Glenn shunt as a rescue strategy for acute right ventricular failure after right ventricular myocardial infarction

We present the case of a 52-year-old woman with cardiogenic shock and refractory right ventricular failure due to spontaneous dissection of the right coronary artery. She remained dependent on mechanical support for several weeks. Both a right ventricular assist device implant and a bidirectional cavopulmonary anastomosis were explored as long-term support options. A history of malignancy and possible right ventricular functional recovery resulted in a decision in favour of the bidirectional cavopulmonary anastomosis and concomitant tricuspid valve annuloplasty. Postoperatively her clinical condition improved significantly, and she could be discharged home. Echocardiography showed normalization of right ventricular dimensions and slight improvement of right ventricular function.

Effect of Sodium-Glucose Cotransporter 2 Inhibitors in Adults With Congenital Heart Disease

BACKGROUND

Heart failure (HF) is the principal cause of morbidity and mortality in adults with congenital heart disease (ACHD). Robust evidence-based treatment options are lacking.

OBJECTIVES

This study aims to evaluate the safety, tolerability, and short-term HF-related effects of sodium-glucose cotransporter 2 inhibitors (SGLT2i) in a real-world ACHD population.

METHODS

All patients with ACHD treated with SGLT2i in 4 European ACHD centers were included in this retrospective study. Data were collected from 1 year before starting SGLT2i to the most recent follow-up. Data on side effects, discontinuation, mortality, and hospitalizations were collected.

RESULTS

In total, 174 patients with ACHD were treated with SGLT2i from April 2016 to July 2023. The mean age was 48.7 ± 15.3 years, 72 (41.4%) were female, and 29 (16.7%) had type 2 diabetes mellitus. Ten (5.7%) patients had mild, 75 (43.1%) moderate, and 89 (51.1%) severe congenital heart disease. HF was the most frequent starting indication (n = 162, 93.1%), followed by type 2 diabetes (n = 11, 6.3%) and chronic kidney disease (n = 1, 0.6%). At median follow-up of 7.7 months (Q1-Q3: 3.9-13.2 months), 18 patients (10.3%) reported side effects, 12 (6.9%) permanently discontinued SGLT2i, and 4 (2.3%) died of SGLT2i-unrelated causes. A significant reduction in the HF hospitalization rate was observed from 6 months before to 6 months after starting SGLT2i (relative rate = 0.30; 95% CI: 0.14-0.62; P = 0.001).

CONCLUSIONS

SGLT2i generally seem safe, well-tolerated, and potentially beneficial in patients with ACHD. SGLT2i was associated with a 3-fold reduction in the 6-month HF hospitalization rate. These results warrant prospective randomized investigation of the potential benefits of SGLT2i for patients with ACHD.

The Potential of the HeartLogicTM Algorithm in Patients with a Left Ventricular Assist Device, an Initial Report

BACKGROUND

Survival and quality-of-life of left ventricular assist device (LVAD) recipients improved significantly because of growing experience and technological advances. However, LVAD-related complication rates, including recurrent episodes of congestion, remain high. Early detection of fluid retention to provide a time-window for medical intervention is the pillar in preventing hospitalizations. The multisensory HeartLogicTM algorithm accurately detected impending congestion in ambulant heart failure patients. The aim of the current study is to investigate the feasibility of HeartLogicTM-driven care in LVAD patients.

METHODS

Consecutive LVAD destination therapy patients were followed-up according the structured HeartLogicTM-based heart failure carepath. An alert triggered a device check-up, and the heart failure team contacted the patient to evaluate for signs and symptoms of impending congestion. An alert was adjudicated as true positive or unexplained. An episode of congestion not preceded by an alert was deemed as a false negative.

RESULTS

Data from 7 patients were included: the median age was 67 years [IQR 61-71], 71% were male and 71% had a non-ischemic aetiology. Total follow-up entailed 12 patient-years. All patients experienced at least one alert. In total, 33 alerts were observed. Majority of alerts (70%, n = 23) were driven by congestion and one alerts (15%) were clinically meaningful but not primarily fluid-retention-related (e.g., altered hemodynamic triggered by a pump thrombosis). Of all the alerts, five (15%) were classified as an unexplained alert, and during follow-up, four false negative episodes were documented.

CONCLUSIONS

HeartLogicTM-driven care with continuous monitoring to detect impending fluid retention in LVAD patients was feasible and deserves further prospective validation.

Fewer Worsening Heart Failure Events With HeartLogic on top of Standard Care: a Propensity-Matched Cohort Analysis

BACKGROUND

The implantable cardiac defibrillator-based HeartLogic algorithm aims to detect impending fluid retention in patients with heart failure (HF). Studies show that HeartLogic is safe to integrate into clinical practice. The current study investigates whether HeartLogic provides clinical benefit on top of standard care and device telemonitoring in patients with HF.

METHODS

A multicenter, retrospective, propensity-matched cohort analysis was performed in patients with HF and implantable cardiac defibrillators, and it compared HeartLogic to conventional telemonitoring. The primary endpoint was the number of worsening HF events. Hospitalizations and ambulatory visits due to HF were also evaluated.

RESULTS

Propensity score matching yielded 127 pairs (median age 68 years, 80% male). Worsening HF events occurred more frequently in the control group (2; IQR 0-4) compared to the HeartLogic group (1; IQR 0-3; P = 0.004). The number of HF hospitalization days was higher in controls than in the HeartLogic group (8; IQR 5-12 vs 5; IQR 2-7; P = 0.023), and ambulatory visits for diuretic escalation were more frequent in the control group than in the HeartLogic group (2; IQR 0-3 vs 1; IQR 0-2; P = 0.0001).

CONCLUSION

Integrating the HeartLogic algorithm in a well-equipped HF care path on top of standard care is associated with fewer worsening HF events and shorter duration of fluid retention-related hospitalizations.

Tolerability and beneficial effects of sacubitril/valsartan on systemic right ventricular failure

OBJECTIVE

Patients with a systemic right ventricle (sRV) in the context of transposition of the great arteries (TGA) after atrial switch or congenitally corrected TGA (ccTGA) are prone to sRV dysfunction. Pharmacological options for sRV failure remain poorly defined. This study aims to investigate the tolerability and effects of sacubitril/valsartan on sRV failure in adult patients with sRV.

METHODS

In this two-centre, prospective cohort study, all consecutive adult patients with symptomatic heart failure and at least moderately reduced sRV systolic function were initiated on sacubitril/valsartan and underwent structured follow-up.

