The patient with Down syndrome and pulmonary arterial hypertension associated with congenital heart disease: from childhood to adulthood

 

Pulmonary arterial hypertension (PAH) is a common complication of congenital heart disease (CHD) that significantly affects its prognosis. Down syndrome is a common comorbidity among patients with PAH associated with CHD. Children born in recent years with CHD have benefited from advances in pediatric cardiac surgery that have modified their evolution compared to adults with the same pathologies. Our objective was to know and compare the characteristics of the adult and pediatric population with DS and PAH associated with CHD.

REHAP and REHIPED are Spanish, voluntary, multicenter registries that include patients with PAH associated with CHD. REHAP started in 2007 and includes patients over 18 years of age. Patients diagnosed with PAH after this time were prospectively included, until 2021. Patients who were followed in the participating centers and diagnosed after January 1998 were retrospectively included in the registry. REHIPED started in 2009 and collects patients between 2 months and 18 years of age. Patients diagnosed with PAH after this time were prospectively included, until 2021. Patients who were followed and diagnosed after January 1998 were retrospectively included. 131 adults and 47 children with DS and PAH associated with CHD were analyzed. Their baseline characteristics, hemodynamics, treatment, and 10-year survival were compared.

Adult patients with DS presented more frequently complete atrioventricular canal defect as underlying heart disease and were mostly in Eisenmenger's situation (84%). In pediatric patients the largest group was post-repair PAH (50%). Functional class was similar in both groups, although adults presented significantly greater hemodynamic severity. Regarding medical treatment, no differences were observed between both groups: there was a very low use of prostanoids both at baseline and at follow-up, and a majority use of oral monotherapy. There were no significant differences in survival.

Corrective surgery in patients with DS has become more frequent over the years: adults are mostly in Eisenmenger's situation, while post-repair PAH is the most numerous group in children. Although adults show greater hemodynamic severity, survival is similar in both groups. Medical treatment, which showed no differences between pediatric and adult age, is very conservative, with most patients on oral monotherapy and rare use of prostanoids.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Janssen MSD

The coronavirus disease 2019 pandemic among adult congenital heart disease patients: findings of a one-year multicentric, international study

Introduction

One year after the beginning of the Coronavirus Disease 2019 (COVID-19) pandemic, the evidence on outcomes among adults with congenital heart disease (ACHD) is still limited.

Purpose

We aimed to compare patient characteristics and outcomes between the first and the subsequent COVID-19 waves and to identify overall predictors for complicated disease course among ACHD patients.

Methods

We collected reported COVID-19 cases among ACHD patients followed at 26 tertiary care centers in 10 European countries between March 27, 2020 and March 25, 2021. Patient characteristics, heart defect complexity and residual problems, medical history, date of diagnosis and course and outcome of COVID-19 were recorded. Cases were stratified into first vs. subsequent COVID-19 waves (cut-off date July 15, 2020). A complicated disease course was defined as hospitalization for COVID-19 requiring ventilation and/or inotropic support, extracorporeal membrane oxygenation or death. Data were reported as median (interquartile range) and counts (percentage).

Results

Overall, 548 cases were included (first wave: n=161; subsequent waves: n=387). Median age 33 (26–44) years, 52% female. Thirty-three patients (6%) had a complicated disease course. Between waves (first vs. subsequent), there were no statistically significant differences related to gender (women 57% vs. 49%, p=0.09), body mass index (BMI) category (p=0.7), heart defect complexity (p=0.08) and residual heart defect-related problems (p=0.6). Patients in the first wave were older, had more often ≥2 comorbidities and a complicated disease course (37 vs 33 years, p=0,001; 17% vs. 7%, p=0.0003; and 9% vs. 5%, p=0.04, respectively). The proportion of deaths did not significantly differed between waves (4% vs 2%, p=0.2). A detailed comparison of the above-reported characteristics is depicted in table 1. From multivariable models, adjusted odds ratios (OR) (95% confidence interval) for the prediction of complicated COVID-19 course are depicted in table 2. Main independent predictors for a complicated disease course were: cyanotic heart disease, including unrepaired cyanotic defects or severe pulmonary hypertension with Eisenmenger syndrome (OR 8.49 [3.14–22.94], p<0.001), BMI >25 kg/m2 (OR 3.91 [1.62–9.43], p=0.002), having ≥2 comorbidities (OR 2.63 [1.05–6.62], p=0.04) and age per five years (OR 1.21 [1.05–1.42], p=0.01).

