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Agasthi P, Van Houten HK, Yao X, Jain CC, Egbe A, Warnes CA, Miranda WR, Dunlay SM, Stephens EH, Johnson JN, Connolly HM, Burchill LJ. Mortality and Morbidity of Heart Failure Hospitalization in Adult Patients With Congenital Heart Disease. J Am Heart Assoc 2023; 12:e030649. [PMID: 38018491 PMCID: PMC10727341 DOI: 10.1161/jaha.123.030649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 10/04/2023] [Indexed: 11/30/2023]
Abstract
BACKGROUND Little is known about outcomes following heart failure (HF) hospitalization among adults with congenital heart disease (CHD) in the United States. We aim to compare the outcomes of HF versus non-HF hospitalizations in adults with CHD. METHODS AND RESULTS Using a national deidentified administrative claims data set, patients with adult congenital heart disease (ACHD) hospitalized with and without HF (ACHDHF+, ACHDHF-) were characterized to determine the predictors of 90-day and 1-year mortality and quantify the risk of mortality, major adverse cardiac and cerebrovascular events, and health resource use. Cox proportional hazard regression was used to compare ACHDHF+ versus ACHDHF- for risk of events and health resource use. Of 26 454 unique ACHD admissions between January 1, 2010 and December 31, 2020, 5826 (22%) were ACHDHF+ and 20 628 (78%) were ACHDHF-. The ACHD HF+ hospitalizations increased from 6.6% to 14.0% (P<0.0001). Over a mean follow-up period of 2.23 ± 2.19 years, patients with ACHDHF+ had a higher risk of mortality (hazard ratio [HR], 1.86 [95% CI, 1.67-2.07], P<0.001), major adverse cardiac and cerebrovascular events (HR, 1.73 [95% CI, 1.63-1.83], P<0.001) and health resource use including rehospitalization (HR, 1.09 [95% CI, 1.05-1.14], P<0.001) and increased postacute care service use (HR, 1.56 [95% CI, 1.32-1.85], P<0.001). Cardiology clinic visits within 30 days of hospital admission were associated with lower 90-day and 1-year all-cause mortality (odds ratio [OR], 0.62 [95% CI, 0.49-0.78], P<0.001; OR, 0.69 [95% CI, 0.58-0.83], P<0.001, respectively). CONCLUSIONS HF hospitalization is associated with increased risk of mortality and morbidity with high health resource use in patients with ACHD. Recent cardiology clinic attendance appears to mitigate these risks.
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Affiliation(s)
| | - Holly K. Van Houten
- Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo ClinicRochesterMNUSA
- OptumLabsMinnetonkaMNUSA
| | - Xiaoxi Yao
- Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo ClinicRochesterMNUSA
- OptumLabsMinnetonkaMNUSA
| | - C. Charles Jain
- Department of Cardiovascular Medicine, Mayo ClinicRochesterMNUSA
| | - Alexander Egbe
- Department of Cardiovascular Medicine, Mayo ClinicRochesterMNUSA
| | - Carole A. Warnes
- Department of Cardiovascular Medicine, Mayo ClinicRochesterMNUSA
| | | | - Shannon M. Dunlay
- Department of Cardiovascular Medicine, Mayo ClinicRochesterMNUSA
- Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo ClinicRochesterMNUSA
| | | | - Jonathan N. Johnson
- Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic Children’s CenterRochesterMNUSA
| | | | - Luke J. Burchill
- Department of Cardiovascular Medicine, Mayo ClinicRochesterMNUSA
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Egbe AC, Miranda WR, Jain CC, Bonnichsen CR, Anderson JH, Dearani JA, Warnes CA, Crestanello J, Connolly HM. Incidence and Outcomes of Advanced Heart Failure in Adults With Congenital Heart Disease. Circ Heart Fail 2022; 15:e009675. [PMID: 36193744 PMCID: PMC9760468 DOI: 10.1161/circheartfailure.122.009675] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND There are limited data about the stage D heart failure (advanced HF) in adults with congenital heart disease. Our study objectives were (1) to determine the incidence of new-onset advanced HF in patients and the relationship between advanced HF and all-cause mortality and (2) to determine the relationship between therapies for advanced HF and all-cause mortality. METHODS Retrospective cohort study of adults with congenital heart disease at Mayo Clinic (2003-2019). We defined advanced HF using the European Society of Cardiology diagnostic criteria for advanced HF. Therapies received by the patients with advanced HF were classified into 3 mutually exclusive groups (treatment pathways): (1) conventional cardiac intervention, (2) transplant listing, and (3) palliative care. RESULTS Of 5309 patients without advanced HF at baseline assessment, 432 (8%) developed advanced HF during follow-up (1.1%/y), and the incidence of advanced HF was higher in patients with severe or complex congenital heart disease. Onset of advanced HF was associated with 6-fold increase in the risk of mortality. Conventional cardiac intervention was associated with significantly higher risk of mortality as compared to transplant listing. The longer the interval from the initial onset of advanced HF to transplant evaluation, the lower the odds of being listed for transplant. CONCLUSIONS Based on these data, we postulate that early identification of patients with advanced HF, and a timely referral for transplant evaluation (instead of conventional cardiac intervention) may offer the best chance of survival for these critically ill patients. Further studies are required to validate this postulation.
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Affiliation(s)
- Alexander C. Egbe
- Department of Cardiovascular Medicine (A.C.E., W.R.M., C.C.J., C.R.B., J.H.A., C.A.W., H.M.C.), Mayo Clinic Rochester, MN
| | - William R. Miranda
- Department of Cardiovascular Medicine (A.C.E., W.R.M., C.C.J., C.R.B., J.H.A., C.A.W., H.M.C.), Mayo Clinic Rochester, MN
| | - C. Charles Jain
- Department of Cardiovascular Medicine (A.C.E., W.R.M., C.C.J., C.R.B., J.H.A., C.A.W., H.M.C.), Mayo Clinic Rochester, MN
| | - Crystal R. Bonnichsen
- Department of Cardiovascular Medicine (A.C.E., W.R.M., C.C.J., C.R.B., J.H.A., C.A.W., H.M.C.), Mayo Clinic Rochester, MN
| | - Jason H. Anderson
- Department of Cardiovascular Medicine (A.C.E., W.R.M., C.C.J., C.R.B., J.H.A., C.A.W., H.M.C.), Mayo Clinic Rochester, MN
| | - Joseph A. Dearani
- Department of Cardiovascular Surgery (J.A.D., J.C.), Mayo Clinic Rochester, MN
| | - Carole A. Warnes
- Department of Cardiovascular Medicine (A.C.E., W.R.M., C.C.J., C.R.B., J.H.A., C.A.W., H.M.C.), Mayo Clinic Rochester, MN
| | - Juan Crestanello
- Department of Cardiovascular Surgery (J.A.D., J.C.), Mayo Clinic Rochester, MN
| | - Heidi M. Connolly
- Department of Cardiovascular Medicine (A.C.E., W.R.M., C.C.J., C.R.B., J.H.A., C.A.W., H.M.C.), Mayo Clinic Rochester, MN
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3
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Marelli A, Beauchesne L, Colman J, Ducas R, Grewal J, Keir M, Khairy P, Oechslin E, Therrien J, Vonder Muhll IF, Wald RM, Silversides C, Barron DJ, Benson L, Bernier PL, Horlick E, Ibrahim R, Martucci G, Nair K, Poirier NC, Ross HJ, Baumgartner H, Daniels CJ, Gurvitz M, Roos-Hesselink JW, Kovacs AH, McLeod CJ, Mulder BJ, Warnes CA, Webb GD. Canadian Cardiovascular Society 2022 Guidelines for Cardiovascular Interventions in Adults With Congenital Heart Disease. Can J Cardiol 2022; 38:862-896. [PMID: 35460862 DOI: 10.1016/j.cjca.2022.03.021] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 03/15/2022] [Accepted: 03/30/2022] [Indexed: 12/12/2022] Open
Abstract
Interventions in adults with congenital heart disease (ACHD) focus on surgical and percutaneous interventions in light of rapidly evolving ACHD clinical practice. To bring rigour to our process and amplify the cumulative nature of evidence ACHD care we used the ADAPTE process; we systematically adjudicated, updated, and adapted existing guidelines by Canadian, American, and European cardiac societies from 2010 to 2020. We applied this to interventions related to right and left ventricular outflow obstruction, tetralogy of Fallot, coarctation, aortopathy associated with bicuspid aortic valve, atrioventricular canal defects, Ebstein anomaly, complete and congenitally corrected transposition, and patients with the Fontan operation. In addition to tables indexed to evidence, clinical flow diagrams are included for each lesion to facilitate a practical approach to clinical decision-making. Excluded are recommendations for pacemakers, defibrillators, and arrhythmia-directed interventions covered in separate designated documents. Similarly, where overlap occurs with other guidelines for valvular interventions, reference is made to parallel publications. There is a paucity of high-level quality of evidence in the form of randomized clinical trials to support guidelines in ACHD. We accounted for this in the wording of the strength of recommendations put forth by our national and international experts. As data grow on long-term follow-up, we expect that the evidence driving clinical practice will become increasingly granular. These recommendations are meant to be used to guide dialogue between clinicians, interventional cardiologists, surgeons, and patients making complex decisions relative to ACHD interventions.
