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Albertini M, Santens B, Fusco F, Sarubbi B, Gallego P, Rodriguez-Puras MJ, Prokselj K, Kauling RM, Roos-Hesselink J, Labombarda F, Van De Bruaene A, Budts W, Waldmann V, Iserin L, Woudstra O, Bouma B, Ladouceur M. External Validation of a Risk Score Model for Predicting Major Clinical Events in Adults After Atrial Switch. J Am Heart Assoc 2024; 13:e032174. [PMID: 38686874 DOI: 10.1161/jaha.123.032174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 03/27/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND A risk model has been proposed to provide a patient individualized estimation of risk for major clinical events (heart failure events, ventricular arrhythmia, all-cause mortality) in patients with transposition of the great arteries and atrial switch surgery. We aimed to externally validate the model. METHODS AND RESULTS A retrospective, multicentric, longitudinal cohort of 417 patients with transposition of the great arteries (median age, 24 years at baseline [interquartile range, 18-30]; 63% men) independent of the model development and internal validation cohort was studied. The performance of the prediction model in predicting risk at 5 years was assessed, and additional predictors of major clinical events were evaluated separately in our cohort. Twenty-five patients (5.9%) met the major clinical events end point within 5 years. Model validation showed good discrimination between high and low 5-year risk patients (Harrell C index of 0.73 [95% CI, 0.65-0.81]) but tended to overestimate this risk (calibration slope of 0.20 [95% CI, 0.03-0.36]). In our population, the strongest independent predictors of major clinical events were a history of heart failure and at least mild impairment of the subpulmonary left ventricle function. CONCLUSIONS We reported the first external validation of a major clinical events risk model in a large cohort of adults with transposition of the great arteries. The model allows for distinguishing patients at low risk from those at intermediate to high risk. Previous episode of heart failure and subpulmonary left ventricle dysfunction appear to be key markers in the prognosis of patients. Further optimizing risk models are needed to individualize risk predictions in patients with transposition of the great arteries.
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Affiliation(s)
- Mathieu Albertini
- Université Paris Cité Inserm, PARCC France
- Centre de Référence des Malformations Cardiaques Congénitales Complexes, M3C Paris France
- Adult Congenital Heart Disease Unit Hôpital Européen Georges Pompidou, APHP Paris France
| | - Beatrice Santens
- Division of Congenital and Structural Cardiology University Hospitals Leuven Leuven Belgium
- Department of Cardiovascular Sciences Catholic University Leuven Leuven Belgium
| | - Flavia Fusco
- Adult Congenital Heart Disease Unit AORN dei Colli-Monaldi Hospital Naples Italy
| | - Berardo Sarubbi
- Adult Congenital Heart Disease Unit AORN dei Colli-Monaldi Hospital Naples Italy
| | - Pastora Gallego
- Adult Congenital Heart Disease Unit Hospital Universitario Virgin del Rocio Seville Spain
- European Reference Network for Rare Low Prevalence and Complex Diseases of the Heart-ERN GUARD Heart Seville Spain
| | - Maria-Jose Rodriguez-Puras
- Adult Congenital Heart Disease Unit Hospital Universitario Virgin del Rocio Seville Spain
- European Reference Network for Rare Low Prevalence and Complex Diseases of the Heart-ERN GUARD Heart Seville Spain
| | - Katja Prokselj
- Department of Cardiology University Medical Centre Ljubljana Ljubljana Slovenia
- Faculty of Medicine University of Ljubljana Ljubljana Slovenia
| | - Robert Martijn Kauling
- Department of Cardiology, Thoraxcenter, ErasmusMC University Medical Center Rotterdam Rotterdam the Netherlands
- European Reference Network for Rare Low Prevalence and Complex Diseases of the Heart-ERN GUARD Heart Rotterdam the Netherlands
| | - Jolien Roos-Hesselink
- Department of Cardiology, Thoraxcenter, ErasmusMC University Medical Center Rotterdam Rotterdam the Netherlands
- European Reference Network for Rare Low Prevalence and Complex Diseases of the Heart-ERN GUARD Heart Rotterdam the Netherlands
| | - Fabien Labombarda
- Department of Cardiology CHU de Caen Caen France
- UNICAEN UR PSIR 4650 Caen France
| | - Alexander Van De Bruaene
- Division of Congenital and Structural Cardiology University Hospitals Leuven Leuven Belgium
- Department of Cardiovascular Sciences Catholic University Leuven Leuven Belgium
| | - Werner Budts
- Division of Congenital and Structural Cardiology University Hospitals Leuven Leuven Belgium
- Department of Cardiovascular Sciences Catholic University Leuven Leuven Belgium
| | - Victor Waldmann
- Université Paris Cité Inserm, PARCC France
- Centre de Référence des Malformations Cardiaques Congénitales Complexes, M3C Paris France
- Adult Congenital Heart Disease Unit Hôpital Européen Georges Pompidou, APHP Paris France
| | - Laurence Iserin
- Université Paris Cité Inserm, PARCC France
- Centre de Référence des Malformations Cardiaques Congénitales Complexes, M3C Paris France
- Adult Congenital Heart Disease Unit Hôpital Européen Georges Pompidou, APHP Paris France
| | - Odilia Woudstra
- Department of Clinical and Experimental Cardiology, Heart Center, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Center University of Amsterdam Amsterdam the Netherlands
| | - Berto Bouma
- Department of Clinical and Experimental Cardiology, Heart Center, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Center University of Amsterdam Amsterdam the Netherlands
| | - Magalie Ladouceur
- Université Paris Cité Inserm, PARCC France
- Centre de Référence des Malformations Cardiaques Congénitales Complexes, M3C Paris France
- Adult Congenital Heart Disease Unit Hôpital Européen Georges Pompidou, APHP Paris France
- Division of Cardiology University Hospital Geneva Geneva Switzerland
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2
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Bevilacqua F, Pasqualin G, Ferrero P, Micheletti A, Negura DG, D'Aiello AF, Giamberti A, Chessa M. Overview of Long-Term Outcome in Adults with Systemic Right Ventricle and Transposition of the Great Arteries: A Review. Diagnostics (Basel) 2023; 13:2205. [PMID: 37443599 DOI: 10.3390/diagnostics13132205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 06/10/2023] [Accepted: 06/24/2023] [Indexed: 07/15/2023] Open
Abstract
The population of patients with a systemic right ventricle (sRV) in biventricular circulation includes those who have undergone an atrial switch operation for destro-transposition of the great arteries (d-TGA) and those with congenitally corrected transposition of the great arteries (ccTGA). Despite the life expectancy of these patients is significantly increased, the long-term prognosis remains suboptimal due to late complications such as heart failure, arrhythmias, and premature death. These patients, therefore, need a close follow-up to early identify predictive factors of adverse outcomes and to implement all preventive therapeutic strategies. This review analyzes the late complications of adult patients with an sRV and TGA and clarifies which are risk factors for adverse prognosis and which are the therapeutic strategies that improve the long-term outcomes. For prognostic purposes, it is necessary to monitor sRV size and function, the tricuspid valve regurgitation, the functional class, the occurrence of syncope, the QRS duration, N-terminal pro B-type natriuretic peptide levels, and the development of arrhythmias. Furthermore, pregnancy should be discouraged in women with risk factors. Tricuspid valve replacement/repair, biventricular pacing, and implantable cardioverter defibrillator are the most important therapeutic strategies that have been shown, when used correctly, to improve long-term outcomes.
