Corrigendum to "Risk of cancer in young and older patients with congenital heart disease and the excess risk of cancer by syndromes, organ transplantation and cardiac surgery: Swedish health registry study (1930-2017)" [The Lancet Regional Health-Europe 18 (2022) 100407]

[This corrects the article DOI: 10.1016/j.lanepe.2022.100407.].

Outcomes after cancer diagnosis in children and adult patients with congenital heart disease in Sweden: a registry-based cohort study

OBJECTIVE

Patients with congenital heart disease (CHD) have an increased cancer risk. The aim of this study was to determine cancer-related mortality in CHD patients compared with non-CHD controls, compare ages at cancer diagnosis and death, and explore the most fatal cancer diagnoses.

DESIGN

Registry-based cohort study.

SETTING AND PARTICIPANTS

CHD patients born between 1970 and 2017 were identified using Swedish Health Registers. Each was matched by birth year and sex with 10 non-CHD controls. Included were those born in Sweden with a cancer diagnosis.

RESULTS

Cancer developed in 758 out of 67814 CHD patients (1.1%), with 139 deaths (18.3%)-of which 41 deaths occurred in patients with genetic syndromes. Cancer was the cause of death in 71.9% of cases. Across all CHD patients, cancer accounted for 1.8% of deaths. Excluding patients with genetic syndromes and transplant recipients, mortality risk between CHD patients with cancer and controls showed no significant difference (adjusted HR 1.17; 95% CI 0.93 to 1.49). CHD patients had a lower median age at cancer diagnosis-13.0 years (IQR 2.9-30.0) in CHD versus 24.6 years (IQR 8.6-35.1) in controls. Median age at death was 15.1 years (IQR 3.6-30.7) in CHD patients versus 18.5 years (IQR 6.1-32.7) in controls. The top three fatal cancer diagnoses were ill-defined, secondary and unspecified, eye and central nervous system tumours and haematological malignancies.

CONCLUSIONS

Cancer-related deaths constituted 1.8% of all mortalities across all CHD patients. Among CHD patients with cancer, 18.3% died, with cancer being the cause in 71.9% of cases. Although CHD patients have an increased cancer risk, their mortality risk post-diagnosis does not significantly differ from non-CHD patients after adjustements and exclusion of patients with genetic syndromes and transplant recipients. However, CHD patients with genetic syndromes and concurrent cancer appear to be a vulnerable group.

Incidence of diabetes mellitus and effect on mortality in adults with congenital heart disease

BACKGROUND

Worldwide, 1-2% of children are born with congenital heart disease (CHD) with 97% reaching adulthood.

OBJECTIVES

This study aims to demonstrate the risk of diabetes in patients with CHD, and the influence of incident diabetes on mortality in CHD patients and controls.

METHODS

By combining data from patient registries, the incidence of adult-onset diabetes registered at age 35 or older, and subsequent mortality risk were analysed in two successive birth cohorts (born in 1930-1959 and 1960-1983), by type of CHD lesion and sex, compared with population-based controls matched for sex and year of birth and followed until a maximum of 87 years of age.

RESULTS

Out of 24,699 patients with CHD and 270,961 controls, 8.4% and 5.6%, respectively, were registered with a diagnosis of diabetes at the age of 35 or older, hazard ratio (HR) 1.47 (95% CI 1.40-1.54). The risk of diabetes was higher in the second birth cohort (HR of 1.74, 95% CI 1.54-1.95) and increased with complexity of CHD. After onset of DM, the total mortality among patients with CHD was 475 compared to 411/ 10,000 person-years among controls (HR 1.16, 95% CI 1.07-1.25).

CONCLUSIONS

In this nationwide cohort of patients with CHD and controls, the incidence of diabetes was almost 50% higher in patients with CHD, with higher risk in the most recent birth cohort and in those with conotruncal defects, with the combination of CHD and diabetes associated with a significantly increased mortality compared to diabetic controls.

Impact of Down Syndrome on Survival Among Patients With Congenital Heart Disease

BACKGROUND

Increasing survival among patients with congenital heart disease (CHD) has recently been reported. However, the impact of Down syndrome (DS) in patients with CHD is still debated. We aimed to estimate survival in patients with CHD with versus without DS compared with matched controls from the general population without CHD or DS.

METHODS AND RESULTS

We linked data from Swedish health registries to identify patients with CHD born between 1970 and 2017. Data from the Total Population Register were used to match each patient with CHD by sex and birth year with 8 controls without CHD or DS. A Cox proportional regression model was used to estimate mortality risk, and Kaplan-Meier curves were analyzed for the survival analysis. We identified 3285 patients with CHD-DS, 64 529 patients with CHD without DS, and 26 128 matched controls. The mortality risk was 25.1 times higher (95% CI, 21.3-29.5) in patients with CHD-DS versus controls. The mortality rate was 2 times higher (95% CI, 1.94-2.31) for patients with CHD with versus without DS. Lower mortality was found during the second versus first birth periods in patients with CHD-DS compared with controls; hazard ratio: 46.8 (95% CI, 29.5-74.0) and 17.7 (95% CI, 12.8-24.42) in those born between 1970 and 1989 versus 1990 and 2017, respectively.

CONCLUSIONS

In this retrospective cohort study, the mortality risk among patients with CHD-DS was 25 times higher compared with matched controls and 2 times higher compared with patients with CHD without DS. Survival was higher in patients with CHD-DS born after versus before 1990, coinciding with the modern era of congenital heart care.

Mortality in Patients With Ebstein Anomaly

BACKGROUND

Low birth prevalence and referral bias constitute significant obstacles to elucidating the natural history of Ebstein anomaly (EA).

OBJECTIVES

An extensive 2-country register-based collaboration was performed to investigate the mortality in patients with EA.

METHODS

Patients born from 1970 to 2017 and diagnosed with EA were identified in Danish and Swedish nationwide medical registries. Each patient was matched by birth year and sex with 10 control subjects from the general population. Cumulative mortality and HR of mortality were computed using Kaplan-Meier failure function and Cox proportional regression model.

RESULTS

The study included 530 patients with EA and 5,300 matched control subjects with a median follow-up of 11 years. In the EA cohort, 43% (228) underwent cardiac surgery. Cumulative mortality was lower for patients diagnosed in the modern era (the year 2000 and later) than for those diagnosed in the prior era (P < 0.001). Patients with isolated lesion displayed lower cumulative mortality than patients with complex lesions did (P < 0.001). Patients with a presumed mild EA anatomy displayed a 35-year cumulative mortality of 11% (vs 4% for the matched control subjects; P < 0.001), yielding an HR for mortality of 6.0 (95% CI: 2.7-13.6), whereas patients with presumed severe EA demonstrated an HR of 36.2 (95% CI: 15.5-84.4) compared with control subjects and a cumulative mortality of 18% 35 years following diagnosis.

CONCLUSIONS

Mortality in patients with EA is high irrespective of presence of concomitant congenital cardiac malformations and time of diagnosis compared with the general population, but overall mortality has improved in the contemporary era.

Percutaneous atrial shunt closure and the risk of recurrent ischemic stroke: A register-based, nationwide cohort study

OBJECTIVES

We aimed to investigate the risk of recurrent stroke in patients with transcatheter closure of an atrial shunt (ASCIos), compared to patients with an atrial shunt and cerebrovascular event (CVE) but only medical treated (ASMed), and to age- and sex-matched control individuals without a previous CVE.

METHODS

In total, 663 ASCIos patients were identified in the Swedish National Patient Register from 1997 to 2016 and matched by using propensity score with 663 ASMed patients. Nine age- and sex-matched controls to ASCIos patients (n = 6,302) without a diagnosis of atrial shunt or history of CVE were randomly selected from the general population.

RESULTS

At a mean follow-up of 6.5 years, the incidence rate of recurrent stroke in the ASCIos group vs ASMed group was 0.9 vs 0.7 per 100 patient-years. The hazard ratio of recurrent stroke in the ASCIos group compared with index stroke in the control group was 9.9 (95% confidence interval, 5.5-17.9). The incidence of atrial fibrillation was similar in the ASCIos and the ASMed group, however four times higher in the ASCIos than in the control group.

CONCLUSIONS

Our large nationwide, register-based cohort study showed that, unexpectedly, the risk of recurrent stroke in the ASCos group was as high as in the ASMed group and almost ten times higher than the risk of an index stroke in matched controls without previous stroke.