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Affiliation(s)
- Ariane Marelli
- McGill University Health Centre, Montréal, Québec, Canada.
| | - Luc Beauchesne
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Jack Colman
- Toronto Adult Congenital Heart Disease Program, Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Robin Ducas
- St. Boniface General Hospital, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Jasmine Grewal
- St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Paul Khairy
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | - Erwin Oechslin
- Toronto Adult Congenital Heart Disease Program, Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Judith Therrien
- Jewish General Hospital, MAUDE Unit, McGill University, Montréal, Québec, Canada
| | | | - Rachel M Wald
- Toronto Adult Congenital Heart Disease Program, Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Candice Silversides
- Toronto Adult Congenital Heart Disease Program, Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | | | - Lee Benson
- The Hospital for Sick Children, University Health Network, Toronto, Ontario, Canada
| | - Pierre-Luc Bernier
- McGill University Health Centre, Montreal Heart Institute, Montréal, Québec, Canada
| | - Eric Horlick
- Toronto Adult Congenital Heart Disease Program, Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Réda Ibrahim
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | | | - Krishnakumar Nair
- Toronto Adult Congenital Heart Disease Program, Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Nancy C Poirier
- Université de Montréal, CHU-ME Ste-Justine, Institut de Cardiologie de Montréal, Montréal, Québec, Canada
| | - Heather J Ross
- Toronto Adult Congenital Heart Disease Program, Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Helmut Baumgartner
- Department of Cardiology III: Adult Congenital and Valvular Heart Disease, University Hospital Muenster, Muenster, Germany
| | - Curt J Daniels
- The Ohio State University Medical Center, Columbus, Ohio, USA
| | - Michelle Gurvitz
- Boston Adult Congenital Heart Program, Boston Children's Hospital, Boston, Massachusetts, USA
| | | | - Adrienne H Kovacs
- Department of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | | | | | | | - Gary D Webb
- Cincinnati Children's Hospital Heart Institute, Cincinnati, Ohio, USA
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Egbe AC, Miranda WR, Warnes CA, Bonnichsen C, Crestanello J, Anderson JH, Connolly HM. Persistent Hypertension and Left Ventricular Hypertrophy After Repair of Native Coarctation of Aorta in Adults. Hypertension 2021; 78:672-680. [PMID: 34247510 PMCID: PMC8363521 DOI: 10.1161/hypertensionaha.121.17515] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
[Figure: see text].
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Affiliation(s)
- Alexander C Egbe
- Department of Cardiovascular Medicine (A.C.E., W.R.M., C.A.W., C.B., H.M.C.), Mayo Clinic Rochester, MN
| | - William R Miranda
- Department of Cardiovascular Medicine (A.C.E., W.R.M., C.A.W., C.B., H.M.C.), Mayo Clinic Rochester, MN
| | - Carole A Warnes
- Department of Cardiovascular Medicine (A.C.E., W.R.M., C.A.W., C.B., H.M.C.), Mayo Clinic Rochester, MN
| | - Crystal Bonnichsen
- Department of Cardiovascular Medicine (A.C.E., W.R.M., C.A.W., C.B., H.M.C.), Mayo Clinic Rochester, MN
| | - Juan Crestanello
- Department of Cardiovascular Surgery (J.C.), Mayo Clinic Rochester, MN
| | - Jason H Anderson
- Division of Pediatric Cardiology (J.H.A.), Mayo Clinic Rochester, MN
| | - Heidi M Connolly
- Department of Cardiovascular Medicine (A.C.E., W.R.M., C.A.W., C.B., H.M.C.), Mayo Clinic Rochester, MN
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Egbe AC, Miranda WR, Anderson JH, Crestanello J, Warnes CA, Connolly HM. A Comparison of Hemodynamic and Clinical Outcomes After Transcatheter Versus Surgical Therapy in Adults in Coarctation of Aorta. J Invasive Cardiol 2021; 33:E191-E199. [PMID: 33570503] [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] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
BACKGROUND Transcatheter stent therapy provides similar acute reduction in coarctation of aorta (COA) gradient and systolic blood pressure (SBP) as compared with surgery. However, there are limited data comparing mid-term outcomes after transcatheter vs surgical therapy for COA. The purpose of this study was to compare temporal changes in Doppler COA gradient and SBP after transcatheter stent therapy versus surgical therapy for COA. METHODS A retrospective study of COA patients (≥18 years old) undergoing transcatheter stent therapy or surgical therapy at Mayo Clinic in Rochester, Minnesota from 2000-2018 was performed. Linear regression analyses were used to compare temporal changes in Doppler gradient and SBP between the 2 groups. Propensity matching was used to adjust for between-group differences in clinical and anatomic characteristics. RESULTS A total of 44 and 128 patients underwent transcatheter and surgical therapy, respectively; there were no significant between-group differences in the anatomy of the thoracic aorta. Both groups had similar acute reduction in Doppler peak gradient (P=.66), mean gradient (P=.41), SBP (P=.22), and upper-to-lower extremity SBP (ULE-SBP) gradient (P=.69). The median follow-up was 46 months (interquartile range, 27-81 months) and 63 months (interquartile range, 41-94 months) in the transcatheter and surgical groups, respectively. There were no significant between-group differences in the temporal change in Doppler peak gradient (P-interaction=.06), mean gradient (P-interaction=.15), SBP (P-interaction=.20), and ULE-SBP gradient (P-interaction=.51). CONCLUSIONS These favorable short- and mid-term outcome data support the use of transcatheter therapy as an alternative to surgery in adults with COA. Further studies are required to determine if these favorable outcomes are maintained on long-term follow-up.
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Affiliation(s)
- Alexander C Egbe
- Mayo Clinic and Foundation, 200 First Street SW, Rochester, MN 55905 USA.
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6
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El-Hamamsy I, Warnes CA, Nishimura RA. The Ross Procedure in Adults: The Ideal Aortic Valve Substitute? J Am Coll Cardiol 2021; 77:1423-1425. [PMID: 33736824 DOI: 10.1016/j.jacc.2021.01.041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 01/28/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Ismail El-Hamamsy
- Department of Cardiovascular Surgery, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
| | - Carole A Warnes
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Rick A Nishimura
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
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7
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Egbe AC, Warnes CA, Connolly HM. Critical Appraisal of the Indications for Intervention in Adults With Coarctation of Aorta. J Am Coll Cardiol 2020; 75:1089-1090. [PMID: 32138970 DOI: 10.1016/j.jacc.2019.12.047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 12/24/2019] [Accepted: 12/30/2019] [Indexed: 10/24/2022]
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Warnes CA, Sutton NR. Challenges of the Transcatheter Approach to Mitral Valve Replacement in Women Contemplating Pregnancy. Circ Cardiovasc Interv 2020; 13:e010227. [PMID: 33320711 DOI: 10.1161/circinterventions.120.010227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Carole A Warnes
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (C.A.W.)
| | - Nadia R Sutton
- Department of Internal Medicine, Division of Cardiovascular Medicine, Michigan Medicine, Ann Arbor (N.R.S.)
