Pregnancy in Patients with the Fontan Operation

Improved survival rates for patients with a Fontan circulation has allowed more women with this complex cardiac physiology to contemplate pregnancy. However, pregnancy in women with a Fontan circulation is associated with a high risk of adverse maternal and fetal outcomes, high rates of miscarriage and preterm delivery. Factors associated with a successful pregnancy outcome are: younger age, normal body weight, absence of significant functional limitation, no Fontan-related complications, and well-functioning single ventricle physiology. Appropriate care with timely preconception counselling and regular, frequent clinical reviews by a multidisciplinary team based at a tertiary centre, improves the chance of a successful pregnancy. Empowerment of patients with education on their specific congenital cardiac condition and its projected trajectory, helps them make informed choices regarding their health, reproductive choices and assists them to achieve their life goals.

Executive functioning of patients with congenital heart disease: 45 years after surgery

BACKGROUND

Nowadays, more than 90% of patients with congenital heart disease (CHD) reach adulthood. However, long-term impact on neurodevelopment and executive functioning in adults with CHD are not completely understood.

PURPOSE

To investigate the self- and informant-reported executive functioning in adults with CHD operated in childhood.

MATERIAL AND METHODS

Longitudinal study of a cohort of patients (n = 194, median age: 49.9 [46.1-53.8]) who were operated in childhood (< 15 years old) between 1968 and 1980 (median follow-up time: 45 [40-53] years) for one of the following diagnoses: atrial septal defect (ASD), ventricular septal defect (VSD), pulmonary stenosis (PS), tetralogy of Fallot (ToF) or transposition of the great arteries (TGA). Behavior Rating Inventory of Executive Function-Adult version (BRIEF-A) questionnaire was used to assess self- and informant-reported executive functioning.

RESULTS

40-53 years after surgery, the CHD group did show significantly better executive functioning compared to the norm data. No significant difference was found between mild CHD (ASD, VSD and PS) and moderate/severe CHD (ToF and TGA). Higher education, NYHA class 1 and better exercise capacity were associated with better self-reported executive functioning, whereas females or patients taking psychiatric or cardiac medications reported worse executive functioning.

CONCLUSIONS

Our findings suggest favorable outcomes (comparable to normative data) regarding executive functioning in adults with CHD, both self- and informant-reported. However, further study is warranted to explore more in detail the different cognitive domains of executive functioning in these patients.

Reproductive health in adults with congenital heart disease: a review on fertility, sexual health, assisted reproductive technology and contraception

INTRODUCTION

Due to the improved survival in individuals with Congenital Heart Disease (CHD), considering their reproductive health has become more important. Currently, this topic is still underexplored.

AREAS COVERED

We discuss fertility, sexuality, Assisted Reproductive Technology (ART) and contraception in adults with CHD.

EXPERT OPINION

Timely counseling regarding fertility, sexuality, pregnancy and contraception is necessary, preferably during teenage years. Due to a lack of data, whether or not to perform ART in adults with CHD is almost always based on expert opinion and follow-up in an expert center is recommended. Future research is necessary to fill the gaps in knowledge on the risks and frequency of complications of ART in adults with CHD, but also to be able to differentiate the relative risks in the different types of CHD. Only then will we be able to counsel adults with CHD correctly and not unjustly deprive someone of a chance of pregnancy.

Prevalence and development of aortic dilation and dissection in women with Turner syndrome: a systematic review and meta-analysis

OBJECTIVES

Women with Turner syndrome (TS) have an increased risk of aortic disease, reducing life-expectancy. This study aimed to systematically review the prevalence of thoracic aortic dilatation, aortic dimensions and growth, and the incidence of aortic dissection.

METHODS

A systematic literature search was conducted up to July 2022. Observational studies with an adult TS population were included, and studies including children aged <15 years old or specific TS populations were excluded.

RESULTS

In total 21 studies were included. The pooled prevalence of ascending aortic dilatation was 23% (95% CI 19-26) at a mean pooled age of 29 years (95% CI 26-32), while the incidence of aortic dissection was 164 per 100.000 patient-years (95% CI 95-284). Three reporting studies showed aortic growth over time to be limited. Risk factors for aortic dilation or dissection were older age, bicuspid aortic valve, aortic coarctation, and hypertension.

CONCLUSION

In adult TS women, ascending aortic dilatation is common and the hazard of aortic dissection increased compared to the general population, whereas aortic growth is limited. Conventional risk markers do not explain all aortic dissection cases; therefore, new imaging parameters and blood biomarkers are needed to improve prediction, allowing for patient-tailored follow-up and surgical decision-making.

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

Cutibacterium acnes endocarditis: a multicenter case series

Background

Infective endocarditis (IE) due to Cutibacterium acnes (C. acnes) (formerly known as Propionibacterium acnes) is challenging to diagnose. It is suggested that patients often present without fever nor inflammatory parameters. Meanwhile, cardiac abscesses and valve dysfunction are often reported, with a high percentage of patients requiring cardiac surgery [1–7]. No study has yet confirmed the atypical presentation of IE caused by C. acnes.

Purpose

To study clinical characteristics and outcomes of patients with C. acnes IE.

Methods

A multinational retrospective case series was conducted. Patients who were diagnosed with definite IE according to the modified Duke criteria between 2010 and 2020 were included. There were six participating hospitals. Cases were identified by positive blood cultures or positive valve/prosthesis cultures. Clinical data was retrieved from medical records.

Results

We identified 61 cases of C. acnes IE. Patients were predominantly male (n=58, 95%) and had previous cardiac surgery (n=56, 91.8%), which in most cases consisted of aortic valve replacement or Bentall procedures (n=34, 60.7% and n=13, 23.2% respectively). The median time between index surgery and presentation was 31 months (IQR 15.9–69.3). At presentation, fever was absent in 59% of patients (n=36). Most patients experienced symptoms for one to two weeks prior to hospital presentation (41%). At presentation, the median CRP level was 35.5 mg/L (IQR 10.0–70.8). Moreover, in 23% of patients (n=14), the median CRP level was not elevated (&lt;10.0 mg/L). The median leucocyte count at presentation was 9.8x109/L (IQR 8.0–12.3), and thus not exceeding the upper limit of the normal range (10.0x109/L). Approximately half of the blood cultures became positive. In addition, the median time to positivity of blood cultures was seven days (IQR 6–9) and 82.4% of patients had a time to positivity of more than five days. (Redo) surgery was performed in 40 patients (65.5%). Peroperatively, valve dehiscence was observed in 19 patients (47.5%) and vegetations and abscesses were present in 16 patients (40%). The 30-day and one-year mortality rates were 4.9% and 11.5% respectively. Eight patients experienced relapse IE during follow-up of which seven initially received conservative treatment.

Conclusion

IE due to C. acnes predominantly concerns males with prosthetic heart valves. The diagnostic process in C. acnes IE is difficult due to its atypical presentation, with frequent absence of fever and inflammatory parameters. Meanwhile, blood cultures remain negative in approximately half of the patients. Moreover, the time to positivity of blood cultures is one week, which further delays the diagnostic process. Redo surgery is required in a high percentage of patients.

Funding Acknowledgement

Type of funding sources: None.

Socio-economic factors determine maternal and noenatal outcomes in women with peripartum cardiomyopathy: a study of the ESC EORP PPCM registry

Background

Peripartum cardiomyopathy (PPCM) is a global disease associated with substantial morbidity and mortality.

Purpose

The aim of this study was to analyse to what extent country- and individual-level socioeconomic factors were associated with maternal and neonatal outcomes.

