; a low medication use group (8-year cumulative survival: 98%), and a cardiovascular and comorbidity group with lower survival (92% and 95%, respectively). Cox regression revealed a strong association between polypharmacy and mortality [hazard ratio (HR) = 3.94 (95% CI 3.22–4.81)], corrected for age, sex, and defect severity. Polypharmacy also increased the risk of hospitalization for adverse drug events [HR = 4.58 (95% CI 2.04–10.29)]. Conclusion Both cardiovascular and non-cardiovascular medication use is high in ACHD with twice as much polypharmacy compared with the matched general population. Patients with polypharmacy had a four-fold increased risk of mortality and adverse drug events. Recognition of distinct medication patterns can help identify patients at highest risk. Drug regimens need repeating evaluation to assess the appropriateness of all prescriptions. More high-quality studies are needed to improve ACHD care with more evidence-based pharmacotherapy.
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Affiliation(s)
- Odilia I Woudstra
- Department of Cardiology, Heart Center, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Meibergdreef 9, AZ Amsterdam, The Netherlands.,Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, CX Utrecht, The Netherlands
| | - Joey M Kuijpers
- Department of Cardiology, Heart Center, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Meibergdreef 9, AZ Amsterdam, The Netherlands.,Netherlands Heart Institute, Moreelsepark 1, EP Utrecht, The Netherlands
| | - Folkert J Meijboom
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, CX Utrecht, The Netherlands
| | - Marco C Post
- Department of Cardiology, St. Antonius Hospital, Koekoekslaan 1, CM Nieuwegein, The Netherlands
| | - Monique R M Jongbloed
- Department of Anatomy & Embryology, Leiden University Medical Center, Albinusdreef 2, ZA Leiden, The Netherlands.,Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, ZA Leiden, The Netherlands
| | - Anthonie L Duijnhouwer
- Department of Cardiology, Radboud University Medical Center, Geert Grooteplein Zuid 10, GA Nijmegen, The Netherlands
| | - Arie P J van Dijk
- Department of Cardiology, Radboud University Medical Center, Geert Grooteplein Zuid 10, GA Nijmegen, The Netherlands
| | - Joost P van Melle
- Department of Cardiology, University Medical Center Groningen, Hanzeplein 1, EZ Groningen, The Netherlands
| | - Thelma C Konings
- Department of Cardiology, VU University Medical Center, De Boelelaan 1117, HV Amsterdam, The Netherlands
| | - Aeilko H Zwinderman
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, AZ Amsterdam, The Netherlands
| | - Barbara J M Mulder
- Department of Cardiology, Heart Center, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Meibergdreef 9, AZ Amsterdam, The Netherlands.,Netherlands Heart Institute, Moreelsepark 1, EP Utrecht, The Netherlands
| | - Berto J Bouma
- Department of Cardiology, Heart Center, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Meibergdreef 9, AZ Amsterdam, The Netherlands
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41
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Woudstra OI, Van Dissel AC, Van Der Bom T, De Bruin - Bon HACM, Van Melle JP, Vliegen HW, Van Dijk APJ, Mulder BJM, Meijboom FJ, Bouma BJ. P2738Prognosis of the systemic right ventricle further refined: a role for myocardial strain analysis. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz748.1055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Background
Predicting heart failure in patients a with systemic right ventricle (sRV) due to transposition of the great arteries (TGA) is difficult. Strain parameters are easily available and detect early myocardial damage.
Purpose
To determine the value of strain parameters compared to cardiovascular magnetic resonance (CMR) derived parameters as predictors for heart failure-free survival in patients with an sRV.
Methods
In participants of a multicenter prospective trial, global longitudinal strain (GLS) was assessed on echocardiography using speckle tracking. Cox regression was used to determine the association of sRV GLS and postsystolic shortening, defined as >20% of myocardial contraction appearing after aortic valve closure, with the combined endpoint of progression of heart failure and death, compared to CMR derived parameters.
Results
Echocardiograms of 61/88 participants could be analyzed (age 34±11 years, 66% male, 34% congenitally corrected TGA). Mean GLS was −13.5±2.9% and 13 (21%) patients had postsystolic shortening. During 8 [7–9] years, 15 (23%) patients met the composite endpoint. sRV ejection fraction (mean 39±9%, HR=0.93/% [95% CI 0.87–0.99]), sRV end systolic volume (mean 80±31 ml/m2, HR=1.19 per 10ml/m2 [95% CI 1.01–1.40]), GLS (HR=1.25/% [95% CI 1.01–1.54]) and postsystolic shortening (HR=4.10 [95% CI 1.48–11.37]) were all associated with heart failure-free survival in univariable analysis. Optimal cut-offs for sRV ejection fraction and GLS were 30% and −10.5%, respectively, with comparable predictive value for heart failure-free survival (iAUC=0.66 and iAUC=0.68). Patients with both decreased strain (>−10.5%) and decreased RVEF (<30%) were at highest risk for heart failure and death (HR=19.83 [95% CI 4.92–80.01], iAUC=0.73).