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9
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Jain CC, Warnes CA, Egbe AC, Cetta F, DuBrock HM, Connolly HM, Miranda WR. Hemodynamics in Adults With the Shone Complex. Am J Cardiol 2020; 130:137-142. [PMID: 32703525 DOI: 10.1016/j.amjcard.2020.06.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 05/31/2020] [Accepted: 06/05/2020] [Indexed: 12/11/2022]
Abstract
Patients with Shone complex (SC) have multiple left-sided obstructive lesions and thus are at risk for left ventricular (LV) remodeling, LV diastolic dysfunction and pulmonary hypertension. Yet, to date, there has been no description of hemodynamics in adults with SC. Retrospective chart review of 25 patients with SC who underwent cardiac catheterization at Mayo Clinic, MN between 2002 and 2019 was performed. SC was defined as multiple left-sided obstructive lesions in the presence of an anatomically abnormal mitral valve. Median age was 32 years (22.5, 42) and 15 patients (60%) were female. The majority of patients (84%) had history of coarctation of the aorta, 10 (40%) had subaortic stenosis, 11 (44%) had prior aortic valve replacement, and 10 (40%) had prior mitral valve replacement. Structural disease at the time of catheterization which warranted intervention within the next year was present in 13 patients (52%). The mean LV end-diastolic pressure was 21.3 ± 9.0 mm Hg (>15 mm Hg in 71%), pulmonary artery peak systolic pressure was 55.4 ± 13.4 mm Hg, and the pulmonary artery mean pressure was 37.0 ± 9.4 mm Hg (>20 mm Hg in 96%). During a mean follow-up of 8.3 ± 4.4 years, there were 7 deaths (28%) and 3 additional patients (12%) underwent cardiac transplantation. In conclusion, adults with SC who underwent catheterization showed significant left-sided heart and pulmonary vascular remodeling. Elevated LV end-diastolic pressure and pulmonary artery pressures were highly prevalent. There were high mortality and cardiac transplant rates in our cohort.
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Affiliation(s)
- C Charles Jain
- Department of Cardiovascular Medicine, Mayo Clinic, Minnesota
| | - Carole A Warnes
- Department of Cardiovascular Medicine, Mayo Clinic, Minnesota
| | | | - Frank Cetta
- Department of Cardiovascular Medicine, Mayo Clinic, Minnesota; Department of Pediatric and Adolescent Medicine/Division of Pediatric Cardiology, Mayo Clinic, Minnesota
| | - Hilary M DuBrock
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota
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Patlolla SH, Dearani JA, Connolly HM, Warnes CA, Lahr BD, Schaff HV, Saran N. Repair of Partial Atrioventricular Septal Defects in Adults: A Single Center Experience. Semin Thorac Cardiovasc Surg 2020; 33:469-478. [PMID: 32858219 DOI: 10.1053/j.semtcvs.2020.08.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 08/20/2020] [Indexed: 11/11/2022]
Abstract
Limited data are available on long-term outcome after repair of partial atrioventricular septal defects (pAVSD) in adults. We sought to review our experience. Between January 1, 1957 and December 31, 2016, 179 adult patients [median age (IQR) 34 (18, 72) years] underwent primary repair of pAVSD. The most common associated defects were secundum atrial septal defect (n = 38) and ventricular septal defect (VSD) (n = 7). Left atrioventricular valve (LAVV) zone of apposition (ZOA) was complete in 47 patients and LAVV regurgitation (≥moderate) was present in 73 patients. Autologous pericardium (n = 79, 45%) and polytetrafluoroethylene felt (n = 56, 32%) were mainly used for pAVSD closure. Repair techniques for LAVV regurgitation included: ZOA suture closure (n = 142), suture annuloplasty (n = 10) and posterior band annuloplasty (n = 9). Six had LAVV replacement. There were 61 deaths over a median follow-up of 21 years (IQR 10, 38), with only 4 early deaths. In a limited subset of patients with 80 paired measurements (n = 40), median right ventricular systolic pressure declined from 43 mm Hg (IQR 35-51) to 33 mm Hg (IQR 30-44) postoperatively (P < 0.001), and this improvement was sustained over long-term follow-up (P = 0.513). A total of 34 patients underwent a reoperation (recurrent LAVV regurgitation, n = 26; left ventricular outflow-tract obstruction, n = 7; LAVV stenosis, n = 4; patch dehiscence, n = 1) with cumulative incidence of 6% and 16% at 10 and 15 years, respectively. Repair of pAVSD in adults can be done safely with low early mortality and good long-term outcomes. Postrepair reduction of pulmonary artery pressure is significant. Despite the low re-operation rates, long-term surveillance remains essential.
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Affiliation(s)
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota.
| | - Heidi M Connolly
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Carole A Warnes
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Brian D Lahr
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Hartzell V Schaff
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Nishant Saran
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
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11
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Possner M, Gordon-Walker T, Egbe AC, Poterucha JT, Warnes CA, Connolly HM, Ginde S, Clift P, Kogon B, Book WM, Walker N, Wagenaar LJ, Moe T, Oechslin E, Kay WA, Norris M, Dillman JR, Trout AT, Anwar N, Hoskoppal A, Broering DC, Bzeizi K, Veldtman G. Hepatocellular carcinoma and the Fontan circulation: Clinical presentation and outcomes. Int J Cardiol 2020; 322:142-148. [PMID: 32828959 DOI: 10.1016/j.ijcard.2020.08.057] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [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: 06/04/2020] [Revised: 07/16/2020] [Accepted: 08/17/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Fontan-associated liver disease (FALD) is universal in patients with a Fontan circulation. Hepatocellular carcinoma (HCC) is one of its severe expressions, and, though rare, frequently fatal. The purpose of this study was to describe the clinical presentation, risk factors, and outcomes of HCC in patients with a Fontan circulation. METHODS A multicenter case series of Fontan patients with a diagnosis of HCC formed the basis of this study. The case series was extended by published cases and case reports. Clinical presentation, tumor characteristics, laboratory and hemodynamic findings as well as treatment types and outcomes, were described. RESULTS Fifty-four Fontan patients (50% female) with a diagnosis of HCC were included. Mean age at HCC diagnosis was 30 ± 9.4 years and mean duration from Fontan surgery to HCC diagnosis was 21.6 ± 7.4 years. Median HCC size at the time of diagnosis was 4 cm with a range of 1 to 22 cm. The tumor was located in the right hepatic lobe in 65% of the patients. Fifty-one percent had liver cirrhosis at the time of HCC diagnosis. Fifty percent of the patients had no symptoms related to HCC and alpha-fetoprotein was normal in 26% of the cases. Twenty-six patients (48%) died during a median follow-up duration of 10.6 (range 1-50) months. CONCLUSIONS HCC in Fontan patients occurs at a young age with a 1-year survival rate of only 50%. Meticulous liver surveillance is crucial to detect small tumors in the early stage.
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Affiliation(s)
- Mathias Possner
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Timothy Gordon-Walker
- Scottish Liver Transplant Unit, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom; The University of Edinburgh, Edinburgh, United Kingdom
| | - Alexander C Egbe
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Carole A Warnes
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Heidi M Connolly
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Salil Ginde
- Division of Pediatric Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Paul Clift
- Department of Cardiology, New Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Brian Kogon
- Department of Cardiothoracic Surgery, Children's Healthcare of Atlanta, Egleston, Emory University, Atlanta, GA, USA
| | - Wendy M Book
- Division of Cardiology, Department of Medicine, Emory University Department of Medicine, Atlanta, GA, USA
| | - Niki Walker
- Scottish Adult Congenital Cardiac Service, Golden Jubilee National Hospital, Glasgow, United Kingdom
| | - Lodewijk J Wagenaar
- Department of Cardiology, Thoraxcentrum Twente, Medisch Spectrum Twente Hospital, Enschede, the Netherlands
| | - Tabitha Moe
- Division of Cardiology, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Erwin Oechslin
- Toronto Congenital Cardiac Centre for Adults, University Health Network / Peter Munk Cardiac Centre, and University of Toronto, Toronto, Ontario, Canada
| | - W Aaron Kay
- Section of Pediatric Cardiology, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA; Krannert Institute of Cardiology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Mark Norris
- Division of Pediatric Cardiology, University of Michigan Congenital Heart Center, C.S. Mott Children's Hospital, Ann Arbor, MI, USA
| | - Jonathan R Dillman
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Andrew T Trout
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Nadeem Anwar
- Division of Gastroenterology, Department of Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Arvind Hoskoppal
- Department of Pediatrics, University of Utah and Intermountain Healthcare, Salt Lake City, UT, USA
| | - Dieter C Broering
- Department of Liver Transplantation, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Khalid Bzeizi
- Adult Congenital Heart Disease, Heart Centre, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Gruschen Veldtman
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Adult Congenital Heart Disease, Heart Centre, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia.