RESULTS

Data of 40 patients were included (40% female, 30% ccTGA, median age 48 (44-53) years). Five patients discontinued therapy during titration. Median follow-up was 24 (12-36) months. The maximal dose was tolerated by 49% of patients. No episodes of hyperkalaemia or renal function decline occurred. Six-minute walking distance increased significantly after 6 months of treatment (569±16 to 597±16 m, p=0.016). Serum N-terminal-prohormone brain natriuretic peptide (NT-proBNP) levels decreased significantly after 3 months (567 (374-1134) to 404 (226-633) ng/L, p<0.001). Small, yet consistent echocardiographic improvements in sRV function were observed after 6 months (sRV global longitudinal strain: -11.1±0.5% to -12.6±0.7%, p<0.001, and fractional area change: 20% (16%-24%) to 26% (19%-30%), p<0.001). The linear mixed-effects model illustrated that after first follow-up moment, no time effect was present for the parameters.

CONCLUSIONS

Treatment with sacubitril/valsartan was associated with a low rate of adverse effects in this adult sRV cohort. Persisting improvement in 6-minute walking test distance, NT-proBNP levels and echocardiographic parameters of sRV function was observed in an on-treatment analysis and showed no differential response based on sex or anatomy.

One-Year Mortality in Patients Undergoing an Implantable Cardioverter Defibrillator or Cardiac Resynchronization Therapy Pulse Generator Replacement: Identifying Patients at Risk

Implantable cardioverter defibrillators (ICDs) significantly contribute to the prevention of sudden cardiac death in selected patients. However, it is essential to identify those who are likely to not have benefit from an ICD and to defer a pulse generator exchange. Easily implementable guidelines for individual risk stratification and decision making are lacking. This study investigates the 1-year mortality of patients who underwent an ICD or cardiac resynchronization therapy with defibrillator function (CRT-D) pulse generator replacement in a contemporary real-world tertiary hospital setting. The cause of death and patient- and procedure-related factors are stratified, and predictive values for 1-year mortality are evaluated. Patients with a follow-up of ≥365 days (or prior mortality) after an ICD or CRT-D exchange at the Leiden University Medical Center from 1 January 2018 until 31 December 2021 were eligible. In total, 588 patients were included (77% male, 69 [60-76] years old, 59% primary prevention, 46% ischemic cardiomyopathy and 37% mildly reduced left ventricular ejection fraction (LVEF)). Patients undergoing a CRT-D replacement or upgrade had a significantly higher 1-year all-cause mortality (10.7% and 11.9%, respectively) compared to patients undergoing ICD (2.8%) exchange (p = 0.002). LVEF ≤ 30%, New York Heart Association class ≥ 3, estimated glomerular filtration rate ≤ 30 mL/min/m2 and haemoglobin ≤ 7 mmol/L were independently associated with mortality within 1 year after pulse generator replacement. There is a growing need for prospectively validated risk scores to weight individualized risk of mortality with the expected ICD therapy benefit and to support a well-informed, shared decision-making process.

Catheter-Based Techniques for Addressing Atrioventricular Valve Regurgitation in Adult Congenital Heart Disease Patients: A Descriptive Cohort

INTRODUCTION

Increasing survival of adult congenital heart disease (ACHD) patients comes at the price of a range of late complications-arrhythmias, heart failure, and valvular dysfunction. Transcatheter valve interventions have become a legitimate alternative to conventional surgical treatment in selected acquired heart disease patients. However, literature on technical aspects, hemodynamic effects, and clinical outcomes of percutaneous atrioventricular (AV) valve interventions in ACHD patients is scarce.

METHOD

This is a descriptive cohort from CAHAL (Center of Congenital Heart Disease Amsterdam-Leiden). ACHD patients with severe AV valve regurgitation who underwent a transcatheter intervention in the period 2020-2022 were included. Demographic, clinical, procedural, and follow-up data were collected from patient records.

RESULTS

Five ACHD patients with severe or torrential AV valve regurgitation are described. Two patients underwent a transcatheter edge-to-edge repair (TEER), one patient underwent a valve-in-valve procedure, one patient received a Cardioband system, and one patient received both a Cardioband system and TEER. No periprocedural complications occurred. Post-procedural AV valve regurgitation as well as NYHA functional class improved in all patients. The median post-procedural NYHA functional class improved from 3.0 (IQR [2.5-4.0]) to 2.0 (IQR [1.5-2.5]). One patient died 9 months after the procedure due to advanced heart failure with multiorgan dysfunction.

CONCLUSION

Transcatheter valve repair is feasible and safe in selected complex ACHD patients. A dedicated heart team is essential for determining an individualized treatment strategy as well as pre- and periprocedural imaging to address the underlying mechanism(s) of AV regurgitation and guide the transcatheter intervention. Long-term follow-up is essential to evaluate the clinical outcomes of transcatheter AV valve repair in ACHD patients.

The potential of sodium-glucose cotransporter 2 inhibitors for the treatment of systemic right ventricular failure in adults with congenital heart disease

Aims

Given the compelling evidence on the effectiveness of sodium-glucose cotransporter 2 inhibitors (SGLT2i) in the conventional heart failure population, SGLT2i deserve exploration in systemic right ventricular (sRV) failure. The initial experience with dapagliflozin in sRV failure patients is described, with a focus on tolerability and short-term effects on clinical outcomes.

Methods and results

Ten patients (70% female, median age 50 years [46.5-52]) with symptomatic sRV failure who received dapagliflozin 10 mg per day on top of optimal medical therapy between 04-2021 and 01-2023 were included. Within 4 weeks, no significant changes in blood pressure, electrolytes, or serum glucose occurred. Creatinine and estimated glomerular filtration rate (eGFR) showed a slight decline (88 ± 17 to 97 ± 23 µmol/L, p = 0.036, and 72 ± 14 vs. 66 ± 16 ml/min/1.73m2, p = 0.020, respectively). At 6 months follow-up (n = 8), median NT-proBNP decreased significantly from 736.6 [589.3-1193.3] to 531.6 [400.8-1018] ng/L (p = 0.012). Creatinine and eGFR recovered to baseline levels. There were no significant changes in echocardiographic systolic sRV or left ventricular function. New York Heart Association class improved significantly in 4 out of 8 patients (p = 0.046), who also showed an improvement in the 6-minute walk test or bicycle exercise test performance. One female patient developed an uncomplicated urinary tract infection. No patients discontinued treatment.

Conclusion

Dapagliflozin was well-tolerated in this small cohort of sRV failure patients. While the early results on the reduction of NT-proBNP and clinical outcome parameters are encouraging, large-scale prospective studies are warranted to thoroughly evaluate the effects of SGLT2i in the growing sRV failure population.