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Affiliation(s)
- Francesca Bevilacqua
- Adult Congenital Heart Disease Unit, Pediatric and Adult Congenital Heart Centre, IRCCS-Policlinico San Donato, 20132 Milano, Italy
- European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart: ERN GUARD-Heart, 00165 Rome, Italy
| | - Giulia Pasqualin
- Adult Congenital Heart Disease Unit, Pediatric and Adult Congenital Heart Centre, IRCCS-Policlinico San Donato, 20132 Milano, Italy
- European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart: ERN GUARD-Heart, 00165 Rome, Italy
| | - Paolo Ferrero
- Adult Congenital Heart Disease Unit, Pediatric and Adult Congenital Heart Centre, IRCCS-Policlinico San Donato, 20132 Milano, Italy
- European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart: ERN GUARD-Heart, 00165 Rome, Italy
| | - Angelo Micheletti
- Adult Congenital Heart Disease Unit, Pediatric and Adult Congenital Heart Centre, IRCCS-Policlinico San Donato, 20132 Milano, Italy
- European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart: ERN GUARD-Heart, 00165 Rome, Italy
| | - Diana Gabriela Negura
- Adult Congenital Heart Disease Unit, Pediatric and Adult Congenital Heart Centre, IRCCS-Policlinico San Donato, 20132 Milano, Italy
- European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart: ERN GUARD-Heart, 00165 Rome, Italy
| | - Angelo Fabio D'Aiello
- Adult Congenital Heart Disease Unit, Pediatric and Adult Congenital Heart Centre, IRCCS-Policlinico San Donato, 20132 Milano, Italy
- European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart: ERN GUARD-Heart, 00165 Rome, Italy
| | - Alessandro Giamberti
- European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart: ERN GUARD-Heart, 00165 Rome, Italy
- Congenital Cardiac Surgery Unit, IRCCS-Policlinico San Donato, 20097 Milano, Italy
| | - Massimo Chessa
- Adult Congenital Heart Disease Unit, Pediatric and Adult Congenital Heart Centre, IRCCS-Policlinico San Donato, 20132 Milano, Italy
- European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart: ERN GUARD-Heart, 00165 Rome, Italy
- Vita Salute San Raffaele University, 20132 Milano, Italy
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3
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Broberg CS, van Dissel A, Minnier J, Aboulhosn J, Kauling RM, Ginde S, Krieger EV, Rodriguez F, Gupta T, Shah S, John AS, Cotts T, Kay WA, Kuo M, Dwight C, Woods P, Nicolarsen J, Sarubbi B, Fusco F, Antonova P, Fernandes S, Grewal J, Cramer J, Khairy P, Gallego P, O'Donnell C, Hannah J, Dellborg M, Rodriguez-Monserrate CP, Muhll IV, Pylypchuk S, Magalski A, Han F, Lubert AM, Kay J, Yeung E, Roos-Hesselink J, Baker D, Celermajer DS, Burchill LJ, Wilson WM, Wong J, Kutty S, Opotowsky AR. Long-Term Outcomes After Atrial Switch Operation for Transposition of the Great Arteries. J Am Coll Cardiol 2022; 80:951-963. [PMID: 36049802 DOI: 10.1016/j.jacc.2022.06.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 05/02/2022] [Accepted: 06/07/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND For patients with d-loop transposition of the great arteries (d-TGA) with a systemic right ventricle after an atrial switch operation, there is a need to identify risks for end-stage heart failure outcomes. OBJECTIVES The authors aimed to determine factors associated with survival in a large cohort of such individuals. METHODS This multicenter, retrospective cohort study included adults with d-TGA and prior atrial switch surgery seen at a congenital heart center. Clinical data from initial and most recent visits were obtained. The composite primary outcome was death, transplantation, or mechanical circulatory support (MCS). RESULTS From 1,168 patients (38% female, age at first visit 29 ± 7.2 years) during a median 9.2 years of follow-up, 91 (8.8% per 10 person-years) met the outcome (66 deaths, 19 transplantations, 6 MCS). Patients experiencing sudden/arrhythmic death were younger than those dying of other causes (32.6 ± 6.4 years vs 42.4 ± 6.8 years; P < 0.001). There was a long duration between sentinel clinical events and end-stage heart failure. Age, atrial arrhythmia, pacemaker, biventricular enlargement, systolic dysfunction, and tricuspid regurgitation were all associated with the primary outcome. Independent 5-year predictors of primary outcome were prior ventricular arrhythmia, heart failure admission, complex anatomy, QRS duration >120 ms, and severe right ventricle dysfunction based on echocardiography. CONCLUSIONS For most adults with d-TGA after atrial switch, progress to end-stage heart failure or death is slow. A simplified prediction score for 5-year adverse outcome is derived to help identify those at greatest risk.