Predicted heart failure-free survival
Conclusion
The predictive value of global longitudinal strain is comparable to CMR derived ejection fraction. Patients with both low ejection fraction and low myocardial strain are at highest risk of heart failure and death. These easily available parameters should be integrated in future risk prediction scores and can be used in the clinic to guide follow-up intensity.
Acknowledgement/Funding
This work was supported by the Dutch Heart Foundation [CVON 2014-18 project CONCOR-genes]
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Affiliation(s)
- O I Woudstra
- Academic Medical Center of Amsterdam, Amsterdam, Netherlands (The)
| | - A C Van Dissel
- Academic Medical Center of Amsterdam, Amsterdam, Netherlands (The)
| | - T Van Der Bom
- Academic Medical Center of Amsterdam, Amsterdam, Netherlands (The)
| | | | - J P Van Melle
- University Medical Center Groningen, Groningen, Netherlands (The)
| | - H W Vliegen
- Leiden University Medical Center, Leiden, Netherlands (The)
| | - A P J Van Dijk
- Radboud University Medical Centre, Nijmegen, Netherlands (The)
| | - B J M Mulder
- Academic Medical Center of Amsterdam, Amsterdam, Netherlands (The)
| | - F J Meijboom
- University Medical Center Utrecht, Utrecht, Netherlands (The)
| | - B J Bouma
- Academic Medical Center of Amsterdam, Amsterdam, Netherlands (The)
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42
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Van Dissel AC, Van Dijk APJ, Duijnhouwer AL, Mulder BJM, Bouma BJ. P1803Refining the 2015 European guidelines risk assessment tool for pulmonary arterial hypertension in adult congenital heart disease. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz748.0555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Current European guidelines advocate a goal-oriented treatment approach in pulmonary arterial hypertension (PAH), based on a comprehensive risk assessment. However, this instrument has been based predominantly on patients with idiopathic PAH and its accuracy has not been well established for PAH associated with congenital heart disease (CHD)–a patient population known to be distinctly different for other PAH aetiologies.
Purpose
To investigate the discriminatory ability of the guidelines risk assessment tool and explore the benefit of including other cut-offs or variables in PAH-CHD.
Methods and results
Data from 112 PAH-CHD patients (age 42.1±16 years, 70% Eisenmenger, 38% Down syndrome) seen between 2004 and 2016 at two specialized adult PAH-CHD expert centres were prospectively collected. Patients were classified as “Low”, “Intermediate”, or “High” risk following the strategy proposed by Kylhammar (Eur Heart J, 2017) based on N-terminal pro-brain natriuretic peptide (NT-proBNP), 6-minute walk distance, functional class and imaging parameters and analysed by Kaplan-Meier method, truncated at 5 years. At baseline, 25% (28) of patients were classified as “Low risk”, 69% (77) as “Intermediate risk” and 6% (7) as “High risk”. Although survival was better (P=0.012) for patients with higher proportions of “Low risk” variables, this method did not discriminate well between the three risk groups (Figure 1A, P=0.371). One-year survival estimates corresponded moderately to those proposed by the guidelines, 96.4% in the “Low risk” (vs. >95%), 94.8% in the “Intermediate risk” (vs. 90–95%), and 85.7% in the “High risk” (vs. <90%) baseline cohorts, respectively. Analysis of different cut-off values for NT-proBNP (i.e., “Low”, “Intermediate”, “High” as <500, 500–1440 and >1400 ng/l, respectively) and use of tricuspid annular plane systolic excursion (TAPSE) measurements (“Low”, “Intermediate”, “High” as <1.6, 2.6–2.7 and >2.7 cm, respectively) as imaging parameter instead of right atrial area improved discrimination between the risk groups (Figure 1B). With these adjustments to the risk assessment tool, survival differed between all three risk groups (P<0.001).
Figure 1
Conclusion
Our preliminary findings suggest that an updated version of the European guidelines risk assessment tool–with different cut-off values for NT-proBNP and use of TAPSE–discriminates more accurately in the PAH-CHD population. Further analysis will be performed to estimate the prognostic benefit of reaching a “Low risk” profile, as this is the recommended treatment goal.