Anomalous Aortic Origin of the Right Coronary Artery: Invasive Haemodynamic Assessment in Adult Patients With High-Risk Anatomic Features

Background

Anomalous aortic origin of a right coronary artery (AAORCA) with an interarterial course merits further evaluation; however, robust risk assessment strategies for myocardial ischemia and sudden cardiac death are currently lacking. The aim of this study is to explore the potential role of fractional flow reserve (FFR), instantaneous wave-free ratio (iFR), and intravascular ultrasound (IVUS) in patients with AAORCA.

Methods

Consecutive adult patients with AAORCA with an interarterial course were included. Computed tomography angiography, noninvasive ischemia detection, and FFR, iFR, and IVUS were performed at baseline and during adrenaline-induced stress. External compression was evaluated with IVUS.

Results

Eight patients (63% female, mean age: 53 ± 9.5 years) were included. Five patients (63%) were symptomatic, and computed tomography angiography revealed high-risk anatomy of the AAORCA in all patients. Only in 1 (12.5%) patient FFR and iFR were positive; however, this was attributed at large to concomitant diffuse atherosclerosis. In 2 of 8 (25%), IVUS revealed external compression; however, the ostial coronary surface area remained unchanged. In all patients, a conservative treatment strategy was pursued. During a mean follow-up of 29.3 months (standard deviation ±2.6 months), symptoms spontaneously disappeared in 4 of 5 (80%) and no adverse cardiac events occurred in any of the patients.

Conclusions

Despite the presence of high-risk anatomy in all patients, none had proven ischemia prompting a conservative treatment strategy. No adverse cardiac events occurred during follow-up, and in the majority of patients, symptoms spontaneously disappeared. Therefore, FFR, iFR, and IVUS with pharmacologic stress merit further investigation and might contribute to ischemia-based risk stratification and management strategies in adult patients with AAORCA.

[Difficult case of differential diagnosis of partial lung atelectasis. Case report]

In December 2018 the patient over 60 years old sought medical help with complaints of persistent cough. Based on computed tomography data there were identified the sings (symptoms) of right lung lower lobe atelectasis. To run this patient diagnostics there were performed 6 bronchoscopies narrowed down by bronchi checks up only and described the right lung central cancer picture. At the same time the biopsy taken during one of the bronchoscopies appeared non informative. Fine needle biopsy of mediastinal lymph nodes and bronchial wall was performed twice: at Tomsk Cancer Research Institute (it was suspected B-cell lymphoma based on biopsy examination) and at The Loginov Moscow Clinical Scientific Center (signs of inflammation based on biopsy examination). The video-assisted thoracoscopy with lymph node dissection of the right lung root was performed in January 2020. As a surgical material analysis result reactive adenopathy was determined. Therefore, during more than 1 year of diagnostic research the genesis of right lung lower lobe atelectasis was not established. The patient was directed to Central Tuberculosis Research Institute for diagnosis verification. Based on clinical and radiological picture Central Tuberculosis Research Institute colleagues suspected a foreign body in the intermediate bronchus. During an endoscopic examination it was revealed stenosis, biopsies were performed, but the foreign body could not be identified. In the pathomorphological laboratory of Central Tuberculosis Research Institute there were conducted histological examination of the material after endobronchial cryobiopsy and rigid needle biopsy. Both gave an unexpected result: invasive mycosis of the bronchial wall. As a conclusion the decision was taken to apply antimycotic therapy on an outpatient basis. As a result, clear clinical and radiological positive dynamics was obtained. In these favorable conditions for endoscopic examination, it was performed vitally essential cryoextraction of foreign body. The foreign body turned out to be a fragment of a spongy bone of a centimeter size. These actions have let to unlock the right lung lower lobe.

Cardiac Fibrosis and Innervation State in Uncorrected and Corrected Transposition of the Great Arteries: A Postmortem Histological Analysis and Systematic Review

In the transposition of the great arteries (TGA), alterations in hemodynamics and oxygen saturation could result in fibrotic remodeling, but histological studies are scarce. We aimed to investigate fibrosis and innervation state in the full spectrum of TGA and correlate findings to clinical literature. Twenty-two human postmortem TGA hearts, including TGA without surgical correction (n = 8), after Mustard/Senning (n = 6), and arterial switch operation (ASO, n = 8), were studied. In newborn uncorrected TGA specimens (1 day-1.5 months), significantly more interstitial fibrosis (8.6% ± 3.0) was observed compared to control hearts (5.4% ± 0.8, p = 0.016). After the Mustard/Senning procedure, the amount of interstitial fibrosis was significantly higher (19.8% ± 5.1, p = 0.002), remarkably more in the subpulmonary left ventricle (LV) than in the systemic right ventricle (RV). In TGA-ASO, an increased amount of fibrosis was found in one adult specimen. The amount of innervation was diminished from 3 days after ASO (0.034% ± 0.017) compared to uncorrected TGA (0.082% ± 0.026, p = 0.036). In conclusion, in these selected postmortem TGA specimens, diffuse interstitial fibrosis was already present in newborn hearts, suggesting that altered oxygen saturations may already impact myocardial structure in the fetal phase. TGA-Mustard/Senning specimens showed diffuse myocardial fibrosis in the systemic RV and, remarkably, in the LV. Post-ASO, decreased uptake of nerve staining was observed, implicating (partial) myocardial denervation after ASO.

Genetic variant in the BRAF gene compatible with Noonan spectrum disorders in an adult Fontan patient with refractory protein losing enteropathy: a follow-up report

Background

Patients with a univentricular heart form a morphological heterogenous group of patients at the most severe end of the congenital heart disease (CHD) spectrum. Over the past decades, more awareness and knowledge has been raised on the genetic contributions to CHD. To date, only a limited number of genes have been identified in the hypoplastic heart, mainly in left-sided hypoplasia. There is still much more to be elucidated in this field.

Case summary

Here, we present a follow-up report of a case of an adult patient after Fontan palliation, born with a.o. tricuspid atresia with hypoplastic right ventricle and pulmonary stenosis. This patient encountered a myriad of late sequalae involving multiple organ systems during the course of his young adult life, including refractory protein losing enteropathy (PLE). Concomitant extracardiac anomalies, in addition to the complex CHD and its complications, prompted for genetic evaluation. Whole exome sequencing showed a variant of uncertain significance in the BRAF gene [NM_004333.4:c.1897T > C p.(Tyr633His)], associated with Noonan spectrum disorders, that is also infamous for lymphoedema and PLE. The variant regards an evolutionarily highly conserved amino acid and is assumed pathogenic according to all prediction programmes. The mutation was most likely de novo.