Adults With Congenital Heart Disease: Trends in Event-Free Survival Past Middle Age

BACKGROUND

The survival of children with congenital heart disease has increased substantially over the past decades, with 97% currently reaching adulthood. The total effect of advanced treatment on future mortality and morbidity in adult survivors with congenital heart disease (CHD) is less well described.

METHODS

We used data from the Swedish National Inpatient, Outpatient, and Cause of Death Register to identify patients with CHD who were born between 1950 and 1999 and were alive at 18 years of age. Ten controls identified from the Total Population Register were matched for year of birth and sex and with each patient with CHD. Follow-up was from 1968 and 18 years of age until death or at the end of the study (2017). Survival percentage with 95% CI for all-cause mortality were performed with Kaplan-Meier survival function. Cox proportional hazard regression models with hazard ratios (HRs) and 95% CI were used to estimate the risk of all-cause mortality.

RESULTS

We included 37 278 patients with adult CHD (ACHD) and 412 799 controls. Mean follow-up was 19.2 years (±13.6). Altogether, 1937 patients with ACHD (5.2%) and 6690 controls (1.6%) died, a death rate of 2.73 per 1000 person-years and 0.84 per 1000 person years, respectively. Mortality was 3.2 times higher (95% CI, 3.0-3.4; P<0.001) among patients with ACHD compared with matched controls. Up to the maximum of 50 years of follow-up, >75% of patients with ACHD were still alive. Mortality was highest among patients with conotruncal defects (HR, 10.13 [95% CI, 8.78-11.69]), but also significantly higher for the more benign lesions, with the lowest risk in patients with atrial septal defects (HR, 1.36 [95% CI, 1.19-1.55]). At least 75% of patients with ACHD alive at 18 years of age lived past middle age and became sexagenerians.

CONCLUSIONS

In this large, nationwide, register-based cohort study of patients with ACHD surviving to 18 years of age, the risk of mortality up to 68 years of age was >3 times higher compared with matched controls without ACHD. Despite this, at least 75% of patients with CHD alive at 18 years of age lived past middle age and became sexagenerians. A notable risk decline in the mortality for patients with ACHD was seen for those born after 1975.

Transcatheter Intervention for Coarctation of the Aorta: A Nordic Population-Based Registry With Long-Term Follow-Up

BACKGROUND

Coarctation of the aorta (CoA), a congenital narrowing of the proximal descending thoracic aorta, is a relatively common form of congenital heart disease. Untreated significant CoA has a major impact on morbidity and mortality. In the past 3 decades, transcatheter intervention (TCI) for CoA has evolved as an alternative to surgery.

OBJECTIVES

The authors report on all TCIs for CoA performed from 2000 to 2016 in 4 countries covering 25 million inhabitants, with a mean follow-up duration of 6.9 years.

METHODS

During the study period, 683 interventions were performed on 542 patients.

RESULTS

The procedural success rate was 88%, with 9% considered partly successful. Complications at the intervention site occurred in 3.5% of interventions and at the access site in 3.5%. There was no in-hospital mortality. During follow-up, TCI for CoA reduced the presence of hypertension significantly from 73% to 34%, but despite this, many patients remained hypertensive and in need of continuous antihypertensive treatment. Moreover, 8% to 9% of patients needed aortic and/or aortic valve surgery during follow-up.

CONCLUSIONS

TCI for CoA can be performed with a low risk for complications. Lifetime follow-up after TCI for CoA seems warranted.

Congenital heart disease: changes in recorded birth prevalence and cardiac interventions over the past half-century in Sweden

AIMS

Our objective was to assess changes in the birth prevalence of CHD over a half-century in a high-resource, nationwide setting, as well as changes in the prevalence of cardiac interventions in this population.

METHODS AND RESULTS

The Swedish National Patient and Cause of Death registers were linked to estimate the annual rates of CHD and cardiac interventions among live-born infants from 1970 to 2017. Additionally, separate estimates were obtained by lesion complexity, from mild to the most complex forms of CHD. Overall, the numbers of live-born infants with a CHD identified varied from 624 to 2459 annual cases, with rates increasing steadily from 5.7 to an average of 20 per 1000 live births at the end of the study period, and with a more pronounced increase from 1996 to 2005. The largest increase over time was observed for mild CHD lesions. Overall, the proportion of cardiac interventions among patients with CHD declined from 40.7% in 1970 to below 15.0% after 2014. However, in the most complex CHD lesion groups, overall cardiac interventions increased from 57.1 to 76.8% in patients with conotruncal defects and from 32.8 to 39.5% in those with severe non-conotruncal defects.

CONCLUSION

The live-birth prevalence of CHD in Sweden more than tripled during the past half-century, most likely resulting from more accurate diagnostic capabilities. The largest increase over time was observed among patients with simple defects. During the same period, overall cardiac interventions decreased whereas interventions for the most complex CHD groups increased.

Burden of morbidity in patients with Ebstein anomaly: a two-country, population-based cohort study including 823 patients

Background

Burden of morbidity in patients with Ebstein anomaly (EA) is to a large extent undescribed.

Purpose

We conducted an extensive two-country register-based collaboration aiming to describe the burden of morbidity in patients with EA.

Methods

Patients born in the period 1930–2017 and diagnosed with EA were identified in Danish and Swedish nationwide medical registries and subsequently merged. Each EA patient was matched by birth year and gender with ten controls without congenital heart disease from the general population. Cox proportional hazard regression model was used to compute risk (hazard ratio (HR)) of morbidity (arrhythmia, heart failure, and stroke). Follow-up started at birth. Patients and controls became at risk at birth.

Results

We included 823 patients and 8,230 matched controls; median follow-up was 13.2 years (interquartile range: 3.5–20.9). In the total EA cohort, 44% (n=366) underwent cardiac surgery, predominantly EA-related surgery (81%) and other congenital cardiac surgery (15%). Approximately half of the cohort had an isolated EA (n=442) and 13% (n=108) had a concomitant atrial septal defect (ASD) only. Patients with non-operated isolated EA had a 9-fold increased risk of arrhythmia and a 5-fold increased risk of heart failure compared with the general population [HR for arrhythmia 9.4 (95% CI: 6.9–12.7) and HR forheart failure 5.2 (95% CI: 3.2–8.3)]. The risk of arrhythmia, heart failure, and stroke among patients with non-operated EA and concomitant ASD was 12.1 (95% CI: 3.0–48.8), 30.6 (95% CI: 3.2–295.2), and 8.2 (95% CI: 0.7–91.2), respectively. The risk of stroke in operated EA patients with concomitant ASD was 43.8 (95% CI: 17.5–109.7). Patients with operated isolated EA had a 25-fold increased risk of developing arrhythmia and 10-fold increased risk of heart failure compared with the general population [HR for arrhythmia 25.0 (95% CI: 17.7–35.3) and HR for heart failure 10.1 (95% CI: 6.0–16.9].

Conclusion

Patients with EA carries a substantial burden of arrhythmia, heart failure, and stroke compared with the general population irrespective of treatment pathway, necessitating meticulous follow-up in specialized adult congenital heart disease clinics to detect and possibly prevent or limit morbidity at an early stage.

Funding Acknowledgement

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

Mortality in patients with Ebstein anomaly: a two-country, population-based cohort study including 530 patients

Background

Low birth prevalence and referral bias constitutes significant obstacles in extending our knowledge regarding the natural history of Ebstein anomaly (EA).

Purpose

In an extensive two-country register-based collaboration we aimed to investigate the survival in EA patients with respect to associated congenital cardiac malformations

Methods

Patients born in the period 1970–2017 and diagnosed with EA were identified in Danish and Swedish nationwide medical registries and subsequently merged. Each EA patient was matched by birth year and gender with ten controls without congenital heart disease from the general population. Cox proportional hazard regression model and Kaplan-Meier survival function were used to compute risk of mortality (hazard ratio) and survival. Follow-up started at birth and patients became risk at time of EA diagnosis.

