Congenital heart disease in adults. Second of two parts

Late Outcomes of Ascending-to-Descending Bypass for Aortic Coarctation

BACKGROUND

Ascending-to-descending aortic bypass is a repair option for patients with complex aortic coarctation. This technique is reported to have minimal early morbidity and mortality; however, the long-term results of the procedure are unknown.

METHODS

This study analyzed the late outcomes of 81 consecutive patients with aortic coarctation who underwent ascending-to-descending aortic bypass through a median sternotomy from January 1985 to December 2012. The study was limited to this interval to allow for a minimum of 10-year follow-up. Fifty-two patients had recurrent coarctation after previous repair, and 44 patients had concomitant cardiac procedures at the time of ascending-to-descending bypass.

RESULTS

There was no perioperative mortality, and overall survival at 5, 10, and 20 years was 94%, 90%, and 85%, respectively, similar to an age- and sex-matched population. There were no interventions for the ascending-to-descending bypass during follow-up, and no deaths were known to be related to the bypass graft. Subsequent cardiac operations were performed through a median sternotomy in 7 patients (9%), and late imaging in 48 patients (59%) demonstrated no hemodynamically significant stenoses or pseudoaneurysms. At late follow-up, median systolic blood pressure was 124 mm Hg, and one-half of the patients were receiving either no or only 1 antihypertensive agent.

CONCLUSIONS

Ascending-to-descending aortic bypass is a safe operation with excellent long-term outcomes for adult patients with complex aortic coarctation. The procedure is durable and appears to improve systemic hypertension. Importantly, ascending-to-descending bypass does not hinder the safe performance of subsequent operations performed through a median sternotomy.

Sedentary behavior and physical activity on exercise capacity in adult patients with congenital heart disease

Background

Reduced exercise capacity is associated with a poor prognosis in adult patients with congenital heart disease (CHD). Reducing sedentary behavior (SB) and increasing physical activity (PA) could be potential strategies that may contribute to enhanced fitness and prevention of acquired cardiovascular disease in adult patients with CHD. The present study aimed to examine the association of SB and PA with exercise capacity in adult patients with CHD.

Methods

Ninety-six adult patients with CHD (age: 18-74 years) underwent measurements of peak oxygen uptake (VO2), % predicted peak VO2, and time spent in SB, light physical activity (LPA), and moderate-to-vigorous physical activity (MVPA). Three regression models (single-activity, partition, and isotemporal substitution) were used to examine the associations of the time spent in SB, LPA, and MVPA with peak VO2 and % predicted peak VO2.

Results

In the single-activity and partition models, time spent in MVPA was consistently associated with peak VO2 and % predicted peak VO2. The isotemporal substitution model indicated that replacing 10-min of SB with the same duration of MVPA was associated with a higher peak VO2 (by 0.454 mL/min/kg [0.100 mL/min/kg, 0.807 mL/min/kg]) and % predicted peak VO2 (by 1.810 % [0.594 %, 3.026 %]).

Conclusion

These findings suggest that reducing SB time and increasing PA time are associated with improved exercise capacity in adult patients with CHD.

Cardiac Catheterization Interventions in the Right Ventricular Outflow Tract and Branch Pulmonary Arteries Following the Arterial Switch Operation

The arterial switch operation for d-transposition of the great arteries achieves anatomic repair but creates the potential for right ventricular outflow tract obstruction as a result of the LeCompte maneuver. The resultant right ventricular hypertension is generally well tolerated but a select group are referred for cardiac catheterization. The outcomes of these catheterizations have not been well described. The objective of this study was to describe the degree and nature of right ventricular outflow tract obstruction found during cardiac catheterization among patients following the arterial switch operation as well as determine the rate of intervention and assess the acute impact of any catheter intervention undertaken. We conducted a retrospective study of patients after arterial switch operation with the LeCompte maneuver and subsequent right heart catheterization. Descriptive statistics were reported, and paired sample t tests were used for analysis. 544 children had an arterial switch operation, of which 110 children (20%) had a cardiac catheterization procedure after surgery and 11% had a right heart catheterization. Of the right heart catheterizations, 90% had an intervention (balloon and/or stent). In the interventional group, the right ventricle to systemic pressure ratio decreased modestly, from 2/3 to half systemic, after balloon dilation and/or stent placement (p < 0.01). No serious complications were observed.

The global effect of aortic coarctation on carotid and renal pulsatile hemodynamics

Coarctation of the aorta (CoA) is a congenital disease characterized by the narrowing of the aorta, typically the descending portion after the left subclavian artery. If left untreated, by the time individuals reach 50 years of age, the mortality rate can reach 90%. Previous studies have highlighted the adverse effects of CoA on local hemodynamics. However, no study has investigated the global hemodynamic effects of CoA in end-organ (brain and kidney) damage. Clinical studies have shown that coarctation acts as a reflection site, potentially damaging the hemodynamics of the brain and kidneys. Our goal in this study is to investigate the underlying mechanisms of these altered wave dynamics and their impacts on the pulsatile hemodynamics of end-organs. In this study, we use a physiologically accurate in-vitro experimental setup that simulates the hemodynamics of systemic circulation. Experiments are conducted across various cardiac outputs, heart rates, and coarctation degrees using aortas across a wide range of aortic stiffnesses. Our principal finding is that CoA increases cerebral blood flow and harmful pulsatile energy transmission to the brain. Conversely, both renal blood flow and pulsatile energy transmission to the kidneys are reduced in CoA at every level of aortic stiffness.

Comparison of Four-Dimensional Flow MRI, Two-Dimensional Phase-Contrast MRI and Echocardiography in Transposition of the Great Arteries

Pulmonary artery (PA) stenosis is a common complication after the arterial switch operation (ASO) for transposition of the great arteries (TGA). Four-dimensional flow (4D flow) CMR provides the ability to quantify flow within an entire volume instead of a single plane. The aim of this study was to compare PA maximum velocities and stroke volumes between 4D flow CMR, two-dimensional phase-contrast (2D PCMR) and echocardiography. A prospective study including TGA patients after ASO was performed between December 2018 and October 2020. All patients underwent echocardiography and CMR, including 2D PCMR and 4D flow CMR. Maximum velocities and stroke volumes were measured in the main, right, and left PA (MPA, LPA, and RPA, respectively). A total of 39 patients aged 20 ± 8 years were included. Maximum velocities in the MPA, LPA, and RPA measured by 4D flow CMR were significantly higher compared to 2D PCMR (p < 0.001 for all). PA assessment by echocardiography was not possible in the majority of patients. 4D flow CMR maximum velocity measurements were consistently higher than those by 2D PCMR with a mean difference of 65 cm/s for the MPA, and 77 cm/s for both the RPA and LPA. Stroke volumes showed good agreement between 4D flow CMR and 2D PCMR. Maximum velocities in the PAs after ASO for TGA are consistently lower by 2D PCMR, while echocardiography only allows for PA assessment in a minority of cases. Stroke volumes showed good agreement between 4D flow CMR and 2D PCMR.