Conclusion

Complicated COVID-19 course among ACHD patients is rare. Outcomes in the first wave were worse when compared to subsequent waves, mainly because patients of the first wave were older and had more comorbidities. Age, cyanotic heart disease (including unrepaired cyanotic defects or severe pulmonary hypertension with Eisenmenger syndrome), having ≥2 comorbidities and a BMI >25 kg/m2 were the main predictors for a complicated disease course.

Funding Acknowledgement

Type of funding sources: None.

Long term outcome of single ventricle physiology with pulmonary restriction not undergoing Fontan repair

Background

Patients with univentricular physiology who do not complete the palliation to Fontan are a heterogeneous group with unknown long term outcome.

Aims

This study aimed at describing the clinical course and long-term survival of patients with SV physiology with restricted pulmonary flow that had not undergone a Fontan type of repair.

Methods

From the prospectively maintained databases of the adult congenital cardiac units of five tertiary referral centers, data from all SV physiology patients were obtained. Patients completing a Fontan type palliation or developing Eisenmenger physiology and segmental pulmonary hypertension were excluded. Baseline data were recorded on the first visit at adult congenital heart disease (ACHD) unit. The primary end point was death.

Results

101 patients (50.5% females) were identified. Mean age at end of follow up was 39.3±11.3 years. Of these, 45 (44.6%) were unoperated (group 1, restricted forward pulmonary flow with or without pulmonary banding), 38 (37.6%) had undergone a cavopulmonary shunt as a definitive palliation (group 2) and 18 (17.8%) had aortopulmonary shunts (group 3). The main diagnosis was double inlet left ventricle (DILV) (N: 52, 51.5%) and most of the ventricle was left (82.2%). The principal reason for not performing a Fontan repair was mean pulmonary artery pressure >18 mmHg. At initial visit at the ACHD unit patients were 32.2±11.1 years of age. 35% of the patients were in NYHA class III-IV, with no differences between groups. However, patients in group 2 had worse oxygen saturation (p=002) and higher haemoglobin (p=0.037). After a mean follow-up of 7.3±4.1 years, mortality was 20.8% (21 patients), being sudden death (7p, 6.9%) the most frequent cause. Patients in group 3 showed worse ventricular function (p=0.0001) and a trend to higher mortality that did not reach statistical significance (HR 2.7, CI 95% 0.91–8.14, P=0.07).

Conclusions

Patients with single ventricle physiology not undergoing Fontan repair are a population of high risk, with sudden death as main driver of mortality. Patients palliated with aortopulmonary shunts are prone to worse ventricular function and a trend to higher mortality.

Funding Acknowledgement

Type of funding source: Public hospital(s)

Pulmonary hypertension and congenital heart disease: medical treatment and risk factors for survival

Background

Pulmonary arterial hypertension (PAH) is a common comorbidity in congenital heart disease (CHD) and significantly affects prognosis. There are four large clinical groups of CHD-related PAH: Eisenmenger syndrome, PAH associated with non-restrictive shunt, PAH associated with restrictive shunt and postoperative PAH. Our purpose was to study the clinical and prognostic differences among them.

Methods

The REHAP is a Spanish multicentre voluntary registry of patients over 14 years of age, which includes patients with CHD and PAH, starting in 2007. 664 patients were analyzed: Baseline characteristics, functional class, right catheterization data, treatment and survival were compared.