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Affiliation(s)
- Craig S Broberg
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA.
| | - Alexandra van Dissel
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA; Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Jessica Minnier
- School of Public Health, Oregon Health and Science University, Portland, Oregon, USA
| | | | | | - Salil Ginde
- Children's Hospital of Wisconsin, Milwaukee, Wisconsin, USA
| | - Eric V Krieger
- University of Washington Medical Center and Seattle Children's Hospital, Seattle, Washington, USA
| | | | - Tripti Gupta
- Ochsner Medical Center, New Orleans, Louisiana, USA
| | | | | | - Timothy Cotts
- University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | - W Aaron Kay
- Krannert Institute of Cardiology, Indianapolis, Indiana, USA
| | - Marissa Kuo
- Ochsner Medical Center, New Orleans, Louisiana, USA
| | - Cindy Dwight
- Krannert Institute of Cardiology, Indianapolis, Indiana, USA
| | - Patricia Woods
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA
| | | | | | | | | | - Susan Fernandes
- Stanford University, School of Medicine, Departments of Pediatrics and Medicine, Palo Alto, California, USA
| | - Jasmine Grewal
- St. Paul's Hospital, Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jonathan Cramer
- Children's Hospital, Omaha & University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Paul Khairy
- Montreal Heart Institute, Montreal, Quebec, Canada
| | | | - Clare O'Donnell
- Green Lane Paediatric and Congenital Cardiac Service, Auckland City Hospital, Auckland, New Zealand
| | - Jane Hannah
- Green Lane Paediatric and Congenital Cardiac Service, Auckland City Hospital, Auckland, New Zealand
| | - Mikael Dellborg
- Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Carla P Rodriguez-Monserrate
- Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA; Department of Medicine, Division of Cardiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | | | | | - Frank Han
- University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Adam M Lubert
- Cincinnati Children's Hospital Medical Center, Heart Institute, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Joseph Kay
- Colorado University School of Medicine, Denver, Colorado, USA
| | - Elizabeth Yeung
- Colorado University School of Medicine, Denver, Colorado, USA
| | | | - David Baker
- University of Sydney and Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - David S Celermajer
- University of Sydney and Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Luke J Burchill
- Royal Melbourne Hospital, Department of Medicine, Melbourne, Victoria, Australia
| | - William M Wilson
- Royal Melbourne Hospital, Department of Medicine, Melbourne, Victoria, Australia
| | - Joshua Wong
- Royal Melbourne Hospital, Department of Medicine, Melbourne, Victoria, Australia
| | - Shelby Kutty
- Johns Hopkins University, Baltimore, Maryland, USA
| | - Alexander R Opotowsky
- Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA; Department of Medicine, Division of Cardiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Cincinnati Children's Hospital Medical Center, Heart Institute, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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4
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Marelli A, Beauchesne L, Colman J, Ducas R, Grewal J, Keir M, Khairy P, Oechslin E, Therrien J, Vonder Muhll IF, Wald RM, Silversides C, Barron DJ, Benson L, Bernier PL, Horlick E, Ibrahim R, Martucci G, Nair K, Poirier NC, Ross HJ, Baumgartner H, Daniels CJ, Gurvitz M, Roos-Hesselink JW, Kovacs AH, McLeod CJ, Mulder BJ, Warnes CA, Webb GD. Canadian Cardiovascular Society 2022 Guidelines for Cardiovascular Interventions in Adults With Congenital Heart Disease. Can J Cardiol 2022; 38:862-896. [PMID: 35460862 DOI: 10.1016/j.cjca.2022.03.021] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 03/15/2022] [Accepted: 03/30/2022] [Indexed: 12/12/2022] Open
Abstract
Interventions in adults with congenital heart disease (ACHD) focus on surgical and percutaneous interventions in light of rapidly evolving ACHD clinical practice. To bring rigour to our process and amplify the cumulative nature of evidence ACHD care we used the ADAPTE process; we systematically adjudicated, updated, and adapted existing guidelines by Canadian, American, and European cardiac societies from 2010 to 2020. We applied this to interventions related to right and left ventricular outflow obstruction, tetralogy of Fallot, coarctation, aortopathy associated with bicuspid aortic valve, atrioventricular canal defects, Ebstein anomaly, complete and congenitally corrected transposition, and patients with the Fontan operation. In addition to tables indexed to evidence, clinical flow diagrams are included for each lesion to facilitate a practical approach to clinical decision-making. Excluded are recommendations for pacemakers, defibrillators, and arrhythmia-directed interventions covered in separate designated documents. Similarly, where overlap occurs with other guidelines for valvular interventions, reference is made to parallel publications. There is a paucity of high-level quality of evidence in the form of randomized clinical trials to support guidelines in ACHD. We accounted for this in the wording of the strength of recommendations put forth by our national and international experts. As data grow on long-term follow-up, we expect that the evidence driving clinical practice will become increasingly granular. These recommendations are meant to be used to guide dialogue between clinicians, interventional cardiologists, surgeons, and patients making complex decisions relative to ACHD interventions.
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Affiliation(s)
- Ariane Marelli
- McGill University Health Centre, Montréal, Québec, Canada.