Methods

In 2011, &gt;100 national and affiliated member cardiac societies of the European Society of Cardiology (ESC) were contacted to contribute to a global registry on PPCM, under the auspices of the ESC EORP Programme. Country-level sociodemographic factors were Gini coefficient (GINI), health expenditure (HE) and human developmental index (HDI). Individual-level sociodemographic factors were income and educational attainment. We investigated the characteristics and outcomes of women with PPCM and their babies according to individual and country-specific socioeconomic status.

Results

739 women from 49 countries were enrolled (Europe [33%], Africa [29%], Asia-Pacific [15%], Middle East [22%]). Overall, 142 (19%) of women were from countries with low HDI, 307 (42%) medium HDI and 290 (39%) high HDI. Patients of Black African ethnicity were almost all from low HDI countries (99.3%), Middle Eastern and Asian patients from medium HDI (37.7% and 26.2%), and Caucasian patients were mostly from high HDI (72%, p&lt;0.001). Women from countries with low HDI had lower income and educational attainment. They also underwent fewer Caesarian sections, but breastfed for longer (20 versus 6 months, p&lt;0.001). Low HDI and low GINI were associated with greater LV dilatation at time of diagnosis (p&lt;0.001), but LV ejection fraction (LVEF) did not differ according to HDI, HE or GINI. Countries with low HE prescribed guideline-directed heart failure therapy less frequently. Low HE was associated with more frequent mortality (p&lt;0.002), whereas HDI and GINI were not. Women from countries with low HDI and low HE had significantly less recovery of LV function. Analysis of maternal outcome as per highest level of educational attainment (i.e., primary [n=154], secondary [n=342], tertiary [n=126]), showed significant differences in LVEF at 6 months (43.7+12.9, 46.5+13.0 and 48.9+11.7 respectively, p=0.022). Low maternal income, irrespective of region of origin, was independently associated with poor outcome (composite of maternal death, re-hospitalization, or LV non-recovery). Neonatal death was more prevalent in countries with low HE (p=0.009) and low HDI (p=0.023) but was not influenced by maternal sociodemographic parameters.

Conclusion

Maternal and neonatal outcomes depended on country-specific socioeconomic characteristics, with a greater prevalence of maternal and neonatal deaths in women from countries with low HE. Globally, women with low income and lower levels of educational attainment had poorer outcomes, irrespective of region. Attempts should be made to improve patient education, and allocation of adequate health resources to improve maternal and neonatal outcomes in PPCM.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): 1. EurObservational Research Programme in conjunction with the Heart Failure Association of the European Society of Cardiology Study Group on Peripartum Cardiomyopathy2. Cape Heart Institute, University of Cape Town, Cape Town, South Africa

Long term outcomes of congenital aortic stenosis in adults: preliminary results of a multicentre study

Background

Congenital aortic stenosis (ConAoS) accounts for 4–8% of all congenital cardiac diagnosis and is associated with important morbidity and mortality. However, little is known about the natural history of ConAoS in adult patients. We aim to evaluate disease progression of ConAoS in young adults, describing both ventricular and valvular characteristics.

Methods

For this retrospective multicentre cohort study, data of one centre is collected up till now. We included ConAoS patients with a valvular stenosis (Vmax ≥2.5 m/s) aged 18–55 years from the Dutch CONCOR national registry from 2001 until 2019, excluding patients with prior aortic valve replacement (AVR) or severe aortic regurgitation. Echocardiographic data was used to determine presence of left ventricular (LV) hypertrophy (LV mass index &gt;115 g/m2 in males and &gt;95 g/m2 in females) and measure aortic jet velocity.

Results

A total of 92 patients (64% male, median age 24 years) were included with a median follow-up duration of 6.3 years (IQR 2.9–13.3). The median aortic jet velocity was 3.3 m/s (IQR 2.7–3.9) at baseline and significantly increased over time to 3.6 m/s (IQR 2.8–4.3) (p&lt;0.001). LV hypertrophy was present in 33% of the patients and 17% of the patients showed signs of concentric remodelling at baseline. AVR was performed in 32 patients (35%, mean age 36±11 years) and one patient died during follow-up. Figure 1 shows significant differences in intervention-free survival for different AS severity groups (p&lt;0.001) and presence of LV hypertrophy (p=0.02).

Conclusion

Although the progression rate of ConAoS seems to be slow, it is often necessary to perform AVR at a relatively young age. After data collection is completed, this study will enable us to identify risk factors for rapid disease progression and further improve current treatment protocols.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Dutch Heart Foundation, Hartekind

Development of psychopathology in adults with congenital heart disease: a 40–53 years follow-up study

Background

Nowadays, more than 90% of patients with congenital heart disease (CHD) reach adulthood. However, little is known about long-term psychopathological problems in these patients.

Purpose

To investigate the development of psychological outcomes of adults with CHD operated in their childhood.

Material and methods

Our unique, single center, longitudinal cohort-study evaluates a series of consecutive patients who underwent cardiac surgery in childhood between 1968 and 1980 every 10 years. Standardized questionnaires were used to measure psychopathology at 4 follow-up time points (1991, 2001, 2011 and 2021) and outcomes were compared with normative data. Results in the current evaluation were corrected for the Covid-19 stringency index.

Results

At the current (4th) evaluation in 2021, 204 patients (46% female, age: 49.9±5.2) participated. Female patients with CHD reported significantly more internalizing problems than the normative group. More specifically, they reported significantly more somatic complaints. Proxy-reports showed significantly less externalizing problems for males. No significant difference was found between simple and moderate/complex CHD in terms of psychopathology. Correction for Covid-19 pandemic stringency showed no significant effect.

Over time, the percentage of patients scoring in the psychopathological range decreased from the first (1991, 25.4%) to the third follow-up (2011, 1.8%). However, the current study showed a significant increase (9.6%) of the psychopathology levels in comparison with 2011. (figure1)

Conclusions

Compared to normative data, female CHD patients reported significantly more internalizing problems, particularly more somatic complaints. Initially, the level of psychopathology decreased over time. However, in the last decade, there was a significant increase in psychopathology, not explained by the Covid-19 pandemic, warranting continuous attention to the psychological health of adults with CHD.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Thorax foundation

Pregnancy outcomes in women with Ebstein's anomaly: data from the EORP Registry of Pregnancy and Cardiac Disease (ROPAC)

Background

Ebstein's anomaly is a rare congenital cardiac condition characterized by displacement of the posterior and septal leaflets of the tricuspid valve towards the apex of the right ventricle. The ESC Guidelines for the management of cardiovascular diseases during pregnancy categorize women with uncomplicated Ebstein's anomaly as modified World Health Organization (mWHO) risk class II. However, data regarding pregnancy outcomes in women with Ebstein's anomaly are scarce.

Purpose

To evaluate the maternal and perinatal risks of pregnancy in women with Ebstein's anomaly.

Methods

All patients with Ebstein's anomaly who had been included in the Registry of Pregnancy and Cardiac Disease (ROPAC), which is an international, prospective, observational registry of pregnant women with underlying cardiac disease (n=5739), were evaluated. The primary outcome was the occurrence of a major adverse cardiac event, defined as maternal mortality, heart failure, arrhythmia, thromboembolic events or endocarditis. The secondary outcomes were obstetric and perinatal outcomes and the influence of pregnancy on tricuspid valve regurgitation.

Results

Thirty-six hospitals in 22 countries enrolled 81 women with Ebstein's anomaly (mean age 29.7 years, 46.9% nulliparous). Seven (8.6%) women had a history of tricuspid valve repair and a further eight (9.9%) of tricuspid replacement. Most women (67.9%) were in NYHA class I. At least one major adverse cardiac event occurred in 8 (9.9%) pregnancies, including heart failure (n=6), supraventricular arrhythmia (n=3) and thromboembolic events (n=2). There was no maternal death. Almost half of the women underwent a Caesarean section (49%) and preterm delivery occurred in 24.7%. Neonatal mortality was 2.5% and four (4.9%) infants had neonatal congenital heart disease. Serial echocardiographic data pre- and postpregnancy were available in 14 women. There was no clear deterioration in tricuspid regurgitation (see Picture 1).