Results

664 patients were analyzed: characteristics are detailed in the table. Patients with Eisenmenger were more frequently treated with oral monotherapy as a first line therapy and received less frequently prostanoids during the follow-up. Patients with Eisenmenger had significantly better prognosis, with the best long-term survival of the 4 groups. In a cox regression model, postoperative PAH has a 1.7 hazard ratio (HR) (reference group: Eisenmenger) after adjustment for age (HR 1.02 p 0,001), functional class (HR NYHA III-IV 2.3 p<0,001), sex (p 0.8) and pulmonary vascular resistance (p 0.7).

Conclusion

The clinical classification of PAH associated with CHD defines both the baseline characteristics and the prognosis of patients. Outcome relates closely to functional class and type of PAH–CHD. Eisenmenger group, which has the most severe hemodynamics, is the one with the best prognosis despite a less aggressive treatment.

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Ferrer, Janssen

2397Lesion-specific risk for sudden cardiac death or life-threatening ventricular arrhythmias in adult congenital heart disease

Background

Risk models for primary prevention strategies in adult congenital heart disease (ACHD) must incorporate the heterogeneous risk for sudden cardiac death (SCD) and life-threatening ventricular arrhythmias (LTVA) as stratified by underlying lesion.

Objectives

To determine lesion-specific risk for SCD and LTVA in ACHD.

Methods

We analyzed 3311 ACHD patients (50% males) prospectively followed-up for 37510 person/years. SCD cases were confirmed by means of the Spanish National Death Registry. In addition, we identified all cases of resuscitated cardiac arrest or ventricular tachycardia requiring cardioversion. According to the incidence rate of the composite end-point of SCD and LTVA, lesions were stratified into four groups of risk. Cumulative freedom from SCD or LTVA in patients at high, moderate, low and very low risk were compared by using Cox regression model with left truncation. The c-index of this lesion-specific risk stratification was calculated by using the β-coefficients. The discriminative ability of this lesion-specific risk stratification was also tested in an external cohort of 203 SCD-LTVA cases and 2287 controls from 20 different centers.

Results

71 patients experienced an event (53 SCD, 18 LTVA). Patients at highest risk (incidence rate >1%) were those with Rastelli procedure, severe coronary abnormalities, complex Fallot and cyanotic patients, either Eisenmenger or non-Eisenmenger; at moderate risk (incidence rate 0.25–1.0%) non-complex Fallot, Mustard/Senning repair, Fontan procedures and congenitally corrected transposition; at low risk (incidence rate 0.1–0.25%) Ebstein anomaly and left heart lesions; and at very low risk (incidence rate <0.1%) left-to-right shunts and right ventricular outflow lesions. The discriminative ability in a multicenter external cohort was excellent (c-index ranged from 0.748 to 0.819 by center).

Lesion-specific risk and C-index

Conclusions

A lesion-specific risk stratification based on the incidence rate of SCD and LTVA was performed and validated. This approach could result in a more individualized risk assessment.

Acknowledgement/Funding

Instituto de Salud Carlos III, Ministerio de Economía y Competividad, Spain (Exp PI14/02099 and PI17/01327) and co-financed by FEDER

Adaptation of the Montreal Cognitive Assessment for elderly Filipino patients

OBJECTIVE

The Montreal Cognitive Assessment (MoCA) is an instrument that aids clinicians in detecting mild cognitive impairment and early Alzheimer's disease. The study aimed to adapt the MoCA for use in the Philippines, and determine its psychometric validity when used in the Filipino setting.

METHODS

The MoCA was adapted by a multidisciplinary team working at the Memory Center of St. Luke's Medical Center, Manila, the Philippines. Contextual adaptation, rather than direct translation, was done. Pilot testing of the Filipino version of the MoCA (MoCA-P) was done on 12 grade 6 pupils and subsequently on 14 cognitively intact elderly people. Reliability testing of the MoCA-P was done on 25 elderly people by trained psychologists. Internal consistency, inter-rater and intra-rater reliability, as well as convergent and divergent validity of the MoCA-P were determined.