Discussion

Genetic screening can provide new insights in the complex and varied phenotype of the (adult) Fontan patient and in the myriad of complications encountered. Adult CHD cardiologists should be aware of genetic syndromes underlying a CHD, concomitant extracardiac anomalies, and a complex clinical course with a broad spectrum of late sequelae.

Contemporary Management Strategies of Baffle Leaks in Adults with a Failing Systemic Right Ventricle Late after Atrial Switch: A Case Series and Literature Overview

Baffle leaks are a frequently encountered and often overlooked complication after the atrial switch procedure for transposition of the great arteries. Baffle leaks are present in up to 50% of non-selected patients, and while they initially may not cause clear symptoms, they can complicate the hemodynamic course and influence the prognosis in this complex patient group. A shunt from the pulmonary venous atrium (PVA) to the systemic venous atrium (SVA) can lead to pulmonary overflow and subpulmonary left ventricular (LV) volume overload, while a shunt from the SVA to the PVA can result in (exercise-associated) cyanosis and paradoxical embolism. We report three cases of baffle leaks in patients with systemic right ventricular (sRV) failure late after the atrial switch procedure. Two symptomatic patients who presented with exercise-associated cyanosis due to SVA to PVA shunting over the baffle leak underwent successful percutaneous baffle leak closure with a septal occluder device. One patient with overt sRV failure and signs of subpulmonary LV volume overload due to PVA to SVA shunting was managed conservatively, as baffle leak closure was expected to lead to an increase in sRV end-diastolic pressure and aggravation of sRV dysfunction. These three cases illustrate the considerations made, challenges faced, and necessity of a patient-tailored approach when addressing baffle leaks.

The development of a decision aid for shared decision making in the Dutch implantable cardioverter defibrillator patient population: A novel approach to patient education

Background

Counseling of Implantable Cardioverter-defibrillator (ICD) patients with regard to individual risks and benefits is challenging. An evidence-based decision aid tailored to the needs of Dutch ICD patients is not yet available. The objective of this pilot project was to structurally evaluate the current clinical practice in The Netherlands and the ICD patient experience, in order to develop an online decision aid to facilitate shared decision making in ICD procedures.

Methods

Between June 2016 and December 2017, a Dutch web-based decision aid was developed according to the Patient Decision Aid Standards (IPDAS) using the RAND-UCLA/multi-stepped Delphi model. Development process consisted of 5 stages in which the Dutch clinical practice was reviewed (stage 1), patients’ needs and their history of decision making was structurally assessed (stages 2A and B) and a modified Delphi consensus process was performed with an expert panel consisting of representatives from different medical fields (stage 3). Results from stages 1–3 were used to design and structure the content of an online-based decision aid (stage 4) which was finally evaluated in a usability testing by patients in stage 5.

Results and conclusion

This study describes the evidence-based approach to the development of the Dutch ICD decision aid. In our population, levels of shared decision-making experience were low. The ICD decision aid was structurally developed for the Dutch ICD patient population. Our upcoming multicenter stepped wedge clustered randomized trial will further evaluate the ICD decision aid in clinical practice.

A novel method to identify an intramural segment in interarterial anomalous coronary arteries on CT-angiography

Background/Introduction

An anomalous coronary artery originating from the opposite sinus of Valsalva (ACAOS) with an interarterial course can be assessed using Computed Tomography Angiography (CTA) for the presence of high-risk characteristics associated with sudden cardiac death. These features include a slit-like ostium, acute angle take-off, and degree of proximal luminal narrowing. However, no robust CTA criteria currently exist to determine the presence of an intramural segment.

Purpose

The aim of this study is to deduct a method to accurately identify an intramural course of interarterial ACAOS on CTA imaging.

Methods

All consecutive adult patients with an interarterial ACAOS that were evaluated at the two academic hospitals between January 2010 and July 2019 were screened for inclusion. Inclusion criteria were availability of a preoperative CTA-scan (0.5–1mm slice-thickness) and peroperative confirmation of the intramural segment. Using multiplanar reconstruction of the CTA, the distance between the lumen of the aorta and the lumen of the ACAOS (defined as “interluminal space” (ILS)) was assessed at 2mm intervals along the intramural segment (Figure 1).

Results

Twenty-five patients (64% female, mean age 46 years, 88% right ACAOS) were included. Analysis showed a mean ILS of 0.69mm±0.15mm at 2mm from the ostium. At the end of the intramural segment where the ACAOS becomes non-intramural, the mean ILS was significantly larger (1.27±0.29mm, p&lt;0.001) (Figure 2). Interobserver agreement evaluation showed good reproducibility of ILS (intraclass correlation coefficient 0.77, p&lt;0.001). ROC-analysis demonstrated that at a cut-off ILS of ≤0.95mm, an intramural segment can be diagnosed with 100% sensitivity and 84% specificity.

Conclusion(s)

The ILS is introduced as novel and robust CTA parameter to identify an intramural course of interarterial ACAOS. An ILS of ≤0.95mm is indicative of an intramural segment with 100% sensitivity and 84% specificity.

Funding Acknowledgement

Type of funding sources: None.

Activation of the HeartLogic algorithm on top of heart failure care: a multicenter propensity-matched cohort analysis

Background

Hospitalization for decompensated heart failure may be prevented by early detection of fluid retention. The multisensory HeartLogic™ algorithm, incorporated in a cardiac implantable electronic device (CIED) aims to detect impending fluid retention and thereby enables timely adjustment of medical therapy. However, it is to be investigated whether HeartLogic™ provides clinical benefit compared to heart failure care with conventional telemonitoring. This analysis investigates the effects of activating HeartLogic™ on top of heart failure care with telemonitoring on the number of episodes with fluid retention and heart failure related hospitalizations.

Methods

Heart failure patients with a CIED were recruited from the outpatient clinics of four European cardiology departments. All patients were included from January 2017 until December 2020, and followed-up for 365 days. Patients with a CIED and an activated HeartLogic™ algorithm were compared to a 1:1 propensity score-based matched control group consisting of patients with CIED on routine telemonitoring. Data of all episodes of (impending) fluid retention with ≥2 signs and symptoms of congestion were included for analyses.

Results

Data of 127 patients with an activated HeartLogic™ algorithm were adequately matched with 127 heart failure patients with a CIED on routine telemonitoring. Median age was 68 [59–75], majority of patients were male (80%), 46% had an ischemic etiology of heart failure. Total follow-up consisted of 254 patient years. During follow up, 77 (61%) individual patients with HeartLogic™ experienced an episode of fluid retention, compared to 85 (67%) induvial patients on routine telemonitoring. Patients with an activated HeartLogic™ algorithm had 1.62±1.78 events of fluid retention per patient year (PPY) compared to 2.61±3.71 events PPY in patients on routine telemonitoring, p&lt;0.01 (Figure 1). Hospitalization for fluid retention occurred in 7 (6%) HeartLogic™ patients (0.06±0.27 hospitalizations PPY) compared to 13 (10%) patients on routine telemonitoring (0.15±0.45 PPY), p=0.07 (Figure 2A). Mean length of hospitalization in days PPY was 0.29±1.46 in patients with HeartLogic™ and 1.59±6.30 in patients on routine telemonitoring, p=0.02 (Figure 2B).