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12
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Mehta LS, Warnes CA, Bradley E, Burton T, Economy K, Mehran R, Safdar B, Sharma G, Wood M, Valente AM, Volgman AS. Cardiovascular Considerations in Caring for Pregnant Patients: A Scientific Statement From the American Heart Association. Circulation 2020; 141:e884-e903. [DOI: 10.1161/cir.0000000000000772] [Citation(s) in RCA: 115] [Impact Index Per Article: 28.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Cardio-obstetrics has emerged as an important multidisciplinary field that requires a team approach to the management of cardiovascular disease during pregnancy. Cardiac conditions during pregnancy include hypertensive disorders, hypercholesterolemia, myocardial infarction, cardiomyopathies, arrhythmias, valvular disease, thromboembolic disease, aortic disease, and cerebrovascular diseases. Cardiovascular disease is the primary cause of pregnancy-related mortality in the United States. Advancing maternal age and preexisting comorbid conditions have contributed to the increased rates of maternal mortality. Preconception counseling by the multidisciplinary cardio-obstetrics team is essential for women with preexistent cardiac conditions or history of preeclampsia. Early involvement of the cardio-obstetrics team is critical to prevent maternal morbidity and mortality during the length of the pregnancy and 1 year postpartum. A general understanding of cardiovascular disease during pregnancy should be a core knowledge area for all cardiovascular and primary care clinicians. This scientific statement provides an overview of the diagnosis and management of cardiovascular disease during pregnancy.
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Egbe AC, Miranda WR, Bonnichsen CR, Warnes CA, Connolly HM. Potential Benefits of Ambulatory Blood Pressure Monitoring in Coarctation of Aorta. J Am Coll Cardiol 2020; 75:2089-2090. [PMID: 32327108 DOI: 10.1016/j.jacc.2020.02.053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Revised: 02/03/2020] [Accepted: 02/18/2020] [Indexed: 10/24/2022]
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Affiliation(s)
- David R Holmes
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (D.R.H., C.A.W., R.A.N.)
| | - Carole A Warnes
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (D.R.H., C.A.W., R.A.N.)
| | - Patrick T O'Gara
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (P.T.O.)
| | - Rick A Nishimura
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (D.R.H., C.A.W., R.A.N.)
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Miranda WR, Warnes CA, Connolly HM, Taggart NW, O'Leary PW, Oh JK, Egbe AC. Echo-Doppler assessment of ventricular filling pressures in adult Fontan patients. Int J Cardiol 2019; 284:28-32. [DOI: 10.1016/j.ijcard.2018.10.077] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Revised: 09/03/2018] [Accepted: 10/24/2018] [Indexed: 10/28/2022]
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Affiliation(s)
- Rick A Nishimura
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Carole A Warnes
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
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Connolly HM, Miranda WR, Egbe AC, Warnes CA. Management of the Adult Patient With Congenitally Corrected Transposition: Challenges and Uncertainties. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2019; 22:61-65. [PMID: 31027566 DOI: 10.1053/j.pcsu.2019.02.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Accepted: 02/20/2019] [Indexed: 01/03/2023]
Abstract
Congenitally corrected transposition (ccTGA) is a rare form of congenital heart disease characterized by atrioventricular and ventriculoarterial discordance. Patients with ccTGA usually have associated congenital cardiovascular conditions; less than 1% have no associated lesions. Generally, ccTGA is identified during infancy or childhood with features of heart failure or cyanosis when there are associated lesions such as ventricular septal defect and/or pulmonic stenosis. Presentation later in life generally occurs when there are either mild or no associated lesions. Presentation during adulthood may be prompted by symptoms or signs of cardiovascular disease or due to abnormal findings on cardiac testing. Management of patients with ccTGA depends on presentation, symptoms, and associated defects. In this review, we will focus on the management of adult patients with ccTGA.
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Affiliation(s)
- Heidi M Connolly
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.
| | - William R Miranda
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Alexander C Egbe
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Carole A Warnes
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
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18
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Regitz-Zagrosek V, Roos-Hesselink JW, Bauersachs J, Blomstrom-Lundqvist C, Cifkova R, De Bonis M, Iung B, Johnson MR, Kintscher U, Kranke P, Lang IM, Morais J, Pieper PG, Presbitero P, Price S, Rosano GMC, Seeland U, Simoncini T, Swan L, Warnes CA. 2018 ESC Guidelines for the management of cardiovascular diseases during pregnancy. Kardiol Pol 2019; 77:245-326. [DOI: 10.5603/kp.2019.0049] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 01/21/2019] [Indexed: 11/25/2022]
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19
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Miranda WR, Hagler DJ, Reeder GS, Warnes CA, Connolly HM, Egbe AC, Taggart NW. Temporary balloon occlusion of atrial septal defects in suspected or documented left ventricular diastolic dysfunction: Hemodynamic and clinical findings. Catheter Cardiovasc Interv 2019; 93:1069-1075. [DOI: 10.1002/ccd.28150] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 01/29/2019] [Indexed: 11/09/2022]
Affiliation(s)
| | - Donald J. Hagler
- Department of Pediatric and Adolescent Medicine/Division of Pediatric CardiologyMayo Clinic Rochester Minnesota
| | - Guy S. Reeder
- Department of Cardiovascular MedicineMayo Clinic Rochester Minnesota
| | - Carole A. Warnes
- Department of Cardiovascular MedicineMayo Clinic Rochester Minnesota
| | - Heidi M. Connolly
- Department of Cardiovascular MedicineMayo Clinic Rochester Minnesota
| | - Alexander C. Egbe
- Department of Cardiovascular MedicineMayo Clinic Rochester Minnesota
| | - Nathaniel W. Taggart
- Department of Pediatric and Adolescent Medicine/Division of Pediatric CardiologyMayo Clinic Rochester Minnesota
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Huntley GD, Deshmukh AJ, Warnes CA, Kapa S, Egbe AC. Longitudinal Outcomes of Epicardial and Endocardial Pacemaker Leads in the Adult Fontan Patient. Pediatr Cardiol 2018; 39:1476-1483. [PMID: 29948032 DOI: 10.1007/s00246-018-1919-3] [Citation(s) in RCA: 10] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Accepted: 06/01/2018] [Indexed: 11/29/2022]
Abstract
Placement of an epicardial pacemaker system is often preferred over an endocardial system in patients who have undergone a Fontan operation, but data are limited on how these two systems perform over time in patients with Fontan palliation. We performed a retrospective review of adults with Fontan palliation who had pacemaker implantation and interrogation data at Mayo Clinic from 1994 to 2014. Lead parameters, pacing mode, and polarity were collected at the earliest device interrogation report. Clinic notes and device interrogation reports were reviewed at implantation, 6 months, and yearly after implantation to determine impedance, capture threshold (CT), and energy threshold (ET). There were 87 patients with 168 leads in the study cohort. The mean follow-up time was 7.7 years (6 months-19 years). There were 143 epicardial leads (57 atrial and 86 ventricular) and 25 endocardial leads (20 atrial and 5 ventricular). There was no difference in the baseline lead parameters between epicardial and endocardial leads for impedance (610 ± 259 versus 583 ± 156 Ω, p = 0.93), CT (2.0 ± 1.3 versus 1.8 ± 1.3 V, p = 0.28), or ET (7.1 ± 12.5 versus 6.8 ± 18.1 µJ, p = 0.29). Compared to endocardial leads, ventricular epicardial leads were associated with temporal decrease in impedance and increase in ET. Regarding clinical outcomes, epicardial leads had higher rates of failure but similar generator longevity in comparison to endocardial leads. Ventricular epicardial leads were associated with temporal decrease in impedance and increase in ET. Epicardial leads had a higher rate of failure but similar generator longevity compared to endocardial leads.