Results

We included 530 patients and 5,300 matched controls; median follow-up was 10.5 years (interquartile range: 3.5–20.9). In the total EA cohort, 43% (n=228) underwent cardiac surgery, predominantly EA-related surgery (81%). Approximately half of the cohort had an isolated EA (n=248), 11% (n=57) had a concomitant atrial septal defect only, and 42% (n=225) other associated congenital cardiac malformations. The 35-year survival in patients with isolated EA was 93%, superior compared with patients with concomitant atrial septal defect (ASD) (83%) and patients with other associated congenital cardiac malformations (72%), Figure 1. Patients with isolated non-operated EA had a risk of mortality of 25.6 (95% confidence interval (CI): 9.0–72.6) compared with the general population. Correspondingly, the risk in patients with surgically managed isolated EA was 21.7 (95% CI: 3.9–118.5). Patients with non-operated EA and a concomitant ASD (only) revealed a 10-fold increased risk of mortality (95% CI: 1.5–75.1) compared with the general population. The risk of mortality was substantially higher in both non-operated and operated EA patients with other associated congenital cardiac malformations, HR of 106.3 (95% CI: 31.8–335.4) and 42.6 (95% CI: 18.5–97.8), respectively.

Conclusions

Concomitant congenital cardiac malformations are common in EA patients and have major influence on survival, irrespective of treatment pathway (surgical versus non-surgical). Nonetheless, isolated non-operated EA patients have a 25-fold increased risk of mortality compared with the general population. Interestingly, concomitant ASD in non-operated patients seems protective in terms of risk of mortality.

Funding Acknowledgement

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

Survival in patients with congenital heart disease and down syndrome

Background

Increasing survivorship among patients with congenital heart disease (CHD) has been reported during the past decades. However, a number of patients with CHD have an associated Down syndrome diagnosis and the long-term prognosis is still debated.

Purpose

The aim of the present study was to estimate the mortality risk in CHD patients with Down syndrome compared to a matched control population without CHD.

Methods

We linked data from the Swedish National Patient Register and Cause of Death Register to identify all CHD patients born between January 1970 and December 2017. Then we identified all CHD patients with Down syndrome. Each CHD patient with Down syndrome was matched for sex and birth year with eight controls without CHD or Down syndrome from the Total Population Register. A Cox proportional regression model was used to estimate the mortality risk and Kaplan Meier for survival analysis.

Results

In total, 3,285 patients with CHD and Down syndrome and 26,128 matched controls were identified. During a mean follow-up of 16.0 (±12.6) years, 558 CHD patients (17%) with Down syndrome, and 198 controls (0.76%) died. CHD patients with Down syndrome had 25.1 times higher risk of mortality (Hazard ratio 25.1, 95%, confidence interval (CI) 21.3–29.5) compared with controls. Patients with the most complex CHD were found to have the highest mortality risk (Hazard ratio 32.3, 95% CI 26.1–39.9). A decrease in risk of mortality during the first year of life was found between the two birth periods, risk of mortality was 46.8 (CI 29.5–74.0) in 1970–1989 and 17.7 (CI 12.8–24.42) 1990–2017. In addition, the mortality risk was two times (95% CI 1.94–2.31) higher for CHD patients with Down syndrome when compared to CHD patients without Down syndrome.

Conclusion

The risk of mortality among CHD patients with Down syndrome was 25 times higher compared to controls without CHD or Down syndrome. The highest risk of mortality was found in patients with complex CHD. The survivorship rate was exponentially increased in CHD patients with Down syndrome that were born after 1990, determining the modern era of congenital heart care.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Swedish state under an agreement between the Swedish Government and county Councils (ALF)

Heart failure and long-term prognosis in patients with congenital heart disease: a nationwide, register-based cohort study

Introduction

Heart failure (HF) is associated with high morbidity and severe prognosis. The aim of this study was to investigate the risk of HF in patients with congenital heart disease (CHD) and to determine the prognosis after HF diagnoses in patients with CHD compared to HF controls without CHD.

Methods

We identified 89,532 patients with CHD born between 1930 and 2017 from the National Patient Register in Sweden and matched with 10 controls without CHD by gender and birth year from the National Population Register. The study population was followed-up until 2017, through the Swedish Patient Register and Cause of Death Register.

Results

Altogether, 7,013 (7.8%) patients with CHD and 9,681 (1.1%) controls developed HF. The overall incidence rate of HF was 31.6 per 104 person-years in patients with CHD and 4.0 per 104 person-years in controls. The mean age for HF diagnoses was 40.3 (± 28.8) in patients with CHD and 66.4 (± 13.6) for controls. The risk for developing HF was significantly higher in complex than non-complex CHD lesion groups, HR 28.7 (26.5–31.0) and HR 6.9 (6.7–7.2) respectively. Mortality incidence rate was twice as high in controls with HF compared to CHD with HF (IR 9.7 (9.4–10.0) and 4.74 (4.6–4.9), respectively). The mortality incidence was higher within all age groups except for 18–39 years and there was no difference between complex and non complex lesions

Conclusion

One out of thirteen CHD patients will develop HF. The highest risk for HF is within CHD patients with complex lesions. CHD patients develops HF at a considerably younger age, reflecting their slightly better prognosis after development of HF compared to controls with HF.

Funding Acknowledgement

Type of funding sources: None.

Ischemic stroke in patients with congenital heart disease and atrial fibrillation

Background

Atrial fibrillation (AF) is one of the most common arrhythmias in patients with congenital heart disease (CHD). The risk of developing AF is more than 20 times higher in patients with CHD compared with non-CHD controls. However, while it is known that young non-CHD patients with AF have a low risk for ischemic stroke (IS), little is known about the risk for IS young CHD patients with AF.

Purpose

To investigate the risk of developing IS in younger patients with CHD and AF compared to non-CHD control patients with AF.

Method

Using data from the National Swedish Patient Register and Cause of Death register, all CHD and born in Sweden between 1970 and 2017 with history of AF were identified. The Swedish total population register was used to identify age and sex matched controls. Among the matched controls, non-CHD patients AF were identified and used as reference group. CHD and non-CHD patients were followed from onset of AF until index IS, death or end of study (31st December 2017). Cox proportional hazard regression model with hazard ratio (HR) and 95% confidence interval (CI) was used to estimate the risk of IS in CHD patients with AF compared with non-CHD controls with AF.

Results

A total of 951 CHD with AF and 606 non-CHD controls with AF were identified. With ages ranging from 0 to 47 years, the median age was 25.6 and 30.7 years for CHD and non-CHD respectively. In patients with CHD and AF, 2.9% of patients (n=28) developed IS during follow up (mean follow up 34 years, SD ± 11.2), compared 0.5% (n=3) in non-CHD controls with AF (mean follow up 37 years, SD ± 9.5 years). The unadjusted HR for IS in CHD patients with AF compared with non-CHD controls with AF was 4.61 (95% CI1.39–15.25). When adjusted for age, sex, hypertension and heart failure, the risk of IS was more than five times higher (HR 5.16, 95% CI 1.52–17.46) in CHD patients compared with non-CHD patients. The adjusted HR for developing IS in non-complex CHD with AF compared with matched controls was 4.56 (95% CI 1.00–20.79). For patients born 1970–1989 the HR of IS was 7.35 (95% CI 1.70–31.75).

Conclusion

In this nationwide, register-based cohort study, the absolute number of IS among younger CHD patients with AF was relatively low. However, the risk for developing IS was more than 5 times higher compared to non-CHD patients with AF; highlighting the need of stroke score models in younger population, particularly to CHD patients.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Swedish state under an agreement between the Swedish government and city Councils

Long-term mortality from birth in individuals with and without isolated congenital aortic stenosis: a nationwide, register-based cohort study

Background

Congenital aortic valve stenosis (CAVS) accounts for almost 5% of congenital heart defects. Increased survival has been reported in patients with complex congenital heart defects over the last decade. However, data on the long-term outcomes of simple defects such as in isolated CAVS, are still limited.

Purpose

The present study aimed to investigate the risk of mortality in patients with isolated CAVS over the last half century in Sweden.

Methods

We used data from the Swedish National Patient and Cause of Death Register to identify patients with isolated CAVS born between 1970 and 2017. Each CAVS was matched with 10 controls without congenital heart disease from the Total Population Register, according to sex and birth year. The maximal follow-up time was from birth up to 47.5 years of age. We estimated mortality rates for cases and controls, and the 95% confidence interval (CI) of their ratio. Kaplan-Meier curves were used to estimate the survival for cases and controls under the follow-up.