Conclusion

Although mortality was zero, in 10% of the pregnant women with Ebstein's anomaly a major adverse cardiac event occurred, most frequently heart failure or arrhythmia. Therefore, women with Ebstein's anomaly should be categorized as mWHO risk class II at least, but perhaps more correctly as II–III. Preconception counseling is crucial, so that women are aware of the potential risks of maternal morbidity, preterm delivery and congenital heart disease and the need for careful monitoring during pregnancy.

Funding Acknowledgement

Type of funding sources: None.

Executive functioning of patients with congenital heart disease: 45 years after surgery

Background

For children with congenital heart disease (CHD), subtle neuropsychological deficits have been reported. However, very little is known about executive functioning in their adulthood.

Purpose

To investigate the self- and informant-reported executive functioning in adults with CHD operated in childhood (&lt;15 years old).

Material and methods

A cohort study of 194 patients (age 50 [46–54] years), operated in childhood between 1968 and 1980 for one of the following diagnosis: atrial septal defect (ASD), ventricular septal defect (VSD), pulmonary stenosis (PS), tetralogy of Fallot (ToF) or transposition of the great arteries (TGA), were evaluated 40–53 years after surgery. The “Behavior Rating Inventory of Executive Functions – Adult version” (BRIEF-A) questionnaire was used to assess self- and informant-reported executive functioning and compared to the general population.

Results

The CHD group did not show worse executive functioning compared to normative data. In addition, no significant difference was found between simple CHD (ASD, VSD and PS) and moderate/complex CHD (ToF and TGA).

Higher education and NYHA class 1 were associated with better self-reported executive functioning, while male patients and patients taking psychiatric or cardiac medications reported worse executive functioning.

Conclusions

Overall, our findings suggest reassuring outcomes regarding executive functioning in adults with CHD. However, these findings should be confirmed with neuropsychological assessment studies.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Thorax Foundation

Male-female differences in acute type B aortic dissection: the DisSEXion study

Background/Introduction

Acute type B aortic dissection (ATBAD) is a cardiovascular emergency with high risk of morbidity and mortality. Elucidating male-female differences in ATBAD might help optimize patient-specific care, while data is scarce on this topic.

Purpose

The aim of this study was to identify differences between male and female ATBAD patients in presentation, management and outcomes.

Methods

A retrospective cohort study was conducted including all consecutive patients who presented with ATBAD between 2007–2017 in four tertiary centers. Non-acute, traumatic, and iatrogenic dissections were excluded. We included patients presenting with an intramural hematoma or penetrating aortic ulcer in acute setting.

Results

The study population consisted of 384 patients, of which 41% (n=156) was female. In comparison to males, females presented at an older age (67 [IQR: 57–73] vs. 62 [IQR: 52–71], p=0.015) and fewer female patients had a history of abdominal aortic aneurysm (6% vs. 15%, p=0.009). Imaging diagnostics revealed a smaller proportion of patients with distally extended dissections in females. DeBakey type IIIb was diagnosed less frequently in females (73% vs. 85%, p=0.008) as was renal artery involvement (48% vs. 66%, p=0.009). Furthermore, classical type B dissection was less often observed in female patients compared to male patients (56% vs. 78%, p&lt;0.001). Absolute maximum thoracic aortic diameters were not significantly different in females and males (44.0 [38.0–50.0] mm vs. 42.0 [39.0–49.0], p=0.870). No male-female differences were found in treatment strategy (p=0.561, Figure 1). In-hospital/30-day mortality was 9.6% in female patients and 11.8% in male patients (p=0.603). Long-term mortality did not show a significant male-female difference (p=0.90) during a median follow-up duration of 6.1 [IQR: 4.1–9.1] years (Figure 2).

Conclusion

This study showed that female patients were older at presentation, while male patients more often had distally extended dissections. Although mortality was not significantly different, we encourage male-female specific risk factor studies on late mortality. In this way ATBAD male and female patients at high risk of mortality can be identified and patient-specific care can be implemented.

Funding Acknowledgement

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

Quantification of right ventricular electromechanical dyssynchrony by two-dimensional multi-plane echocardiography in adults with repaired Tetralogy of Fallot

Funding Acknowledgements

Type of funding sources: None.

Background

Electromechanical dyssynchrony between right ventricular (RV) free wall and septum contraction in repaired Tetralogy of Fallot (ToF) contributes to inefficient RV mechanics and ultimately reduced systolic function (1). Whilst current assessment of RV synchronicity involves the lateral wall and septum, the use of two-dimensional multi-plane echocardiography (2D-MPE) enables additional RV walls to be evaluated, reflecting global myocardial dynamics (2).

Purpose

The aim of this study is to gain new insights into regional RV wall mechanics using 2D-MPE, determining the potential added value of this imaging model in the assessment of electromechanical synchronicity.

Methods 

Twenty ToF patients and fifteen healthy controls underwent detailed RV assessment using 2D-MPE. Furthermore, all ToF patients underwent on the same day cardiac magnetic resonance imaging (cMRI). RV wall longitudinal strain (LS) and synchronicity of contraction were measured using speckle tracking in three different RV walls (lateral, anterior and inferior) and the RV septum. RV synchronicity was assessed by the time to peak (TTP) deformation delay between the basal RV wall and mid septal segment. Additionally, mechanical dispersion was calculated as the standard deviation of average TTP strain values across four (SD-4: basal-mid septal and lateral), six (SD-6: inclusive inferior wall) and eight segments (SD-8: inclusive anterior and inferior walls).

Results

RV wall average LS was significantly lower in ToF patients compared to the control group (-20.8 ± 4.0% vs -28.1 ± 3.6%, p = &lt;0.001). In ToF patients, higher LS values were seen in the lateral (-21.5 ± 4.7%) and inferior (-20.7 ± 3.7%) walls compared to the anterior (-19.0 ± 4.5%) wall. RV wall to septum TTP delay was significantly increased for all segments in ToF patients compared to healthy controls (all p &lt;0.03). In ToF patients, inferior wall-septum TTP delay was 50 [5, 89]ms whilst the lateral (65 [26, 81]ms) and anterior wall (66 [40, 98]ms) delay was longer. In healthy controls meanwhile, peak RV wall and septal deformation occurred almost simultaneously (table 1). SD-4 was significantly greater in ToF patients compared to controls (39 [23, 56]ms vs 14 [0, 21]ms, p = 0.001) however SD-6 and SD-8 were not significantly different (36 [22, 53]ms vs 22 [17, 35], p = 0.09; 31 [17, 51]ms vs 30 [20, 32]ms, p = 0.33). The association between mechanical dispersion measurements and cMRI-derived right ventricular ejection fraction (RVEF)  strengthened with the inclusion of additional RV walls (SD-4 R² = -0.18; SD-6 R² = -0.18; SD-8 R² = -0.27).

Conclusion

2D MPE provides new insights into RV regional deformation and evaluates the association between the mechanics of individual RV walls and the septum. Further research is required to expand upon this novel approach for the assessment of regional RV function. Abstract Table 1  Abstract Figure 1

Infective endocarditis in adult patients with congenital heart disease: results from the ESC EORP EURO-ENDO registry

Background

Congenital Heart Disease (CHD) predisposes to Infective Endocarditis (IE)

Purpose

To characterize and to determine the prognosis of IE in this specific population.

