Perioperative echocardiography-derived right ventricle function parameters and early outcomes after tetralogy of Fallot repair in mid-childhood: a single-center, prospective observational study

Assessing Right Ventricular Function in the Perioperative Setting, Part II: What About Catheters?

Echocardiography is a standard tool for assessing right ventricular (RV) function in the perioperative setting, but in high-risk cases, additional monitoring may be required. Patients with pulmonary hypertension, pre-existing RV failure, or undergoing complex surgeries (eg, pulmonary endarterectomy, LVAD implantation, or transplantation) are particularly vulnerable. Catheter-based techniques, such as pulmonary artery catheterization (PAC), provide continuous, functional data and may be valuable in intensive care or when echocardiography is limited. Despite concerns over complications, PACs can help assess hemodynamics, cardiac output, and RV performance, aiding early detection of RV failure in select high-risk patients.

The outcome of surgery for congenital heart disease in India: A systematic review and metanalysis

Background

The mortality risks of children undergoing various cardiac surgeries for congenital heart disease (CHD) in India are not well defined. We conducted a systematic review and meta-analysis to estimate the inhospital mortality of various common CHD surgeries reported in India and compared it to representative data from established Western databases.

Methods and Results

We searched four bibliographic databases for studies published in India over the last 25 years. In total, 135 studies met the inclusion criteria and included 30,587 patients aged from 1 day to 65 years. The pooled mortality rate of 43 Indian studies reporting multiple CHD surgical outcomes is 5.63% (95% confidence interval [CI]: 4.26-7.16; I 2 = 93.9%), whereas the Western data showed a pooled mortality rate of 2.65% (P value for comparison <0.0001). The pooled mortality risk for ventricular septal defect closure and tetralogy of Fallot repair in Indian studies was 2.87% (95% CI: 0.76-5.91; I 2 = 62.4%) and 4.61% (95% CI: 2.0-8.02; I 2 = 87.4%), respectively. The estimated mortality risk was higher than the Western databases for all subcategories studied except for surgeries in the grown-ups with CHD population and coarctation repair.

Conclusions

The estimated mortality risks are higher among Indian patients undergoing cardiac surgery for CHD as compared to Western data. We need prospective multicentric data to document whether the observed excess mortality exists after adjusting for various high-risk features and comorbidities in Indian patients. We need systemic measures to improve the outcomes of CHD surgeries in India.

Echocardiographic Findings in a Cohort of Perinatally HIV-Infected Adolescents Compared with Uninfected Peers from the Cape Town Adolescent Antiretroviral Cohort

BACKGROUND

Little is known about the cardiac health of perinatally HIV-infected (PHIV+) adolescents on antiretroviral therapy (ART) in sub-Saharan Africa. The authors examined cardiac structure and function in PHIV+ adolescents on ART compared with HIV-uninfected (HIV-) adolescents.

METHODS

Echocardiography was performed on PHIV+ and age- and sex-frequency-matched HIV- adolescents enrolled in the Cape Town Adolescent Antiretroviral Cohort. Participants were eligible if they were 9 to 14 years of age and had been on ART for ≥6 months.

RESULTS

Overall, 474 PHIV+ adolescents (median age, 12 years; 51% boys; mean age at ART initiation, 5 years) and 109 HIV- adolescents (median age, 11.8 years; 45% boys) were included. The mean duration on ART was 7 years, with 37% starting treatment before 2 years of age. Compared with HIV- adolescents, PHIV+ adolescents had higher median Z scores for left ventricular (LV) internal end-diastolic dimension, LV end-systolic posterior wall thickness, and end-systolic interventricular septal thickness. PHIV+ adolescents had a lower median Z score for right ventricular internal end-diastolic dimension as compared with HIV- adolescents. There was no difference in ejection fraction or diastolic function between groups. Later initiation of ART (after 6 years) was associated with increased risk for LV hypertrophy (odds ratio, 2.9; 95% CI, 1.3-6.6; P = .01) compared with those who started ART earlier. PHIV+ adolescents with World Health Organization stage IV HIV infection were at increased risk (odds ratio, 2.2; 95% CI, 1.0-4.6; P = .05) of having LV diastolic dysfunction compared with those with less advanced clinical disease.

CONCLUSIONS

This study revealed subtle differences in echocardiographic parameters between PHIV+ and HIV- adolescents. Although these were not clinically significant, starting ART at an older age was a significant risk factor for LV hypertrophy, while more advanced clinical disease was associated with LV diastolic dysfunction.

Assessing Right Ventricular Function in the Perioperative Setting, Part II: What About Catheters?