Results

A total of 1,258 patients with isolated CAVS and 12,550 matched controls were included in the study. The median follow-up was 24.5 years (interquartile range (IQR):18.0) for cases and 25.5 years (IQR: 17.6) for controls respectively. The overall risk of mortality was more than three times higher for patients with isolated CAVS, compared with matched controls, hazard ratio (HR) 3.1 (95%, CI 2.1–4.5). Survival at 47.5 years of age was 94.1% for cases and 97.3% for controls. Within the first year of life, the mortality risk in patients with isolated CAVS was more than 19 times higher (95%, CI 8.8–43.6) than controls. By contrast, when diagnosed with isolated CAVS above the age of 10 years, the risk of mortality was 2.1 times higher (95%, CI 1.1–3.5) compared to controls.

Conclusions

The mortality in patients with isolated CAVS was more than three times higher compared with matched controls. The highest mortality was found in patients with a diagnosis of isolated CAVS diagnosed within the first year after birth, verifying the critical form of the disease. Furthermore, patients diagnosed with isolated CAVS later in life (hence clinically assumed as a mild form of valvulopathy) have a mortality risk twice as high as controls, highlighting the need for follow-up and lifetime management, even in the mild forms of valvulopathies.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Swedish state under an agreement between the Swedish Government and county Councils (ALF)

Chronic kidney disease in patients with congenital heart disease – a nationwide, register-based cohort study

Aims

To investigate the risk of chronic kidney disease (CKD) in young patients with congenital heart disease (CHD) (age 0–47 years) compared with age- and sex-matched controls without CHD.

Methods and results

Using data from the Swedish National Patient Register and the Cause of Death Register, 71,936 patients with CHD (50.2% male) born between 1970 and 2017 were identified. Each patient with CHD was matched by sex and age to 10 controls without CHD (n = 714,457). Follow-up data were collected for patients with CHD and controls until 2017. During a median follow-up of 13.5 (5.8; 25.5) years, 379 (0.5%) patients with CHD and 679 (0.1%) controls developed CKD. The risk of CKD was 6.4 times higher in patients with CHD than controls [95% confidence interval (CI): 5.65–7.27] and was highest in patients with severe non-conotruncal defects [hazard ratio (HR): 11.31; 95% CI: 7.37–17.36]. Compared with matched controls, the absolute and relative risks of CKD were greater for CHD patients born between 1997 and 2017 (HR: 9.98; 95% CI: 8.05–13.37) (incidence 39.5 per 100 000 person-years). The risk of CKD remained significantly higher after adjusting for hypertension, acute kidney injury, and diabetes mellitus (HR: 4.37; 95% CI: 3.83–5.00).

Conclusion

Although the absolute risk of CKD in young patients with CHD is relatively low, patients with CHD are six times more likely to develop CKD than non-CHD controls up to the age of 47 years. Further data are needed to inform guidelines on the prevention and follow-up of CKD in CHD patients.

Epilepsy in patients with congenital heart disease: A nationwide cohort study

BACKGROUND

Congenital heart disease (CHD) is the most common congenital defect, and reports suggest an increased risk of subsequent epilepsy. We used Swedish comprehensive population-based registers to investigate the risk of epilepsy in patients with CHD compared to matched controls and identify underlying factors of epilepsy.

METHODS

All patients with CHD born between 1970 and 2017 and 10 age- and sex-matched controls were included. Epilepsy was ascertained by International Statistical Classification of Diseases and Related Health Problems codes, and the cumulative hazard of epilepsy was described using Cox regression.

RESULTS

The study cohort consisted of 71,941 patients with CHD and 714,462 matched controls. The cumulative incidence of epilepsy in the study period was 3% in patients with CHD and 0.9% in controls. The risk of epilepsy was 3.6 times higher (95%, confidence interval: 3.4-3.8) in patients with CHD than in controls. Among patients with CHD, several brain comorbidities, including intellectual disability and stroke, as well as having undergone more than two cardiac interventions were significantly associated with epilepsy in a multivariable model.

CONCLUSIONS

In this nationwide, register-based cohort study, we found an almost fourfold increased risk of epilepsy in patients with CHD compared to controls; however, the absolute risk was low. Among the identified risk factors, stroke may be potentially preventable.

Cause‐Specific Mortality in Patients During Long‐Term Follow‐Up After Atrial Switch for Transposition of the Great Arteries

Background

Little is known about the cause of death (CoD) in patients with transposition of the great arteries palliated with a Mustard or Senning procedure. The aim was to describe the CoD for patients with the Mustard and Senning procedure during short‐ (<10 years), mid‐ (10–20 years), and long‐term (>20 years) follow‐up after the operation.

Methods and Results

This is a retrospective, descriptive multicenter cohort study including all Nordic patients (Denmark, Finland, Norway, and Sweden) who underwent a Mustard or Senning procedure between 1967 and 2003. Patients who died within 30 days after the index operation were excluded. Among 968 patients with Mustard/Senning palliated transposition of the great arteries, 814 patients were eligible for the study, with a mean follow‐up of 33.6 years. The estimated risk of all‐cause mortality reached 36.0% after 43 years of follow‐up, and the risk of death was highest among male patients as compared with female patients ( P =0.004). The most common CoD was sudden cardiac death (SCD), followed by heart failure/heart transplantation accounting for 29% and 27%, respectively. During short‐, mid‐, and long‐term follow‐up, there was a change in CoD with SCD accounting for 23.7%, 46.6%, and 19.0% ( P =0.002) and heart failure/heart transplantation 18.6%, 22.4%, and 46.6% ( P =0.0005), respectively.

Conclusions

Among patients corrected with Mustard or Senning transposition of the great arteries, the most common CoD is SCD followed by heart failure/heart transplantation. The CoD changes as the patients age, with SCD as the most common cause in adolescence and heart failure as the dominant cause in adulthood. Furthermore, the risk of all‐cause mortality, SCD, and death attributable to heart failure or heart transplantation was increased in men >10 years after the Mustard/Senning operation.

Risk of cancer in young and older patients with congenital heart disease and the excess risk of cancer by syndromes, organ transplantation and cardiac surgery: Swedish health registry study (1930-2017)

Background

Increasing survival of patients with congenital heart disease (CHD) will result in an increased risk of age-dependent acquired diseases later in life. We aimed to investigate the risk of cancer in young and older patients with CHD and to evaluate the excess risk of cancer by syndromes, organ transplantation and cardiac surgery.

Methods

Patients with CHD born between 1930 and 2017 were identified using Swedish Health Registers. Each patient with CHD (n = 89,542) was matched by sex and birth year with ten controls without CHD (n = 890,472) from the Swedish Total Population Register.

Findings

4012 patients with CHD (4·5%) and 35,218 controls (4·0%) developed cancer. The median follow-up time was 58·8 (IQR 42·4-69·0) years. The overall cancer risk was 1·23 times higher (95% confidence interval (CI) 1·19-1·27) in patients with CHD compared with matched controls, and remained significant when patients with syndromes and organ transplant recipients were excluded. The risk of cancer was higher in all CHD age groups, and in patients that underwent cardiac surgery during the first year after birth (Hazard Ratio 1·83; 95% CI 1·32-2·54). The highest risk was found in children (0-17 years), HR 3·21 (95% CI 2·90-3·56).

Interpretation

The cancer risk in patients with CHD was 23% higher than in matched controls without CHD. The highest risk was found in children and in the latest birth cohort (1990-2017).

Funding

Funding by the Swedish state (Grant Number: 236611), the Swedish Research Council (Grant Number: 2019-00193), the Swedish Childhood Cancer Fund (Grant Number: SP2017-0012) and the Swedish Heart-Lung Foundation (Grant Number: 20190724).