Methods

The ESC EORP EURO-ENDO study is a prospective international study in patients (n=3111) diagnosed with IE. In this pre-specified ancillary analysis, we aimed to describe adult patients with CHD (n=365, 11·7%) and compare them with patients without CHD (non-CHD, n=2746) in terms of baseline characteristics and 1-year outcome.

Results

CHD patients (73% men, age 44·8±16·6 years) were younger and had less comorbidities. Of the CHD patients, 14% had a dental procedure in the 6 months before hospitalization versus 7% in non-CHD patients (p&lt;0·001) and more often positive blood cultures for Streptococcus viridans (16·4% vs 8·8%, p&lt;0·001). As in non-CHD patients, IE affected most often the left-sided valves. For CHD patients, in-hospital mortality was 9·0% vs 18·1% in non-CHD patients (p&lt;0·001), and also 1-year outcome was more favourable (log-rank for all-cause mortality p&lt;0·0001), even after adjustment for age (Hazard Ratio (HR) 0·61; 95% CI 0·45–0·81). Within the CHD population, multivariable Cox regression revealed the following predictors for mortality: fistula (HR 6·97), cerebral embolus (HR 4·64), renal insufficiency (HR 3·44), Staphylococcus aureus as causative agent (HR 2·06) and failure to undertake surgery when indicated (HR 5·93).

Conclusion

CHD patients with IE have better outcome in terms of all-cause mortality. The observed high incidence of dental procedures prior to IE fuels the discussion about the need for antibiotic prophylaxis.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Since the start of EORP, the following companies have supported the program: Abbott Vascular Int. (2011–2021), Amgen Cardiovascular (2009–2018), AstraZeneca (2014–2021), Bayer AG (2009–2018), Boehringer Ingelheim (2009–2019), Boston Scientific (2009–2012), The Bristol Myers Squibb and Pfizer Alliance (2011–2019), Daiichi Sankyo Europe GmbH (2011–2020), The Alliance Daiichi Sankyo Europe GmbH and Eli Lilly and Company (2014–2017), Edwards (2016–2019), Gedeon Richter Plc. (2014–2016), Menarini Int. Op. (2009–2012), MSD-Merck & Co. (2011–2014), Novartis Pharma AG (2014–2020), ResMed (2014–2016), Sanofi (2009–2011), Servier (2009–2021), Vifor (2019–2022). Survival CHD vs non-CHD patients

Hypertensive disorders of pregnancy in women with structural heart disease: data from the ESC EORP Registry of Pregnancy and Cardiac disease (ROPAC)

Background

Hypertensive disorders of pregnancy (HDP) are estimated to occur in 10% of pregnancies in the general population and preeclampsia specifically in 3–5%. HDP are suggested to be more common in and less well tolerated by women with heart disease. However, the current data are conflicting and this knowledge gap impacts clinical practice guidelines.

Purpose

To harness the well characterized data of the Registry of Pregnancy and Cardiac disease (ROPAC) to examine the frequency of HDP in women with structural heart disease and its impact on maternal and perinatal outcomes.

Methods

The ROPAC registry (n=5739) is a worldwide prospective registry on pregnancies in women with heart disease, including congenital heart disease (CHD, n=3295), valvular heart disease (VHD, n=1648), cardiomyopathy (CMP, n=438), aortopathy (AOP, n=217), ischemic heart disease (IHD, n=95), and pulmonary arterial hypertension (PAH, n=45). We defined HDP as either chronic hypertension, gestational hypertension, and/or preeclampsia (including HELLP syndrome and eclampsia) and assessed the frequency of HDP in each heart disease category. Predictors of preeclampsia were identified using multivariable logistic regression. The proportion of women with adverse maternal, pregnancy, and fetal/neonatal outcomes were described among women with preeclampsia or HDP, and compared between women with and women without HDP using chi-square tests.

Results

In total, the frequency of HDP and preeclampsia was 9.3% and 2.6% in CHD, 7.5% and 2.2% in VHD, 18.7% and 7.1% in CMP, 15.7% and 2.8% AOP, 35.8% and 6.3% in IHD, and 22.2% and 11.1% in PAH. Independent predictors of preeclampsia were chronic hypertension (OR 3.06, 95% CI 2–4.69), nulliparity (2.39, 1.68–3.38), HDP in a previous pregnancy (2.29, 1.11–4.7), gestational diabetes in the current pregnancy (2.13, 1.13–4.03), pulmonary hypertension (1.71, 1.08–2.7) and age (1.04, 1.01–1.07). In women with preeclampsia and heart disease, maternal mortality was 3.5% and heart failure was 29.1%. Maternal mortality (1.4% vs 0.6%, p=0.042), heart failure (18.5% vs 10.6%), Caesarean section (61.2% vs 48.4%), preterm births (27.4% vs 16.9%), low Apgar score (9.8% vs 6.6%), small for gestational age (14.6% vs 9.7%) and neonatal mortality (1.7% vs 0.4%) were higher in women with than women without HDP (all p&lt;0.001 except maternal mortality).

Conclusions

The frequency of HDP is increased (&gt;10%) in CMP, AOP, IHD and PAH, but not in CHD and VHD. The high frequency of HDP is partly due to chronic hypertension, but the incidence of preeclampsia is also increased (&gt;5%) in CMP, IHD and PAH. Among women with cardiac disease, HDP were associated with adverse maternal and perinatal outcomes. The high maternal mortality rate of 3.5% in women with heart disease and preeclampsia warrants close clinical monitoring and a better understanding of the optimal management strategies in the complex population group.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Funding from “Zabawas Foundation” and “De Hoop Foundation” in addition to the support from EORP is greatly acknowledged. Since the start of EORP, the following companies have supported the programme: Abbott Vascular Int. (2011–2021), Amgen Cardiovascular (2009–2018), AstraZeneca (2014–2021), Bayer AG (2009–2018), Boehringer Ingelheim (2009–2019), Boston Scientific (2009–2012), The Bristol Myers Squibb and Pfizer Alliance (2011–2019), Daiichi Sankyo Europe GmbH (2011–2020), The Alliance Daiichi Sankyo Europe GmbH and Eli Lilly and Company (2014–2017), Edwards (2016–2019), Gedeon Richter Plc. (2014–2016), Menarini Int. Op. (2009–2012), MSD-Merck & Co. (2011–2014), Novartis Pharma AG (2014–2020), ResMed (2014–2016), Sanofi (2009–2011), Servier (2009–2021), Vifor (2019–2022). HDP in women with heart diseaseIncidence of HDP per diagnosis group

Wall shear stress angle determines aortic growth in patients with bicuspid aortic valves

Funding Acknowledgements

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): The Dutch Heart Foundation

Background

Patients with bicuspid aortic valve (BAV) have altered flow velocity patterns with different wall shear stress (WSS) distributions in the ascending aorta compared to patients with tricuspid aortic valves. These WSS distributions are associated with aortic dilatation in cross sectional studies, however, longitudinal data demonstrating a potential causative role is missing.

Purpose

The aim of this study was to assess the differences in WSS distributions between BAV patients and healthy subjects and to determine the predictive value of WSS for aortic growth in patients with a BAV.

Methods

Forty patients with a BAV and 32 healthy matched subjects were prospectively studied by 4D-flow cardiovascular magnetic resonance (CMR). Peak velocity, pulse wave velocity, aortic distensibility, peak systolic WSS (magnitude), the different WSS components (axial and circumferential), and WSS angle were assessed in the proximal ascending aorta. WSS angle was defined as the angle between the WSSmagnitude and WSSaxial component. In the BAV patients, aortic volumetric growth over three years was determined in the proximal ascending aorta (first 5cm) based on CT angiography. Multivariate linear regression analysis was used to identify independent predictors of aortic volumetric growth.