| | - Luc Beauchesne
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Jack Colman
- Toronto Adult Congenital Heart Disease Program, Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Robin Ducas
- St. Boniface General Hospital, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Jasmine Grewal
- St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Paul Khairy
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | - Erwin Oechslin
- Toronto Adult Congenital Heart Disease Program, Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Judith Therrien
- Jewish General Hospital, MAUDE Unit, McGill University, Montréal, Québec, Canada
| | | | - Rachel M Wald
- Toronto Adult Congenital Heart Disease Program, Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Candice Silversides
- Toronto Adult Congenital Heart Disease Program, Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | | | - Lee Benson
- The Hospital for Sick Children, University Health Network, Toronto, Ontario, Canada
| | - Pierre-Luc Bernier
- McGill University Health Centre, Montreal Heart Institute, Montréal, Québec, Canada
| | - Eric Horlick
- Toronto Adult Congenital Heart Disease Program, Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Réda Ibrahim
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | | | - Krishnakumar Nair
- Toronto Adult Congenital Heart Disease Program, Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Nancy C Poirier
- Université de Montréal, CHU-ME Ste-Justine, Institut de Cardiologie de Montréal, Montréal, Québec, Canada
| | - Heather J Ross
- Toronto Adult Congenital Heart Disease Program, Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Helmut Baumgartner
- Department of Cardiology III: Adult Congenital and Valvular Heart Disease, University Hospital Muenster, Muenster, Germany
| | - Curt J Daniels
- The Ohio State University Medical Center, Columbus, Ohio, USA
| | - Michelle Gurvitz
- Boston Adult Congenital Heart Program, Boston Children's Hospital, Boston, Massachusetts, USA
| | | | - Adrienne H Kovacs
- Department of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | | | | | | | - Gary D Webb
- Cincinnati Children's Hospital Heart Institute, Cincinnati, Ohio, USA
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5
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Ladouceur M, Segura de la Cal T, Gaye B, Valentin E, Ly R, Iserin L, Legendre A, Mousseaux E, Li W, Rafiq I, Kempny A, Barradas-Pires A, Babu-Narayan SV, Gatzoulis MA, Dimopoulos K. Effect of medical treatment on heart failure incidence in patients with a systemic right ventricle. Heart 2021; 107:1384-1389. [PMID: 33958396 DOI: 10.1136/heartjnl-2020-318787] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 04/06/2021] [Accepted: 04/12/2021] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND To date, clinical trials have been underpowered to demonstrate a benefit from ACE inhibitors (ACEis) or angiotensin II receptor blockers (ARBs) in preventing systemic right ventricle (sRV) failure and disease progression in patients with transposition of the great arteries (TGA). This observational study aimed to estimate the effect of ACEi and ARB on heart failure (HF) incidence and mortality in a large population of patients with an sRV. METHODS Data on all patients with an sRV under active follow-up at two tertiary centres between January 2007 and September 2018 were studied. The effect of ACEi and ARB on the incidence of HF and mortality was estimated using a propensity score weighting approach to control confounding. RESULTS Among the 359 patients with an sRV (32.2 (IQR 26.4-38.3) years, 59.3% male, 66% complete TGA with atrial switch repair and 34% congenitally corrected TGA), 79 (22%) had a moderate to severe sRV dysfunction and 138 (38%) were treated with ACEi or ARB. Fourteen (3.6%) patients died, 8 (2.1%) underwent heart transplantation and 46 (11.8%) had a new HF event over a median follow-up of 7.1 (IQR 4.0-9.4) years. On multivariate Cox analysis with adjustment using propensity score weighting approaches, ACEi or ARBs treatment was not significantly associated with a lower HF incidence or mortality in patients with an sRV. CONCLUSIONS Despite significant neurohormonal activation described in patients with an sRV, there is still no evidence of a beneficial effect of ACEi or ARB on morbidity and mortality in this population.
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Affiliation(s)
- Magalie Ladouceur
- Adult Congenital Heart Disease Unit, Hôpital Européen Georges Pompidou, Centre de référence des Malformations Cardiaques Congénitales Complexes, Assistance Publique-Hôpitaux de Paris, Paris University, Paris, France
- Centre de Recherche Cardiovasculaire de Paris, U970, INSERM, Paris, France
| | - Teresa Segura de la Cal
- Adult Congenital Heart Disease and Pulmonary Hypertension Unit, Hospital 12 de Octubre, Madrid, Spain
| | - Bamba Gaye
- Centre de Recherche Cardiovasculaire de Paris, U970, INSERM, Paris, France
| | - Eugenie Valentin
- Centre de Recherche Cardiovasculaire de Paris, U970, INSERM, Paris, France
| | - Reaksmei Ly
- Adult Congenital Heart Disease Unit, Hôpital Européen Georges Pompidou, Centre de référence des Malformations Cardiaques Congénitales Complexes, Assistance Publique-Hôpitaux de Paris, Paris University, Paris, France
- Centre de Recherche Cardiovasculaire de Paris, U970, INSERM, Paris, France
| | - Laurence Iserin
- Adult Congenital Heart Disease Unit, Hôpital Européen Georges Pompidou, Centre de référence des Malformations Cardiaques Congénitales Complexes, Assistance Publique-Hôpitaux de Paris, Paris University, Paris, France
| | - Antoine Legendre
- Adult Congenital Heart Disease Unit, Hôpital Européen Georges Pompidou, Centre de référence des Malformations Cardiaques Congénitales Complexes, Assistance Publique-Hôpitaux de Paris, Paris University, Paris, France
- Pediatric Cardiology, Centre de référence des Malformations Cardiaques Congénitales Complexes, Necker, AP-HP, Paris, France
| | - Elie Mousseaux
- Centre de Recherche Cardiovasculaire de Paris, U970, INSERM, Paris, France
- Department of Cardiovascular Radiology, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris University, Paris, France
| | - Wei Li
- Adult Congenital Heart Centre, National Centre for Pulmonary Hypertension, Royal Brompton Hospital, London, UK
| | - Isma Rafiq
- Adult Congenital Heart Centre, National Centre for Pulmonary Hypertension, Royal Brompton Hospital, London, UK
| | - Aleksander Kempny
- Adult Congenital Heart Centre, National Centre for Pulmonary Hypertension, Royal Brompton Hospital, London, UK
| | - Ana Barradas-Pires
- Adult Congenital Heart Centre, National Centre for Pulmonary Hypertension, Royal Brompton Hospital, London, UK
| | - Sonya V Babu-Narayan
- Adult Congenital Heart Centre, National Centre for Pulmonary Hypertension, Royal Brompton Hospital, London, UK
- National Heart and Lung Institute, Imperial College School of Medicine, London, UK
| | - Michael A Gatzoulis
- Adult Congenital Heart Centre, National Centre for Pulmonary Hypertension, Royal Brompton Hospital, London, UK
| | - Konstantinos Dimopoulos
- Adult Congenital Heart Centre, National Centre for Pulmonary Hypertension, Royal Brompton Hospital, London, UK
- National Heart and Lung Institute, Imperial College School of Medicine, London, UK
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6
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Chih S, McDonald M, Dipchand A, Kim D, Ducharme A, Kaan A, Abbey S, Toma M, Anderson K, Davey R, Mielniczuk L, Campbell P, Zieroth S, Bourgault C, Badiwala M, Clarke B, Belanger E, Carrier M, Conway J, Doucette K, Giannetti N, Isaac D, MacArthur R, Senechal M. Canadian Cardiovascular Society/Canadian Cardiac Transplant Network Position Statement on Heart Transplantation: Patient Eligibility, Selection, and Post-Transplantation Care. Can J Cardiol 2020; 36:335-356. [PMID: 32145863 DOI: 10.1016/j.cjca.2019.12.025] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 12/16/2019] [Accepted: 12/17/2019] [Indexed: 12/17/2022] Open
Abstract
Significant practice-changing developments have occurred in the care of heart transplantation candidates and recipients over the past decade. This Canadian Cardiovascular Society/Canadian Cardiac Transplant Network Position Statement provides evidence-based, expert panel recommendations with values and preferences, and practical tips on: (1) patient selection criteria; (2) selected patient populations; and (3) post transplantation surveillance. The recommendations were developed through systematic review of the literature and using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. The evolving areas of importance addressed include transplant recipient age, frailty assessment, pulmonary hypertension evaluation, cannabis use, combined heart and other solid organ transplantation, adult congenital heart disease, cardiac amyloidosis, high sensitization, and post-transplantation management of antibodies to human leukocyte antigen, rejection, cardiac allograft vasculopathy, and long-term noncardiac care. Attention is also given to Canadian-specific management strategies including the prioritization of highly sensitized transplant candidates (status 4S) and heart organ allocation algorithms. The focus topics in this position statement highlight the increased complexity of patients who undergo evaluation for heart transplantation as well as improved patient selection, and advances in post-transplantation management and surveillance that have led to better long-term outcomes for heart transplant recipients.