Conclusion

In a real-world multicenter heart failure population, activation of the HeartLogic™ algorithm was associated with a lower number of episodes of fluid retention per patient and a shorter duration of hospitalization for congestive heart failure.

Funding Acknowledgement

Type of funding sources: None.

A comprehensive analysis of the intramural segment in interarterial anomalous coronary arteries using computed tomography angiography

Aims

An anomalous coronary artery originating from the opposite sinus of Valsalva (ACAOS) with an interarterial course can be assessed using computed tomography angiography (CTA) for the presence of high-risk characteristics associated with sudden cardiac death. These features include a slit-like ostium, acute angle take-off, proximal luminal narrowing, and an intramural segment. To date, no robust CTA criteria exist to determine the presence of an intramural segment. We aimed to deduct new CTA parameters to distinguish an intramural course of interarterial ACAOS.

Methods and results

Twenty-five patients with an interarterial ACAOS (64% female, mean age 46 years, 88% right ACAOS) from two academic hospitals were evaluated. Inclusion criteria were the availability of a preoperative CTA scan (0.51 mm slice thickness) and peroperative confirmation of the intramural segment. Using multiplanar reconstruction of the CTA, the distance between the lumen of the aorta and the lumen of the ACAOS [defined as ‘interluminal space’ (ILS)] was assessed at 2 mm intervals along the intramural segment. Analysis showed a mean ILS of 0.69 ± 0.15 mm at 2 mm from the ostium. At the end of the intramural segment where the ACAOS becomes non-intramural, the mean ILS was significantly larger (1.27 ± 0.29 mm, P &lt; 0.001). Interobserver agreement evaluation showed good reproducibility (intraclass correlation coefficient 0.77, P &lt; 0.001). Receiver operator characteristic analysis demonstrated that at a cut-off ILS of &lt;0.95 mm, an intramural segment can be diagnosed with 100% sensitivity and 84% specificity.

Conclusion

The ILS is introduced as a novel and robust CTA parameter to identify an intramural course of interarterial ACAOS. An ILS of &lt;0.95 mm is indicative of an intramural segment.

Non-invasive identification of slow conducting anatomical isthmuses in patients with tetralogy of Fallot by 3D late gadolinium enhancement cardiovascular magnetic resonance

Funding Acknowledgements

Type of funding sources: None.

Background

Patients with repaired tetralogy of Fallot (rTOF) remain at risk of sudden cardiac death due to reentrant sustained monomorphic ventricular tachycardia (SMVT). Slow conducting anatomical isthmuses (SCAI), in particular SCAI3 at the outlet septum, bordered by the pulmonary annulus and the ventricular septal defect patch, are the dominant substrate for SMVT. Electroanatomical mapping (EAM) is the invasive gold standard to identify SCAIs, and transection of SCAI by catheter ablation has been correlated with favorable long-term outcome. Non-invasive identification of SCAI for risk stratification and treatment planning is needed but has not been established yet. Three-dimensional (3D) late gadolinium-enhanced (LGE) cardiovascular magnetic resonance (CMR) facilitates accurate visualization of morphologically complex hearts with high-spatial resolution.

Objective

The study thought to determine whether 3D LGE-CMR can identify SCAIs.

Methods

Consecutive patients with rTOF who underwent right ventricular (RV) EAM and 3D LGE-CMR were included. LGE-CMR-derived 3D RV reconstructions were created (ADAS-3D) and merged with 3D RV EAM data. Mapping points were superimposed on the CMR-derived 3D reconstruction allowing for direct comparison of EAM data and local signal intensity (SI). The optimal SI cut-off to identify low bipolar voltage (LBV, BV&lt;1.76mV) was determined by receiver operating characteristic carve. An abnormal AI on LGE-CMR was defined as AI with continuous SI above the obtained cut-off connecting AI borders.

Results

Forty-eight rTOF patients (34±16 years, 58% male) were included. At EAM, 21 patients had normal AI, and 20 and 7 had a SCAI (&lt;0.5m/s) or blocked AI, which was AI3 in all. Patients with SCAI showed low BV of AI3 (median 0.7 [range 0.25-2.59] mV). In 11 patients, 14 SMVTs could be induced, all related to SCAI3.

A total of 9240 points were analyzed, showing a significant correlation between BV and SI (R=0.4, P&lt;0.001). The optimal SI cut-off to identify LBV was 42% of the maximal SI (MSI) (AUC 0.80; sensitivity, 74%; specificity, 78%). Using this cut-off of MSI, a SCAI or blocked AI3 could be correctly identified by LGE-CMR in all 27 patients, and a normal AI3 could be correctly confirmed by LGE-CMR in 14/21 patients with normal EAM findings (Figure). The sensitivity and specificity of 3D LGE-CMR for identifying SCAI or blocked AI3 were 100% and 67%, respectively. Of note, among patients with normal EAM findings, those with abnormal AI3 on LGE-CMR had significantly lower BV of AI3 than those with normal AI3 on LGE-CMR (2.06 [Range, 1.62-2.60] vs. 3.53 [2.22-5.67] mV, P&lt;0.01).

Conclusion

3D LGE-CMR can identify SCAI with 100% sensitivity and may identify diseased AI3 even before critical conduction delay occurs. This technique may allow for non-invasive risk stratification of VT and can refine patient selection for invasive EAM.

The effects of high-degree AV block requiring chronic ventricular pacing after tricuspid valve surgery in patients with a systemic right ventricle

Funding Acknowledgements

Type of funding sources: None.

Background

Patients with transposition of the great arteries(TGA) after atrial switch or congenitally corrected TGA(ccTGA) are prone to systemic right ventricular(sRV) failure. Atrioventricular(AV)-conduction disturbances requiring chronic ventricular pacing and tricuspid valve(TV) regurgitation aggravate sRV dysfunction. Timely TV surgery stabilizes sRV function, yet is a risk factor for AV-block, potentially contributing to sRV failure due to pacing-induced dyssynchrony. The aim of this study is to explore the incidence, timing and functional consequences of AV-block requiring ventricular pacing after TV surgery in sRV patients.