Spatial Distribution and Birth Prevalence of Congenital Heart Disease in Iran: A Systematic Review and Hierarchical Bayesian Meta-analysis

BACKGROUND

This study aimed to comprehensively analyze the overall congenital heart disease (CHD) prevalence in live births and children in Iran, along with evaluating the spatial distribution of CHD birth prevalence across various geographical regions within the country.

METHODS

A Bayesian hierarchical meta-analysis (PROSPERO 2022: CRD42022331281) was performed to determine the pooled prevalence. A systematic search was conducted using Web of Science, ScienceDirect, PubMed, Iranian Research Institute for Information Science and Technology (IranDoc), Scientific Information Database (SID), and Magiran until October 4, 2023. Cross-sectional and cohort studies in both English and Persian languages, focusing on the age range of 0-10 years, were considered for the study population. The study quality was evaluated using the Agency for Healthcare Research and Quality (AHRQ) Risk of Bias tool. Heterogeneity was assessed by I2 and τ2 statistics, and publication bias by Egger's and Begg's tests.

RESULTS

The meta-analysis included 62 studies, revealing an overall CHD prevalence of 2.5 per 1000 births. Over time, CHD birth prevalence in Iran has consistently increased. Spatial distribution analysis, including spatial autocorrelation and local spatial autocorrelation, indicated no spatial clustering (P=.46) or aggregation (P=.65) among Iran's provinces. Geographic disparities were significant (P=.000), with the northern and eastern regions showing the highest and lowest CHD prevalence, respectively.

CONCLUSION

The overall CHD prevalence in Iran is lower than global rates, but it continues to rise. Furthermore, there are variations in birth prevalence among different regions of Iran. Environmental, genetic, socioeconomic, and diagnostic accessibility differences are possibly involved in regional variation. The limitations like heterogeneity among studies, the potential inaccuracy of reports due to limited use of accurate diagnostic methods in some studies, and the absence of population-based models to investigate prevalence, underscore the urgent need for standardized diagnostic approaches, and the utilization of population-wide birth defect registries to accurately assess CHD prevalence in Iran.

Late follow-up of neo-aortic dimensions and coronary arteries in adult patients after the arterial switch operation

Background

After the arterial switch operation (ASO) for transposition of the great arteries (TGA), neo-aortic dilatation and coronary arterial anomalies, especially an interarterial course and acute coronary artery take-off angle, are commonly found. Long-term follow-up data after ASO is scarce. Aim of this study was to determine the prevalence of neo-aortic dilatation and coronary abnormalities, with special emphasis on acute coronary take-off angle, in adult TGA-ASO patients.

Methods

In this retrospective cohort study, all adult TGA-ASO patients with ≥1 CT-angiography (CTA) at the age of ≥16 years were included.

Results

Eighty-one patients, 69 % male and median age 21.0 [18.5-22.8] years, were included. At baseline, maximum neo-aortic diameter was 39.2 ± 5.3 mm; 35 (43 %) patients had neo-aortic dilatation (neo-aortic diameter of >40 mm), 22 (27 %) patients had an acute coronary take-off angle (<30°), and 5 (6 %) patients had an interarterial course of the RCA (2 %) or LCA (4 %). Neo-aortic or coronary artery re-intervention occurred in 10 (12 %) patients. All 10 patients had neo-aortic dilatation or coronary take-off angle of <30° on baseline CTA.

Conclusion

This study reports a prevalence of 43 % of neo-aortic dilatation, 6 % of interarterial coronary course and 27 % for acute coronary take-off angle (<30°) at a median term of 21.0 years post ASO. All patients with a neo-aortic re-intervention or coronary artery re-intervention during follow-up had a maximum neo-aortic diameter of >40 mm or a coronary take-off angle of <30° at baseline CTA. This hypothesis generating study suggests that an active surveillance in patients with neo-aortic dilation and/or an acute angulation of < 30° post ASO might be considered and requires prospective evaluation.

QRS fragmentation versus QRS prolongation in predicting right ventricular enlargement and dysfunction in children and adults with repaired Tetralogy of Fallot

Patients with repaired Tetralogy of Fallot (rTOF) have risks of late life-threatening sequelae, including right ventricular (RV) dilation and failure, arrhythmias, and sudden death. QRS prolongation is a well-known ECG predictor of these outcomes but has poor sensitivity for mortality. Growing evidence demonstrates QRS fragmentation (fQRS) as a better prognostic marker for mortality in adults with rTOF, though the two markers have not been directly compared as correlates for CMR abnormalities. Additionally, fQRS has never been studied in pediatric TOF. This single institution retrospectively reviewed 138 CMRs in rTOF patients (median age 21.7 years) who had a corresponding 12-lead ECG within 1 year. fQRS was defined as ≥3 R-waves/notches in the R/S complex (>2 in right bundle branch block) in ≥2 contiguous leads. QRS prolongation was defined as QRS ≥160 ms. Nearly half (46%) the sample had fQRS (42.1% of pediatric subgroup), and 26% had QRS prolongation. Both markers were significantly associated with reduced RV ejection fraction (EF%) (p < 0.01) and larger RV end-diastolic volumes (p < 0.01). QRS prolongation alone predicted lower LV EF% (p = 0.02). Regression analyses showed both QRS prolongation (p < 0.01) and fQRS (p < 0.01) independently associated with reduced RV EF%; QRS prolongation alone predicted RV dilation (p < 0.01). We concluded that both QRS prolongation and fQRS are equivalent as significant markers of RV dysfunction in rTOF patients. QRS prolongation may be a better surrogate for RV dilation specifically. fQRS was frequently seen in children with rTOF and was significantly associated with similar late structural sequelae.