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Affiliation(s)
- Sharon Chih
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada.
| | - Michael McDonald
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Anne Dipchand
- Labatt Family Heart Centre, Hospital for Sick Children, Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Daniel Kim
- University of Alberta, Edmonton, Alberta, Canada
| | - Anique Ducharme
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | | | - Susan Abbey
- Centre for Mental Health, University Health Network and Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Mustafa Toma
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Kim Anderson
- Halifax Infirmary, Department of Medicine-Cardiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Ryan Davey
- University of Western Ontario, London, Ontario, Canada
| | - Lisa Mielniczuk
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | | | | | - Christine Bourgault
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, Québec
| | - Mitesh Badiwala
- Peter Munk Cardiac Centre, University Health Network and Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | | | | | - Michel Carrier
- Department of Surgery, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Jennifer Conway
- Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
| | | | | | - Debra Isaac
- University of Calgary, Calgary, Alberta, Canada
| | | | - Mario Senechal
- Institut Universitaire de Cardiologie et de Pneumologie de Québec (IUCPQ), Université Laval, Laval, Québec, Canada
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7
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Carazo M, Andrade L, Kim Y, Wilson W, Wu FM. Assessment and management of heart failure in the systemic right ventricle. Heart Fail Rev 2020; 25:609-621. [DOI: 10.1007/s10741-020-09914-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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8
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Woudstra OI, van Dissel AC, van der Bom T, de Bruin-Bon RHACM, van Melle JP, van Dijk APJ, Vliegen HW, Mulder BJM, Tanck MWT, Meijboom FJ, Bouma BJ. Myocardial Deformation in the Systemic Right Ventricle: Strain Imaging Improves Prediction of the Failing Heart. Can J Cardiol 2019; 36:1525-1533. [PMID: 32553818 DOI: 10.1016/j.cjca.2019.12.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 11/28/2019] [Accepted: 12/10/2019] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Predicting heart failure events in patients with a systemic right ventricle (sRV) due to transposition of the great arteries (TGA) is important for timely intensification of follow-up. This study assessed the value of strain compared with currently used parameters as predictor for heart failure-free survival in patients with sRV. METHODS In participants of a multicentre trial, speckle-tracking echocardiography (STE) was performed to assess global longitudinal strain (GLS), mechanical dispersion (MD), and postsystolic shortening (PSS). Cox regression was used to determine the association of STE parameters with the combined end point of progression of heart failure and death, compared with cardiovascular magnetic resonance (CMR) and computed tomography (CT) derived parameters. RESULTS Echocardiograms of 60 patients were analyzed (mean age 34 ± 11 years, 65% male, 35% congenitally corrected TGA). Mean GLS was -13.5 ± 2.9%, median MD was 49 (interquartile range [IQR] 30-76) ms, and 14 patients (23%) had PSS. During a median 8 (IQR 7-9) years, 15 patients (25%) met the end point. GLS, MD, and PSS were all associated with heart failure-free survival in univariable analysis. After correction for age, only GLS (optimal cutoff > -10.5%) and CMR/CT-derived sRV ejection fraction (optimal cutoff < 30%) remained associated with heart failure-free survival: hazard ratio (HR) 8.27, 95% confidence interval (CI) 2.50-27.41 (P < 0.001), and HR 4.34, 95% CI 1.48-12.74 (P = 0.007), respectively). Combining GLS and ejection fraction improved prediction, with patients with both GLS > -10.5% and sRV ejection fraction < 30% at highest risk (HR 19.69, 95% CI 4.90-79.13; P < 0.001). CONCLUSIONS The predictive value of GLS was similar to that of CMR/CT-derived ejection fraction. The combination of GLS and ejection fraction identified patients at highest risk of heart failure and death. Easily available STE parameters can be used to guide follow-up intensity and can be integrated into future risk prediction scores.
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Affiliation(s)
- Odilia I Woudstra
- Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands; Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Alexandra C van Dissel
- Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands; Netherlands Heart Institute, Utrecht, The Netherlands
| | - Teun van der Bom
- Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Rianne H A C M de Bruin-Bon
- Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Joost P van Melle
- Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Arie P J van Dijk
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Hubert W Vliegen
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Barbara J M Mulder
- Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands; Netherlands Heart Institute, Utrecht, The Netherlands
| | - Michael W T Tanck
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Folkert J Meijboom
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Berto J Bouma
- Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands.