Methods

Consecutive adolescent and adult patients with a sRV who underwent TV surgery in the period 1989-2020 and follow-up at our centre were included in this observational cohort study. Demographic and clinical data was collected from patient records.

Results

Data of 28 patients(54% female, 57% ccTGA, mean age at surgery 38±13 years) was analysed. Mean follow-up duration was 9.7±6.8 years. Five patients(18%) already had chronic(&gt;40%) subpulmonary left ventricular pacing preoperatively, of which 2 received cardiac resynchronization therapy(CRT) upgrade prior to surgery. One patient received CRT during TV surgery. Of the remaining 22 patients at risk for AV-block after surgery, 9(41%) developed an indication for chronic pacing during follow-up, of which 3(33%) before hospital discharge and a total of 5(56%) within 24 months postoperatively, Figure 1. Five(20%) patients received CRT during follow-up due to progressive heart failure(HF). In one patient with transvenous upgrade, effective resynchronization was not attained due to suboptimal lead position. Of the patients receiving chronic pacing, 9(75%) died, underwent ventricular assist device(VAD) implantation or required CRT due to progressive HF. Only 4(31%) patients with native AV-conduction reached this composite endpoint(p=0.027). QRS duration, a surrogate marker for dyssynchrony, was significantly higher in patients with chronic pacing than with native AV-conduction(217±24 vs 116±23msec, p=0.000), as was NT-pro-BNP(2746[1242–6879] vs 495[355–690]ng/L, p=0.004) and the percentage of patients with ≥1 class of deterioration of systolic sRV function(p=0.001), Figure 2.

Conclusions

Patients with a failing sRV who undergo TV surgery are prone to AV-conduction abnormalities with 41% developing an indication for chronic ventricular pacing during follow-up. The patient group with chronic pacing has significantly more events of the composite endpoint of death, VAD implantation or upgrade to CRT, higher percentage of ≥1 grade deterioration of systolic sRV function and higher levels of HF biomarker NT-pro-BNP. Implantation of an epicardial sRV lead at the time of TV surgery for future CRT may be considered to attenuate the detrimental effects of subpulmonary ventricular pacing in this HF prone patient group with complex anatomy that limits transvenous possibilities.

Atrioventricular Block Necessitating Chronic Ventricular Pacing After Tricuspid Valve Surgery in Patients With a Systemic Right Ventricle: Long-Term Follow-Up

Background

Patients with transposition of the great arteries (TGA) after an atrial switch or congenitally corrected TGA (ccTGA) are prone to systemic right ventricular (sRV) failure. Tricuspid valve (TV) regurgitation aggravates sRV dysfunction. Timely TV surgery stabilizes sRV function, yet the development of atrioventricular (AV)-conduction disturbances in the course of sRV failure can contribute to sRV dysfunction through pacing-induced dyssynchrony. This study aims to explore the incidence, timing, and functional consequences of AV-block requiring ventricular pacing after TV surgery in patients with sRV.

Methods

Consecutive adolescent and adult patients with an sRV who underwent TV surgery between 1989 and 2020 and followed-up at our center were included in this observational cohort study.

Results

The data of 28 patients (53% female, 57% ccTGA, and a mean age at surgery 38 ± 13 years) were analyzed. The mean follow-up was 9.7 ± 6.8 years. Of the remaining 22 patients at the risk of developing high degree AV-block after TV surgery, 9 (41%) developed an indication for chronic ventricular pacing during follow-up, of which 5 (56%) within 24 months postoperatively (3 prior to hospital discharge). The QRS duration, a surrogate marker for dyssynchrony, was significantly higher in patients with chronic left ventricular pacing than in patients with native AV-conduction (217 ± 24 vs. 116 ± 23 ms, p = 0.000), as was the heart failure biomarker NT-pro-BNP [2,746 (1,242–6,879) vs. 495 (355–690) ng/L, p = 0.004] and the percentage of patients with ≥1 echocardiographic class of deterioration of systolic sRV function (27 vs. 83%, p = 0.001). Of the patients receiving chronic subpulmonary ventricular pacing (n = 12), 9 (75%) reached the composite endpoint of progressive heart failure [death, ventricular assist device implantation, or upgrade to cardiac resynchronization therapy (CRT)]. Only 4 (31%) patients with native AV-conduction (n = 13) reached this composite endpoint (p = 0.027).

Conclusion

Patients with a failing sRV who undergo TV surgery are prone to develop AV-conduction abnormalities, with 41% developing an indication for chronic ventricular pacing during 10 years of follow-up. Patients with chronic subpulmonary ventricular pacing have a significantly longer QRS complex duration, have higher levels of the heart failure biomarker NT-pro-BNP, and are at a higher risk of deterioration of systolic sRV function and progressive heart failure.

Performance of a HeartLogicTM Based Care Path in the Management of a Real-World Chronic Heart Failure Population

Aim

Early detection of impending fluid retention and timely adjustment of (medical) therapy can prevent heart failure related hospitalizations. The multisensory cardiac implantable electronic device (CIED) based algorithm HeartLogicTM aims to alert in case of impending fluid retention. The aim of the current analysis is to evaluate the performance of the HeartLogicTM guided heart failure care path in a real-world heart failure population and to investigate whether the height of the index and the duration of the alert state are indicative of the degree of fluid retention.

Methods

Consecutive adult heart failure patients with a CIED and an activated HeartLogicTM algorithm were eligible for inclusion. Patients were followed up according to the hospital's heart failure care path. The device technician reviewed alerts for a technical CIED checkup. Afterwards, the heart failure nurse contacted the patient to identify impending fluid retention. An alert was either true positive or false positive. Without an alert a patient was true negative or false negative.

Results

Among 107 patients, [82 male, 70 (IQR 60–77) years, left ventricular ejection fraction 37 ± 11%] 130 HeartLogicTM alerts were available for analysis. Median follow up was 14 months [IQR 8–23]. The sensitivity to detect impending fluid retention was 79%, the specificity 88%. The positive predictive was value 71% and the negative predictive value 91%. The unexplained alert rate was 0.23 alerts/patient year and the false negative rate 0.17 alerts/patient year. True positive alerts [42 days (IQR 28–63)] lasted longer than false positive alerts [28 days (IQR 21–44)], p = 0.02. The maximal HeartLogicTM index was higher in true positive alerts [26 (IQR 21–34)] compared to false positive alerts [19 (IQR 17–24)], p &lt; 0.01. Patients with higher HeartLogicTM indexes required more intense treatment (index height in outpatient setting 25 [IQR 20–32], day clinic treatment 28 [IQR 24–36] and hospitalized patients 45 [IQR 35–58], respectively), p &lt; 0.01.