Cerium Oxide Nanoparticles with Entrapped Gadolinium for High T 1 Relaxivity and ROS-Scavenging Purposes

Gadolinium chelates are employed worldwide today as clinical contrast agents for magnetic resonance imaging. Until now, the commonly used linear contrast agents based on the rare-earth element gadolinium have been considered safe and well-tolerated. Recently, concerns regarding this type of contrast agent have been reported, which is why there is an urgent need to develop the next generation of stable contrast agents with enhanced spin-lattice relaxation, as measured by improved T ₁ relaxivity at lower doses. Here, we show that by the integration of gadolinium ions in cerium oxide nanoparticles, a stable crystalline 5 nm sized nanoparticulate system with a homogeneous gadolinium ion distribution is obtained. These cerium oxide nanoparticles with entrapped gadolinium deliver strong T ₁ relaxivity per gadolinium ion (T ₁ relaxivity, r ₁ = 12.0 mM^-1 s^-1) with the potential to act as scavengers of reactive oxygen species (ROS). The presence of Ce³⁺ sites and oxygen vacancies at the surface plays a critical role in providing the antioxidant properties. The characterization of radial distribution of Ce³⁺ and Ce⁴⁺ oxidation states indicated a higher concentration of Ce³⁺ at the nanoparticle surfaces. Additionally, we investigated the ROS-scavenging capabilities of pure gadolinium-containing cerium oxide nanoparticles by bioluminescent imaging in vivo, where inhibitory effects on ROS activity are shown.

Outcome and survival after open heart surgery for adults with congenital heart disease - a single center experience

Introduction. Congenital heart disease (CHD) is the most common type of birth defect today. The adult congenital heart disease (ACHD) population is constantly growing and becoming older and more patients require cardiac surgery. The objective of this study was to review the surgical outcome of the open heart procedures performed on ACHD patients in the last 10 years at Sahlgrenska University Hospital (SUH) through a retrospective descriptive cohort study. Methods. A retrospective data collection was performed for 421 patients who underwent a total of 439 surgical procedures between 2009 and 2018 at the Cardiothoracic department in SUH. The primary outcomes were early (<30 days) and late survival. Secondary outcomes were postoperative complications and independent risk factors for postoperative complications. Results. 30-day mortality was 1.9%. Long-term survival after 3, 5 and 10 years were 96% ± 1, 94.3% ± 1.3 and 92.4% ± 1.8. 82 major complications occurred after 46 procedures (11.6%). The most common major complication was re-exploration due to hemorrhage. Risk factors for major complications were acute surgery and prolonged extracorporeal circulation time. 173 minor complications occurred after 90 procedures (22.5%). The most common minor complication was prolonged intensive care unit stay (>48 h). Conclusion. This study presents satisfactory early and midterm survival. The survival and frequency of major postoperative complications are well in line with what other studies have presented. Patients undergoing resternotomies had no increased risk for mortality or postoperative complications.

ON THE POSSIBILITY TO RESOLVE GADOLINIUM- AND CERIUM-BASED CONTRAST AGENTS FROM THEIR CT NUMBERS IN DUAL-ENERGY COMPUTED TOMOGRAPHY

Cerium oxide nanoparticles with integrated gadolinium have been proved to be useful as contrast agents in magnetic resonance imaging. Of question is their performance in dual-energy computed tomography. The aims of this work are to determine (1) the relation between the computed tomography number and the concentration of the I, Gd or Ce contrast agent and (2) under what conditions it is possible to resolve the type of contrast agent. Hounsfield values of iodoacetic acid, gadolinium acetate and cerium acetate dissolved in water at molar concentrations of 10, 50 and 100 mM were measured in a water phantom using the Siemens SOMATOM Definition Force scanner; gadolinium- and cerium acetate were used as substitutes for the gadolinium-integrated cerium oxide nanoparticles. The relation between the molar concentration of the I, Gd or Ce contrast agent and the Hounsfield value was linear. Concentrations had to be sufficiently high to resolve the contrast agents.

Mortality in patients with isolated congenital complete atrioventricular block in Sweden: a register-based, nationwide cohort study

Purpose

The congenital heart block is a rare but potentially serious heart conduction disease and associated with high mortality during the fetal or neonatal periods. Earlier reports are based on relatively small number of patients and there are limited data about long-term outcomes.

Methods

Data were collected from the Swedish Patient and Cause of Death register to identify all patients who were born and diagnosed with isolated congenital complete atrioventricular block (CCAVB) between 1970 and 2017. Each patient with isolated CCAVB was matched with 10 control individuals, by birth year and sex from the Total Population Register.

Results

Totally 506 patients with CCAVB and 5,050 controls included in the study (55.3% males). The incidence rate of mortality in patients with isolated CCAVB was 166 per 10.000 person-years. The overall risk of mortality in patients with isolated CCAVB was 45.4 times (95% confidence interval (CI) 32.7–62.9) higher compared to matched controls. In a subgroup investigation, the highest risk of mortality was found in patients with isolated CCAVB from birth until the age of 17 (hazard ratio 80.8, 95% CI 51.6–126.4), compared to matched controls without CCAVB.

Conclusion

In this nationwide cohort study, patients with isolated CCAVB was associated with more than 40-fold risk for overall mortality compared to age and sex matched controls. The greatest risk was found during childhood. Regularly follow-up in tertiary centers and the aware of high risk of complications may be the key to prevention.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The Swedish Government, the Swedish Research Council

Prenylcysteine oxidase 1, an emerging player in atherosclerosis

The research into the pathophysiology of atherosclerosis has considerably increased our understanding of the disease complexity, but still many questions remain unanswered, both mechanistically and pharmacologically. Here, we provided evidence that the pro-oxidant enzyme Prenylcysteine Oxidase 1 (PCYOX1), in the human atherosclerotic lesions, is both synthesized locally and transported within the subintimal space by proatherogenic lipoproteins accumulating in the arterial wall during atherogenesis. Further, Pcyox1 deficiency in Apoe^-/- mice retards atheroprogression, is associated with decreased features of lesion vulnerability and lower levels of lipid peroxidation, reduces plasma lipid levels and inflammation. PCYOX1 silencing in vitro affects the cellular proteome by influencing multiple functions related to inflammation, oxidative stress, and platelet adhesion. Collectively, these findings identify the pro-oxidant enzyme PCYOX1 as an emerging player in atherogenesis and, therefore, understanding the biology and mechanisms of all functions of this unique enzyme is likely to provide additional therapeutic opportunities in addressing atherosclerosis.

Protein interaction, monocyte toxicity and immunogenic properties of cerium oxide crystals with 5% or 14% gadolinium, cobalt oxide and iron oxide nanoparticles - an interdisciplinary approach

Metal oxide nanoparticles are widely used in both consumer products and medical applications, but the knowledge regarding exposure-related health effects is limited. However, it is challenging to investigate nanoparticle interaction processes with biological systems. The overall aim of this project was to improve the possibility to predict exposure-related health effects of metal oxide nanoparticles through interdisciplinary collaboration by combining workflows from the pharmaceutical industry, nanomaterial sciences, and occupational medicine. Specific aims were to investigate nanoparticle-protein interactions and possible adverse immune reactions. Four different metal oxide nanoparticles; CeO_x nanocrystals with 5% or 14% Gd, Co₃O₄, and Fe₂O₃, were characterized by dynamic light scattering and high-resolution transmission electron microscopy. Nanoparticle-binding proteins were identified and screened for HLA-binding peptides in silico. Monocyte interaction with nanoparticle-protein complexes was assessed in vitro. Herein, for the first time, immunogenic properties of nanoparticle-binding proteins have been characterized. The present study indicates that especially Co₃O₄-protein complexes can induce both 'danger signals', verified by the production of inflammatory cytokines and simultaneously bind autologous proteins, which can be presented as immunogenic epitopes by MHC class II. The clinical relevance of these findings should be further evaluated to investigate the role of metal oxide nanoparticles in the development of autoimmune disease. The general workflow identified experimental difficulties, such as nanoparticle aggregate formation and a lack of protein-free buffers suitable for particle characterization, protein analyses, as well as for cell studies. This confirms the importance of future interdisciplinary collaborations.

Long-term outcomes after myocardial infarction in middle-aged and older patients with congenital heart disease-a nationwide study

Aims 

We aimed to describe the risk of myocardial infarction (MI) in middle-aged and older patients with congenital heart disease (ACHD) and to evaluate the long-term outcomes after index MI in patients with ACHD compared with controls.

Methods and results 

A search of the Swedish National Patient Register identified 17 189 patients with ACHD (52.2% male) and 180 131 age- and sex-matched controls randomly selected from the general population who were born from 1930 to 1970 and were alive at 40 years of age; all followed up until December 2017 (mean follow-up 23.2 ± 11.0 years). Patients with ACHD had a 1.6-fold higher risk of MI compared with controls [hazard ratio (HR) 1.6, 95% confidence interval (CI) 1.5–1.7, P < 0.001] and the cumulative incidence of MI by 65 years of age was 7.4% in patients with ACHD vs. 4.4% in controls. Patients with ACHD had a 1.4-fold increased risk of experiencing a composite event after the index MI compared with controls (HR 1.4, 95% CI 1.3–1.6, P < 0.001), driven largely by the occurrence of new-onset heart failure in 42.2% (n = 537) of patients with ACHD vs. 29.5% (n = 2526) of controls.