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9
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Morrison ML, Grant B, McCrossan BA, Sands AJ, Owens CG, Spence MS, Casey FA, Craig BG, Lockhart CJ. 32 year follow up of patients following atrial redirection surgery for transposition of the great arteries. CONGENIT HEART DIS 2019; 14:846-853. [DOI: 10.1111/chd.12822] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 06/11/2019] [Accepted: 06/19/2019] [Indexed: 11/28/2022]
Affiliation(s)
- M. Louise Morrison
- Department of Paediatric Cardiology The Royal Belfast Hospital for Sick Children, Belfast Health & Social Care Trust Belfast UK
| | - Brian Grant
- Department of Paediatric Cardiology The Royal Belfast Hospital for Sick Children, Belfast Health & Social Care Trust Belfast UK
| | - Brian A. McCrossan
- Department of Paediatric Cardiology The Royal Belfast Hospital for Sick Children, Belfast Health & Social Care Trust Belfast UK
- Department of Adult Congenital Heart Disease The Royal Victoria Hospital, Belfast Health & Social Care Trust Belfast UK
| | - Andrew J. Sands
- Department of Paediatric Cardiology The Royal Belfast Hospital for Sick Children, Belfast Health & Social Care Trust Belfast UK
- Department of Adult Congenital Heart Disease The Royal Victoria Hospital, Belfast Health & Social Care Trust Belfast UK
| | - Colum G. Owens
- Department of Adult Congenital Heart Disease The Royal Victoria Hospital, Belfast Health & Social Care Trust Belfast UK
| | - Mark S. Spence
- Department of Adult Congenital Heart Disease The Royal Victoria Hospital, Belfast Health & Social Care Trust Belfast UK
| | - Frank A. Casey
- Department of Paediatric Cardiology The Royal Belfast Hospital for Sick Children, Belfast Health & Social Care Trust Belfast UK
| | - Brian G. Craig
- Department of Paediatric Cardiology The Royal Belfast Hospital for Sick Children, Belfast Health & Social Care Trust Belfast UK
- Department of Adult Congenital Heart Disease The Royal Victoria Hospital, Belfast Health & Social Care Trust Belfast UK
| | - Christopher J. Lockhart
- Department of Adult Congenital Heart Disease The Royal Victoria Hospital, Belfast Health & Social Care Trust Belfast UK
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10
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Van De Bruaene A, Toh N, Hickey EJ, Benson L, Horlick E, Granton JT, Williams WG, Roche SL. Pulmonary hypertension in patients with a subaortic right ventricle: prevalence, impact and management. Heart 2019; 105:1471-1478. [DOI: 10.1136/heartjnl-2019-314756] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 04/04/2019] [Accepted: 04/10/2019] [Indexed: 02/06/2023] Open
Abstract
ObjectiveThis study sought to determine the prevalence, predictors, prognostic relevance and evolution of pulmonary hypertension (PH) (mean pulmonary artery pressure ≥25 mm Hg) in adult patients with a subaortic right ventricle (RV) in a biventricular circulation (2V-RV).MethodsWe analysed retrospective data from patients with 2V-RV undergoing cardiac catheterisation in our centre between 2000 and 2018. Echocardiographic assessment of subpulmonary ventricular pressures (left ventricular systolic pressure (LVSP)), age and B-type natriuretic peptide (BNP) were assessed as PH screening tools. Kaplan-Meier curves examined time to a composite outcome of death, transplant or ventricular assist device (VAD). Data from repeat catheterisations were analysed to evaluate PH changes over time, including the effects of therapy.ResultsA total of 141 patients (median age 39 (IQR 33–45) years, 68% men) underwent 191 cardiac catheterisations. At baseline, 55% had PH (isolated postcapillary 24%, combined precapillary and postcapillary 26% and precapillary 5%). BNP (area under the curve 0.80; 95% CI 0.72 to 0.88; p<0.0001), but not age at catheterisation or echocardiographic estimates of LVSP were associated with the presence of PH. The absence of PH and BNP <100 pg/mL discriminated a subgroup at very low risk during short-term (2.5 (1.3–3.9) years) follow-up (p<0.0001). Diuretics, milrinone and VAD improved haemodynamics over time.ConclusionPH is prevalent in patients with 2V-RV even when asymptomatic. It is difficult to identify by echocardiography and most importantly, is strongly associated with adverse outcomes. PH affects prognosis and transplant options for this patient group and yet is often amenable to treatment. Awareness of these results ought to lower the threshold for invasive haemodynamic assessment and may change the management of failing patients with 2V-RV.
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11
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Myocardial fibrosis and its relation to adverse outcome in transposition of the great arteries with a systemic right ventricle. Int J Cardiol 2019; 271:60-65. [PMID: 30223379 DOI: 10.1016/j.ijcard.2018.04.089] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Revised: 04/05/2018] [Accepted: 04/20/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND Myocardial dysfunction has been implicated in gradual heart failure in transposition of the great arteries (TGA) with a systemic right ventricle (RV). Fibrosis can be assessed using the extracellular volume fraction (ECV). Our aim was to measure ECV and determine its associations with clinical findings and outcomes. METHODS We prospectively measured ECV in systemic RV subjects (either D-loop after atrial switch or L-loop) and healthy controls. T1 measurements for a single mid-ventricular short-axis plane before and 3, 7, and 15 min after gadolinium contrast were used to quantify systemic ventricular ECV. Individuals with elevated ECV were compared to those without. RESULTS In 53 TGA subjects (age 34.6 ± 10.3 years, 41% female) the mean ECV for the systemic RV (28.7 ± 4.4%) was significantly higher than the left ventricle in 22 controls (26.1 ± 2.8%, P = 0.0104). Those with an elevated ECV (n = 15, 28.3%) had a higher b-type natriuretic peptide (BNP) (P < 0.011) and a longer 6-min walk distance (P = 0.021), but did not differ by age, arrhythmia history, ventricular volume, function, or circulating collagen byproducts. At follow-up (median 4.4 years), those experiencing major cardiovascular endpoints (new arrhythmia, arrhythmia device, heart failure hospitalization, listing for transplantation, mechanical support, or cardiovascular death, n = 14) had a higher ECV. ECV, age, and BNP were independent predictors of cardiac events in Cox-proportional hazard models. CONCLUSIONS Myocardial fibrosis is common in the systemic RV and associated with a higher BNP. Elevated CMR-derived ECV was associated with adverse clinical outcome. The findings suggest a role of diffuse myocardial fibrosis in clinical deterioration of the systemic RV.