RESULTS

The MoCA-P yielded a high level of internal consistency (Cronbach's alpha; = 0.938). Inter-rater and intra-rater reliability were 0.887 (p ≤ 0.05) and 0.969 (p ≤ 0.05), respectively. The MoCA-P correlated negatively with the Epworth Sleepiness Scale (r = -0.233) and had a positive but low correlation with the Mini-Mental State Examination (r = 0.555).

CONCLUSION

Contextual translation and pilot testing yielded several modifications of the MoCA. The MoCA-P is a reliable instrument for use in elderly Filipino patients. Further diagnostic validation of the MoCA-P to establish cutoff scores that would discriminate elderly individuals with normal cognition from those with dementia is needed to establish the clinical utility of the test.

Renal bicarbonate reabsorption and hydrogen ion excretion in normal infants

After acute administration of ammonium chloride, infants 1 to 16 months of age were similar to older children in their capacity to acidify their urine. The infants had a higher rate of excretion of titratable acid and a lower rate of excretion of ammonium but were similar in their rate of excretion of total hydrogen ion.Bicarbonate titrations performed in infants during the first year of life demonstrated a threshold ranging from 21.5 to 22.5 mmoles per L, maximal rate of reabsorption from 2.6 to 2.9 mmoles per 100 ml glomerular filtrate, and marked titration splay. A nephronic frequency distribution curve of the ratio of glomerular filtration rate to tubular reabsorptive capacity demonstrated both heterogeneity and skewing to the right, suggesting the presence of significant numbers of nephrons with low tubular transport capacity relative to filtration rate.It is suggested that the "physiologic acidosis" of the infant is due neither to a limited renal capacity to excrete hydrogen ion nor to a reduced capacity for reabsorption of bicarbonate, but rather to a low renal plasma bicarbonate threshold. Although the level of the threshold may relate to the kinetics of bicarbonate reabsorption during this period, it appears to be due at least in part to functional and morphologic heterogeneity of nephrons.

Effect of circulatory assistance on premature death and long-term prognosis

BACKGROUND

Patients undergoing urgent heart transplantation (HT) have a poorer prognosis and more long-term complications. The objective of this study was to compare the preoperative course in patients undergoing urgent HT according to the need for preoperative intra-aortic balloon counterpulsation (IABP).

MATERIALS AND METHODS

We studied 102 consecutive patients including 23 patients with IABP who underwent urgent HT between January 2000 and September 2006. We excluded patients who received combination transplants, those who underwent repeat HT, and pediatric patients who underwent HT. The statistical methods used were the t test for quantitative variables and the chi(2) test for qualitative variables. A logistic regression model was constructed to assess the possible relationship between IABP and other variables on premature death within 30 days after HT.

RESULTS

Mean (SD) patient-age was 50 (10) years. No significant differences were observed in baseline characteristics between the IABP and the non-IAPB groups. The IABP patient group had higher rates of acute graft failure (45.5% vs 35.4%; P = .46) and premature death (18.8% vs 14.8%; P = .67) and shorter long-term survival (40.6 [34.9] vs 54.5 [43.7] mo; P = .30). Multivariate analysis demonstrated no association between the need for IABP and increased frequency of premature death.

CONCLUSIONS

Use of IABP is not associated with premature or late death. We recommend use of IABP in patients with acute decompensated heart failure to stabilize them before HT.