Results

Of the BAV patients, 21 (53%) had a left-right fusion pattern and eight patients had Turner syndrome. WSSaxial was significantly lower in BAV patients compared to healthy subjects (p = 0.008) and WSScircumferential and WSS angle were significantly higher (both p &lt; 0.001, see Figure). WSSmagnitude, pulse wave velocity, and aorta distensibility were not statistically significant different. WSSmagnitude (0.69 N/m² [0.51-0.81] vs 1.08 N/m² [0.89-1.24], p = 0.005), WSSaxial (0.50 N/m² [0.39-0.61] vs 0.72 N/m²  [0.54-0.94], p = 0.015) and WSScircumferential (0.34 N/m² [0.32-0.46] vs 0.64 N/m² [0.47-0.81], p = 0.008) were significantly lower in BAV Turner patients compared to BAV non-Turner patients, while WSS angle (40° [34-41] vs 40° [32-48], p = 0.607) was not statistically significant different. During a follow-up of three years, there was a significant growth of the proximal ascending aorta in the BAV patients (1.2 cm3 [-0.2-2.5], p = 0.001). In multivariate analysis corrected for baseline aortic volume and diastolic blood pressure, WSS angle was the only independent predictor for proximal aortic volume growth (β=0.108, p = 0.030).

Conclusions

Increased WSScircumferential and especially WSS angle are present in patients with BAV. WSS angle was the only independent predictor of aortic growth. These findings highlight the potential role of  WSS measurements in patients with BAV to stratify patients at risk for aortic dilation.

Serial MRI-based right ventricular mechanical wall stress measurements and their association with right ventricle function in patients with repaired Tetralogy of Fallot

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): Stichting Hartekind en Thorax Foundation

Background

Optimal timing of pulmonary valve replacement (PVR) in Tetralogy of Fallot (TOF) patients remains challenging. Wall stress is considered to be a possible early marker of right ventricular (RV) dysfunction. With patient-specific computational models, wall stress can be determined regionally and with high accuracy, especially in complex shaped ventricles such as in TOF patients. We aimed to 1) develop patient-specific computational models to assess RV diastolic wall stresses and 2) investigate the association of wall stresses and their change over time with functional parameters in TOF patients.

Methods

Repaired TOF patients with at least moderate pulmonary regurgitation (PR) and prior to PVR were included. MRI-based patient-specific computational ventricular models were created (figure). The ventricular geometry was created by stacking endo- and epicardial contours traced on short axis SSFP cine images. Pressure in the right ventricle was estimated from echocardiography. Mid-diastolic wall stress in the RV free wall was analysed globally and regionally (basal, mid, apical, anterior, lateral and posterior) at two time points. RV ejection fraction (RVEF), NT-proBNP and exercise tests (% maximum predicted workload) were used as outcomes for RV function. Associations between wall stresses and outcomes were investigated using linear mixed models adjusted for follow-up duration.

Results

Five males and five females were included with an age at baseline of 24 (IQR 16-28) years and RV end-diastolic volume of 140 (IQR 127-144) ml/m2. The period between the two time points was 7.0 (IQR 5.8-7.3) years. Global wall stress of the RV free wall combining both time points was 5.8 kPa (IQR 5.2-7.2). There was no statistical difference between baseline and follow-up global wall stress. The mean wall stresses in the mid region was 1.69 kPa (p &lt; 0.01) higher than in the basal region and was 1.05 kPa (p = 0.03) higher than in the apical region cross-sectionally. The wall stress also increased more in the mid region compared to basal and apical region, corrected for duration of follow-up. Patients with more severe PR at baseline demonstrated a higher increase of global wall stress over time (p = 0.02), especially in lateral free wall. Higher global free wall stresses were cross-sectionally independently associated with lower RVEF, adjusted for LVEF and RVEDV (β=-1.29 % RVEF per kPa increase in wall stress, p = 0.01). This association was most prominent in the anterior, basal and mid part. No statistically significant association was found between wall stress, NT-proBNP, and exercise capacity.

Conclusions

This study generated a novel MRI-based method to calculate wall stress in geometrically complex ventricles. Wall stress associated negatively with RVEF in patients with TOF and PR. This promising tool for RV wall stress analysis can be used in future larger studies to validate these preliminary findings and to assess the predictive value of wall stress in TOF.

Abstract Figure.

1050 Normal imaging findings after aortic valve implantation on 18f-fluorodeoxyglucose positron emission tomography with computed tomography and computed tomography angiography

Purpose

Although 18F-Fluorodeoxyglucose (18F-FDG) Positron Emission Tomography (PET) with computed tomography (CT) and cardiac computed tomography angiography (CTA) are essential tools in diagnosing prosthetic heart valve (PHV) endocarditis, the normal imaging findings in the first year after PHV implantation on 18F-FDG-PET/CT and CTA have not been studied prospectively. We prospectively assessed the perivalvular FDG uptake at different time points after aortic PHV implantation and assessed the normal imaging findings on CTA.

Materials and methods

Patients who had undergone uncomplicated aortic PHV implantation were included and underwent 18F-FDG PET/CT and CTA at 5(±1) weeks (group 1), 12(±2) weeks (group 2) or 52(±8) weeks (group 3) after implantation. After a preparatory diet to suppress normal myocardial glucose uptake, FDG uptake in the myocardium as well as around the PHV was scored using the Qualification Visual Score for Hypermetabolism (QVSH) as "none" (&lt; mediastinum), "low" (&gt; mediastinum but &lt; liver), "intermediate" (&gt; liver), or "high" (intense uptake) and quantitative analysis was performed with maximum Standardized Uptake Value (SUVmax) and target to background ratio (SUVratio) on standardized European Association of Nuclear Medicine Research Ltd. (EARL) reconstructions by an experienced nuclear medicine physician. CTA was analysed for image quality, artefacts and stranding of the peri-aortic fat by a cardiac radiologist.

Results

In total 37 patients (group 1: n = 12, group 2: n = 12, group 3: n = 13) (age 66 ± 8 years) were included. Myocardial FDG uptake was intermediate or less in 29/37 scans (78%). QVSH around the PHV was 8/12(67%) low and 4/12(33%) intermediate in group 1, 7/12(58%) low and 5/12(42%) intermediate in group 2 and 8/13(62%) low and 5/13(38%) intermediate in group 3 (p = 0.91). No scan was scored as "none" or "high". EARL SUVmax was 3.48 ± 0.57, 3.50 ± 0.59 and 3.34 ± 0.55 (mean ± SD, p = 0.77) and EARL SUVratio was 2.00 ± 0.29, 1.96 ± 0.41 and 1.71 ± 0.26 (mean ± SD, p = 0.07) for groups 1, 2 and 3, respectively.

One patient in group 3 refused to undergo the additional CTA and one CTA in group 3 could not be analysed for image quality and artefacts due to techniqual difficulties. Overall CTA image quality was "good" or "excellent" with an artefact score of "virtually none" or "mild" in most cases (n = 33, 94%). Stranding of peri-aortic fat was seen in 27/35 (77%) of these patients (group 1: n = 11; group 2: n = 9; group 3: n = 7) with no signs of FDG uptake on PET/CT scan.

Conclusion

Baseline FDG uptake around aortic PHV at 5, 12 and 52 weeks after implantation is similar and mild in the majority of cases with an overall mean SUVmax and SUVratio of 3.44 ± 0.56 and 1.89 ± 0.34 respectively. CTA revealed baseline post-surgical findings in the first year after PHV implantation.

P987 Comprehensive systolic right ventricular longitudinal strain analysis in congenital heart disease patients with different right ventricular loading conditions

Conclusion

Comprehensive RV function analysis reveals decreased RV function in all CHD subgroups compared with healthy subjects. GLS showed RV systolic function to be the worst in the systemic RV but however could not differentiate between subpulmonic RV groups confirming the load independent functional analysis capacity of GLS.