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Affiliation(s)
- Geoffrey D Huntley
- School of Medicine, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55905, USA.
| | | | - Carole A Warnes
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Suraj Kapa
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Alexander C Egbe
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
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21
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Regitz-Zagrosek V, Roos-Hesselink JW, Bauersachs J, Blomström-Lundqvist C, Cífková R, De Bonis M, Iung B, Johnson MR, Kintscher U, Kranke P, Lang IM, Morais J, Pieper PG, Presbitero P, Price S, Rosano GMC, Seeland U, Simoncini T, Swan L, Warnes CA. 2018 ESC Guidelines for the management of cardiovascular diseases during pregnancy. Eur Heart J 2018; 39:3165-3241. [PMID: 30165544 DOI: 10.1093/eurheartj/ehy340] [Citation(s) in RCA: 1052] [Impact Index Per Article: 175.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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22
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Egbe AC, Poterucha JT, Warnes CA, Connolly HM, Baskar S, Ginde S, Clift P, Kogon B, Book WM, Walker N, Wagenaar L, Moe T, Oechslin E, Kay WA, Norris M, Gordon-Walker T, Dillman JR, Trout A, Anwar N, Hoskoppal A, Veldtman GR. Hepatocellular Carcinoma After Fontan Operation. Circulation 2018; 138:746-748. [DOI: 10.1161/circulationaha.117.032717] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | | | | | | | - Shankar Baskar
- Cincinnati Children’s Hospital, OH (S.B., J.R.D., A.T., N.A., G.R.V.)
| | - Salil Ginde
- Medical College of Wisconsin, Milwaukee (S.G., M.N.)
| | - Paul Clift
- New Queen Elizabeth Hospital, Birmingham, United Kingdom (P.C.)
| | - Brian Kogon
- Emory Adult Congenital Heart Center, Atlanta, GA (B.K., W.M.B.)
| | - Wendy M. Book
- Emory Adult Congenital Heart Center, Atlanta, GA (B.K., W.M.B.)
| | - Niki Walker
- Golden Jubilee National Hospital, Glasgow, United Kingdom (N.W.)
| | | | | | | | - W. Aaron Kay
- Indiana University School of Medicine, Indianapolis (W.A.K.)
| | - Mark Norris
- Medical College of Wisconsin, Milwaukee (S.G., M.N.)
| | | | | | - Andrew Trout
- Cincinnati Children’s Hospital, OH (S.B., J.R.D., A.T., N.A., G.R.V.)
| | - Nadeem Anwar
- Cincinnati Children’s Hospital, OH (S.B., J.R.D., A.T., N.A., G.R.V.)
| | - Arvind Hoskoppal
- University of Utah and Intermountain Healthcare, Salt Lake City (A.H.)
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Egbe AC, Warnes CA. Cardiovascular Adverse Events After Aortic Valve Replacement in Mixed Aortic Valve Disease: Beyond Ejection Fraction. J Am Coll Cardiol 2018; 68:2591-2593. [PMID: 27931620 DOI: 10.1016/j.jacc.2016.09.948] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Revised: 09/13/2016] [Accepted: 09/14/2016] [Indexed: 10/20/2022]
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Abstract
The growing population of adults with congenital heart disease (CHD) poses challenges for cardiac surgeons, general cardiologists and CHD sub specialists. The patients themselves, often believing themselves to be 'totally corrected' following operative repair, also face challenges with re-operations and lifelong cardiac problems. This review examines the challenges of the past, present and future for both medical providers and patients.
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Affiliation(s)
- Carole A Warnes
- Department of Cardiovascular Diseases, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
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25
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Kapa S, Vaidya V, Hodge DO, McLeod CJ, Connolly HM, Warnes CA, Asirvatham SJ. Right ventricular dysfunction in congenitally corrected transposition of the great arteries and risk of ventricular tachyarrhythmia and sudden death. Int J Cardiol 2018; 258:83-89. [DOI: 10.1016/j.ijcard.2018.01.107] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 01/06/2018] [Accepted: 01/22/2018] [Indexed: 11/25/2022]
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26
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Miranda WR, Egbe AC, Hagler DJ, Taggart NW, Nishimura RA, Connolly HM, Warnes CA. Filling pressures in Fontan revisited: Comparison between pulmonary artery wedge, ventricular end-diastolic, and left atrial pressures in adults. Int J Cardiol 2018; 255:32-36. [DOI: 10.1016/j.ijcard.2017.12.098] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 12/22/2017] [Indexed: 10/18/2022]
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Egbe A, Khan AR, Miranda WR, Ammash NM, Warnes CA, Said SS, Taggart NW, Akintoye E, Veldtman GR, Connolly HM. Mechanism for temporal changes in exercise capacity after Fontan palliation: Role of Doppler echocardiography. Am Heart J 2018; 196:144-152. [PMID: 29421006 DOI: 10.1016/j.ahj.2017.10.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Accepted: 10/16/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND The objective was to better understand Doppler hemodynamics and exercise capacity in patients with Fontan palliation by delineating the hemodynamic mechanism for temporal changes in their peak oxygen consumption (V̇o2). METHODS We performed a retrospective review of adult Fontan patients with systemic left ventricle (LV) who underwent serial transthoracic echocardiograms (TTE) and cardiopulmonary exercise tests (CPET) at Mayo Clinic in 2000-2015. TTE and CPET data were used (1) to determine agreement between V̇o2 and Doppler-derived LV function indices (eg, stroke volume index [SVI] and cardiac index [CI]) and (2) to determine agreement between temporal changes in peak V̇o2 and LV function indices. RESULTS Seventy-five patients (44 men; 59%) underwent 191 pairs of TTE and CPET. At baseline, mean age was 24±3 years, peak V̇o2 was 22.9±4.1 mL/kg/min (63±11 percent predicted), SVI was 43±15 mL/m2, and CI was 2.9±0.9 L/min/m2. Peak V̇o2 correlated with SVI (r=0.30, P<.001) and with CI (r=0.45, P<.001) in the 153 pairs of TTE and CPET in patients without cirrhosis. Temporal changes in percent predicted peak V̇o2 correlated with changes in SVI (r=0.48, P=.005) and CI (r=0.49, P=.004) among the 33 patients without interventions during the study. In the 19 patients with Fontan conversion, percent predicted peak V̇o2 and chronotropic index improved. CONCLUSIONS Overall, there was a temporal decline in peak V̇o2 that correlated with decline in Doppler SVI. In the patients who had Fontan conversion operation, there was a temporal improvement in peak V̇o2 that correlated with improvement in chronotropic index.
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Egbe AC, Huntley GD, Connolly HM, Ammash NM, Deshmukh AJ, Khan AR, Said SM, Akintoye E, Warnes CA, Kapa S. Outcomes of cardiac pacing in adult patients after a Fontan operation. Am Heart J 2017; 194:92-98. [PMID: 29223440 DOI: 10.1016/j.ahj.2017.08.019] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Accepted: 08/23/2017] [Indexed: 01/20/2023]
Abstract
BACKGROUND Cardiac pacing can be challenging after a Fontan operation, and limited data exist regarding pacing in adult Fontan patients. The objectives of our study were to determine risk factors for pacing and occurrence of device-related complications (DRCs) and pacemaker reinterventions. METHODS We performed a retrospective review of Fontan patients from 1994 through 2014. We defined DRCs as lead failure, lead recall, cardiac perforation, lead thrombus/vegetation, or device-related infection, and cardiovascular adverse events (CAEs) as venous thrombosis, stroke, death, or heart transplant. Pacemaker reintervention was defined as lead failure or recall. RESULTS Of 439 patients, 166 (38%) had pacemakers implanted (79 during childhood; 87, adulthood); 114 patients (69%) received epicardial leads initially, and 52 (31%), endocardial leads. Pacing was initially atrial in 52 patients (31%); ventricular, 30 (18%); or dual chamber, 84 (51%). There were 37 reinterventions (1.9% per year) and 48 DRCs (2.4% per year). Pacemaker implantation during childhood was a risk factor for DRCs (hazard ratio, 2.01 [CI, 1.22-5.63]; P = .03). There were 70 CAEs (venous thrombosis, 5; stroke, 11; transplant, 8; and death, 46), yielding a rate of 3.5% per year. DRCs, CAEs, and reintervention rates were comparable for patients with epicardial or endocardial leads. CONCLUSIONS More than one-third of adult Fontan patients referred to Mayo Clinic had pacemaker implantation. Epicardial leads were associated with high rate of pacemaker reinterventions but similar DRC rates in comparison to endocardial leads.