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Affiliation(s)
- A C Van Dissel
- Academic Medical Center of Amsterdam, Cardiology, Amsterdam, Netherlands (The)
| | - A P J Van Dijk
- Radboud University Medical Centre, Cardiology, Nijmegen, Netherlands (The)
| | - A L Duijnhouwer
- Radboud University Medical Centre, Cardiology, Nijmegen, Netherlands (The)
| | - B J M Mulder
- Academic Medical Center of Amsterdam, Cardiology, Amsterdam, Netherlands (The)
| | - B J Bouma
- Academic Medical Center of Amsterdam, Cardiology, Amsterdam, Netherlands (The)
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Vehmeijer JT, Koyak Z, Vink AS, Budts W, Harris L, Silversides CK, Oechslin EN, Zwinderman AH, Mulder BJM, de Groot JR. Prolonged T peak -T end interval is a risk factor for sudden cardiac death in adults with congenital heart disease. CONGENIT HEART DIS 2019; 14:952-957. [PMID: 31573144 PMCID: PMC7003836 DOI: 10.1111/chd.12847] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Revised: 09/05/2019] [Accepted: 09/11/2019] [Indexed: 11/29/2022]
Abstract
Objective Adult congenital heart disease (ACHD) patients are at risk of sudden cardiac death (SCD). However, methods for risk stratification are not yet well‐defined. The Tpeak‐Tend (TpTe) interval, a measure of dispersion of ventricular repolarization, is a risk factor for SCD in non‐ACHD patients. We aim to evaluate whether TpTe can be used in risk stratification for SCD in ACHD patients. Design From an international multicenter cohort of 25 790 ACHD patients, we identified all SCD cases. Cases were matched to controls by age, gender, congenital defect, and (surgical) intervention. Outcome Measures TpTe was measured on a standard 12‐lead ECG. The maximum TpTe of all ECG leads (TpTe‐max), mean (TpTe‐mean), and TpTe dispersion (maximum minus minimum) were obtained. Odds ratios (OR) for SCD cases vs controls were calculated using conditional logistic regression analysis. Results ECGs were available for 147 cases (median age at death 33.5 years (quartiles 26.2, 48.7), 66% male) and 267 controls. The mean TpTe‐max was 97 ± 24 ms in cases vs 84 ± 17 ms in controls (P < .001); TpTe‐mean was 70 ± 16 vs 63 ± 10 ms (P < .001); and dispersion was 51 ± 22 ms vs 41 ± 16 ms (P = .02), respectively. Assessing each ECG lead separately, TpTe in lead aVR predicted SCD most accurately. TpTe in lead aVR was 71 ± 23 ms in cases vs 61 ± 13 ms in controls (P < .001). After adjusting for impaired ventricular function, heart failure symptoms, and prolonged QRS duration, the OR of SCD of TpTe in lead aVR at an optimal cutoff of 80 ms was 5.8 (95% CI 2.7‐12.4, P < .001). Conclusions The TpTe interval is associated with SCD in ACHD patients. Particularly, TpTe in lead aVR can be used as an independent risk factor for SCD in ACHD patients and may, therefore, add precision to current risk prediction models.
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Affiliation(s)
- Jim T Vehmeijer
- Department of Clinical and Experimental Cardiology, Heart Center, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Zeliha Koyak
- Department of Clinical and Experimental Cardiology, Heart Center, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - A Suzanne Vink
- Department of Clinical and Experimental Cardiology, Heart Center, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Werner Budts
- Department of Cardiology, Universitair Ziekenhuis Leuven, Leuven, Belgium.,Department of Cardiovascular Sciences, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Louise Harris
- Division of Cardiology, Peter Munk Cardiac Centre, Toronto Congenital Cardiac Centre for Adults, University of Toronto, Toronto, Ontario, Canada
| | - Candice K Silversides
- Division of Cardiology, Peter Munk Cardiac Centre, Toronto Congenital Cardiac Centre for Adults, University of Toronto, Toronto, Ontario, Canada
| | - Erwin N Oechslin
- Division of Cardiology, Peter Munk Cardiac Centre, Toronto Congenital Cardiac Centre for Adults, University of Toronto, Toronto, Ontario, Canada
| | - Aeilko H Zwinderman
- Department of Clinical Epidemiology and Biostatistics, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Barbara J M Mulder
- Department of Clinical and Experimental Cardiology, Heart Center, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands.,Netherlands Heart Institute, Utrecht, the Netherlands
| | - Joris R de Groot
- Department of Clinical and Experimental Cardiology, Heart Center, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
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44
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Siegmund AS, Kampman MAM, Oudijk MA, Mulder BJM, Sieswerda GTJ, Koenen SV, Hummel YM, de Laat MWM, Sollie-Szarynska KM, Groen H, van Dijk APJ, van Veldhuisen DJ, Bilardo CM, Pieper PG. Maternal right ventricular function, uteroplacental circulation in first trimester and pregnancy outcome in women with congenital heart disease. Ultrasound Obstet Gynecol 2019; 54:359-366. [PMID: 30334300 DOI: 10.1002/uog.20148] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 09/25/2018] [Accepted: 10/11/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE Pregnant women with congenital heart disease (CHD) have an increased risk of abnormal uteroplacental flow, measured from the second trimester onwards, which is associated with pregnancy complications affecting the mother and the fetus. Maternal right ventricular (RV) dysfunction has been suggested as a predisposing factor for impaired uteroplacental flow in these women. The aim of this study was to investigate the association of first-trimester uteroplacental flow