Pregnancy outcomes in women with a systemic right ventricle and transposition of the great arteries results from the ESC-EORP Registry of Pregnancy and Cardiac disease (ROPAC)

Objective

Cardiac disease is a major cause of maternal mortality. Data regarding pregnancy outcomes in women with a systemic right ventricle (sRV) are scarce. We studied pregnancy outcomes in women with an sRV after the atrial switch procedure for transposition of the great arteries (TGA) or congenitally corrected TGA (CCTGA).

Methods

The ESC EORP Registry of Pregnancy and Cardiac Disease is an international prospective registry of pregnant women with cardiac disease. Pregnancy outcomes (maternal/fetal) in all women with an sRV are described. The primary end point was a major adverse cardiac event (MACE) defined as maternal death, supraventricular or ventricular arrhythmias requiring treatment, heart failure, aortic dissection, endocarditis, ischaemic coronary event and other thromboembolic events.

Results

Altogether, 162 women with an sRV (TGA n=121, CCTGA n=41, mean age 28.8±4.6 years) were included. No maternal mortality occurred. In 26 women, at least one MACE occurred, heart failure in 16 (9.8%), arrhythmias (atrial 5, ventricular 6) in 11 (6.7%) and others in 4 (2.5%). Prepregnancy signs of heart failure as well as an sRV ejection fraction <40% were predictors of MACE. One woman experienced fetal loss, while no neonatal mortality was observed. No significant differences were found between women with CCTGA and TGA. In the subset of women who had an echocardiogram before and after pregnancy, no clear deterioration in sRV was observed.

Conclusion

The majority of women with an sRV tolerated pregnancy well with a favourable maternal and fetal outcome. Heart failure and arrhythmias were the most common MACE.

P1351 Right ventricular diameter added to D-dimer independently influence on prognosis of patients with pulmonary embolism and intermediate risk

Purpose

The paper was aimed to determine predictors for of patients with pulmonary embolism (PE) and intermediate risk.

Methods

84 patients with PE from National registry on VTE (age 60.3 + 12.5 years) were selected in a prospective study. Bedside echocardiography was done in all of them. Pulmonary embolism was confirmed by CT angiography. They were stratified as intermediate risk pts due to simplified PESI score &gt; 1. Study population was followed up for 6.7 months. Multivariate regression analysis was done when right ventricular diameter (RV, mean 37.5 mm), systolic pulmonary artery pressure (68 + 23 mmHg), measured by echocardiography, D-dimer level at baseline 2654.5 + 420,3ng/ml, number of comorbidities (2.4 + 0,7) and occurred symptoms (3.1 + 0,9) entered the model. A model was adjusted for age.

Results

D-dimer revealed as a predictor for length of hospitalization (β 0,25, p 0,05), and RV diameter as a factor for duration of anticoagulation (β 0,29, p 0,05).

Conclusion

Our results imply that baseline measurement of right ventricular diameter when added to D-dimer independently influence on short and long term prognosis of patients with pulmonary embolism and intermediate risk.

Low density lipoprotein size in relation to carotid intima-media thickness in coronary artery disease

OBJECTIVE

With increasing interest in the role of non-traditional lipid risk factors in coronary artery disease, we undertook this study to relate LDL subclass size and carotid intima-media thickness of the common carotid artery in coronary artery disease patients.

METHODS

The study was conducted in 106 patients during their first visit (study group I) and after 12 months (study group II). Intima-media thickness of the common carotid artery was determined using B-mode ultrasound. Separation of LDL subclasses was preformed by 3-31 % polyacrylamide gradient gel electrophoresis.

RESULTS

LDL3 was the dominant subclass in both study groups, but there was statistically significant difference in the distribution of dominant LDL subclasses (p<0.01). The mean carotid intima- media thickness was significantly increased (p<0.001) in coronary artery disease patients after 12 months period. There was significant negative correlation between intima-media thickness and LDL size in both study groups (p<0.05). Intima-media thickness was not significantly correlated with plasma lipid concentrations. Multiple regression analyses show that strongest independent predictor of the intima-media thickness variation was diastolic blood pressure, followed by LDL size and age, and accounted for 29 % of the observed variability in intima-media thickness.

CONCLUSION

LDL particle size is independently associated with carotid intima-media thickness in coronary artery disease patients with normal levels of traditional lipid risk. These results imply that small, dense LDL subclasses are an important indicator for assessing atherosclerosis and its progression (Tab. 4, Ref. 39).