Large cameral coronary artery fistula in a 5 months old infant with unusual presentation and fatal outcome: -case report

BACKGROUND

Congenital coronary fistulas (CAFs) are uncommon abnormalities communicating the coronary arteries with the cardiac chambers or portion of the systemic or pulmonary circulation. Over 90% of the cases drain into the right side of the heart with only 3% terminating in the left ventricle. Infants with a large CAFs may develop congestive heart failure.

CASE PRESENTATION

A 5 months old female infant presented with labored breathing and worsening of bluish discoloration of the lips and extremities following a prolonged cry. She had a history of breastfeeding difficulty and noticeable bluish discoloration of the lips and extremities since birth. The infant was wasted and had a fast heart rate, bluish lips, and nail beds with clubbing of fingers and toes. A cardiac murmur was noted during her medical checkup. Chest x-ray showed cardiomegaly. Echocardiography and CT angiography showed large Cameral CAF involving the left main and left anterior descending artery draining into the left ventricle. The tricuspid valve was dysplastic, there was secundum ASD, and VSD with a right to left shunt. The patient developed episode of cyanotic spells after crying excessively following a CT angiographic procedure which culminated in respiratory arrest and her demise. She was managed as a case of hypoxic spells in the ICU before her death.

CONCLUSION

This report unveiled unfamiliar case of Cameral coronary artery fistula with left-to-left shunting, cyanosis, and dysplastic tricuspid valve.

Challenges and outcomes of pregnancy in an uncorrected Tetralogy of Fallot with pulmonary atresia and major aorta-pulmonary collateral arteries (MAPCA): a case report

BACKGROUND

Tetralogy of Fallot is a severe type of congenital heart disease (CHD) and one of the leading indirect causes of mortality & morbidity among women with CHD. We came across a rare case of an uncorrected Tetralogy of Fallot with pulmonary atresia and major aortopulmonary collateral arteries in pregnancy.

CASE PRESENTATION

We are reporting the challenges in managing a pregnancy of 25-years-old G3 P0110, previous one stillbirth and who was diagnosed to have congenital heart disease during pregnancy following spontaneous abortion.

CONCLUSIONS

This case report highlights the role of multidisciplinary care in managing such a high risk case. It also emphasizes the role of cardiac examination of every woman before pregnancy so that definitive treatment or optimization can be done in time for a better outcome.

Implications of Transfusion in Adults with Congenital Heart Disease Undergoing Cardiac Surgery

The number of adults with congenital heart disease (CHD) requiring cardiovascular (CV) surgery is increasing rapidly in today's era. We hypothesized that exposure to perioperative blood products is associated with worse outcomes in adults. All adults (≥ 18 years old) undergoing CV surgery with Cardio-Pulmonary Bypass (CPB) between 2015 and 2020 were reviewed retrospectively. Associations between transfusion and outcomes were studied by univariable logistic regression and Wilcoxon rank sum tests. Cox/ logistic regression was used to assess (a) postoperative ventilation time and length of stay, and (b) major complications, respectively. Of 323 patients, 170 (53%) received blood products perioperatively. The median age was 27 (interquartile range [IQR]: 22-36) years, there were 181 (46%) males, and 16 (5%) patients had single ventricle anatomy. Patients receiving products experienced more complications (OR: 6.6, 95% CI: [2.9, 14.7], p < 0.001) specifically, cardiac arrest (OR: 8.8, 95% CI: [1.1, 71.9], p = 0.04). Transfusion was associated with greater frequency of thrombosis ((OR: 7.8, 95% CI: [1.8, 34.7], p = 0.01)), longer ventilation time (HR: 3.0, 95% CI: [2.4, 3.9], p < 0.001), and longer hospital length of stay (HR: 2.7, 95% CI: [2.1, 3.4], p < 0.001). Longer CPB time (OR: 1.0, 95% CI: [1.0, 1.1], p < 0.001) and prior cardiac surgery (OR: 1.6, 95% CI: [1.3, 2.1], p < 0.001) were independent predictors of perioperative blood product transfusion. Adults who received perioperative blood products experienced more complications and worse in-hospital outcomes. Future research on optimizing blood product transfusion based on risk prediction is needed to optimize outcomes in adults with CHD.

Durable Mechanical Circulatory Support in Adult Congenital Heart Disease: Reviewing Clinical Considerations and Experience

Adults with congenital heart disease (ACHD) patients are one of the fastest growing populations in cardiology, and heart failure (HF) is the most common cause of morbidity and mortality amongst them. The need for advanced HF therapies in ACHD patients stands to grow substantially. The anatomic considerations for placing durable mechanical circulatory support (MCS) devices in ACHD patients often require specialized approaches. Despite this, increasing evidence suggests that durable MCS can be implanted safely with favorable outcomes in ACHD patients. Expansion of MCS use in ACHD patients is imperative to improve their clinical outcomes. Knowledge of ACHD-specific anatomic and physiologic considerations is crucial to HF programs’ success as they work to provide care to this growing population.

Surgical Treatment of Adults with Uncorrected Tetralogy of Fallot: A Clinical Case Series

The tetralogy of Fallot is the most common form of cyanotic congenital heart malformations. However, its association with Down syndrome is uncommon. We present two patients with uncorrected during childhood tetralogy of Fallot. One of them had also Down syndrome. We performed a complete surgical correction: closure of the inter-ventricular defect, right ventricular outflow tract reconstruction, pulmonary valve prosthesis and pulmonary artery patch repair (in one of the cases). The postoperative period was uncomplicated, patients were discharged on days 12 and 10, and the follow-up showed a significant functional class improvement.

Central retinal artery occlusion with cilioretinal sparing in a patient with Eisenmenger syndrome

A young boy in his 20s presented with sudden diminution of vision in right eye 2 days ago. Best-corrected visual acuity was hand movement in right eye and 20/20 in left eye. Funduscopy demonstrated diffuse retinal opacification and swelling at the posterior pole with a cherry red spot at the macula. There was sparing of the superonasal macula with a patent cilioretinal artery. OCT showed diffuse inner retinal thickening of the temporal macula. He was diagnosed as central retinal artery occlusion with cilioretinal sparing in right eye. He was a known case of Eisenmenger syndrome secondary to a large congenital ventricular septal defect. Medical history was notable for prominent pulmonary hypertension and shortness of breath on exertion. Physical examination revealed a harsh systolic murmur. Extremities showed digital erythema and severe clubbing. Chest X-ray demonstrated cardiomegaly. Laboratory examination revealed haemoglobin-220 g/L, haematocrit-60%, serum iron-20 µg/dL.