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Egbe AC, Khan AR, Boler A, Said SM, Geske JB, Miranda WR, Akintoye E, Connolly HM, Warnes CA, Oh JK. Role of diastolic function indices in the risk stratification of patients with mixed aortic valve disease. Eur Heart J Cardiovasc Imaging 2017; 19:668-674. [DOI: 10.1093/ehjci/jex148] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Accepted: 06/09/2017] [Indexed: 11/13/2022] Open
Affiliation(s)
- Alexander C Egbe
- Division of Cardiovascular Diseases, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Arooj R Khan
- Division of Cardiovascular Diseases, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Amber Boler
- Division of Cardiovascular Diseases, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Sameh M Said
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Jeffrey B Geske
- Division of Cardiovascular Diseases, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - William R Miranda
- Division of Cardiovascular Diseases, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Emmanuel Akintoye
- Department of Internal Medicine, Wayne State University/Detroit Medical Center, 3990 John R, Detroit, MI 48201, USA
| | - Heidi M Connolly
- Division of Cardiovascular Diseases, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Carole A Warnes
- Division of Cardiovascular Diseases, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Jae K Oh
- Division of Cardiovascular Diseases, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
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Egbe AC, Luis SA, Padang R, Warnes CA. Outcomes in Moderate Mixed Aortic Valve Disease: Is it Time for a Paradigm Shift? J Am Coll Cardiol 2017; 67:2321-2329. [PMID: 27199054 DOI: 10.1016/j.jacc.2016.03.509] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2015] [Revised: 03/08/2016] [Accepted: 03/08/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND A direct comparison of outcomes between moderate mixed aortic valve disease (MAVD) and isolated aortic stenosis (AS) or aortic regurgitation (AR) has not been performed, making evidence-based recommendations difficult in patients with MAVD. OBJECTIVES This study sought to determine adverse event (AE) occurrence (the primary endpoint), defined as New York Heart Association functional class III/IV symptoms, aortic valve replacement, or cardiac death, and to compare AE rates between MAVD and isolated AS or AR. METHODS Asymptomatic patients were identified with moderate MAVD and an ejection fraction ≥50% and were followed at Mayo Clinic from 1994 to 2013. Moderate MAVD was defined as a combination of moderate AS and moderate AR. Age- and sex-matched control groups were selected with isolated moderate AR (n = 117), moderate AS (n = 117), or severe AS (n = 117). RESULTS At 9.1 ± 4.2 years of follow-up, patients with moderate MAVD (n = 251) had a mean age of 63 ± 11 years, 73% were male, and 38% had bicuspid valve. AE occurred in 193 (77%) patients in this group, including symptom development (69%), aortic valve replacement (67%), and cardiac death (4%). Predictors of AE were older age (hazard ratio [HR]: 1.71 per decade; 95% confidence interval [CI]: 1.38 to 1.97 per decade; p = 0.001), and relative wall thickness >0.42 (HR: 2.01; 95% CI: 1.86 to 2.33; p = 0.002). AE rates were similar in the MAVD and severe AS group (71% vs. 68% at 5 years; p = 0.49), but were significantly higher compared with the moderate AS and AR groups. CONCLUSIONS MAVD patients had outcomes comparable to those with severe AS, and preserved ejection fraction and should be monitored closely for symptoms.
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Affiliation(s)
- Alexander C Egbe
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Sushil A Luis
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Ratnasari Padang
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Carole A Warnes
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota.
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Egbe AC, Khan AR, Ammash NM, Barbara DW, Oliver WC, Said SM, Akintoye E, Warnes CA, Connolly HM. Predictors of procedural complications in adult Fontan patients undergoing non-cardiac procedures. Heart 2017; 103:1813-1820. [DOI: 10.1136/heartjnl-2016-311039] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Revised: 03/29/2017] [Accepted: 04/09/2017] [Indexed: 12/16/2022] Open
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Egbe AC, Connolly HM, Khan AR, Niaz T, Said SS, Dearani JA, Warnes CA, Deshmukh AJ, Kapa S, McLeod CJ. Outcomes in adult Fontan patients with atrial tachyarrhythmias. Am Heart J 2017; 186:12-20. [PMID: 28454826 DOI: 10.1016/j.ahj.2016.12.015] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Accepted: 12/24/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND The optimal management strategy for atrial tachyarrhythmia in the Fontan population is unknown. METHODS Retrospective review of 264 adult Fontan patients with atrial tachyarrhythmia evaluating 3 clinically adopted scenarios: antiarrhythmic drug (AAD) therapy, catheter ablation (CA), and Fontan conversion (FC). These patients were followed up at Mayo Clinic from 1994 to 2014. The study objective was to compare freedom from atrial tachyarrhythmia recurrence (AR) and occurrence of composite adverse events (stroke, heart failure hospitalization, death, or heart transplant) between treatment groups. RESULTS The age of atrial tachyarrhythmia onset was 25 ± 4 years, time from Fontan operation was 13 ± 6 years, follow-up was 74 ± 18 months, atriopulmonary Fontan was 215 (81%), and atrial flutter/intra-atrial reentry tachycardia was 173 (65%). In those managed with AAD (n = 110), freedom from AR was 7% at 60 months. Catheter ablation (n = 31) was associated with an acute procedural success of 94%, and freedom from AR was 41% at 60 months. Fontan conversion (n = 33) resulted in a perioperative mortality of 3%, and freedom from AR was 51% at 60 months. Fontan conversion and CA were similar with regard to AR (P = .14) and significantly better compared with AAD (P < .0001). Adverse events were found to occur more frequently in the patients with AR (P < .0001) and the patients treated with AAD only (P < .0001). CONCLUSIONS Catheter ablation and FC operations are associated with less recurrence of atrial tachyarrhythmia compared with AAD. Atrial tachyarrhythmias are more likely to recur in patients with a longer history of the arrhythmia and are associated with more adverse events. Early referral to a specialty center for these interventions should be considered.
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Egbe AC, Warnes CA. Predictor of left ventricular dysfunction after aortic valve replacement in mixed aortic valve disease. Int J Cardiol 2017; 228:511-517. [DOI: 10.1016/j.ijcard.2016.11.237] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2016] [Revised: 11/05/2016] [Accepted: 11/10/2016] [Indexed: 12/19/2022]
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Canobbio MM, Warnes CA, Aboulhosn J, Connolly HM, Khanna A, Koos BJ, Mital S, Rose C, Silversides C, Stout K. Management of Pregnancy in Patients With Complex Congenital Heart Disease: A Scientific Statement for Healthcare Professionals From the American Heart Association. Circulation 2017; 135:e50-e87. [PMID: 28082385 DOI: 10.1161/cir.0000000000000458] [Citation(s) in RCA: 215] [Impact Index Per Article: 30.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Today, most female children born with congenital heart disease will reach childbearing age. For many women with complex congenital heart disease, carrying a pregnancy carries a moderate to high risk for both the mother and her fetus. Many such women, however, do not have access to adult congenital heart disease tertiary centers with experienced reproductive programs. Therefore, it is important that all practitioners who will be managing these women have current information not only on preconception counseling and diagnostic evaluation to determine maternal and fetal risk but also on how to manage them once they are pregnant and when to refer them to a regional center with expertise in pregnancy management.
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Egbe AC, Luis SA, Padang R, Warnes CA. Reply: Early Surgery for Mixed Aortic Valve Disease: A Precocious or Premature Proposition? J Am Coll Cardiol 2016; 68:1926-1927. [PMID: 27765201 DOI: 10.1016/j.jacc.2016.08.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Accepted: 08/01/2016] [Indexed: 10/20/2022]
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Stan MN, Sathananthan M, Warnes CA, Brennan MD, Thapa P, Bahn RS. Amiodarone-induced thyrotoxicosis in adults with congenital heart disease--clinical presentation and response to therapy. Endocr Pract 2016; 20:33-40. [PMID: 24013980 DOI: 10.4158/ep13059.or] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [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]
Abstract
OBJECTIVE The development of amiodarone-induced thyrotoxicosis (AIT) can threaten the hemodynamic stability of adult patients with congenital heart disease (CHD). Here, we describe the natural history and treatment response of AIT in this at-risk population. METHODS We studied retrospectively all cases of AIT that occurred in CHD patients at our institution after a minimum of 3 months on amiodarone. Subjects were identified from the cohort of adults with CHD who were treated at the Mayo Clinic Adult CHD clinic between 1987 and 2009. RESULTS We identified 23 cases of AIT: 7 were type 1, 13 were type 2, and 3 were undefined due to insufficient data. Most patients were symptomatic (17 of 23, 74%), with arrhythmia and weight loss as the most common symptoms. The majority (12 of 23, 52%) were initially observed; 10 patients (43%) were treated medically and 1 patient (5%) underwent thyroidectomy. Four patients from the observation group eventually required active treatment and 3 patients from the medical group required surgery. Asymptomatic patients tended to resolve under observation (5 of 7, 71.4%) rather than progress to active treatment (0 of 4) (P = .06). Discontinuation of amiodarone, AIT type, or use of perchlorate did not impact AIT duration. CONCLUSION AIT in CHD patients exhibits a wide range of severity and sensitivity to medical therapy. Asymptomatic patients display a trend toward AIT resolution with observation alone. Amiodarone continuation does not appear to impact management outcome or disease duration. Additional studies in this high-risk population could identify elements of pathophysiology that would point toward better disease prevention and treatment.