measurements with prepregnancy maternal cardiac function and pregnancy complications in women with CHD, with particular focus on the potential role of RV (dys)function. METHODS This study included 138 pregnant women with CHD from the prospective ZAHARA III study (Zwangerschap bij Aangeboren HARtAfwijkingen; Pregnancy and CHD). Prepregnancy clinical and echocardiographic data were collected. Clinical evaluation, echocardiography (focused on RV function, as assessed by tricuspid annular plane systolic excursion (TAPSE)) and uterine artery (UtA) pulsatility index (PI) measurements were performed at 12, 20 and 32 weeks of gestation. Univariable and multivariable regression analyses were performed to assess the association between prepregnancy variables and UtA-PI during pregnancy. The association between UtA-PI at 12 weeks and cardiovascular, obstetric and neonatal complications was also assessed. RESULTS On multivariable regression analysis, prepregnancy TAPSE was associated negatively with UtA-PI at 12 weeks of gestation (β = -0.026; P = 0.036). Women with lower prepregnancy TAPSE (≤ 20 mm vs > 20 mm) had higher UtA-PI at 12 weeks (1.5 ± 0.5 vs 1.2 ± 0.6; P = 0.047). Increased UtA-PI at 12 weeks was associated with obstetric complications (P = 0.003), particularly hypertensive disorders (pregnancy-induced hypertension and pre-eclampsia, P = 0.019 and P = 0.026, respectively). CONCLUSIONS In women with CHD, RV dysfunction before pregnancy seems to impact placentation, resulting in increased resistance in UtA flow, which is detectable as early as in the first trimester. This, in turn, is associated with pregnancy complications. Early monitoring of uteroplacental flow might be of value in women with CHD with pre-existing subclinical RV dysfunction to identify pregnancies that would benefit from close obstetric surveillance. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- A S Siegmund
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - M A M Kampman
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - M A Oudijk
- Department of Obstetrics, University of Amsterdam, Amsterdam Universities Medical Centre, location Academic Medical Center, Amsterdam, The Netherlands
| | - B J M Mulder
- Department of Cardiology, University of Amsterdam, Amsterdam Universities Medical Centre, location Academic Medical Center, Amsterdam, The Netherlands
| | - G T J Sieswerda
- Department of Cardiology, University of Utrecht, University Medical Center Utrecht, Utrecht, The Netherlands
| | - S V Koenen
- Department of Obstetrics, University of Utrecht, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Y M Hummel
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - M W M de Laat
- Department of Obstetrics, University of Amsterdam, Amsterdam Universities Medical Centre, location Academic Medical Center, Amsterdam, The Netherlands
| | - K M Sollie-Szarynska
- Department of Obstetrics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - H Groen
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - A P J van Dijk
- Department of Cardiology, Radboud University, Radboud University Medical Center, Nijmegen, The Netherlands
| | - D J van Veldhuisen
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - C M Bilardo
- Department of Obstetrics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - P G Pieper
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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45
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Meijs TA, Warmerdam EG, Slieker MG, Krings GJ, Molenschot MMC, Meijboom FJ, Sieswerda GT, Doevendans PA, Bouma BJ, de Winter RJ, Mulder BJM, Voskuil M. Medium-term systemic blood pressure after stenting of aortic coarctation: a systematic review and meta-analysis. Heart 2019; 105:1464-1470. [PMID: 31315937 DOI: 10.1136/heartjnl-2019-314965] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 06/27/2019] [Accepted: 07/01/2019] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE Long-term prognosis of patients with coarctation of the aorta (CoA) is impaired due to the high prevalence of hypertension and consequent cardiovascular complications. Although stent implantation results in acute anatomical and haemodynamic benefit, limited evidence exists regarding the late clinical outcome. In this meta-analysis, we aimed to evaluate the medium-term effect of stent placement for CoA on systemic blood pressure (BP). METHODS PubMed, EMBASE and Cochrane databases were searched for non-randomised cohort studies addressing systemic BP ≥12 months following CoA stenting. Meta-analysis was performed on the change in BP from baseline to last follow-up using a random-effects model. Subgroup analyses and meta-regression were conducted to identify sources of heterogeneity between studies. RESULTS Twenty-six studies with a total of 1157 patients and a median follow-up of 26 months were included for final analysis. Meta-analysis showed a 20.3 mm Hg (95% CI 16.4 to 24.1 mm Hg; p<0.00001) reduction in systolic BP and an 8.2 mm Hg (12 studies; 95% CI 5.2 to 11.3 mm Hg; p<0.00001) reduction in diastolic BP. A concomitant decrease in the use of antihypertensive medication was observed. High systolic BP and peak systolic gradient at baseline and stenting of native CoA were associated with a greater reduction in systolic BP at follow-up. CONCLUSIONS Stent implantation for CoA is associated with a significant decline in systolic and diastolic BP during medium-term follow-up. The degree of BP reduction appears to be dependent on baseline systolic BP, baseline peak systolic gradient, and whether stenting is performed for native or recurrent CoA.