Trans-catheter closure of large PDA in adult patients with Amplatzer device: case series

Ductus arteriosus is a physiological structure if not closed after birth, may lead to many complications. Today, trans-catheter closure of patent ductus arteriosus with Occluder devices is the preferred method. Surgical ligation is used only in certain cases such as large symptomatic patent ductus arteriosus in very small infants and premature babies; unfavourable structure of the duct or economic considerations. In this article, we described haemodynamic and morphological characteristics of five patients with large patent ductus arteriosus which were occluded with Amplatzer device.From 23 January, 2010 to 31 July, 2018, five patients referred to our clinic with large patent ductus arteriosus and pulmonary arterial hypertension for further evaluation. After assessing them with various diagnostic methods, we decided to close defect with ventricular septal defect Occluder device. Patients aged 21-44 years and one of them was male. Ductus closure was successfully done with ventricular septal defect Occluder device. Closure was successful for all of them but in one case, whose device was embolized to pulmonary artery after 24 hr and he underwent surgery.Trans-catheter closure of large patent ductus arteriosus in adult patients with pulmonary hypertension is feasible. Despite the fact that complications may occur even with the most experienced hands, the 'double disk' Amplatzer ventricular septal defect muscular Occluder could be advantageous in this setting.

Modeling Transposition of the Great Arteries with Patient-Specific Induced Pluripotent Stem Cells

The dextro-transposition of the great arteries (d-TGA) is one of the most common congenital heart diseases. To identify biological processes that could be related to the development of d-TGA, we established induced pluripotent stem cell (iPSC) lines from two patients with d-TGA and from two healthy subjects (as controls) and differentiated them into endothelial cells (iPSC-ECs). iPSC-EC transcriptome profiling and bioinformatics analysis revealed differences in the expression level of genes involved in circulatory system and animal organ development. iPSC-ECs from patients with d-TGA showed impaired ability to develop tubular structures in an in vitro capillary-like tube formation assay, and interactome studies revealed downregulation of biological processes related to Notch signaling, circulatory system development and angiogenesis, pointing to alterations in vascular structure development. Our study provides an iPSC-based cellular model to investigate the etiology of d-TGA.

MicroRNA-183-3p Is a Predictor of Worsening Heart Failure in Adult Patients With Transposition of the Great Arteries and a Systemic Right Ventricle

Aim: MicroRNAs (miRNAs) have been shown to play an important role in the progression of heart failure (HF). The aim of our study was to analyze miRNAs in the blood of patients with transposition of the great arteries and a systemic right ventricle (TGA-RV) in order to identify those that predict worsening HF.

Materials and Methods: In 36 patients with TGA-RV, SurePrint™ 8 × 60K Human v21 miRNA microarrays were used to determine the miRNA abundance profiles and compared to 35 age- and gender-matched healthy volunteers (HVs). MiRNAs that were most significantly abundant or best related to worsening HF were further validated by RT-qPCR.

Results: Using miRNA array analysis, a total of 50 down-regulated and 56 up-regulated miRNAs were found to be differentially abundant in TGA-RV patients compared to HVs. Six of these 106 miRNAs were significantly related to worsening HF. After validation by RT-qPCR, four miRNAs turned out to be significantly associated with worsening HF, namely miR-150-5p, miR-1255b-5p, miR-423-3p, and miR-183-3p. In the stepwise multivariable Cox regression analysis, ejection fraction of the systemic RV, high sensitive TNT and miR-183-3p were found to be independent predictors of worsening HF (P = 0.001, P = 0.002, and P = 0.001, respectively).

Conclusions: In patients with TGA-RV, miR-183-3p is an independent predictor of worsening HF and thus may be used as additional biomarker in the risk assessment of these patients.

Role of computed tomography in adult congenital heart disease: A review

Due to advances in cardiac surgery, perioperative care and transcatheter interventions, the majority of infants with congenital heart disease (CHD) now survive and reach adulthood. Transthoracic Echocardiography (TTE) is considered the primary imaging modality in evaluation of patients with CHD. However, in adults it can be limited due to several reasons. Although cardiac magnetic resonance (CMR) is extremely useful in evaluating cardiac morphology and function, it is not widely available, takes a long time to obtain images, and cannot be done in severely ill patients or patients that have claustrophobia. Due to high spatial and temporal resolution, isotropic imaging fast imaging and wide availability, multidetector computed tomography (MDCT) has emerged as an excellent alternative modality in the evaluation of adult congenital heart disease (ACHD). It can be performed on patients with hardware and those with claustrophobia, due to shorter image acquisition time. In this article, the commonly encountered congenital heart disorders in adults are reviewed, whether incidentally discovered on a computed tomography (CT), on a CT done to evaluate sequela of unknown CHD, or known treated CHD. To appropriately perform and evaluate CT imaging for postoperative correction or palliation congenital heart disease in adults, the imager should know the detailed cardiac anatomy, details of the operative technique used, and be familiar with the common short and long term post-operative complications.

Electrophysiologic Management and Considerations for D-transposition of the Great Arteries After Atrial Baffle Repair

This unique case highlights the electrophysiologic management and risk assessment of sudden cardiac death in a 35-year-old woman with a history of D-transposition of the great arteries status post–Mustard atrial switch repair.

The effect of coarctation degrees on wall shear stress indices

Coarctation of the aorta (CoA) is a congenital tightening of the proximal descending aorta. Flow quantification can be immensely valuable for an early and accurate diagnosis. However, there is a lack of appropriate diagnostic approaches for a variety of cardiovascular diseases, such as CoA. An accurate understanding of the disease depends on measurements of the global haemodynamics (criteria for heart function) and also the local haemodynamics (detailed data on the dynamics of blood flow). Playing a significant role in clinical processes, wall shear stress (WSS) cannot be measured clinically; thus, computation tools are needed to give an insight into this crucial haemodynamic parameter. In the present study, in order to enable the progress of non-invasive approaches that quantify global and local haemodynamics for different CoA severities, innovative computational blueprint simulations that include fluid-solid interaction models are developed. Since there is no clear approach for managing the CoA regarding its severity, this study proposes the use of WSS indices and pressure gradient to better establish a framework for treatment procedures in CoA patients with different severities. This provides a platform for improving CoA therapy on a patient-specific level, in which physicians can perform treatment methods based on WSS indices on top of using a mere experience. Results show how severe CoA affects the aorta in comparison to the milder cases, which can give the medical community valuable information before and after any intervention.