Conclusion 

Patients with ACHD had an increased risk of developing MI and of recurrent MI, new-onset heart failure, or death after the index MI, compared with controls, mainly because of a higher incidence of newly diagnosed heart failure in patients with ACHD. Recognizing and managing the modifiable cardiovascular risk factors should be of importance to reduce morbidity and mortality in patients with ACHD.

Allele frequency spectrum of known ankylosing spondylitis associated variants in a Swedish population

Objective: The genetic predisposition to ankylosing spondylitis (AS) has been most widely studied in cohorts with European ancestry. However, within Europe, disease prevalence is higher in Sweden. Given this, we aimed to characterize known AS susceptibility variants in a homogeneous Swedish data set, assessing reproducibility and direction of effect.Method: The power to detect association within an existing Swedish targeted sequencing study (381 controls; 310 AS cases) was examined, and a set of published associations (n = 151) was intersected with available genotypes. Association to disease was calculated using logistic regression accounting for population structure, and HLA-B27 status was determined with direct polymerase chain reaction genotyping.Results: The cases were found to be 92.3% HLA-B27 positive, with the data set showing ≥ 80% predictive power to replicate associations, with odds ratios ≥ 1.6 over a range of allele frequencies (0.1-0.7). Thirty-four markers, representing 23 gene loci, were available for investigation. The replicated variants tagged MICA and IL23R loci (p < 1.47 × 10^-3), with variable direction of effect noted for gene loci IL1R1 and MST1.Conclusion: The Swedish data set successfully replicated both major histocompatibility complex (MHC) and non-MHC loci, and revealed a different replication pattern compared to discovery data sets. This was possibly due to population demographics, including HLA-B27 frequency and measured comorbidities.

Sex Hormones in Men with Abdominal Aortic Aneurysm

BACKGROUND

Abdominal aortic aneurysm (AAA) primarily affects elderly men. The impact of sex on aneurysm development has been associated with an effect of sex hormones, through mechanisms that are not fully understood. This study aimed to examine the association between levels of sex hormones and the occurrence of AAA in elderly men.

METHODS

A prospective case-control study was conducted including 452, 65-year old men participating in screening for AAA, 2013-2019; 230 men with AAA and 222 men with an aortic diameter<30mm (controls). Questionnaires and blood samples were collected and stored consecutively. Serum levels of total testosterone, estradiol, progesterone, luteinizing hormone and sex hormone binding globulin were analyzed by electrochemiluminescent immunoassays. Multivariable logistic regression analysis was used to assess the association of sex hormones with AAA.

RESULTS

The median aneurysm diameter was 33mm. Men with AAA had higher estradiol and progesterone levels than controls (93pmol/L vs. 84pmol/L, p=.003 and 0.41nmol/L vs. 0.17nmol/L, p<.001). Testosterone levels were lower in men with AAA than in controls (13nmol/L vs. 14nmol/L, p=.026). AAA was associated with detectable levels of progesterone(OR 6.69, 95%CI 3.86-11.47), smoking(OR 5.26, 95%CI 3.12-8.85), coronary heart disease(OR 4.06, 95%CI 1.92-8.58) and body mass index>25(OR 2.26, 95%CI 1.34-3.82).

CONCLUSION

The observed higher levels of estradiol and progesterone in men with AAA, suggest an impact of sex hormones on aneurysm development. The association between progesterone levels and aortic diameter, stress the importance of focusing on the potential effect of this unconsidered female sex hormone on aneurysm formation.

Burden of Ischemic Stroke in Patients With Congenital Heart Disease: A Nationwide, Case-Control Study

Background

Patients with congenital heart disease (CHD) are at increased risk of developing ischemic stroke (IS) compared with controls without CHD. However, the long‐term outcomes after IS, including IS recurrence and mortality risk, remain unclear.

Methods and Results

We identified all patients with CHD in Sweden who were born between 1930 and 2017 using the Swedish National Patient Register and the Cause of Death Register. Ten controls without CHD were randomly selected from the general population and matched for birth year and sex for each patient with CHD. The follow‐up of the study population was performed between January 1970 and December 2017. In total, 88 700 patients with CHD (50.6% men) and 890 450 matched controls (51.0%) were included in this study. During a mean follow‐up of 25.1±22.0 years, patients with CHD had a 5‐fold higher risk of developing an index IS (hazard ratio [HR], 5.01; 95% CI, 4.81–5.22) compared with controls. However, the risk of developing a recurrent IS was lower in patients with CHD compared with controls (HR, 0.66; 95% CI, 0.56–0.78), an observation that persisted after adjustment for cardiovascular risk factors and comorbidities. Patients with CHD were also at a significantly lower risk of all‐cause mortality after index IS than controls (HR, 0.53; 95% CI, 0.49–0.58).

Conclusions

Patients with CHD had a 5‐fold higher risk of developing index IS compared with matched controls. However, the risk of recurrent IS stroke and all‐cause mortality were 34% and 47% lower, respectively, in patients with CHD compared with controls.

Does persistent (patent) foramen ovale closure reduce the risk of recurrent decompression sickness in scuba divers?

INTRODUCTION

Interatrial communication is associated with an increased risk of decompression sickness (DCS) in scuba diving. It has been proposed that there would be a decreased risk of DCS after closure of the interatrial communication, i.e., persistent (patent) foramen ovale (PFO). However, the clinical evidence supporting this is limited.

METHODS

Medical records were reviewed to identify Swedish scuba divers with a history of DCS and catheter closure of an interatrial communication. Thereafter, phone interviews were conducted with questions regarding diving and DCS. All Swedish divers who had had catheter-based PFO-closure because of DCS were followed up, assessing post-closure diving habits and recurrent DCS.

RESULTS

Nine divers, all with a PFO, were included. Eight were diving post-closure. These divers had performed 6,835 dives (median 410, range 140-2,200) before closure, and 4,708 dives (median 413, range 11-2,000) after closure. Seven cases with mild and 10 with serious DCS symptoms were reported before the PFO closure. One diver with a small residual shunt suffered serious DCS post-closure; however, that dive was performed with a provocative diving profile.

CONCLUSION

Divers with PFO and DCS continue to dive after PFO closure and this seems to be fairly safe. Our study suggests a conservative diving profile when there is a residual shunt after PFO closure, to prevent recurrent DCS events.

Autoantibodies associated with primary biliary cholangitis are common among patients with systemic lupus erythematosus even in the absence of elevated liver enzymes

Knowledge of concomitant autoimmune liver diseases (AILD) is more detailed in primary Sjögren's syndrome (pSS) compared to systemic lupus erythematosus (SLE). Herein, the prevalence of autoantibodies associated with autoimmune hepatitis (AIH) and primary biliary cholangitis (PBC) was investigated in stored sera from patients with SLE (n = 280) and pSS (n = 114). Antibodies against mitochondria (AMA), liver-kidney microsomal (LKM) antigen, smooth muscle (SMA) and anti-nuclear antibodies (ANA) were analysed with immunofluorescence microscopy. In addition, AILD-associated autoantibodies were tested with immunoblot. Prior to sampling, eight SLE (2·9%) and three pSS (2·6%) cases were diagnosed with AILD. Among SLE-cases without known AILD (n = 272), 26 (9·6%) had PBC-associated autoantibodies, 15 (5·5%) AIH-associated autoantibodies (excluding ANA) and one serological overlap. Most subjects with PBC-associated autoantibodies had liver enzymes within reference limits (22 of 27, 81%) or mild laboratory cholestasis (two of 27, 7·4%), while one fulfilled the diagnostic PBC-criteria. AMA-M2 detected by immunoblot was the most common PBC-associated autoantibody in SLE (20 of 272, 7·4%). The prevalence of SMA (4·4%) was comparable with a healthy reference population, but associated with elevated liver enzymes in four of 12 (25%), none meeting AIH-criteria. The patient with combined AIH/PBC-serology had liver enzymes within reference limits. Among pSS cases without known AILD (n = 111), nine (8·1%) had PBC-associated, 12 (10·8%) AIH-associated autoantibodies and two overlapped. PBC-associated autoantibodies were found as frequently in SLE as in pSS but were, with few exceptions, not associated with laboratory signs of liver disease. Overall, AILD-associated autoantibodies were predominantly detected by immunoblot and no significant difference in liver enzymes was found between AILD autoantibody-negative and -positive patients.