Abstract P987 Figure.

P990 Multi-plane echocardiographic analysis of right ventricular function in patients with systemic and subpulmonic physiology

Conclusion

This study provides for the first time an extensive RV specific analysis of the systemic RV. The feasibility of all RV parameters in the four-view iRotate model is excellent in CHD and represents a reproducible, easily applicable and complete RV assessment in daily practice. Systolic function is significantly reduced in systemic RV compared to subpulmonic RV physiology.

Abstract P990 Figure.

P5280The impact of background phase offset errors in cardiovascular magnetic resonance phase contrast imaging: a multi-scanner study

Background

Phase contrast (PC) CMR flow measurements (FM) are widely used for blood flow assessment, but they suffer from phase offset errors (POE). Stationary phantom correction limits these inaccuracies, however, this adds scan time. Stationary tissue (ST) correction is an alternative method that does not require additional scanning. The aim of this study was to evaluate the impact of POE, to assess interscanner variation, and to evaluate the ST correction usage.

Methods

We included 166 patients in which both aorta and main pulmonary artery FM were acquired including static gelatin phantom data. Subjects were scanned on three types of 1.5T scanners from the one vendor. Uncorrected and ST corrected FM were compared with phantom corrected FM, our reference value, and corrected for BSA. A difference of >10% in net flow was defined as clinically relevant. Regurgitation fraction was calculated and POE influences were assessed. Regurgitation severity was graded and POE influence on severity grading was assessed.

Results

Of the 166 cases included, the median age was 27 (5–74) years. Overall, the median difference between no corrected and phantom corrected FM was ≤6%, however, with a wide range of over- and underestimation (−155%–78% change) (figure). ST correction resulted in larger differences compared to no correction (p<0.01). Clinically significant differences were seen in 19% of all FM with no correction and in 30% of with ST correction (p<0.01). Furthermore, there were significant differences between scanners (no correction 10%, p<0.01; ST correction, p<0.01). Regurgitation severity indexing changed in 38 (11%) cases with no correction and in 48 (48%) with ST correction.

Magnitude of flow change with and without offset corrections (n=332) Flow (ml/m2) Δ no correction and phantom correction (%) Δ ST correction and phantom correction (%) Clinically significant difference (>10%) Mean ± SD Median IQR Range Median IQR Range No correction, N (%) ST correction , N (%) MRI 1 (n=126) 50±12 3 0 to 6 −8 to 30 5 −3 to 9 −26 to 28 13 (10%) 34 (27%) MRI 2 (n=102) 48±13 −2 −15 to 6 −155 to 78 5 −3 to 11 −74 to 52 50 (49%) 50 (49%) MRI 3 (n=104) 48±12 −1 −1 to 0 −7 to 14 2 −2 to 5 −39 to 29 1 (1%) 16 (15%) Total (n=332) 49±12 0 −2 to 4 −155 to 78 3 −2 to 8 −74 to 52 64 (19%) 100 (30%)

Conclusion

Background POE have a significant impact on flow quantification and regurgitation severity. Unexpectedly, background correction using ST correction worsens accuracy compared to no correction. POE vary greatly between scanners. Therefore, careful assessment of FM at each scanner is essential to determine if routine phantom scanning is necessary.

P2881Eligibility for a subcutaneous defibrillator based on standard 12-lead electrocardiogram

Background

Currently, the eligibility for a subcutaneous implantable defibrillator (S-ICD) system relies on a pre-implant vector screening based on the automated screening tool (AST).

Objective

To determine 12-lead ECG characteristics associated with eligibility for an S-ICD in a heterogeneous population at risk for sudden cardiac death (SCD). The goal is to determine patient eligibility for S-ICD using the standard 12-lead ECG, thereby avoiding additional AST screening.

Methods

We prospectively evaluated the eligibility for an S-ICD in 254 consecutive patients at risk for SCD. We identified 12-lead ECG parameters which were independently associated with AST passing (≥1 vector) using multivariable logistical regression analysis in our derivation cohort. The final model was tested in a separate validation cohort.

Results

The overall passing rate was 92% in our derivation cohort. Independent 12-lead ECG characteristics associated with AST passing were QRS≤130 ms, absence of QRS/T discordance in lead II and R/T-ratio ≥3.5 in lead II (Table). Eighty-three of 254 patients (33%) fulfilled these three criteria and had a passing rate of 100%. Of the validation cohort, 37 of 60 patients (62%) fulfilled all three criteria and also had a passing rate of 100%. The interobserver agreement for applying the ECG model was 90% (Cohen's Kappa=0.80).

Table 1 Variables Univariable Multivariable OR (95% CI) P-value OR (95% CI) P-value QRS ≤130 ms 9.65 (3.66–25.43) <0.01 8.09 (2.88–22.77) <0.01 QTc ≤450 ms 3.33 (1.18–9.54) 0.02 Absence of T-wave inversion in lead I 2.74 (1.03–7.25) 0.04 Absence of T-wave inversion in lead II 3.65 (1.29–10.33) 0.02 Absence of QRS/T-wave discordance in lead II 5.05 (1.98–12.92) <0.01 4.19 (1.49–11.74) <0.01 Absence of QRS/T-wave discordance in lead aVF 3.95 (1.53–10.19) <0.01 R/T-ratio ≥3.5 in lead II 3.58 (1.27–10.01) 0.02 4.21 (1.27–13.95) 0.02 R/T-ratio ≥3.5 in lead aVF 3.16 (1.18–8.42) 0.02 OR = odds ratio; CI = confidence interval.

Figure 1

Conclusion

Using the standard 12-lead ECG, we developed a simple screening model with a high specificity for S-ICD eligibility. Our results suggest that patients who fulfill the three ECG criteria do not need additional AST-screening. Therefore, we developed a simple flowchart to determine eligibility for an S-ICD that can be easily implemented in daily clinical practice (Figure).

6127Maternal, fetal and obstetric outcome in patients with thoracic aortic disease: an ancillary analysis of the ROPAC registry

Background

Cardiovascular disease is the leading cause of death during pregnancy with thoracic aortic dissection being one of the main causes. Thoracic aortic disease (TAD) is most commonly related to hereditary disorders and congenital heart malformations such as bicuspid aortic valve (BAV). Pregnancy is considered as a trigger for aortic complications in women with underlying aortic disease. With this analysis, we aim to study the maternal and fetal outcome of pregnancy in women with TAD.

Methods

The Registry Of Pregnancy And Cardiac disease (ROPAC) is a large, prospective and global registry and enrolled 4418 women from January 2011 onwards with known cardiac disease (mainly congenital and valvular disease) before pregnancy.

Results

TAD was present in 217 woman prior to pregnancy. Almost half of them were Marfan patients (MFS), 20% had a BAV, 7.4% Turner syndrome and 23% of patients had no underlying genetic defect or associated congenital heart defect. 35.5% of patients had aortic dilatation of which 6% had an aortic diameter above 45mm.

Half of patients had previous pregnancies with no significant difference in parity between woman with and without aortic dilatation. Four patients of which 3 MFS patients had an acute aortic dissection (three type A and one type B aortic dissection) but no lethal (maternal of fetal) events occurred. Two patients presented with ventricular arrhythmia of whom one MFS patient. Caesarian section was not performed significantly more frequent in patients with aortic dilatation. Birth weight was lower in the group of woman with aortic dilatation, related to the use of beta-blocking agents. However, intra-uterine growth retardation and prematurity did not occur more frequently.

Conclusion

This ancillary analysis of the ROPAC data provides the first large prospective data on pregnancy risk of patients with a wide range of TAD.