Valvular heart disease in congenital heart disease: a narrative review

Patients with congenital heart disease (CHD) are one of the fastest growing populations in cardiology, and valvular pathology is at the center of many congenital lesions. Derangements in valvular embryology lead to several anomalies prone to dysfunction, each with hemodynamic effects that require appropriate surveillance and management. Surgical innovation has provided new treatments that have improved survival in this population, though has also contributed to esotericism in patients who already have unique anatomic and physiologic considerations. Conduit and prosthesis durability are often monitored collaboratively with general and specialized congenital-focused cardiologists. As such, general cardiologists must become familiar with valvular disease with CHD for appropriate care and referral practices. In this review, we summarize the embryology of the semilunar and atrioventricular (AV) valves as a foundation for understanding the origins of valvular CHD and describe the mechanisms that account for heterogeneity in disease. We then highlight the categories of pathology from the simple (e.g., bicuspid aortic valve, isolated pulmonic stenosis) to the more complex (e.g., Ebstein's anomaly, AV valvular disease in single ventricle circulations) with details on natural history, diagnosis, and contemporary therapeutic approaches. Care for CHD patients requires collaborative effort between providers, both CHD-specialized and not, to achieve optimal patient outcomes.

Computational analysis of cardiac structure and function in congenital heart disease: Translating discoveries to clinical strategies

Increased availability and access to medical image data has enabled more quantitative approaches to clinical diagnosis, prognosis, and treatment planning for congenital heart disease. Here we present an overview of long-term clinical management of tetralogy of Fallot (TOF) and its intersection with novel computational and data science approaches to discovering biomarkers of functional and prognostic importance. Efforts in translational medicine that seek to address the clinical challenges associated with cardiovascular diseases using personalized and precision-based approaches are then discussed. The considerations and challenges of translational cardiovascular medicine are reviewed, and examples of digital platforms with collaborative, cloud-based, and scalable design are provided.

[The adult with tetralogy of fallot: what the clinical cardiologist needs to know]

Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart disease. After more than seven decades of the first palliative surgery, TOF prognosis has changed dramatically. The prevalence of TOF is approximately 3 per 10 000 births, representing 7 to 10% of congenital heart disease. With a higher survival into adulthood, the clinical cardiologist faces challenges in the management of this population, from severe pulmonary regurgitation to heart failure and ventricular arrhythmias. Its prevalence is approximately 3 per 10 000 live births, representing 7 to 10% of congenital heart disease. This review will describe the most relevant aspects of the care of adult patients with this disease.

Cardiac Neural Crest Cells: Their Rhombomeric Specification, Migration, and Association with Heart and Great Vessel Anomalies

Outflow tract abnormalities are the most frequent congenital heart defects. These are due to the absence or dysfunction of the two main cell types, i.e., neural crest cells and secondary heart field cells that migrate in opposite directions at the same stage of development. These cells directly govern aortic arch patterning and development, ascending aorta dilatation, semi-valvular and coronary artery development, aortopulmonary septation abnormalities, persistence of the ductus arteriosus, trunk and proximal pulmonary arteries, sub-valvular conal ventricular septal/rotational defects, and non-compaction of the left ventricle. In some cases, depending on the functional defects of these cells, additional malformations are found in the expected spatial migratory area of the cells, namely in the pharyngeal arch derivatives and cervico-facial structures. Associated non-cardiovascular anomalies are often underestimated, since the multipotency and functional alteration of these cells can result in the modification of multiple neural, epidermal, and cervical structures at different levels. In most cases, patients do not display the full phenotype of abnormalities, but congenital cardiac defects involving the ventricular outflow tract, ascending aorta, aortic arch and supra-aortic trunks should be considered as markers for possible impaired function of these cells. Neural crest cells should not be considered as a unique cell population but on the basis of their cervical rhombomere origins R3-R5 or R6-R7-R8 and specific migration patterns: R3-R4 towards arch II, R5-R6 arch III and R7-R8 arch IV and VI. A better understanding of their development may lead to the discovery of unknown associated abnormalities, thereby enabling potential improvements to be made to the therapeutic approach.

Heart failure in the adult Ebstein patient

Ebstein anomaly comprises approximately 1% of all congenital heart diseases. It occurs when the tricuspid valve fails to properly delaminate from the right ventricle, resulting in a clinical spectrum of abnormal tricuspid valve morphology and right ventricular dysfunction. Due to the anatomy of the tricuspid valve and right ventricle, as well as associated right- and left-sided pathology, patients are at risk for both right and left ventricular failure and the associated symptoms of each. Ebstein patients are also at risk for atrial arrhythmias, due to the atrial enlargement intrinsic to the anatomy, as well as the presence of potential accessory pathways. Arrhythmias are generally poorly tolerated, particularly in the setting of ventricular dysfunction. Cyanosis may also be present in Ebstein patients, due to the common occurrence of atrial communications, which can exacerbate other symptoms of heart failure. Treatment of heart failure can be through pharmacologic and procedural interventions, depending on the underlying cause of heart failure. While early heart failure symptoms may be treated with medical management, most Ebstein patients will require surgery. Various surgical and catheter-based interventions targeting the tricuspid valve and the atrialized right ventricular tissue have been developed to help treat the underlying cause of the heart failure. The optimal timing of transcatheter and surgical intervention in the Ebstein patient to prevent or treat heart failure needs further study.

Orthodontics in patients with significant medical co-morbidities

A wide variety of patients with medical co-morbidities may present to general orthodontic practice. It is important for the treating clinician to have a general understanding of key medical conditions that may impact upon the treatment and management options. This clinical supplement provides a treatment-focused summative update for the orthodontist regarding significant medical co-morbidities, their general prevalence and an exploration of potential impacts upon orthodontic treatment. This review also discusses the significance of key medications and provides suggestions for the safe provision of orthodontic treatment.

CT evaluation of unrepaired/incidental congenital cardiovascular diseases in adults

Congenital heart disease (CHD) affects approximately one million people in the USA with the number increasing by 5% each year. Patients are usually both diagnosed and treated in infancy, however many of them may have subclinical CHD that remains undiagnosed until late adulthood. Patients with complex CHD tend to be symptomatic and are diagnosed at a younger age than those with a single defect. CHDs can be divided into three categories, including cardiac, great vessels and coronary artery anomalies. Recent advances in computed tomography (CT) technology with faster acquisition time and improved spatial resolution allow for detailed evaluation of cardiac morphology and function. The concomitant increased utilization of CT has simultaneously led to more sensitive detection and more thorough diagnosis of CHD. Recognition of and understanding the imaging attributes specific to each anomaly is important for radiologists in order to make a correct and definite diagnosis. This article reviews the spectrum of CHDs, which persist into adulthood that may be encountered by radiologists on CT.