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Affiliation(s)
- Marius N Stan
- Department of Internal Medicine, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota
| | | | - Carole A Warnes
- Department of Internal Medicine, Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Michael D Brennan
- Department of Internal Medicine, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota
| | - Prabin Thapa
- Department of Health Sciences Research, Division of Biostatistics, Mayo Clinic, Rochester, Minnesota
| | - Rebecca S Bahn
- Department of Internal Medicine, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota
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Goel K, Foley TA, Warnes CA, McLeod CJ. Pseudoaneurysm Development After Ablation for Atrial Tachycardia in a Patient With Single-Ventricle Anatomy. JACC Clin Electrophysiol 2016; 2:524-525. [DOI: 10.1016/j.jacep.2016.01.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Revised: 01/04/2016] [Accepted: 01/07/2016] [Indexed: 11/27/2022]
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Egbe AC, Connolly HM, Poterucha JT, Warnes CA. Bicuspid and Unicuspid Aortic Valve: Fate of Moderate/Severe Mixed Aortic Valve Disease. CONGENIT HEART DIS 2016; 12:24-31. [PMID: 27375186 DOI: 10.1111/chd.12391] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [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] [Accepted: 06/06/2016] [Indexed: 11/24/2022]
Abstract
OBJECTIVES There is a paucity of data about mixed aortic valve disease (MAVD) in patients with bicuspid/unicuspid aortic valve (BAV). This study sought to describe the outcomes of patients with moderate/severe MAVD. METHODS We queried our database for patients with BAV and moderate/severe MAVD seen between 1994 and 2013. We excluded patients with baseline New York Heart Association (NYHA) III/IV symptoms, left ventricular ejection fraction <50%, aortic dimension >50 mm, and significant disease of other valves. The purpose of the study was to determine the freedom from NYHA III/IV symptoms and aortic valve replacement (AVR). RESULTS We identified 138 patients with moderate/severe MAVD; mean age was 51 ± 12 years; 112 (81%) were males; and follow-up was 8.5 ± 4 years. Ninety-two patients (67%) underwent AVR within 3.7 ± 2.5 years. Mechanical prostheses were implanted in 73 patients (79%); 22 patients (26%) and 36 patients (39%) had concomitant coronary artery bypass graft and aorta replacement during AVR respectively. There were no surgical deaths. Freedom from AVR was 84%, 51%, and 20% at 1, 5 and 10 years respectively. Predictors of AVR were age at presentation (hazard ratio [HR] 5.22; confidence interval [CI] 3.10 to 6.64) for every decade increase in age; and having severe stenosis or regurgitation at the time of presentation (HR 1.32; CI 1.05 to 3.16). CONCLUSIONS Age and disease severity should be incorporated in the risk assessment of BAV patients with MAVD, and patients with both risk factors should be monitored closely.
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Affiliation(s)
- Alexander C Egbe
- Divisions of *Cardiovascular Diseases, Mayo Clinic Rochester, Minn, USA
| | - Heidi M Connolly
- Divisions of *Cardiovascular Diseases, Mayo Clinic Rochester, Minn, USA
| | - Joseph T Poterucha
- Divisions of *Cardiovascular Diseases, Mayo Clinic Rochester, Minn, USA.,Pediatric Cardiology, Mayo Clinic Rochester, Minn, USA
| | - Carole A Warnes
- Divisions of *Cardiovascular Diseases, Mayo Clinic Rochester, Minn, USA
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Okamura H, McLeod CJ, DeSimone CV, Webster TL, Bonnichsen CR, Grogan M, Phillips SD, Connolly HM, Ammash NM, Warnes CA, Friedman PA. Right Parasternal Lead Placement Increases Eligibility for Subcutaneous Implantable Cardioverter Defibrillator Therapy in Adults With Congenital Heart Disease. Circ J 2016; 80:1328-35. [PMID: 27109124 DOI: 10.1253/circj.cj-16-0153] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [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: 01/10/2023]
Abstract
BACKGROUND The subcutaneous implantable cardioverter defibrillator (S-ICD) provides an attractive option for patients with congenital heart disease (CHD) in whom a transvenous defibrillator is contraindicated. Given the unusual cardiac anatomy and repolarization strain, the surface electrocardiogram (ECG) is frequently abnormal, potentially increasing the screen failure rate. METHODS AND RESULTS We prospectively screened 100 adult CHD patients regardless of the presence of clinical indication for ICD utilizing a standard left sternal lead placement, as well as a right parasternal position. Baseline patient and 12-lead ECG characteristics were examined to assess for predictors of screen failure. Average patient age was 48±14 years, average QRS duration was 134±37 ms, and 13 patients were pacemaker dependent. Using the standard left parasternal electrode position, 21 patients failed screening. Of these 21 patients with screen failure, 9 passed screening with the use of right parasternal electrode positioning, reducing screening failure rate from 21% to 12%. QT interval and inverted T wave anywhere in V2-V6 leads were found to be independent predictors of left parasternal screening failure (P=0.01 and P=0.04, respectively). CONCLUSIONS Utilization of both left and right parasternal screening should be used in evaluation of CHD patients for S-ICD eligibility. ECG repolarization characteristics were also identified as novel predictors of screening failure in this group. (Circ J 2016; 80: 1328-1335).
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Reddin G, Poterucha JT, Dearani JA, Warnes CA, Cetta F. Cone Reconstruction of Atypical Ebstein Anomaly Associated with Right Ventricular Apical Hypoplasia. Tex Heart Inst J 2016; 43:78-80. [PMID: 27047292 DOI: 10.14503/thij-15-5011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Cone reconstruction for tricuspid valve repair has revolutionized the surgical treatment of Ebstein anomaly. We present the case of a 58-year-old woman with atypical Ebstein anomaly and right ventricular apical hypoplasia who was spared from palliative shunt physiology by our use of cone reconstruction. Compared with other techniques, cone reconstruction of the tricuspid valve more closely replicates normal valvular anatomy and function. This surgical procedure can be applied to many anatomic variations of Ebstein anomaly, as in our patient's apparently unique instance of atypical Ebstein anomaly with right ventricular apical hypoplasia.
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Egbe AC, Poterucha JT, Warnes CA. Mixed aortic valve disease: midterm outcome and predictors of adverse events. Eur Heart J 2016; 37:2671-8. [DOI: 10.1093/eurheartj/ehw079] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 01/26/2016] [Indexed: 11/14/2022] Open
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Poterucha JT, Anavekar NS, Egbe AC, Julsrud PR, Connolly HM, Ammash NM, Warnes CA. Survival and outcomes of patients with unoperated single ventricle. Heart 2015; 102:216-22. [PMID: 26701967 DOI: 10.1136/heartjnl-2015-308440] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [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: 07/22/2015] [Accepted: 11/23/2015] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE Patients with unoperated single ventricle (SV) rarely survive into adulthood with good functional status and may develop Eisenmenger's syndrome (ES). We report outcomes of a 30-year cohort of such patients. METHODS Adult patients with unoperated SV were identified by searching the Mayo Clinic medical record from 1984 to 2014. Clinical data were collected and compared between patients with pulmonary stenosis (PS) and ES. RESULTS 24 patients were identified (median peak-age 56 (31-77) years (11 ES, 13 PS); 22 had left ventricular morphology. 50-year transplant-free survival was 65% (95% CI 43 to 81). Median age at death was 55 years (31-77 years); 15 deaths (62%) occurred before oral pulmonary vasodilators were commercially available. Two-thirds of the cohort demonstrated preserved New York Heart Association functional class and median EF was 60% (49% to 62%). The majority of patients to survive into the fifth decade exhibited anatomy of double-inlet LV (DILV) with PS. CONCLUSION Selected patients with unoperated SV with PS and ES can survive with good functional class up to the eighth decade with good medical management. DILV/PS appears to be the ideal phenotype for advanced survival. Our outcomes may be considered when such patients with SV having 'balanced' physiology are evaluated for Fontan palliation. However, additional prospective study will be necessary to verify this assertion.