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Affiliation(s)
- Timion A Meijs
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Martijn G Slieker
- Department of Pediatric Cardiology, Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | - Gregor J Krings
- Department of Pediatric Cardiology, Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | - Mirella M C Molenschot
- Department of Pediatric Cardiology, Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | - Folkert J Meijboom
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Gertjan T Sieswerda
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Pieter A Doevendans
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands.,Netherlands Heart Institute, Utrecht, The Netherlands
| | - Berto J Bouma
- Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands
| | - Robbert J de Winter
- Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands
| | - Barbara J M Mulder
- Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands
| | - Michiel Voskuil
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
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46
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Yin 殷晓科 X, Wanga S, Fellows AL, Barallobre-Barreiro J, Lu R, Davaapil H, Franken R, Fava M, Baig F, Skroblin P, Xing Q, Koolbergen DR, Groenink M, Zwinderman AH, Balm R, de Vries CJM, Mulder BJM, Viner R, Jahangiri M, Reinhardt DP, Sinha S, de Waard V, Mayr M. Glycoproteomic Analysis of the Aortic Extracellular Matrix in Marfan Patients. Arterioscler Thromb Vasc Biol 2019; 39:1859-1873. [PMID: 31315432 PMCID: PMC6727943 DOI: 10.1161/atvbaha.118.312175] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Supplemental Digital Content is available in the text. Marfan syndrome (MFS) is caused by mutations in FBN1 (fibrillin-1), an extracellular matrix (ECM) component, which is modified post-translationally by glycosylation. This study aimed to characterize the glycoproteome of the aortic ECM from patients with MFS and relate it to aortopathy.
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Affiliation(s)
- Xiaoke Yin 殷晓科
- From the King's British Heart Foundation Centre, King's College London, United Kingdom (X.Y., A.L.F., J.B.-B., R.L., M.F., F.B., P.S., Q.X., M.M.)
| | - Shaynah Wanga
- Department of Medical Biochemistry, Amsterdam Cardiovascular Sciences (S.W., C.J.M.d.V., V.d.W.), Amsterdam UMC, University of Amsterdam, the Netherlands.,Department of Cardiology (S.W., R.F., M.G., B.J.M.M.), Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Adam L Fellows
- From the King's British Heart Foundation Centre, King's College London, United Kingdom (X.Y., A.L.F., J.B.-B., R.L., M.F., F.B., P.S., Q.X., M.M.)
| | - Javier Barallobre-Barreiro
- From the King's British Heart Foundation Centre, King's College London, United Kingdom (X.Y., A.L.F., J.B.-B., R.L., M.F., F.B., P.S., Q.X., M.M.)
| | - Ruifang Lu
- From the King's British Heart Foundation Centre, King's College London, United Kingdom (X.Y., A.L.F., J.B.-B., R.L., M.F., F.B., P.S., Q.X., M.M.)
| | - Hongorzul Davaapil
- Department of Medicine, Wellcome-MRC Cambridge Stem Cell Institute, University of Cambridge, United Kingdom (H.D., S.S.)
| | - Romy Franken
- Department of Cardiology (S.W., R.F., M.G., B.J.M.M.), Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Marika Fava
- From the King's British Heart Foundation Centre, King's College London, United Kingdom (X.Y., A.L.F., J.B.-B., R.L., M.F., F.B., P.S., Q.X., M.M.)
| | - Ferheen Baig
- From the King's British Heart Foundation Centre, King's College London, United Kingdom (X.Y., A.L.F., J.B.-B., R.L., M.F., F.B., P.S., Q.X., M.M.)
| | - Philipp Skroblin
- From the King's British Heart Foundation Centre, King's College London, United Kingdom (X.Y., A.L.F., J.B.-B., R.L., M.F., F.B., P.S., Q.X., M.M.)
| | - Qiuru Xing
- From the King's British Heart Foundation Centre, King's College London, United Kingdom (X.Y., A.L.F., J.B.-B., R.L., M.F., F.B., P.S., Q.X., M.M.)