Conclusion

The CIED-based HeartLogicTM algorithm facilitates early detection of impending fluid retention and thereby enables clinical action to prevent this at early stage. The current analysis illustrates that higher and persistent alerts are indicative for true positive alerts and higher index values are indicative for more severe fluid retention.

The first experience with sodium-glucose cotransporter 2 inhibitor for the treatment of systemic right ventricular failure

In congenitally corrected transposition of the great arteries, the morphological right ventricle supports the systemic circulation. This chronic exposure to pressure overload ultimately leads to systemic right ventricular (sRV) dysfunction and heart failure. Pharmacological options for the treatment of sRV failure are poorly defined and no solid recommendations are made in the most recent guidelines. Sodium-glucose cotransporter 2 (SGLT-2) inhibitors are a new class of antihyperglycaemic drugs that have been demonstrated to significantly reduce the risk of worsening heart failure and death from cardiovascular causes in patients with chronic heart failure with reduced left ventricular ejection fraction, yet no data are available in sRV patients. We report on the treatment and clinical follow-up of a patient with advanced heart failure and poor sRV function in the context of congenitally corrected transposition of the great arteries, who did not tolerate sacubitril/valsartan and had a high burden of heart-failure-related hospitalizations. Treatment with dapagliflozin was well tolerated and resulted in (small) subjective and objective functional and echocardiographic improvement and a reduction in heart-failure-related hospitalizations.

Successful hybrid cardiac resynchronization therapy in a patient with failing systemic right ventricle and significant tricuspid regurgitation in transposition of the great arteries after atrial switch procedure according to Mustard

Background

Patients with a systemic right ventricle (sRV) in the context of transposition of the great arteries (TGA) late after atrial switch are prone to heart failure. Complications like tricuspid valve regurgitation (TR) can further aggravate sRV dysfunction. Tricuspid valve regurgitation is usually secondary to annular dilatation and restriction. Criteria for cardiac resynchronization therapy (CRT) in this patient group are not well defined and should be considered on a case-by-case basis.

Case summary

We present a case of a 42-year-old male with sRV failure and TR in the context of TGA after atrial switch. Patient had progressive reduction in exercise capacity. Electrocardiogram showed a wide QRS complex (right bundle branch block configuration). Echocardiography showed significant TR and signs of electromechanical dyssynchrony of the failing sRV with severely reduced systolic function. He underwent heart catheterization and invasive haemodynamic evaluation to assess the potential benefit of CRT. During sequential atrial-sRV pacing, 20% increase in Dp/Dt was measured, suggesting that he would be a CRT responder. Concomitant angiography showed no baffle leakage nor obstructive coronary artery disease. Hybrid CRT-defibrillator implantation resulted in successful resynchronization and improved sRV function, reduced TR and better exercise capacity.

Discussion

Invasive haemodynamic contractility evaluation can help assess the potential benefit of CRT in patients with systemic right ventricular failure in the context of transposition of TGA after atrial switch. Successful CRT can result in improved sRV function, reduced TR and improved exercise capacity.

Case report of the broad spectrum of late complications in an adult patient with univentricular physiology palliated by the Fontan circulation

Background

At the most severe end of the spectrum of congenital heart disease are patients with an univentricular physiology. They comprise a heterogeneous group of congenital heart malformations that have the common characteristic that the cardiac morphology is not equipped for sustaining a biventricular circulation.

Case summary

Here, we present a case of an adult patient after Fontan palliation, illustrative of the complex clinical course and the broad spectrum of complications that can be encountered during follow-up, highlighting the need for a multidisciplinary approach in the clinical care for these patients.

Discussion

During the surgical Fontan procedure, the inferior vena cava is connected to the pulmonary circulation, after prior connection of the superior vena cava to the pulmonary arterial circulation. The resulting cavopulmonary connection, thus lacking a subpulmonic ventricle, provides non-pulsatile passive flow of oxygen-poor blood from the systemic venous circulation into the lungs, and the functional monoventricle pumps the oxygen-rich pulmonary venous return blood into the aorta. With an operative mortality of <5% and current 30-year survival rates up to 85%, the adult population of patients with a Fontan circulation is growing. This increase in survival is, however, inevitably accompanied by long-term complications affecting multiple organ systems, resulting in decline in cardiovascular performance.

Conclusion

For optimal treatment, the evaluation in a multidisciplinary team is mandatory, using the specific expertise of the team members to timely detect and address late complications and to support quality of life.

Implantable cardioverter-defibrillators and the older patient: the Dutch clinical practice

Background and objective

Balance between benefit and burden of implantable cardioverter-defibrillator (ICD) therapy is more debatable in older patients, compared to younger patients. Of around 6000 yearly implanted ICDs in the Netherlands, 1:4 is received by patients ≥75 years. We aimed to evaluate the current clinical practice in the Netherlands for ICD implants and generator replacements, with a special focus on the older ICD patients.

Research design and methods

Cardiologists from all Dutch ICD implanting centres (n = 28) were interviewed. Questions aimed to evaluate outpatient care, pre-operative patient assessment, end-of-life-care counselling, evaluation of social and cognitive wellbeing, clinical evaluation of all patients prior to ICD replacement, and the consideration of the option to downgrade or not replace a device.

Results

Implanting cardiologists from all 28 implanting centres were approached for an interview. Response rate was 86%. Management appeared diverse. An age ≥80 years was consistently reported as incentive for more extensive patient evaluation. Patients were invited for counselling prior to device replacements in only the minority (46%) of hospitals. Downgrade or non-replacement was performed in rare cases. End-of-life care discussions were not standard procedure in 67% of the hospitals. Evaluation of social and cognitive wellbeing of patients was based solely on the general clinical impression of the physician in 83%, or not at all assessed in 8% of the centres.

Discussion and implication

A structured framework for care and evaluation of cognitive and/or physical limitations is currently absent in most hospitals. At time of ICD (re-)evaluation, several factors may be considered before deciding on (continuation of) ICD therapy: patient preferences and comorbidity, the need for pacemaker therapy, primary vs. secondary prevention, procedural risks, and patient preferences.

Clinical decision making in frequently encountered anomalous aortic origin of coronary arteries, the impact of IVUS

Introduction

The aim in the diagnostic work-up of patients with an anomalous aortic origin of coronary arteries (AAOCA) is to determine whether the course of the coronary artery is benign or malignant. In patients with AAOCA with an interarterial course the guidelines on diagnostics are concise. Recommended CT-scan imaging does not evaluate stress-induced functional consequences like external compression by the pulmonary artery as the scan is performed in a resting state. Non-invasive ischemia detection techniques often lack sufficient sensitivity. To improve functional stratification, exploration of new diagnostic modalities in the diagnostic workup of AAOCA is mandatory.