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12
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Rajpal S, Alshawabkeh L, Opotowsky AR. Current Role of Blood and Urine Biomarkers in the Clinical Care of Adults with Congenital Heart Disease. Curr Cardiol Rep 2017; 19:50. [DOI: 10.1007/s11886-017-0860-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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13
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Popelová JR, Tomková M, Tomek J. NT-proBNP predicts mortality in adults with transposition of the great arteries late after Mustard or Senning correction. CONGENIT HEART DIS 2017; 12:448-457. [DOI: 10.1111/chd.12466] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 02/18/2017] [Accepted: 03/17/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Jana Rubáčková Popelová
- Department of Cardiac Surgery; Hospital Na Homolce; Prague Czech Republic
- Pediatric Heart Centre, Faculty Hospital Motol; Prague Czech Republic
| | - Markéta Tomková
- Department of Cardiac Surgery; Hospital Na Homolce; Prague Czech Republic
- Nuffield Department of Medicine; University of Oxford; Oxford United Kingdom
| | - Jakub Tomek
- Department of Cardiac Surgery; Hospital Na Homolce; Prague Czech Republic
- Department of Physiology, Anatomy and Genetics; University of Oxford; Oxford United Kingdom
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14
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Hegarova M, Brotanek J, Kubanek M, Kockova R, Franekova J, Lanska V, Netuka I, Melenovsky V, Malek I, Kautzner J. B-type natriuretic peptide: powerful predictor of end-stage chronic heart failure in individuals with systolic dysfunction of the systemic right ventricle. Croat Med J 2017; 57:343-50. [PMID: 27586549 PMCID: PMC5048222 DOI: 10.3325/cmj.2016.57.343] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
AIM To assess whether B-type natriuretic peptide (BNP) can serve as a predictor of end-stage chronic heart failure (CHF) in patients with severe systolic dysfunction of the systemic right ventricle (SRV). METHODS We performed a retrospective analysis in 28 patients with severe systolic dysfunction of the SRV (ejection fraction 23 ± 6%) who were evaluated as heart transplant (HTx) candidates between May 2007 and October 2014. The primary endpoints of the study (end-stage CHF) were progressive CHF, urgent HTx, and ventricular assist device (VAD) implantation. Plasma BNP levels were measured using a chemiluminescent immunoassay. RESULTS During median follow-up of 29 months (interquartile range, 9-50), 3 patients died of progressive CHF, 5 patients required an urgent HTx, and 6 patients underwent VAD implantation. BNP was a strong predictor of end-stage CHF (hazard ratio per 100 ng/L: 1.079, 95% confidence interval, 1.042-1.117, P<0.001). The following variables with corresponding areas under the curve (AUC) were identified as the most significant predictors of end-stage CHF: BNP (AUC 1.00), New York Heart Association functional class class III or IV (AUC 0.98), decompensated CHF in the last year (AUC 0.96), and systolic dysfunction of the subpulmonal ventricle (AUC 0.96). CONCLUSION BNP is a powerful predictor of end-stage CHF in individuals with systolic dysfunction of the SRV.
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Affiliation(s)
| | | | - Milos Kubanek
- Milos Kubanek, Department of Cardiology, Institute for Clinical and Experimental Medicine, Videnska 1958/9, Prague, Czech Republic,
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15
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Baggen VJ, van den Bosch AE, Eindhoven JA, Schut ARW, Cuypers JA, Witsenburg M, de Waart M, van Schaik RH, Zijlstra F, Boersma E, Roos-Hesselink JW. Prognostic Value of N-Terminal Pro-B-Type Natriuretic Peptide, Troponin-T, and Growth-Differentiation Factor 15 in Adult Congenital Heart Disease. Circulation 2017; 135:264-279. [DOI: 10.1161/circulationaha.116.023255] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Accepted: 10/19/2016] [Indexed: 01/06/2023]
Abstract
Background:
The number of patients with adult congenital heart disease (ACHD) is rapidly increasing. To optimize patient management, there is a great need to accurately identify high-risk patients. Still, no biomarker has been firmly established as a clinically useful prognostic tool in this group. We studied the association of N-terminal pro-B-type natriuretic peptide (NT-proBNP), high-sensitive troponin-T, and growth-differentiation factor 15 with cardiovascular events in ACHD.
Methods:
Clinically stable patients with ACHD who routinely visited the outpatient clinic between April 2011 and April 2013 underwent clinical assessment, electrocardiography, echocardiography, and biomarker measurement (NT-proBNP, high-sensitive troponin-T, and growth-differentiation factor 15) at the time of study inclusion. Patients were prospectively followed for the occurrence of cardiovascular events (death, heart failure, hospitalization, arrhythmia, thromboembolic events, and reintervention). Survival curves were derived by the Kaplan-Meier method, and Cox regression was performed to investigate the relation between biomarkers and events with adjustment for multiple clinical and echocardiographic variables.
Results:
In total, 595 patients were included (median age, 33 years; interquartile range, 25–41 years; 58% male; 90% New York Heart Association class I). Patients were followed during a median of 42 (interquartile range, 37–46) months. Of the 3 evaluated biomarkers, NT-proBNP in the upper quartile (>33.3 pmol/L) was most strongly associated with cardiovascular events (n=165, adjusted hazard ratio, 9.05 [3.24–25.3],
P
<0.001) and with death or heart failure (n=50, adjusted hazard ratio, 16.0 [2.04–126],
P
<0.001). When NT-proBNP was analyzed as a continuous variable, similar findings were retrieved. The cumulative proportion of patients with death and heart failure was only 1% in the lowest 2 NT-proBNP quartiles. Elevated NT-proBNP (>14 pmol/L), elevated high-sensitive troponin-T (>14 ng/L), and elevated growth-differentiation factor 15 (>1109 ng/L) identified those patients at highest risk of cardiovascular events (log-rank
P
<0.0001).
Conclusions:
NT-proBNP provides prognostic information beyond a conventional risk marker model in patients with ACHD and can reliably exclude the risk of death and heart failure. Elevated levels of NT-proBNP, high-sensitive troponin-T, and growth-differentiation factor 15 identify patients at highest risk of cardiovascular events. These biomarkers therefore may play an important role in the monitoring and management of patients with ACHD.