| | - David R Koolbergen
- Department of Cardiothoracic Surgery (D.R.K.), Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Maarten Groenink
- Department of Cardiology (S.W., R.F., M.G., B.J.M.M.), Amsterdam UMC, University of Amsterdam, the Netherlands.,Department of Radiology (M.G.), Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Aeilko H Zwinderman
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics (A.H.Z.), Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Ron Balm
- Department of Surgery (R.B.), Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Carlie J M de Vries
- Department of Medical Biochemistry, Amsterdam Cardiovascular Sciences (S.W., C.J.M.d.V., V.d.W.), Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Barbara J M Mulder
- Department of Cardiology (S.W., R.F., M.G., B.J.M.M.), Amsterdam UMC, University of Amsterdam, the Netherlands.,Netherlands Heart Institute, Utrecht (B.J.M.M.)
| | - Rosa Viner
- Thermo Fisher Scientific, San Jose, CA (R.V.)
| | | | - Dieter P Reinhardt
- Faculty of Medicine, Department of Anatomy and Cell Biology and Faculty of Dentistry, McGill University, Montreal, Canada (D.P.R.)
| | - Sanjay Sinha
- Department of Medicine, Wellcome-MRC Cambridge Stem Cell Institute, University of Cambridge, United Kingdom (H.D., S.S.)
| | - Vivian de Waard
- Department of Medical Biochemistry, Amsterdam Cardiovascular Sciences (S.W., C.J.M.d.V., V.d.W.), Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Manuel Mayr
- From the King's British Heart Foundation Centre, King's College London, United Kingdom (X.Y., A.L.F., J.B.-B., R.L., M.F., F.B., P.S., Q.X., M.M.)
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47
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van der Palen RLF, van der Bom T, Dekker A, Tsonaka R, van Geloven N, Kuipers IM, Konings TC, Rammeloo LAJ, Ten Harkel ADJ, Jongbloed MRM, Koolbergen DR, Mulder BJM, Hazekamp MG, Blom NA. Progression of aortic root dilatation and aortic valve regurgitation after the arterial switch operation. Heart 2019; 105:1732-1740. [PMID: 31292191 PMCID: PMC6855793 DOI: 10.1136/heartjnl-2019-315157] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 05/03/2019] [Accepted: 05/14/2019] [Indexed: 11/29/2022] Open
Abstract
Objective To study neo-aortic growth and the evolution of neo-aortic valve regurgitation (AR) in patients with transposition of the great arteries (TGA) after arterial switch operation (ASO) from newborn to adulthood and to identify patients at risk. Methods Neo-aortic dimensions (annulus/root/sinotubular junction) and neo-aortic valve regurgitation were assessed serially in 345 patients with TGA who underwent ASO between 1977 and 2015. Linear mixed-effect models were used to assess increase of neo-aortic dimensions over time and to identify risk factors for dilatation. Risk factor analysis for AR by using time-dependent Cox regression models. Results After a rapid increase in the first year after ASO and proportional growth in childhood, neo-aortic dimensions continue to increase in adulthood without stabilisation. Annual diameter increase in adulthood was 0.39±0.06, 0.63±0.09 and 0.54±0.11 mm for, respectively, neo-aortic annulus, root and sinotubular junction, all significantly exceeding normal growth. AR continues to develop over time: freedom from AR ≥moderate during the first 25 years post-ASO was 69%. Risk factors for root dilatation were complex TGA anatomy (TGA-ventricular septal defect (VSD), double outlet right ventricle with subpulmonary VSD) and male gender. Risk factors for AR ≥moderate were: complex TGA anatomy and neo-aortic growth. Per millimetre increase in aortic root dimension, there was a 9% increase in the hazard of AR ≥moderate. Bicuspid pulmonary valve did not relate to the presence of root dilatation or AR. Conclusion After ASO, neo-aortic dilatation proceeds beyond childhood and is associated with an increase in AR incidence over time. Careful follow-up of the neo-aortic valve and root function is mandatory, especially in males and in patients with complex TGA anatomy.