MFS patients are highly represented in the registry and are a vulnerable group to develop severe complications during pregnancy or peripartum with occurrence of aortic dissection in 3% of patients and ventricular arrhythmia in one. Serial follow-up by a specialized multidisciplinary team throughout pregnancy and postpartum period and patient tailored management of delivery is advised.

P624The prognostic value of myocardial deformation in patients with congenital aortic stenosis

Background

Congenital aortic stenosis (AoS) is associated with significant mortality and morbidity but predictors for clinical outcome are scarce. Strain analysis provides a robust and reproducible method for early detection of left ventricular (LV) dysfunction, which might be of prognostic value. Therefore we aimed to assess the prognostic value of LV global longitudinal strain (GLS) and global longitudinal early diastolic strain rate (GLSre) with regard to cardiovascular events.

Methods

This prospective study, included clinically stable patients with congenital AoS between 2011–2013. LV GLS and GLSre was performed in the apical 4, 3 and 2-chamber views using Tomtec software. The endpoint was a composite of death, heart failure, hospitalization, arrhythmia, thrombo-embolic events and re-intervention.

Results

In total 138 patients were included (33 [26–43] years, 86 (62%) male), NYHA class I: 134 (97%). Mean LV GLS was −15.3±3.2%, GLSre 0.66±0.18 s–1. Both correlated with NT-proBNP, LV volumes and ejection fraction (strongest LV GLS with LV EF: r −0.539, p<0.001, strongest LV GLSre with age: r −0.376 p<0.001). During median follow-up of 5.9 [5.5–6.2] years, the endpoint occurred in 53 (38%) patients: 4 patients died, 9 developed heart failure, 22 arrhythmias, 8 thrombo-embolic events and 35 re-interventions. Both LV GLS (standardized HR (sHR 0.62 (95% CI 0.47–0.81) and GLSre (sHR 0.62 (95% CI 0.47–0.83) were associated with the endpoint. Additional multivariable analysis showed that both GLS and GLSre were associated independent of left atrial volume, NT-proBNP and prior re-interventions.

Figure 1

Conclusion

Left ventricular GLS and GLSre are reduced in adult patients with congenital AoS. Both markers are associated with adverse cardiac events and have clear clinical relevance

Acknowledgement/Funding

Erasmus Thorax Foundation

P2740Quantitative assessment of the entire right ventricle from one acoustic window: an attractive approach in patients with congenital heart disease

Background

Right ventricular (RV) function is recognized as a prognostic factor in congenital heart disease (CHD). The accuracy of established parameters as tricuspid annular plane systolic excursion (TAPSE), right ventricular fractional area change (RVFAC) and tissue Doppler imaging (TDI S') are limited as the parameters reflect only a limited region of the RV. We previously introduced a novel four-view approach with different RV walls visualized in their long axis from one apical view using 2D-transthoracic echocardiographic (TTE) iRotate mode.

Aims

To extensive evaluate the entire RV function using iRotate echocardiography in a whole spectrum of CHD patients with abnormally loaded RV; both feasibility and RV echocardiographic parameters as comparison with healthy subjects is evaluated.

Methods and results

One hundred and forty-two CHD patients with abnormally loaded RV and 89 healthy subjects were included. All subjects underwent complete TTE with evaluation of TAPSE, TDI S' and peak systolic global longitudinal RV strain (RV-GLS) from the RV walls using the four-view iRotate model. The feasibility of TAPSE and RV S' ranged between 94% and 100%. The feasibility of RV-GLS in CHD was 98%, 69%, 87% and 72% respectively in the lateral, anterior, inferior and inferior coronal view walls. With the exception of RV S' in the inferior coronal view, all parameters were significantly lower in the CHD vs healthy subjects (p<0.001) (Table).

i-Rotate RV wall GLS (%) RV wall GLS (%) Measurement Feasibility Congenital (n=142) Controls (n=89) P-value Lateral 97.9 −17.6±5.0 −25.4±4.5 <0.001 Anterior 69.0 −15.9±4.9* −24.2±4.5 <0.001 Inferior 88.7 −17.2±4.7 −23.3±4.4 <0.001 Inferior coronal view 72.5 −15.1±4.5* ** −20.8±5.2 <0.001 Data expressed as mean ± SD or %. p<0.05 for *Lateral vs Anterior and vs Inferior CV; **Inferior vs Inferior CV.

Conclusion

The feasibility of all RV parameters in the four-axis iRotate model is excellent in CHD and represents a reproducible, easily applicable and complete RV assessment in daily practice. RV function is significantly decreased in the CHD group using both load dependent and independent parameters. Complete RV strain analysis reveals regional differences in patients with CHD.

P1006Conduction disorders in patients with congenital heart disease and right atrial volume overload: an intraoperative epicardial mapping study

Background

Various atrial regions may contribute to the arrhythmogenic substrate for atrial tachyarrhythmias, including atrial fibrillation (AF), in patients with right atrial (RA) volume overload in congenital heart disease (CHD). It is widely recognized that structural and electrical remodelling of the RA occurs, but a previous endovascular mapping study showed that the left atrium (LA) was also affected in patients with atrial septal defect (ASD). The role of Bachmann's bundle (BB) and posterior left atrium (PLA) is yet unknown.

Purpose

To quantify and compare prevalence and severity of conduction disorders during sinus rhythm between atrial regions in patients with CHD and RA volume overload, using intraoperative high-resolution epicardial mapping.

Methods

Thirty-one patients (female: n=18, age: 48.5±13.8 years, history of AF: n=5) undergoing cardiac surgery for secundum ASD (n=18), sinus venosus defect (n=11) or isolated partial abnormal pulmonary venous return (n=2) were included. Intra-operative epicardial mapping (N=128/192 electrodes, interelectrode distance: 2mm) of the RA, BB, LA and PLA was performed during sinus rhythm. Conduction delay (CD) and block (CB) were quantified per region as proportion (%), length of lines (mm) and maximum conduction time (Δ local activation time between two adjacent electrodes).

Results

Proportion of CD on BB was 3.9% (2.3–4.9), RA 3.1% (1.9–3.8), PLA 2.4% (1.2–3.6) and LA 2.3% (1–3) and was higher on BB compared to PLA (p=0.002) and LA (p<0.001) but not RA (p=0.063). Proportion of CB on BB was 2.1% (1.2–5.4), RA 2.2% (1.1–3.4), PLA 0.8% (0.1–2.4) and LA 0.8% (0.3–1.6) and was smaller on LA compared to BB (p=0.001) and RA (p=0.004).

There were no significant differences in length of CD/CB lines between regions, except that length of the longest CB line per patient was longer in the RA compared to LA (p=0.008).

Maximum conduction time was highest in the RA (median 40ms) as opposed to BB (31ms), LA (21ms) and PLA (18ms; all p<0.0083 with Bonferroni correction), suggesting conduction disorders were more severe in the RA.

For sub analysis, the RA surface was divided into 1) the crista terminalis region and 2) the lateral RA wall. In the crista terminalis region, proportions of CD and CB were higher, CD/CB lines were longer and maximum conduction times were higher (all p<0.05). Differences between patients with and without AF were solely observed on BB: patients with AF had a higher proportion and longer lines of CB (p<0.05), though outcomes should be interpreted with caution due to the small number of patients with AF.

Conclusions

In adult patients with CHD and RA volume overload, both RA and BB were affected by conduction disorders. More specifically, conduction disorders in the RA were mainly concentrated in the crista terminalis region. These findings suggest that not only the RA but also BB may be involved in the arrhythmogenic substrate for atrial tachyarrhythmias in these patients.

Acknowledgement/Funding

Dutch Heart Foundation [no 2012T0046]; LSH-Impulse [no 40-43100-98-008]; CVON [no 914728] and VIDI [no 91717339] to N.M.S. de Groot.