Ebstein's anomaly of tricuspid valve with aortic stenosis and coarctation of aorta: Successful single-stage repair of a rare adult congenital heart disease

Ebstein's anomaly of the tricuspid valve is infrequently associated with left heart anomalies. The association of aortic stenosis in Ebstein's anomaly has been reported to be extremely rare and the association of coarctation of aorta is even rarer especially in adults. The combination of all three of these lesions is virtually unknown without any references in literature. We report here an unusual case of Ebstein's anomaly of the tricuspid valve and severe aortic stenosis with coarctation of aorta in an adult who presented to us with exertional dyspnoea in the third decade and underwent a successful single-stage intracardiac repair.

Ebstein's anomaly: epidemiological analysis and presentation of different prenatal management

OBJECTIVES

To present the crucial role of echocardiographic examination in perinatal care and analyze influence of prenatal treatment for neonatal outcome. Furthermore, the attempt to answer the question if there was any relationship between the occurrence of fetal Ebstein's anomaly and environmental risk factors in polish population.

METHODS

Forty-five prenatal diagnoses of Ebstein's anomaly were compiled over the 21-year period (1998‒2018) form our single unit. The analysis included the assessment of maternal parameters (age, past obstetric history, and place of residence) and fetal parameters (sex, gestational age, anatomy, the fetal cardiovascular condition assessed by the CVPS, associated extracardiac anomalies or malformations, prenatal treatment, delivery and follow-up).

RESULTS

The average age of gravida was 29.5 years (± 5.2 years) and gravidae <35 years of age accounted for 80% . There were 43 singleton pregnancies and 2 cases of multiple pregnancy. Ebstein's anomaly was mostly (averagely) diagnosed at 28th week of gestation. Forty-three fetuses had normal karyotypes and two had trisomy 21. Cardiomegaly was present in 91% (41) of fetuses. The average heart area to chest area ratio was 0.56 (± 0.12). In 21 cases, there was only fetal monitoring - echocardiographic examinations and postnatal mortality was 44.4%. In 5 cases, transplacental digoxin treatment was administered and mortality was: 40%. In another 5 cases, only steroid therapy was applied and postnatal mortality was 100%. Steroids and transplacental digoxin treatment were administered in 11 cases and mortality was 63.6%. In 3 last cases transplacental digoxin treatment, steroids and maternal hyperoxygenation therapy were given and mortality was 0%. Cesarean section rate was 49%. Moreover, due to Ebstein's anomaly regional peak of occurrence benzopyrene was deliberated as environmental risk factor.

CONCLUSIONS

Fetal Ebstein's anomaly occurred in our population in healthy young women, expecting their first child and malformation was not related to fetus gender, nor to maternal health condition. Our data can be a new signal for the development of novel treatment strategies in therapy in fetuses with Ebstein's anomaly.

Echocardiography and MRI parameters associated with exercise capacity in patients after the arterial switch operation

BACKGROUND

The arterial switch operation (ASO) for transposition of the great arteries has excellent survival, but a substantial number of patients suffer from a reduced exercise capacity. The goal of this study was to identify imaging parameters associated with a reduced exercise capacity in patients after ASO.

METHODS

A retrospective analysis was performed of ASO patients who underwent cardiopulmonary exercise testing (CPET) between 2007 and 2017. Reduced exercise performance was defined as a reduced workload peak (W_peak) with Z-score <-2 or a peak oxygen uptake indexed for weight (VO_2peak/kg) with Z-score <-2. Data on echocardiography and cardiac magnetic resonance performed within 1 year of the CPET were collected for comparison.

RESULTS

A total of 81 ASO patients (age 17±7 years) were included. Reduced exercise performance was found in 22 patients (27%) as expressed by either a reduced W_peak and/or a reduced VO_2peak/kg. Main pulmonary artery gradient and tricuspid regurgitation gradient by echocardiography were found to be associated with reduced W_peak (p=0.031; p=0.020, respectively). The main pulmonary artery gradient and tricuspid regurgitation gradient by echocardiography were found to be associated with reduced VO_2peak/kg (p=0.009; p=0.019, respectively). No left ventricular parameters were found to be associated with abnormal exercise performance.

CONCLUSION

This study demonstrates that ASO patients frequently experience reduced exercise capacity. Echocardiographic evidence of main pulmonary artery stenosis and increased right ventricular pressure were associated with reduced exercise capacity, and are therefore key to monitor during serial follow-up of ASO patients.

A novel de novo dominant mutation of NOTCH1 gene in an Iranian family with non-syndromic congenital heart disease

Background

Congenital heart disease (CHD) is the most common birth defect which can arises from different genetic defects. The genetic heterogeneity of this disease leads to restricted success in candidate genes screening method. Emerging approaches such as next‐generation sequencing (NGS)‐based genetic analysis might provide a better understating of CHD etiology in the patients who are left undiagnosed. To this aim, in this study, we survived the causes of CHD in an Iranian family who was consanguineous and had two affected children.

Methods

Affected individuals of this family were checked previously by PCR‐direct sequencing for six candidate genes (NKX2‐5, ZIC3, NODAL, FOXH1, GJA1, GATA4) and had not revealed any reported CHD causative mutations. Whole‐exome sequencing (WES) was performed on this family probond to determine the underlying cause of CHD, and the identified variants were confirmed and segregated by Sanger sequencing.

Results

We identified one heterozygous missense mutation, c.T6797C (p.Phe2266Ser), in the NOTCH1 gene, which seems to be the most probably disease causing of this family patients. This mutation was found to be novel and not reported on 1000 Genomes Project, dbSNP, and ExAC.

Conclusion

Worldwide, mutations in NOTCH1 gene are considered as one of the most known causes of CHD. The found NOTCH1 variant in this family affected individuals was the first report from Iran. Yet again, this result indicates the importance of NOTCH1 screening in CHD patients.