An-depth assessment of right ventricular function is important in a many perioperative settings. After exploring 2-dimensional echo-based evaluation, other proposed monitoring modalities are discussed. Pressure-based methods of right ventricular appraisal is discussed. Flow-based assessment is reviewed. An overview of the state of current right ventricular 3-dimensional echocardiography and its potential to construct clinical pressure-volume loops in conjunction with pressure measurements is provided. An overview of right ventricular assessment modalities that do not rely on 2-dimensional echocardiography is discussed. Tailored selection of monitoring modalities can be of great benefit for the perioperative physician. Integrating modalities offers optimal estimations of right ventricular function.

Echocardiographic assessment of right heart size and function in dogs with pulmonary valve stenosis

INTRODUCTION/OBJECTIVES

We sought to determine the prevalence and clinical significance of right heart remodeling and right ventricular (RV) dysfunction in dogs with pulmonary valve stenosis (PS). We also sought to evaluate repeatability of several measurements of severity of PS, right heart size, and RV function in dogs with PS.

ANIMALS, MATERIALS AND METHODS

Several indices of right atrial (RA) size and RV size and function were prospectively evaluated in 48 dogs with PS. Regression analysis was used to determine if indices of right heart size and function were independently associated with maximum transpulmonary pressure gradient (max PG) and adverse clinical findings (exercise intolerance, syncope, or right heart failure). Eight dogs underwent a second echocardiogram performed by the same operator to assess repeatability of the echocardiographic indices, which was quantified by coefficient of variation (CV) and repeatability coefficient.

RESULTS

Increased RA size (81%), increased RV wall thickness (83%), and decreased tricuspid annular plane systolic excursion (TAPSE [81%]) were common. Right atrial size, end-diastolic RV area, and RV wall thickness were independently associated with max PG. Decreased TAPSE was independently associated with adverse clinical findings. All indices except RA area (18.6%) and RV systolic velocity (20.7%) had CVs <15%. Repeatability coefficients are available to help distinguish a true change versus measurement variability during serially obtained exams.

CONCLUSIONS

Right heart remodeling and RV dysfunction are common in dogs with PS and are associated with echocardiographic and clinical severity. Results support the quantitative assessment of right heart size and function in dogs with PS.

Multisystem impairment in South African adolescents with Perinatally acquired HIV on antiretroviral therapy (ART)

INTRODUCTION

Adolescents with perinatally acquired HIV (PHIV) are at risk of chronic disease due to long-standing immune suppression, HIV disease and antiretroviral therapy (ART) exposure. However, there are few data on multisystem disease in this population. We investigated the overlapping burden of neurocognitive, cardiovascular, respiratory and/or renal impairment among PHIV positive (PHIV+) adolescents.

METHODS

In this cross-sectional analysis, participants aged 9 to 14 years on ART for >6 months were recruited from seven sites across Cape Town from July 2013 through March 2015, together with age-matched HIV-negative (HIV-) adolescents. Impairment at enrolment was assessed across neurocognitive functioning (using the youth-International HIV Dementia Scale); cardiac function (echocardiogram abnormality); respiratory function (abnormal spirometry) and renal function (abnormal glomerular filtration rate).

RESULTS AND DISCUSSION

Overall, 384 PHIV+ and 95 HIV- adolescents were included (mean age, 11.9 years; 49% female). Median age of ART initiation was 4.2 years (IQR: 1.7 to 7.6) and median CD4 count was 709 (IQR: 556 to 944) with 302 (79%) of PHIV+ adolescents virologically suppressed. Abacavir and Zidovudine were the most commonly used nucleoside reverse transcriptase inhibitors (NRTIs) with 60% of adolescents on non-nucleoside reverse transcriptase inhibitors (NNRTI) and 38% on a protease inhibitor (PI). Among PHIV+ adolescents, 167 (43.5%) had single system impairment only, 110 (28.6%) had two systems involved, and 39 (10.2%) had three or four systems involved. PHIV+ participants had more 2-system and 3-system impairment than HIV-, 110 (28.6%) versus 17 (17.9%), p = 0.03 and 39 (10.2%) versus 3 (4.3%), p = 0.03. PHIV+ participants who had failed a year of school (73.8% vs. 46.4%, p = 0.00) and with a viral load >1000 copies/mL at enrolment (16.8% vs. 8.1%, p = 0.03) were more likely to have dual or multisystem impairment. Of those with cardiac impairment, 86.7% had an additional system impaired. Similarly, in those with neurocognitive impairment, almost 60% had additional systems impaired and of those with respiratory impairment, 74% had additional systems impaired.

CONCLUSIONS

Despite relatively early ART initiation, there is a substantial burden of multisystem chronic impairment among PHIV+ adolescents. This phenomenon needs to be further explored as this population ages and begins to engage in adult lifestyle factors that may compound these impairments.