Cholesteryl ester transfer protein, low density lipoprotein particle size and intima media thickness in patients with coronary heart disease

Cholesteryl ester transfer protein (CETP) plays a key role in reverse cholesterol transport and high density lipoprotein (HDL) metabolism. Predominance of small, dense LDL particles is associated with an increased risk of atherosclerosis and coronary heart disease (CHD).The aim of the study was to determine the potential relationship between the CETP concentration and low density lipoprotein (LDL) particle size and their association with intima media thickness (IMT) in patients with CHD. Lipid parameters, CETP concentration and LDL particle size were determined in 100 healthy subjects (control group) and in 100 patients with CHD, aged 43 to 77 years. Plasma CETP concentrations were measured by an enzyme-linked immuno-sorbent assay with two different monoclonal antibodies. LDL subclasses were separated by nondenaturing polyacrilamide 3-31% gradient gel electrophoresis. CETP concentration was higher in patients compared to controls (2.02 ± 0.75 mg/ml vs. 1.74 ± 0.63 mg/ml, p<0.01). Mean LDL particle size (nm) was significantly smaller in patients than in controls (24.5 ± 1.1 vs. 26.1 ± 0.9; p<0.001). There was no relation between LDL particle size and CETP concentration (r=-0.1807, p=0.072). Age, diastolic blood pressure, CETP concentration and LDL particle size were independent factors for determing IMT by multiple linear regression analysis. They accounted for 35.2 % of the observed variability in IMT. CETP is not an independent contributor of LDL particle size. CETP might play a role in determining lipoprotein distributions, but did not seem to be the sole factor in the formation of small LDL particles.

Low-molecular weight heparin enoxaparin in the treatment of acute coronary syndromes without ST segment elevation

OBJECTIVES

We compared the incidence of adverse cardiac outcomes of enoxaparin vs unfractionated heparin in the management of ACS-NSTE.

BACKGROUND

Low-molecular-weight heparins are the potential new standard in the treatment of acute coronary syndromes without ST-segment elevation (ACS-NSTE). The benefit is addressed to significant diminution of the adverse clinical events--recurrent angina (RA), myocardial infarction (MI), heart failure (HF), cerebrovascular insult (ICV), coronary artery by-pass graft (CABG), percutaneous coronary intervention (PCI) and death.

METHODS

Sixty patients with ACS-NSTE were randomised to receive Enoxaparin 1 mg/kg body weight s.c twice daily (n=30) and unfractionated heparin (Heparin - "Biochemie" 25.000 IU/5 ml), according to Rashke nomogram (n=30). The end point were RA, MI, HF, ICV, CABG, PCI and death at day 180. The Kaplan-Meier estimation technique was used to compared the time to events for two treatments. A p<0.05 was considered to indicate significance.

RESULTS

For 180 days, RA, MI, HF, ICV and death were lower in the Enoxaparin vs UFH group (36.6% vs 73.3%, p=0.001), (30% vs 53.3%, p=0.05), (13.3% vs 23.3%, p=0.31), (3.3% vs 10%, p=0.29), (3.3% vs 10%, p=0.31), respectively. CABG were similar 13.3% (p=0.96). PCI were performing in 33.3% in UFH vs 90% in LMWH (p=0.0001).

CONCLUSION

The use of Enoxaparin in ACS-NSTE schows impressive decrease of incidence of ischemic events (Fig. 7, Ref. 8). Full Text (Free, PDF) www.bmj.sk.

Correlation between the aPTT and clinical events in acute coronary syndromes treated with unfractionated heparin

OBJECTIVE

The primary objective of this study is to analyse relationship between activated partial thromboplastin time (aPTT) and clinical events in patients with unstable coronary artery disease.

BACKGROUND

Unfractionated heparin (UFH) is considered as a standard therapy in the management of unstable coronary artery disease. His efficacy is concerned to low rate of adverse events, but it shows lack of correlation between aPTT and clinical outcomes.

METHODS

Thirty patients with acute coronary syndromes were randomised to receive weight-adjusted unfractionated heparin (Heparin-"Biochemie" 25.000 IU/5 ml), according to Rashke nomogram. Six hours after the initial bolus dose, the aPTT was measured and the heparin infusion was adjusted. Relationship between the aPTT and the day of onset of recurrent angina (RA), myocardial infarction (MI), heart failure (HF), death, and target vascular revasularization (TVR) during six months follow-up was evaluated.

RESULTS

At 6 h, 40 % of patients achieved the target level of aPTT (60-85 sec). Also, 40 % patients were below the target range, 41.6 % had aPTT less than 30 sec and 20 % were above the target range. We noted significant difference between heparin dosing and aPTT (p=0.0000). But we did not find significant difference between aPTT and outcomes as RA and MI (p=1.0, p=0.42). Pearson Product Moment Correlation shows negative correlations between aPTT and the day of onset of RA (r=-0.05) and TVR (r=-0.23), and pozitive correlations for MI (r=0.35) and death (r=0.87).

CONCLUSION

The level of aPTT shows discordance with the onset of clinical events and is a weak predictor of outcomes (Tab. 2, Fig. 7, Ref 5).