[Utility of pravastin in cardiac transplant dyslipidemia]

Patients undergoing cardiac transplantation are at increased risk of dyslipidemia (60% to 80%). Lipid-lowering treatment in these patients should be aggressive given the known role of dyslipidemia in chronic transplant rejection. The objective of this study was to evaluate the efficacy and safety of pravastatina therapy and its effect upon cyclosporine levels in a population of dyslipidemic cardiac transplant patients.A total of 20 cardiac transplant patients were enrolled in this 39-week length prospective observational study. Patients had serum cholesterol levels exceeding 200 mg/dl, and received pravastatin therapy at the adequate dose to obtain an optimal lipid profile without significant adverse effects. Pravastatin, at a mean dose of 50 18 mg/day, produced a significant reduction in total cholesterol levels (from 291 32 to 203 25 mg/dl, p < 0.05), LDL cholesterol (from 187 34 to 102 15 mg/dl, p < 0.05) and an increase in HDL-cholesterol levels (from 48 16 to 55 14, p < 0.05). A slight asymptomatic increase in CPK levels was observed but no differences in cyclosporine levels. Pravastatin has shown to be an effective and safe therapy in dyslipidemic cardiac transplant patients.

Three new European cases of urofacial (Ochoa) syndrome

We report on three European cases of urofacial (Ochoa) syndrome. This entity was originally described in Colombian patients and very few cases have been reported from other countries. It is likely that they may be missed because of variability of the urinary problems and failure to recognize the characteristic facial grimacing. Establishing an early diagnosis has important consequences for the management and prognosis of urinary problems in these patients.

Right ventricular infarction mimicking anterior infarction: a case report

Right ventricular infarction usually occurs in association with inferior infarction, with no remarkable electrocardiographic signs in conventional leads. This report describes a patient with a previous inferior acute myocardial infarction who developed right ventricular infarction with significant anterior lead ST segment elevation (V1-V4) caused by the loss of two large right ventricular branches during a coronary angioplasty of the right coronary artery. The case is discussed and the literature is reviewed.

[Emergency implantation of intracoronary stent after acute occlusion of the common trunk of the left coronary artery]

Nowadays, the implantation of coronary endoprosthesis within the left main coronary artery is not considered as an absolute contraindication. Here, we show a case of acute occlusion within the left main coronary artery. This was resolved by implanting a stent during a programmed cardiac catheterization. It should be stressed that this problem was occurred without manipulating the left coronary tree. In addition, the patient was in cardiac arrest when the stent was implanted. Cardiopulmonary resuscitation was applied because of this condition.

[Ketotic hiperglycinemia: one case of possible propionic acidemia (author's transl)]

Authors present the first case to be observed in Spain of neonatal propionic acidemia. The subject is a newborn with symtoms free interval, family consanquinity and siblings who have died prematurely with a similar picture of hyperventilation "sine materiae", progressive metabolic acidosis without anionic discrepancy and terminal coma. The possibility that it might be a question of other metabolopathies is under discussion, but bio-chemical examination, with discovery of large quantities of propionic acid in urine (51 mcg./ml.) and concentrations of aminoacids in plasma, strongly suggest the diagnosis of a new case of neonatal propionic acidemia.

[Urinary tract infections presenting with jaundice (author's transl)]

Ten two to ten weeks old children are presented with urinary tract infection and jaundice. In six cases "E. coli" was the causative organism. Laboratory data seemed to indicate that hemolisis was an important factor in the pathogenesis of jaundice. Treatment with appropriate antibiotics was favorable in all cases. Urinary tract infection with bacteriemia and jaundice is probably the most frequent cause of jaundice among children of two to ten weeks of age.

[Alterations of renal function in pyelonephritis (author's transl)]

Renal function was investigated in a group of ten patients aged two months to eleven years, with chronic or recurrent urinary tract infection caused by different malformations of the urinary tract. The following tests were performed: endogenous creatinine clearance, maximal urinary concentrating ability, urinary acidification, maximal urinary diluting ability, free water clearance, index of fractional distal sodium delivery and index of distal tubular reabsorption of sodium. It is concluded that the follow-up of glomerular function by means of creatinine clearance and of tubular function by means of maximal concentrating ability consitute the most sensible way to detect renal functional impairment in children with chronic or recurrent pyelonephritis.