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Affiliation(s)
- Roel L F van der Palen
- Division of Pediatric Cardiology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Teun van der Bom
- Department of Cardiology, Amsterdam UMC, Univ of Amsterdam, Amsterdam, The Netherlands
| | - Annika Dekker
- Division of Pediatric Cardiology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Roula Tsonaka
- Department of Biomedical Data Sciences, Section Medical Statistics, Leiden University Medical Center, Leiden, The Netherlands
| | - Nan van Geloven
- Department of Biomedical Data Sciences, Section Medical Statistics, Leiden University Medical Center, Leiden, The Netherlands
| | - Irene M Kuipers
- Division of Pediatric Cardiology, Department of Pediatrics, Amsterdam UMC, Univ of Amsterdam, Amsterdam, The Netherlands
| | - Thelma C Konings
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Lukas A J Rammeloo
- Division of Pediatric Cardiology, Department of Pediatrics, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Arend D J Ten Harkel
- Division of Pediatric Cardiology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Monique R M Jongbloed
- Department of Anatomy&Embryology, Leiden University Medical Center, Leiden, The Netherlands.,Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Dave R Koolbergen
- Department of Cardiothoracic Surgery, Amsterdam UMC, Univ of Amsterdam, Amsterdam, The Netherlands.,Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Barbara J M Mulder
- Department of Cardiology, Amsterdam UMC, Univ of Amsterdam, Amsterdam, The Netherlands
| | - Mark G Hazekamp
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Nico A Blom
- Division of Pediatric Cardiology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands.,Division of Pediatric Cardiology, Department of Pediatrics, Amsterdam UMC, Univ of Amsterdam, Amsterdam, The Netherlands
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48
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Vehmeijer JT, Koyak Z, Zwinderman AH, Harris L, Peinado R, Oechslin EN, Silversides CK, Bouma BJ, Budts W, van Gelder IC, Oliver JM, Mulder BJM, de Groot JR. PREVENTION-ACHD: PRospEctiVE study on implaNTable cardioverter-defibrillator therapy and suddeN cardiac death in Adults with Congenital Heart Disease; Rationale and Design. Neth Heart J 2019; 27:474-479. [PMID: 31270738 PMCID: PMC6773785 DOI: 10.1007/s12471-019-1297-3] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Many adult congenital heart disease (ACHD) patients are at risk of sudden cardiac death (SCD). An implantable cardioverter-defibrillator (ICD) may prevent SCD, but the evidence for primary prevention indications is still unsatisfactory. STUDY DESIGN PREVENTION-ACHD is a prospective study with which we aim to prospectively validate a new risk score model for primary prevention of SCD in ACHD patients, as well as the currently existing guideline recommendations. Patients are screened using a novel risk score to predict SCD as well as current ICD indications according to an international Consensus Statement. Patients are followed up for two years. The primary endpoint is the occurrence of SCD and sustained ventricular arrhythmias. The Study was registered at ClinicalTrials.gov (NCT03957824). CONCLUSION PREVENTION-ACHD is the first prospective study on SCD in ACHD patients. In the light of a growing and aging population of patients with more severe congenital heart defects, more robust clinical evidence on primary prevention of SCD is urgently needed.
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Affiliation(s)
- J T Vehmeijer
- Heart Center, Department of Cardiology, Academic Medical Center-University of Amsterdam, Amsterdam, The Netherlands.
| | - Z Koyak
- Heart Center, Department of Cardiology, Academic Medical Center-University of Amsterdam, Amsterdam, The Netherlands
| | - A H Zwinderman
- Department of Clinical Epidemiology and Biostatistics, Academic Medical Center-University of Amsterdam, Amsterdam, The Netherlands
| | - L Harris
- Division of Cardiology, Peter Munk Cardiac Center, Toronto Congenital Cardiac Center of Adults, University of Toronto, Toronto, Canada
| | - R Peinado
- Department of Cardiology, La Paz University Hospital, Autonomous University of Madrid, Madrid, Spain
| | - E N Oechslin
- Division of Cardiology, Peter Munk Cardiac Center, Toronto Congenital Cardiac Center of Adults, University of Toronto, Toronto, Canada
| | - C K Silversides
- Division of Cardiology, Peter Munk Cardiac Center, Toronto Congenital Cardiac Center of Adults, University of Toronto, Toronto, Canada
| | - B J Bouma
- Heart Center, Department of Cardiology, Academic Medical Center-University of Amsterdam, Amsterdam, The Netherlands
| | - W Budts
- Department of Cardiology, Universitair Ziekenhuis Leuven, Department of Cardiovascular Sciences, Katholieke Universiteit Leuven, Leuven, Belgium
| | - I C van Gelder
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - J M Oliver
- Department of Cardiology, Gregorio Marañon University Hospital and CIBERCV, Madrid, Spain
| | - B J M Mulder
- Heart Center, Department of Cardiology, Academic Medical Center-University of Amsterdam, Amsterdam, The Netherlands.,Netherlands Heart Institute, Utrecht, The Netherlands