Pregnancy in a healthy population: dynamics of NTproBNP and hs-cTroponin T

OBJECTIVE

To describe the intraindividual changes of heart biomarker levels during and after pregnancy and to evaluate existing cut-off levels for heart failure or myocardial ischaemia in pregnant women.

METHOD

A total of 196 healthy pregnant women were recruited from maternal outpatient clinics and included in the study. Blood samples were obtained on four occasions: at 10-12 gestational weeks (gw), 20-25 gw, after delivery and 6 months postpartum and analysed for N-terminal pro-brain natriuretic peptide (NTproBNP) and high sensitive cardiac troponin T (hs-cTNT). Echocardiography ruled out existing cardiac disease. Estimated glomerular filtration rate (eGFR) was calculated.

RESULTS

There were significant changes in NTproBNP between the measurements with the highest NTproBNP at 10-12 gw and the lowest value being at 20-25 gw, (with eGFR being the highest). Hs-cTNT was significantly higher at the peripartum measurement compared with the other measurements (p<0.05). Regardless, the 95th percentile for both biomarkers was below cut-off levels of 300 ng/L for NTproBNP and 14 ng/L for hs-cTNT. There was an association between NTproBNP above the upper limit of normal of 125 ng/L and eGFR (p=0.04) and between hs-cTNT >5.0 ng/L and time from delivery to blood sample (p=0.001) at the peripartum measurement. Both were associated with the use of oxytocin.

CONCLUSION

Existing cut-off values for ruling out heart failure (NTproBNP <300 ng/L) and myocardial ischaemia (hs-cTNT <14 ng/L) are applicable during pregnancy and after delivery. Elevated levels mandate further attention on cardiac symptoms and renal function.

Post-operative musculoskeletal outcomes in patients with coarctation of the aorta following different surgical approaches

BACKGROUND

The aim of this study was to examine range of motion and muscle function in the upper extremity and spine in patients with coarctation of the aorta (CoA) comparing different surgical approaches.

METHODS

From October 2017 to February 2019, 150 patients were assessed for inclusion. A total of 99 patients (n = 75 CoA, n = 24 control), were included and assessed regarding muscle function, arm length and circumference, and spinal and thoracic mobility.

RESULTS

There were significant differences between the right and left arm in patients with CoA, operated with the subclavian flap technique compared to controls in regards to shoulder flexion (p < 0.001), elbow flexion (p = 0.001), shoulder abduction (p = 0.02), handgrip strength (p = 0.01), length of upper arm (p < 0.001), lower arm (p < 0.001), and of whole arm (p < 0.001), circumference regarding upper arm (p = 0.001), lower arm (p < 0.001), and wrist (p < 0.001). Structural scoliosis was more frequent in patients who had undergone thoracotomy (25.4%) than patients who had not undergone a thoracotomy (5.9%, p = 0.04), and were often located in the thoracic part of the spine.

CONCLUSION

Patients with CoA operated on using the subclavian flap technique have impaired muscle function as well as reduced arm length and circumference. An increased rate of structural scoliosis was found in patients who underwent thoracotomy, in comparison with patients who had not undergone a thoracotomy. Further research is needed to determine whether muscle function impaired by surgical procedures can be improved with exercise.

Survival in Children With Congenital Heart Disease: Have We Reached a Peak at 97%?

Background

Despite advances in pediatric health care over recent decades, it is not clear whether survival in children with congenital heart disease (CHD) is still increasing.

Methods and Results

We identified all patients with CHD using nationwide Swedish health registries for 1980 to 2017. We examined the survival trends in children with CHD; we investigated the mortality risk in patients with CHD compared with matched controls without CHD from the general population using Cox proportional regression models and Kaplan–Meier survival analysis. Among 64 396 patients with CHD and 639 012 matched controls without CHD, 3845 (6.0%) and 2235 (0.3%) died, respectively. The mean study follow‐up (SD) was 11.4 (6.3) years in patients with CHD. The mortality risk was 17.7 (95% CI, 16.8–18.6) times higher in children with CHD compared with controls. The highest mortality risk was found during the first 4 years of life in patients with CHD (hazard ratio [HR], 19.6; 95% CI, 18.5–20.7). When stratified by lesion group, patients with non‐conotruncal defects had the highest risk (HR, 97.2; 95% CI, 80.4–117.4). Survival increased substantially according to birth decades, but with no improvement after the turn of the century where survivorship reached 97% in children with CHD born in 2010 to 2017.

Conclusions

Survival in children with CHD has increased substantially since the 1980s; however, no significant improvement has been observed this century. Currently, >97% of children with CHD can be expected to reach adulthood highlighting the need of life‐time management.

Risk of myocardial infarction in middle aged and older patients with coarctation of the aorta

Introduction

Previous case-control studies have compared the risk of coronary artery disease/myocardial infarction (MI) in patients with coarctation of the aorta (CoA) with other congenital heart disease diagnoses, however, these studies have only included younger patients in their 20s and 30s, not older patients. As the atherosclerotic burden is increasing with increasing age, it is important to study the risk of MI in older patients (from early middle age and older) with CoA.

Purpose

The aim of our study was to investigate the risk of MI in older patients (≥40 years) with CoA, and to compare this risk with the risk in patients of the same age with ventricular septal defects (VSD), the most common congenital heart condition.

Methods

We used data from the Swedish National Patient Registry (NPR) to identify all patients alive at 40 years of age with a diagnosis of CoA or VSD, born during the period 1930–1970. The follow-up through the NPR and the Cause-specific Death Registry started in January 1970 and went on until December 2017.

Results

Altogether 1204 patients with CoA and 2079 patients with VSD were identified in the registers, and in total, 97 (8.1%) patients with CoA and 162 (7.8%) patients with VSD developed an MI during follow up. Mean follow up time was 20.6±10.3 years in CoA patients and 21.3±10.9 in the VSD group. The risk of MI was similar in CoA compared with VSD patients (HR 1.1, 95% confidence interval 0.9–1.5, p=0.3) Median age at MI was similar in CoA patients and in VSD patients; in CoA 59.8 years (range 40.1–87.5), in VSD 61.2 (range 40.2–87.5), p=0.3. Hypertension (diagnosed before MI or within a year after MI) was more common in CoA patients with an MI (58.8%) compared with VSD patients (37.7%), however, prevalence of diabetes mellitus and hyperlipidemia was similar in both patient groups (18.6% and 21.6% in CoA respectively, compared to 17.9% and 22.8% in VSD group). After adjustment for hypertension, diabetes mellitus and hyperlipidemia, the risk of MI remained similar in patients with CoA and VSD (hazard ratio 1.1, 95% confidence interval 0.8–1.4, p=0.5).

Conclusion

In this large nationwide study, we found that in older patients with CoA (median age at MI 60 years, range 40–88 years) the risk of MI was not increased and similar to that of patients with VSD with similar age at MI. Adjustment for hypertension, diabetes mellitus and hyperlipidemia did not modify this finding which suggests that patients with CoA do not have an increased risk of MI, compared to patients with VSD.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): This work was funded by the Swedish state under an agreement between the Swedish government and county councils, the ALF agreement (Grant number: 236611) and the Swedish Heart-Lung Foundation (Grant Number: 20090724).

Transcatheter interventions of coarctation of the aorta (CoA): a multinational population-based registry – procedural complications

Background

Patients with a native or re CoA with an invasively meassured peak to peak gardient &gt;20 mmHg have a guideline indication for intervention. The decision regarding transcatheter versus surgical intervention depends on a variety of factors including location and complexity of CoA, patient/parent preference and availability of a team capable to perform the intevention with a low rate of complications. The aim of the present analysis was to describe factors associated with risk for procedural complications during transcatheter interventions in CoA. Separate anlysis was done for complications at intervention site and at access site.