Neopulmonary Outflow Tract Obstruction Assessment by 4D Flow MRI in Adults With Transposition of the Great Arteries After Arterial Switch Operation

BACKGROUND

The main complication in adult patients with transposition of the great arteries (TGA) treated by an arterial switch operation (ASO) is neopulmonary outflow tract stenosis (NPOTS). However, pulmonary flow velocity measurements cannot always be performed with transthoracic echocardiography (TTE) due to complex anatomical features. 4D flow MRI allows detection, quantification, and location of the obstruction site along the NPOTS.

PURPOSE AND HYPOTHESIS

To investigate the accuracy of 4D flow for the diagnosis of NPOTS in adults with TGA corrected by ASO.

STUDY TYPE

Prospective.

POPULATION

Thirty-three adult patients with TGA treated by ASO (19 men, mean age 25.5 years old).

FIELD STRENGTH/SEQUENCE

Accelerated 4D flow research sequence at 3T.

ASSESSMENT

Maximum NPOTS velocities on TTE and 4D flow MRI done the same day.

STATISTICAL TESTS

Pearson correlation coefficient, paired t-test, and Bland-Altman analysis were used to investigate the relationship between TTE and MRI data.

RESULTS

In 16 patients (48.5%), evaluation of NPOTS anatomy was not obtained by TTE, while it was always possible by 4D flow. Peak flow velocity (PV) measurements in Doppler and 4D flow were highly correlated (r = 0.78; P < 0.001). PV >350 cm.s^-1 was detected in only one patient (3%) by TTE vs. five patients (15%) by 4D flow. Moreover, a high correlation was found between PV and the right ventricle (RV) mass index to body surface area when using 4D flow (r = 0.63; P < 0.001). The location of NPOTS was determined in all patients using 4D flow and concerned the main pulmonary artery in 42%.

DATA CONCLUSION

Compared to TTE, 4D flow MRI provides better sensitivity to detect and locate NPOTS in patients with TGA treated by ASO. 4D flow PV measurements in NPOTS were well correlated with TTE PV and RV mass.

LEVEL OF EVIDENCE

1 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2020;51:1699-1705.

Emerging clinical applications of strain imaging and three-dimensional echocardiography for the assessment of ventricular function in adult congenital heart disease

Management of congenital heart disease (CHD) in adults (ACHD) remains an ongoing challenge due to the presence of residual hemodynamic lesions and development of ventricular dysfunction in a large number of patients. Echocardiographic imaging plays a central role in clinical decision-making and selection of patients who will benefit most from catheter interventions or cardiac surgery.. Recent advances in both strain imaging and three-dimensional (3D)-echocardiography have significantly contributed to a greater understanding of the complex pathophysiological mechanisms involved in CHD. The aim of this paper is to provide an overview of emerging clinical applications of speckle-tracking imaging and 3D-echocardiography in ACHD with focus on functional assessment, ventriculo-ventricular interdependency, mechanisms of electromechanical delay, and twist abnormalities in adults with tetralogy of Fallot (TOF), a systemic RV after atrial switch repair or in double discordance ventricles, and in those with a Fontan circulation.

Language development in children with congenital heart disease aged 12-24 months

This longitudinal study aims to describe the trajectory of language development in children with CHD aged 12-24 months assessed through an early monitoring and individualized intervention program. We also sought to determine whether early language performances, at 12 months of age, predict 24-month language abilities. We conducted developmental assessments of 49 children with CHD using the Bayley Scales of Infant and Toddler Developmental, third edition (Bayley-III) at 12 and 24 months, and the MacArthur-Bates Communicative Development Inventories (MBCDI) at 12, 18 and 24 months. Compared to normative populations, CHD patients showed significantly lower mean scores in both receptive and expressive language scales of the Bayley-III and the MBCDI at 12 months, whereas at 18 and 24 months only expressive language scores were reduced. No differences were found in the cognitive scale. Communicative gestures at 12 months were significantly predictive of language skills at 24 months of age. Our findings indicate specific vulnerability of language outcome, especially in expressive skills, rather than a global cognitive impairment in our patients with CHD. We recommend using communicative gestures as an early marker of language development to improve our ability to detect language delays in this population.

Huge aneurysmal fistula from left main artery to right atrium in a man with atypical chest pain and dyspnea on exertion

We present a 33-year-old man with atypical chest pain and with no significant past medical history. The patient was finally diagnosed as a case of huge fistula from the left main coronary artery to the right atrium, a very rare condition with challenging diagnostic and therapeutic approaches. The majority of cases of coronary artery fistula are small, asymptomatic and clinically undetectable; they frequently do not cause any complications and can spontaneously resolve. However, larger fistulas are frequently three times the size of a typical caliber of a coronary artery and may or may not cause symptoms or complications.

Pulmonary artery interventions after the arterial switch operation: Unique and significant risks

BACKGROUND

In the modern era, results of the arterial switch operation (ASO) for transposition of the great arteries are excellent. However, because of the LeCompte maneuver, there may be a propensity for development of pulmonary artery stenosis. We encountered atypical complications of pulmonary artery stenting in patients after the ASO, including aorto-pulmonary fistula and coronary compression.

METHODS

We performed a 10-year retrospective review of catheterizations performed in patients after ASO in our institution with a focus on adverse events.

RESULTS

Diagnostic and interventional catheterizations were performed in 47 patients. In 29 patients, 37 interventional procedures performed, which included pulmonary artery angioplasty and/or stenting. In this group, there were five major adverse events (14%), including three aorto-pulmonary fistulae and one coronary artery compression among patients having stent implantation or stent redilation. In addition, there were 6/37 (16%) intended stent procedures, which were aborted because there appeared to be high-risk of significant adverse events.

CONCLUSIONS

This review suggests that percutaneous intervention on pulmonary artery stenosis after ASO has high-risk and should be undertaken advisedly. Prior thorough evaluation of coronary arteries is mandatory as coronary reimplantation sites may be adjacent to sites of pulmonary artery stenosis. Furthermore, if pulmonary artery stent implantation or stent redilation is contemplated, the risk of stent fracture and possible AP fistula should be recognized. Primary use of reinforced covered stents should be considered.