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Affiliation(s)
- Joseph T Poterucha
- Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Nandan S Anavekar
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA Division of Cardiovascular Radiology, Department of Radiology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Alexander C Egbe
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Paul R Julsrud
- Division of Cardiovascular Radiology, Department of Radiology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Heidi M Connolly
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Naser M Ammash
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Carole A Warnes
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
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Van Hare GF, Ackerman MJ, Evangelista JAK, Kovacs RJ, Myerburg RJ, Shafer KM, Warnes CA, Washington RL. Eligibility and Disqualification Recommendations for Competitive Athletes With Cardiovascular Abnormalities: Task Force 4: Congenital Heart Disease. J Am Coll Cardiol 2015; 66:2372-2384. [DOI: 10.1016/j.jacc.2015.09.036] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Van Hare GF, Ackerman MJ, Evangelista JAK, Kovacs RJ, Myerburg RJ, Shafer KM, Warnes CA, Washington RL. Eligibility and Disqualification Recommendations for Competitive Athletes With Cardiovascular Abnormalities: Task Force 4: Congenital Heart Disease. Circulation 2015; 132:e281-91. [DOI: 10.1161/cir.0000000000000240] [Citation(s) in RCA: 104] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Jeejeebhoy FM, Zelop CM, Lipman S, Carvalho B, Joglar J, Mhyre JM, Katz VL, Lapinsky SE, Einav S, Warnes CA, Page RL, Griffin RE, Jain A, Dainty KN, Arafeh J, Windrim R, Koren G, Callaway CW. Cardiac Arrest in Pregnancy. Circulation 2015; 132:1747-73. [DOI: 10.1161/cir.0000000000000300] [Citation(s) in RCA: 217] [Impact Index Per Article: 24.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
This is the first scientific statement from the American Heart Association on maternal resuscitation. This document will provide readers with up-to-date and comprehensive information, guidelines, and recommendations for all aspects of maternal resuscitation. Maternal resuscitation is an acute event that involves many subspecialties and allied health providers; this document will be relevant to all healthcare providers who are involved in resuscitation and specifically maternal resuscitation.
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Webb G, Mulder BJ, Aboulhosn J, Daniels CJ, Elizari MA, Hong G, Horlick E, Landzberg MJ, Marelli AJ, O'Donnell CP, Oechslin EN, Pearson DD, Pieper EP, Saxena A, Schwerzmann M, Stout KK, Warnes CA, Khairy P. The care of adults with congenital heart disease across the globe: Current assessment and future perspective. Int J Cardiol 2015; 195:326-33. [DOI: 10.1016/j.ijcard.2015.04.230] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Accepted: 04/29/2015] [Indexed: 11/30/2022]
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Poterucha JT, Johnson JN, Qureshi MY, O'Leary PW, Kamath PS, Lennon RJ, Bonnichsen CR, Young PM, Venkatesh SK, Ehman RL, Gupta S, Smyrk TC, Dearani JA, Warnes CA, Cetta F. Magnetic Resonance Elastography: A Novel Technique for the Detection of Hepatic Fibrosis and Hepatocellular Carcinoma After the Fontan Operation. Mayo Clin Proc 2015; 90:882-94. [PMID: 26059757 PMCID: PMC4500048 DOI: 10.1016/j.mayocp.2015.04.020] [Citation(s) in RCA: 85] [Impact Index Per Article: 9.4] [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: 01/21/2015] [Revised: 04/01/2015] [Accepted: 04/15/2015] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To evaluate the utility of magnetic resonance elastography (MRE) in screening patients for hepatic fibrosis, cirrhosis, and hepatocellular carcinoma after the Fontan operation. PATIENTS AND METHODS Hepatic MRE was performed in conjunction with cardiac magnetic resonance imaging in patients who had undergone a Fontan operation between 2010 and 2014. Liver stiffness was calculated using previously reported techniques. Comparisons to available clinical, laboratory, imaging, and histopathologic data were made. RESULTS Overall, 50 patients at a median age of 25 years (range, 21-33 years) who had undergone a Fontan operation were evaluated. The median interval between Fontan operation and MRE was 22 years (range, 16-26 years). The mean liver stiffness values were increased: 5.5 ± 1.4 kPa relative to normal participants. Liver stiffness directly correlated with liver biopsy-derived total fibrosis score, time since operation, mean Fontan pressure, γ-glutamyltransferase level, Model for End-Stage Liver Disease score, creatinine level, and pulmonary vascular resistance index. Liver stiffness was inversely correlated with cardiac index. All 3 participants with hepatic nodules exhibiting decreased contrast uptake on delayed postcontrast imaging and increased nodule stiffness had biopsy-proven hepatocellular carcinoma. CONCLUSION The association between hepatic stiffness and fibrosis scores, Model for End-Stage Liver Disease scores, and γ-glutamyltransferase level suggests that MRE may be useful in detecting (and possibly quantifying) hepatic cirrhosis in patients after the Fontan operation. The correlation between stiffness and post-Fontan time interval, mean Fontan pressure, pulmonary vascular resistance index, and reduced cardiac index suggests a role for long-term hepatic congestion in creating these hepatic abnormalities. Magnetic resonance elastography was useful in detecting abnormal nodules ultimately diagnosed as hepatocellular carcinoma. The relationship between stiffness with advanced fibrosis and hepatocellular carcinoma provides a strong argument for additional study and broader application of MRE in these patients.
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Affiliation(s)
- Joseph T Poterucha
- Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN.
| | - Jonathan N Johnson
- Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN
| | - M Yasir Qureshi
- Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN
| | - Patrick W O'Leary
- Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Ryan J Lennon
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Crystal R Bonnichsen
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, Rochester, MN
| | | | | | | | - Sounak Gupta
- Department of Pathology, Mayo Clinic, Rochester, MN
| | | | - Joseph A Dearani
- Division of Cardiac Surgery, Department of Surgery, Mayo Clinic, Rochester, MN
| | - Carole A Warnes
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Frank Cetta
- Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN; Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, Rochester, MN
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Abstract
Because of the growing population of patients with congenital heart disease (CHD), most maternal cardiac disease is now congenital in origin. For women with complex CHD, pregnancy poses an increased risk for both the mother, with complications of arrhythmias and heart failure being the most common, and the baby, with a higher chance of miscarriage, intrauterine growth retardation, and the need for early delivery. Pre-pregnancy counseling must be performed by cardiologists who have expertise in both CHD and pregnancy, with a detailed clinical assessment of the patient and the current hemodynamic situation, including echocardiography and an exercise test. In each case the approach must be individualized with consideration of the risks in each case. In some cases, such as Eisenmenger syndrome, pregnancy is contraindicated. Optimum outcomes in these complex patients are achieved when a multidisciplinary approach is used, involving maternal-fetal medicine specialists, cardiologists with expertise in CHD and obstetric anesthesia.
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Halperin JL, Williams ES, Fuster V, Fuster V, Halperin JL, Williams ES, Cho NR, Iobst WF, Mukherjee D, Vaishnava P, Smith SC, Bittner V, Gaziano JM, Giacomini JC, Pack QR, Polk DM, Stone NJ, Wang S, Balady GJ, Bufalino VJ, Gulati M, Kuvin JT, Mendes LA, Schuller JL, Narula J, Chandrashekhar Y, Dilsizian V, Garcia MJ, Kramer CM, Malik S, Ryan T, Sen S, Wu JC, Ryan T, Berlacher K, Lindner JR, Mankad SV, Rose GA, Wang A, Dilsizian V, Arrighi JA, Cohen RS, Miller TD, Solomon AJ, Udelson JE, Garcia MJ, Blankstein R, Budoff MJ, Dent JM, Drachman DE, Lesser JR, Grover-McKay M, Schussler JM, Voros S, Wann LS, Kramer CM, Hundley WG, Kwong RY, Martinez MW, Raman SV, Ward RP, Creager MA, Gornik HL, Gray BH, Hamburg NM, Iobst WF, Mohler ER, White CJ, King SB, Babb JD, Bates ER, Crawford MH, Dangas GD, Voeltz MD, White CJ, Calkins H, Awtry EH, Bunch TJ, Kaul S, Miller JM, Tedrow UB, Jessup M, Ardehali R, Konstam MA, Manno BV, Mathier MA, McPherson JA, Sweitzer NK, O’Gara PT, Adams JE, Drazner MH, Indik JH, Kirtane AJ, Klarich KW, Newby LK, Scirica BM, Sundt TM, Warnes CA, Bhatt AB, Daniels CJ, Gillam LD, Stout KK, Harrington RA, Barac A, Brush, JE, Hill JA, Krumholz HM, Lauer MS, Sivaram CA, Taubman MB, Williams JL. ACC 2015 Core Cardiovascular Training Statement (COCATS 4) (Revision of COCATS 3). J Am Coll Cardiol 2015. [DOI: 10.1016/j.jacc.2015.03.017] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Affiliation(s)
| | | | | | - Christopher J. McLeod
- Address reprint requests and correspondence: Dr. Christopher J. McLeod, Division of Cardiovascular Diseases, Mayo Clinic, 200 1st St SW, Rochester, MN 55905
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