Methods

All consecutive patients undergoing catheter interventions for CoA from 1st of January 2000 to 31st of December 2016 were identified by each of the particpating nine centers. The nine centers perform all catheter interventions for CoA for a complete population coverage of 25 millions inhabitants. A common protocol was filled out from medical records. Exclusion criteria were weight less than 20 kg at the time of intervention or Norwood surgery for hypoplastic left heart surgery. Complications at the intervention site included aneurysm formation, dissection of the aorta, extravasation of the aorta or neurological impairment. Complications at the access site was defined as any complication that prolonged the hospital stay.

Results

590 interventions were performed on 520 patients: two interventions n=76, three: n=11, four n=2 and one patient underwent five interventions. There was no mortality in relation to the procedure or during the hospitalisation. The age span of the patients was wide; 4–79 years old (median= 23). 51% had a native CoA, 42% post surgery re-CoA, 22% had had a previous catheter intervention. In 160 (27%) of the interventions balloon dilatation only was performed. Overall, procedural succes was 87%, n=513, 44 procedures (8%) were partially successful and 9 procedures (2%) were not successful. 512 (87%) had one day in hospital stay and 17 patients (6%) had a hospital stay longer than 3 days. In 11 procedures (1.9%) at least one complication occurred at the intervention site; (6 aneurysm formation, 3 neurological impairment, 3 dissection of aorta, 2 extra vasation of aorta), nine of them without prolonged hospital stay. In 25 procedures (4.2%) at least one complications at the access site was observed. Access site complications were associated with older age (mean 38 years (10–79))

Conclusions

In a large, multicenter registry with complete follow-up, complications at the intervention site occurred in 1.9% and at the access site in 4.2% of interventions. Transcatheter intervention of CoA can be performed with low risk of complications.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): ALF-LUA, Gothenburg Heart and Lung Foundation

Risk of ischemic stroke in adult patients with congenital heart disease

Introduction

With an increasing proportion of adults with congenital heart disease (CHD) surviving into middle age and beyond, CHD patients will be at increased risk of acquired cardiovascular conditions, such as ischemic stroke. Compared to controls, patients with CHD have a higher prevalence of arrhythmias, persistent shunts enabling paradoxical embolization, heart failure, mechanical valves as well as potentially hypercoagulable states, all of which can further increase the risk of stroke.

Purpose

The aim of our study was to investigate the risk of developing ischemic stroke in adults with CHD in Sweden compared to controls from the general population.

Methods

We used data from the Swedish National Patient and Cause of Death registries to identify all CHD patients ≥18 years of age, born during the period 1930–1998, with a first time diagnosis of ischemic stroke. Follow-up started in January 1970 and went on until December 2017. Approximately ten controls matched for age and sex were randomly selected from the general population for each patient with CHD. CHD diagnoses were classified into six lesion groups according to a previously published hierarchical classification system.

Results

In total, 43,110 patients with CHD and 474,267 controls were included in the study (51.4% men) and mean follow up time was 25.4±18.4 years. Patients with CHD had a 6 times higher risk of developing an ischemic stroke compared with controls (hazard ratio 6.0, 95% confidence interval 5.8–6.2, p≤0.001), with altogether 8.8% (n=3785) of CHD patients developing ischemic stroke compared with 1.6% (n=7516) of controls. Ischemic stroke was more common in all CHD lesion groups; however, patients with atrial septal defects/patent foramen ovale had the highest incidence rate of ischemic stroke with an incidence rate of 76.1 events/10,000 patient years compared with 8.7 in controls. Patients with CHD and ischemic stroke had markedly less hypertension, diabetes mellitus and hypercholesterolemia, compared with controls (7.1%, 2.0%, 2.9% respectively in CHD patients, compared with 19.6%, 6.6%, 5.3%, in controls, p≤0.001 for all). In addition, atrial fibrillation and heart failure were only slightly more common in CHD patients with ischemic stroke compared to controls (atrial fibrillation: 12.0% in CHD vs 10.4% in controls, p=0.01; heart failure: 8.7% in CHD vs 7.3% in controls, p=0.009).

Conclusion

In this large nationwide study, we found that the risk of ischemic stroke in adult patients with CHD was six times higher than in controls, despite a lower prevalence of common risk factors for stroke such as hypertension, diabetes mellitus and hypercholesterolemia. In addition, atrial fibrillation and heart failure were only slightly more common in CHD patients compared with controls. This implies that the etiology of ischemic stroke might be different in CHD patients compared with controls.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): This work was funded by the Swedish state under an agreement between the Swedish government and county councils, the ALF agreement (Grant number: 236611) and the Swedish Heart-Lung Foundation (Grant Number: 20090724).

Transcatheter intervention of coarctation of the aorta (CoA): a multinational population-based registry – effect on hypertension

Background

CoA is associated with hypertension caused by reduced wind kessel function in the aortic arch, general hypoplasia of the arch and/or essential hypertension. In patients with a native or recurrent/rest CoA, a gradient &gt;20 mmHg by non-invasive meassurement if associated with hypertension is an ESCguideline indication for intervention. We studied the persistence and presence of hypertension after transcatheter intervention of a CoA

Methods

All consecutive patients undergoing catheter interventions for CoA from 1st of January 2000 to 31st of December 2016 were identified by each of the particpating nine centers. The nine centers perform all catheter interventions for CoA for a complete population coverage of 25 millions inhabitants. A common protocoll was filled out from medical records. Hypertension was defined as a pre-intervention blood pressure above 140/80 or pharmacological treatment of hypertension. Exclusion criteria were weight less than 20 kg at the time of intervention or Norwood surgery

Results

590 interventions were performed on 520 patients: two interventions n=76, three: n=11, four n=2 and one patient underwent five interventions. Before intervention, 437 (74%) of the patients were hypertensive and 285 were on pharmacologocal treatment; 134 (48%) were treated with one drug, 79 patients (28%) with two drugs, 41 patients (15%) with three drugs and 14 (5%) with four drugs. After the intervention during follow up hypertension was present in 294 patients (50%, p&lt;0.001 vs pre) of whom 270 (46%) were on pharmacological treatment; with one drug, n=128 (48%), two drugs n=93 (34%), three drugs n=34 (13%) or 4 drugs n=7 (3%).

Conclusions

Catheter intervention of CoA reduced the presence of hypertension significantly from 74% down to 50% but many patients will remain hypertensive and in need for treatment. Life time follow up also after transcatheter CoA intervention seems warranted.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): ALF-LUA, Heart and Lung Foundation

Validation of myocardial infarction diagnosis in patients with congenital heart disease in Sweden

Background

The population of adults with congenital heart disease (CHD) is growing, and increasingly more patients with CHD reach older ages. Patients with CHD are at an increased risk of myocardial infarction (MI) with increased age. Diagnosing MI in patients with CHD can be challenging in clinical practice owing to a high prevalence of aberrant electrocardiograms, ventricular hypertrophy, and heart failure, among other factors. The National Swedish Patient Register (NPR) is widely used in epidemiological studies; however, MI diagnoses specifically in patients with CHD have never been validated in the NPR.

Methods

We contacted hospitals and medical archive services to request medical records for 249 patients, born during 1970–2012, with both CHD and MI diagnoses and who were randomly selected from the NPR by the Swedish National Board of Health and Welfare. Follow-up was until 2015. We performed a medical chart review to validate the MI diagnoses; we also validated CHD diagnoses to ensure that only patients with confirmed CHD diagnoses were included in the MI validation process.

Results

We received medical records for 96.4% (n = 238/249) of patients for validation of CHD diagnoses. In total, 74.8% (n = 178/238) had a confirmed CHD diagnosis; of these, 70.2% (n = 167) had a fully correct CHD diagnosis in the NPR; a further 4.6% (n = 11) had a CHD diagnosis, but it was misclassified. MI diagnoses were validated in 167 (93.8%) patients with confirmed CHD. Of the patients with confirmed CHD, 88.0% (n = 147/167) had correct MI diagnoses. Patients with non-complex CHD diagnoses had more correct MI diagnoses than patients with complex CHD (91.0%, n = 131 compared with 69.6%, n = 16). The main cause for incorrect MI diagnoses was typographical error, contributing to 50.0% of the incorrect diagnoses.

Conclusions

The validity of MI diagnoses in patients with confirmed CHD in the NPR is high, with nearly 9 of 10 MI diagnoses being correct (88.0%). MI in patients with CHD can safely be studied using the NPR.