Use of Speckle Tracking Echocardiography to Assess Left Ventricular Systolic Function in Patients with Surgically Repaired Tetralogy of Fallot: Global and Segmental Assessment

Patients with repaired Tetralogy of Fallot (rToF) can have significant right and left ventricular dysfunction which can impact clinical outcome. Conventional echocardiographic evaluation using ejection fraction can be limited in detecting early stages of deteriorating left ventricular (LV) systolic function. Speckle-tracking echocardiography (STE) provides a promising emerging tool for early detection of LV systolic dysfunction. The aim of this cross-sectional study is to evaluate the left ventricular global and regional function using STE in rToF patients with preserved left ventricular ejection fraction to detect early signs of LV dysfunction. The study is a retrospective review of the medical records and transthoracic echocardiograms of rTOF patients who were seen in the pediatric cardiology clinic at our institution from August 2016 till May 2018. The rTOF group was compared with a matched healthy control group. Offline strain analysis of TTE studies was completed in each subject according to mode set by the American Society of Echocardiography. Twenty-two patients with rTOF and 22 age-matched controls (rTOF 18.7 ± 6 years and control 14.6 ± 9.6 years, P value 0.19) were included during the study period. The rTOF group consisted of 12 males and 10 females, whereas the control group consisted of 15 males and 7 females. There was no significant difference in terms of LV ejection fraction using both 2-chamber as well as 4-chamber views. Global LV longitudinal strain was significantly lower in the rTOF group compared with the control group (rTOF - 15.92 ± 3.16 vs control - 22.79 ± 2.45, P value 0.00). All 17 segments showed significantly lower longitudinal strains in rTOF group compared with the control group. Global circumferential left ventricle strain was significantly lower in the rTOF patients compared with the control group (- 17.24 ± 5.86 vs - 22.74 ± 3.99, P value 0.001). 13 out of 16 segments had lower circumferential strains in the rTOF patients compared with controls. Asymptomatic surgically repaired TOF patients exhibited abnormal segmental and global left ventricle longitudinal and circumferential strains despite having normal left ventricle ejection fraction. Our findings suggest subclinical damage to the left ventricle systolic function post-surgical repair of TOF. 2-D speckle-tracking echocardiography may be used as a valuable method in the early recognition of left myocardial systolic function impairment in patients after TOF repair. The application of this method to guide clinical decision and management of rTOF patients such as earlier pulmonary valve replacement or risk stratification for sudden cardiac death needs further investigation.

Long-term Management of the Arterial Switch Patient

PURPOSE OF REVIEW

This review paper describes the management of patients with dextro-transposition of the great arteries (D-TGA) with a focus on the complications seen and the appropriate care required to identify and prevent adverse events.

RECENT FINDINGS

D-TGA is a form of cyanotic congenital heart disease (CHD) representing ~ 3% of all CHD and almost 20% of all cyanotic CHD. Since the late 1980s, standard of care is to repair these patients with an arterial switch operation (ASO) as opposed to a Mustard/Senning operation. The long-term survival and complication rates are superior in the ASO. Long-term follow-up is recommended for all D-TGA patients and includes management with adult congenital heart disease specialists and the use of echocardiography and advanced imaging with CT or MRI. The most common complications seen are pulmonary stenosis, coronary artery stenosis, and neo-aortic regurgitation. Careful evaluation of new symptoms or declining function is essential in preventing and treating these long-term sequelae.

Risk Factors for Ventricular Septal Defects in Murmansk County, Russia: A Registry-Based Study

Cardiovascular malformations are one of the most common birth defects among newborns and constitute a leading cause of perinatal and infant mortality. Although some risk factors are recognized, the causes of cardiovascular malformations (CVMs) remain largely unknown. In this study, we aim to identify risk factors for ventricular septal defects (VSDs) in Northwest Russia. The study population included singleton births registered in the Murmansk County Birth Registry (MCBR) between 1 January 2006 and 31 December 2011. Infants with a diagnosis of VSD in the MCBR and/or in the Murmansk Regional Congenital Defects Registry (up to two years post-delivery) constituted the study sample. Among the 52,253 infants born during the study period there were 744 cases of septal heart defects (SHDs), which corresponds to a prevalence of 14.2 [95% confidence interval (CI) of 13.2–15.3] per 1000 infants. Logistic regression analyses were carried out to identify VSD risk factors. Increased risk of VSDs was observed among infants born to mothers who abused alcohol [OR = 4.83; 95% CI 1.88–12.41], or smoked during pregnancy [OR = 1.35; 95% CI 1.02–1.80]. Maternal diabetes mellitus was also a significant risk factor [OR = 8.72; 95% CI 3.16–24.07], while maternal age, body mass index, folic acid and multivitamin intake were not associated with increased risk. Overall risks of VSDs for male babies were lower [OR = 0.67; 95% CI 0.52–0.88].

Implantable Cardioverter-defibrillators in Adult Congenital Heart Disease

With improved surgical techniques and medical therapies, many patients who are born with complex congenital heart defects are now living well into adulthood. As these patients age, an increasingly common cause of mortality is sudden cardiac death (SCD) from ventricular tachyarrhythmias. The implantable cardioverter-defibrillator (ICD) is a therapy with the ability to prevent some of these deaths; however, there are many diagnostic and technical challenges that remain in the congenital heart disease (CHD) population. We performed a literature review, searching PubMed for articles that examined the role of ICDs in CHD. We herein present the evidence for when to place an ICD in CHD patients, stratified by subtype as relevant. Then, we discuss the technical challenges and complications that are unique to this patient population. We conclude that, despite active work in the area, more research is needed given the small event rates and clinical variability within CHD populations.

Co-Occurrence of Pheochromocytoma-Paraganglioma and Cyanotic Congenital Heart Disease: A Case Report and Literature Review

Pheochromocytoma and paraganglioma (PHEO-PGL) and cyanotic congenital heart disease (CCHD) are both rare diseases. We reported a 30-year-old patient with a right adrenal gland nodule and a retroperitoneal mass and history of functional single atrium and ventricle. ¹²³I-metaiodobenzylguanidine scintigraphy showed intense uptake in both lesions. Laboratory investigation demonstrated elevated urinary norepinephrine. Preoperative α-blockade was initiated. A successful open resection of right adrenal and retroperitoneal masses was performed. Pathological examination confirmed PHEO-PGL. Postoperative urinary norepinephrine returned to normal level. A systematic case review in English publications in PubMed and EMBASE suggested a hypothesis that there may exist a possible link between PHEO-PGL and hypoxia from CCHD, which was also indicated in our case. Due to higher risk for PHEO-PGL, a lower threshold of suspicion should be considered in CCHD patients. Therefore, active screening and early treatment of PHEO-PGL are recommended in CCHD patients and clinicians should keep on a long-term follow-up to monitor PHEO-PGL recurrence if hypoxia is not corrected.