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Affiliation(s)
- Vivan J.M. Baggen
- From Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands (V.J.M.B., A.E.v.d.B., J.A.E., A.-R.W.S., J.A.A.E.C., M.W., F.Z., E.B., J.W.R.-H.); Cardiovascular Research School COEUR, Rotterdam, the Netherlands (V.J.M.B., J.A.E., E.B.); Department of Clinical Chemistry, Erasmus Medical Center, Rotterdam, the Netherlands (M.d.W., R.H.N.v.S.); and Department of Clinical Epidemiology, Erasmus Medical Center, Rotterdam, the Netherlands (E.B.)
| | - Annemien E. van den Bosch
- From Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands (V.J.M.B., A.E.v.d.B., J.A.E., A.-R.W.S., J.A.A.E.C., M.W., F.Z., E.B., J.W.R.-H.); Cardiovascular Research School COEUR, Rotterdam, the Netherlands (V.J.M.B., J.A.E., E.B.); Department of Clinical Chemistry, Erasmus Medical Center, Rotterdam, the Netherlands (M.d.W., R.H.N.v.S.); and Department of Clinical Epidemiology, Erasmus Medical Center, Rotterdam, the Netherlands (E.B.)
| | - Jannet A. Eindhoven
- From Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands (V.J.M.B., A.E.v.d.B., J.A.E., A.-R.W.S., J.A.A.E.C., M.W., F.Z., E.B., J.W.R.-H.); Cardiovascular Research School COEUR, Rotterdam, the Netherlands (V.J.M.B., J.A.E., E.B.); Department of Clinical Chemistry, Erasmus Medical Center, Rotterdam, the Netherlands (M.d.W., R.H.N.v.S.); and Department of Clinical Epidemiology, Erasmus Medical Center, Rotterdam, the Netherlands (E.B.)
| | - Anne-Rose W. Schut
- From Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands (V.J.M.B., A.E.v.d.B., J.A.E., A.-R.W.S., J.A.A.E.C., M.W., F.Z., E.B., J.W.R.-H.); Cardiovascular Research School COEUR, Rotterdam, the Netherlands (V.J.M.B., J.A.E., E.B.); Department of Clinical Chemistry, Erasmus Medical Center, Rotterdam, the Netherlands (M.d.W., R.H.N.v.S.); and Department of Clinical Epidemiology, Erasmus Medical Center, Rotterdam, the Netherlands (E.B.)
| | - Judith A.A.E. Cuypers
- From Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands (V.J.M.B., A.E.v.d.B., J.A.E., A.-R.W.S., J.A.A.E.C., M.W., F.Z., E.B., J.W.R.-H.); Cardiovascular Research School COEUR, Rotterdam, the Netherlands (V.J.M.B., J.A.E., E.B.); Department of Clinical Chemistry, Erasmus Medical Center, Rotterdam, the Netherlands (M.d.W., R.H.N.v.S.); and Department of Clinical Epidemiology, Erasmus Medical Center, Rotterdam, the Netherlands (E.B.)
| | - Maarten Witsenburg
- From Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands (V.J.M.B., A.E.v.d.B., J.A.E., A.-R.W.S., J.A.A.E.C., M.W., F.Z., E.B., J.W.R.-H.); Cardiovascular Research School COEUR, Rotterdam, the Netherlands (V.J.M.B., J.A.E., E.B.); Department of Clinical Chemistry, Erasmus Medical Center, Rotterdam, the Netherlands (M.d.W., R.H.N.v.S.); and Department of Clinical Epidemiology, Erasmus Medical Center, Rotterdam, the Netherlands (E.B.)
| | - Monique de Waart
- From Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands (V.J.M.B., A.E.v.d.B., J.A.E., A.-R.W.S., J.A.A.E.C., M.W., F.Z., E.B., J.W.R.-H.); Cardiovascular Research School COEUR, Rotterdam, the Netherlands (V.J.M.B., J.A.E., E.B.); Department of Clinical Chemistry, Erasmus Medical Center, Rotterdam, the Netherlands (M.d.W., R.H.N.v.S.); and Department of Clinical Epidemiology, Erasmus Medical Center, Rotterdam, the Netherlands (E.B.)
| | - Ron H.N. van Schaik
- From Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands (V.J.M.B., A.E.v.d.B., J.A.E., A.-R.W.S., J.A.A.E.C., M.W., F.Z., E.B., J.W.R.-H.); Cardiovascular Research School COEUR, Rotterdam, the Netherlands (V.J.M.B., J.A.E., E.B.); Department of Clinical Chemistry, Erasmus Medical Center, Rotterdam, the Netherlands (M.d.W., R.H.N.v.S.); and Department of Clinical Epidemiology, Erasmus Medical Center, Rotterdam, the Netherlands (E.B.)
| | - Felix Zijlstra
- From Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands (V.J.M.B., A.E.v.d.B., J.A.E., A.-R.W.S., J.A.A.E.C., M.W., F.Z., E.B., J.W.R.-H.); Cardiovascular Research School COEUR, Rotterdam, the Netherlands (V.J.M.B., J.A.E., E.B.); Department of Clinical Chemistry, Erasmus Medical Center, Rotterdam, the Netherlands (M.d.W., R.H.N.v.S.); and Department of Clinical Epidemiology, Erasmus Medical Center, Rotterdam, the Netherlands (E.B.)
| | - Eric Boersma
- From Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands (V.J.M.B., A.E.v.d.B., J.A.E., A.-R.W.S., J.A.A.E.C., M.W., F.Z., E.B., J.W.R.-H.); Cardiovascular Research School COEUR, Rotterdam, the Netherlands (V.J.M.B., J.A.E., E.B.); Department of Clinical Chemistry, Erasmus Medical Center, Rotterdam, the Netherlands (M.d.W., R.H.N.v.S.); and Department of Clinical Epidemiology, Erasmus Medical Center, Rotterdam, the Netherlands (E.B.)
| | - Jolien W. Roos-Hesselink
- From Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands (V.J.M.B., A.E.v.d.B., J.A.E., A.-R.W.S., J.A.A.E.C., M.W., F.Z., E.B., J.W.R.-H.); Cardiovascular Research School COEUR, Rotterdam, the Netherlands (V.J.M.B., J.A.E., E.B.); Department of Clinical Chemistry, Erasmus Medical Center, Rotterdam, the Netherlands (M.d.W., R.H.N.v.S.); and Department of Clinical Epidemiology, Erasmus Medical Center, Rotterdam, the Netherlands (E.B.)
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