| | - J R de Groot
- Heart Center, Department of Cardiology, Academic Medical Center-University of Amsterdam, Amsterdam, The Netherlands
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49
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Bokma JP, de Wilde KC, Vliegen HW, van Dijk AP, van Melle JP, Meijboom FJ, Zwinderman AH, Groenink M, Mulder BJM, Bouma BJ. Value of Cardiovascular Magnetic Resonance Imaging in Noninvasive Risk Stratification in Tetralogy of Fallot. JAMA Cardiol 2019; 2:678-683. [PMID: 28241248 DOI: 10.1001/jamacardio.2016.5818] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Importance Adults late after total correction of tetralogy of Fallot (TOF) are at risk for major complications. Cardiovascular magnetic resonance (CMR) imaging is recommended to quantify right ventricular (RV) and left ventricular (LV) function. However, a commonly used risk model by Khairy et al requires invasive investigations and lacks CMR imaging to identify high-risk patients. Objective To implement CMR imaging in noninvasive risk stratification to predict major adverse clinical outcomes. Design, Setting, and Participants This multicenter study included 575 adult patients with TOF (4.083 patient-years at risk) from a prospective nationwide registry in whom CMR was performed. This study involved 5 tertiary referral centers with a specialized adult congenital heart disease unit. Multivariable Cox hazards regression analysis was performed to determine factors associated with the primary end point. The CMR variables were combined with the noninvasive components of the Khairy et al risk model, and the C statistic of the final noninvasive risk model was determined using bootstrap sampling. The data analysis was conducted from January to December 2016. Main Outcomes and Measures The composite primary outcome was defined as all-cause mortality or ventricular arrhythmia, defined as aborted cardiac arrest or documented ventricular fibrillation and ventricular tachycardia (lasting ≥30 seconds or recurrent symptomatic). Results Of the 575 patients with TOF, 57% were male, and the mean (SD) age was 31 (11) years. During a mean (SD) follow-up of 7.1 (3.5) years, the primary composite end point occurred in 35 patients, including all-cause mortality in 13 patients. Mean (SD) RV ejection fraction (EF) was 44% (10%), and mean (SD) LV EF was 53% (8%). There was a correlation between RV EF and LV EF (R, 0.36; 95% CI, 0.29-0.44; P < .001). Optimal thresholds for ventricular function (RV EF <30%: hazard ratio, 3.90; 95% CI, 1.84-8.26; P < .001 and LV EF <45%: hazard ratio, 3.23; 95% CI, 1.57-6.65; P = .001) were independently predictive in multivariable analysis. Both thresholds were included in a point-based noninvasive risk model (C statistic, 0.75; 95% CI, 0.63-0.85) and combined with the noninvasive components of the Khairy et al risk model. Conclusions and Relevance In patients with repaired TOF, biventricular dysfunction on CMR imaging was associated with major adverse clinical outcomes. The quantified thresholds (RV EF <30% and LV EF <45%) may be implemented in noninvasive risk stratification.
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Affiliation(s)
- Jouke P Bokma
- Department of Cardiology, Academic Medical Center Amsterdam, Amsterdam, the Netherlands2Interuniversity Cardiology Institute of the Netherlands, Utrecht, the Netherlands
| | - Koen C de Wilde
- Department of Cardiology, Academic Medical Center Amsterdam, Amsterdam, the Netherlands
| | - Hubert W Vliegen
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Arie P van Dijk
- Department of Cardiology, Radboud University Medical Center Nijmegen, Nijmegen, the Netherlands
| | - Joost P van Melle
- Department of Cardiology, University of Groningen, Groningen University Medical Center, Groningen, the Netherlands
| | - Folkert J Meijboom
- Department of Cardiology, Utrecht University Medical Center, Utrecht, the Netherlands
| | - Aeilko H Zwinderman
- Department of Clinical Epidemiology, Biostatistics, and Bioinformatics, Academic Medical Center Amsterdam, Amsterdam, the Netherlands
| | - Maarten Groenink
- Department of Cardiology, Academic Medical Center Amsterdam, Amsterdam, the Netherlands2Interuniversity Cardiology Institute of the Netherlands, Utrecht, the Netherlands
| | - Barbara J M Mulder
- Department of Cardiology, Academic Medical Center Amsterdam, Amsterdam, the Netherlands2Interuniversity Cardiology Institute of the Netherlands, Utrecht, the Netherlands
| | - Berto J Bouma
- Department of Cardiology, Academic Medical Center Amsterdam, Amsterdam, the Netherlands2Interuniversity Cardiology Institute of the Netherlands, Utrecht, the Netherlands
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van Riel ACMJ, Systrom DM, Oliveira RKF, Landzberg MJ, Mulder BJM, Bouma BJ, Maron BA, Shah AM, Waxman AB, Opotowsky AR. Development of a Right Ventricular Outflow Tract Gradient During Upright Exercise: A Hemodynamic Observation. J Am Coll Cardiol 2019; 69:595-597. [PMID: 28153114 DOI: 10.1016/j.jacc.2016.11.039] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Revised: 10/27/2016] [Accepted: 11/14/2016] [Indexed: 11/28/2022]
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