P6500Genetics links abdominal and thoracic aorta aneurysm

Introduction

Familial disease, with a genetic cause, occurs in at least 20–30% of the families of patients with an aortic aneurysm. In these families there is an increased risk for relatives. Therefor family screening is recommended around the age of 50–60 years for first degree relatives of patients with an abdominal aneurysm (AAA) and relatives of patients with thoracic aorta aneurysms (TAA). However current guidelines do not specify the extend of aorta screening for relatives of patients with AAA and patients with TAA. Current practice is that first degree relatives of AAA patients are offered abdominal echo screening for AAA and relatives of TAA patients cardiologic echo for TAAA. Although co- occurrence of AAA with TAAA in rare genetic disease is well known, for other familial aneurysm disease, the frequency of the co-occurrence of AAA and TAAA has not been established.

Purpose

To improve family screening for familial aneurysm, and identify the role of underlying genetic defects.

Methods

To determine the genetics of AAA, whole exome sequencing and CT family screening of the complete aorta was performed in 391 families with familial aneurysm. These families are nested in a patient cohort ascertained form unselected consecutively diagnosed AAA patients visiting the Vascular Surgery Clinic at the our MC.

Results

In 391 families, 360 relatives had a dilated aorta. The spectrum of aortic features in the relatives included 210 (58%) relatives with AAA, 102 (28%) relatives with TAA. Co-occurrence of AAA and TAA was noted in 41 (11%) relatives. In addition 66 (18%) and 79 (22%) had a dilation in the arteria iliaca communis sinistra resp. dextra. In 18 families pathogenic mutations in 11 aneurysm genes were detected.

Conclusion

To reduce underdiagnoses of relatives of AAA patients, CT screening of the total aorta and the iliac arteries is the method of choice, and should replace echo screening of specific parts of the aorta in relatives. Updating the guidelines for family screening for aortic aneurysms is needed to improve early detection and treatment of family members with aorta dilatations.

Acknowledgement/Funding

Stichting Lijf en Leven

P1818Descending aortic thoracic diameter: a risk marker for major adverse cardiovascular outcomes in women

Background

Thoracic aortic diameters have been associated with cardiovascular risk factors and atherosclerosis. However, limited evidence regarding the role of thoracic aortic diameters as risk markers for major cardiovascular outcomes among women and men exist.

Purpose

To evaluate the independent associations between crude and indexed ascending and descending aortic (AA and DA) diameters with major cardiovascular outcomes among women and men and to provide optimal cutoff values associated with increased cardiovascular risk.

Methods and results

2178 women and men ≥55 years from the prospective population-based Rotterdam Study underwent multi-detector CT scan of thorax. Crude diameters of the AA and DA were measured and indexed by height, weight, body surface area (BSA) and body mass index (BMI). Incidence of stroke, coronary heart disease (CHD), heart failure (HF), cardiovascular and all-cause mortality were evaluated during 13 years of follow-up.

Weight-, BSA-, or BMI-indexed AA diameters showed significant associations with total or cardiovascular mortality in both sexes and height-indexed values showed association with HF in women. Crude AA diameters were associated with stroke in men and HF in women. For DA, crude and almost all indexed diameters showed significant associations with either stroke, HF, cardiovascular or total mortality in women. Only weight-, BSA- and BMI-indexed values were associated with total mortality in men. For crude DA diameter, the risk for stroke increased significantly at the 75th percentile among men while the risks for HF and cardiovascular mortality increased at the 75th and 85th percentiles respectively in women.

Conclusions

Our study suggests a role for descending thoracic aortic diameter as a marker for increased cardiovascular risk, in particular for stroke, heart failure and cardiovascular mortality among women. The cut points for increased risk for several of cardiovascular outcomes were below the 95th percentile of the distribution of aortic diameters.

The ESC ACCA EAPCI EORP acute coronary syndrome ST-elevation myocardial infarction registry

Aims 

The Acute Cardiac Care Association (ACCA)–European Association of Percutaneous Coronary Intervention (EAPCI) Registry on ST-elevation myocardial infarction (STEMI) of the EurObservational programme (EORP) of the European Society of Cardiology (ESC) registry aimed to determine the current state of the use of reperfusion therapy in ESC member and ESC affiliated countries and the adherence to ESC STEMI guidelines in patients with STEMI.

Methods and results 

Between 1 January 2015 and 31 March 2018, a total of 11 462 patients admitted with an initial diagnosis of STEMI according to the 2012 ESC STEMI guidelines were enrolled. Individual patient data were collected across 196 centres and 29 countries. Among the centres, there were 136 percutaneous coronary intervention centres and 91 with cardiac surgery on-site. The majority of centres (129/196) were part of a STEMI network. The main objective of this study was to describe the demographic, clinical, and angiographic characteristics of patients with STEMI. Other objectives include to assess management patterns and in particular the current use of reperfusion therapies and to evaluate how recommendations of most recent STEMI European guidelines regarding reperfusion therapies and adjunctive pharmacological and non-pharmacological treatments are adopted in clinical practice and how their application can impact on patients’ outcomes. Patients will be followed for 1 year after admission.

Conclusion 

The ESC ACCA-EAPCI EORP ACS STEMI registry is an international registry of care and outcomes of patients hospitalized with STEMI. It will provide insights into the contemporary patient profile, management patterns, and 1-year outcome of patients with STEMI.

[Update of the ESC guidelines 2018 on cardiovascular diseases during pregnancy : Most important facts]

Heart diseases are the most common cause of maternal death during pregnancy in Western countries. The current ESC guidelines 2018 for the management of cardiovascular diseases during pregnancy is a guide for any physician facing the challenge of caring for pregnant women with cardiovascular diseases. Among the new concepts compared to 2011, are recommendations to classify maternal risk due to the modified World Health Organization (mWHO) classification, introduction of the pregnancy heart team, guidance on assisted reproductive therapy, specific recommendations on anticoagulation for low-dose and high-dose requirements of vitamin K antagonists and the potential use of bromocriptine in peripartum cardiomyopathy. The Food and Drug Administration (FDA) categories A-D and X should no longer be used. Therefore, the table of drugs was completed with detailed information from animal and human studies on maternal and fetal risks. The new findings on specific heart diseases are presented in detail in the respective chapters.

Influence of age and sex on left ventricular diastolic strain analysis

Speckle tracking analysis (STE) of the left ventricle offers a new method to assess left ventricular (LV) diastolic function. LV diastolic strain measurements offer a non-invasive, global and direct measure of LV diastolic function. However, there is little data on normal values and the influence of anthropomorphic factors which is crucial in clinical practice for new techniques. The aims of this study were to formulate reference values for LV diastolic strain rate, elucidate effects of age and sex on LV diastolic strain analysis and compare STE measurements with conventional LV diastolic measurements. One-hundred-forty-seven healthy subjects aged 20–72 years (≥ 28 subjects per age decade) were prospectively included (Mean age 44 ± 13.7 years, 50% female) and examined with electrocardiography and 2D-echocardiography, including speckle tracking. Left ventricular peak early diastolic strain rate (Sre) was measured in the apical windows, using STE. Men had significantly lower LV Sre values than women (1.02 ± 0.22 vs. 1.18 ± 0.23, p value < 0.001). Left ventricular Sre was inversely associated with age, with values decreasing with ageing. An inverse relation was also found with blood pressure and body surface area. Linear regression analysis showed that LV Sre was independently associated with both age and sex. A multivariable linear regression analysis for LV Sre with conventional LV diastolic variables accounted for 70.9% of the variation of LV Sre, showing good model performance. Reference values for LV Sre are reported and found to be both age- and sex-dependent. Therefore we recommend age- and sex-specific references values to be used in daily clinical practice.