Purpose

The purpose is to explore the potential role of intravascular ultrasound (IVUS) in the diagnostic workup of patients with AAOCA.

Methods

Nine patients with an anomalous right coronary artery with an interarterial course were analyzed. A cardiologist evaluated the complaints. Anatomical features of the AAOCA were assessed with CT-scan imaging. Further analyses included ischemia detection and coronary angiography. To assess stress-induced ischemia IVUS and invasive measurements – fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) – were performed at rest and during adrenaline-induced stress. A slit-like orifice was classified as a width/length (W/L) ratio of ≤0.50, an oval orifice as 0.51–0.9 and a round orifice as &gt;0.91.

Results

Potential cardiac complaints were present in seven patients. In 8 (89%) patients CT-images showed an acute angle, in 8 (89%) proximal narrowing and an aortic take-off above the pulmonary valve in 4 (44%). In 7 (78%) patients a slit-like orifice and in two (22%) an oval orifice were observed (table 1). IVUS at rest showed a slit-like orifice in one patient classified as an oval orifice on the CT-images and vice versa in another patient (table 2). The patients classified as an oval orifice with IVUS showed no external compression during adrenaline-induced stress. In 4 (57%) out of 7 patients with an slit-like orifice on IVUS, the width remained unchanged or increased during adrenaline infusion. In 2 patients the width decreased slightly, however, these patients were asymptomatic and no ischemia was detected. In 1 (14%) patient the width remained 1.4mmm and the length increased from 3.2mm to 4.7mm. In this case the vessel ostium was fully engaged with the IVUS catheter, hence, the width could not decrease during adrenaline infusion. This was regarded as external compression. In addition, in this patient ischemia was detected.

Conclusion(s)

In two (22%) out of 9 patients IVUS gave a better insight of the shape of the orifice than CT. Additionally, the anatomic and functional-dynamic components of compression could be defined with adrenaline-induced stress. Therefore, IVUS can contribute to a better understanding of the functional consequences of the anatomical features and of potential stress-induced external compression.

Funding Acknowledgement

Type of funding sources: None. Table 1Table 2

The coronary arteries in adults after arterial switch: a systematic review

Background

Coronary artery status in adults longterm after the arterial switch operation (ASO) is unclear. As a consequence, current follow-up strategies for coronary assessment remain controversial. We conducted a systemic review to provide an overview of coronary complications during adulthood and to evaluate the value of coronary imaging in adults after ASO, in light of current guidelines.

Material and method

Studies describing coronary complications or coronary imaging after ASO in adults were considered eligible for review and analysis. Articles were screened for the inclusion of adult ASO patients and data on coronary complications and findings of coronary imaging were collected. In cohort studies with both adults (≥18 years) and non-adults (&lt;18 years) only outcomes in identifiable adults were analyzed.

Results

A total of 993 adults were followed with a median follow-up of 2.0 years after reaching adulthood. Myocardial ischemia was suspected in 16/192 patients (6.8%). The number of coronary interventions was 4 (0.4%) and coronary death was reported in 4 (0.4%) patients. The following coronary abnormalities were found by routine coronary computer tomography CT (cCT): stenosis (4%), acute angle (40%), kinking (24%) and interaterial course (11%). No coronary events were reported during pregnancy (n=45).

Conclusion

The reported number of coronary interventions (0.4%) and of coronary death (0.4%) during a median follow-up of 2 years in 993 ASO adults is low. Coronary abnormalities including acute angle, kinking and interarterial course were commonly found by cCT. The 2020 European Society of Cardiology (ESC) guidelines state that routine screening for coronary pathologies is questionable. However, based on current findings and in line with the 2018 American ACC/AHA guidelines we suggest a baseline assessment of the coronary arteries in all adult ASO patients. Thereafter, an individualized coronary follow-up strategy, based upon coronary findings, is advisable.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Hartstichting Freedom from coronary complications

Assessment of the intramural segment of interarterial anomalous coronary arteries originating from the opposite sinus of Valsalva on CT angiography

Background

Of the coronary anomaly variants, an anomalous coronary artery originating from the opposite sinus (AAOCA) with an interarterial course poses the highest the risk of sudden cardiac death. Assessment of high risk anatomical characteristics can be done with Computed Tomography Angiography (CTA). High risk features are a slit-like ostium, acute angle take-off, proximal narrowing and an intramural course. For an intramural course no clear-cut CT parameters exist.

Purpose

To deduct new CTA criteria to identify an intramural course as well as the length of the intramural segment based on peroperative findings.

Material and methods

Twenty patients were included that received unroofing surgery of the right or left AAOCA between 2010 and 2019. All patients had a pre-operative CTA (0.5–1mm slice-thickness) performed. The presence of the intramural segment was measured peroperatively by the surgeon and used as indicator for CTA evaluation. Using multiplanar reconstructions, CTA images were rotated perpendicular to the horizontal plane of the aortic valve annulus and AAOCA to assess the distance between the aortic and AAOCA lumen and the shape of the AAOCA. This was done at every 2mm for the length of the intramural course as described by the surgeon (Figure 1).

Results

Analysis of 20 patients (40% male, AAORCA n=17, age at diagnosis AAOCA 45.6±10.5 years), showed a mean intramural length of 11.5±2.4mm at surgery. The median distance between the aortic and AAOCA lumen was 0.76mm (IQR 0.72–0.97mm) for the intramural segment. At the distal end of the intramural part (indicated by no. 5 in Figure 1), the mean distance was 1.20mm±0.27mm. The median ratio between the antero-posterior and transverse diameter of the AAOCA lumen at the distal end of the intramural part was 0.94 (IQR 0.88–0.99). Along the intramural part (Figure 1, no. 1–4) this ratio was 0.56mm±0.11mm, indicating a more flattened ostial shape along the course of the vessel.

Conclusions

Results indicate that an aortic to AAOCA lumen distance of ≤0.76mm on CTA is suggestive of an intramural course. A distance between the aorta and AAOCA of ≥1.2mm combined with an antero-posterior to transverse diameter ratio of 0.94 of the AAOCA indicates that the intramural trajectory has ended.

Funding Acknowledgement

Type of funding sources: None.

Asymmetry and Heterogeneity: Part and Parcel in Cardiac Autonomic Innervation and Function

The cardiac autonomic nervous system (cANS) regulates cardiac adaptation to different demands. The heart is an asymmetrical organ, and in the selection of adequate treatment of cardiac diseases it may be relevant to take into account that the cANS also has sidedness as well as regional differences in anatomical, functional, and molecular characteristics. The left and right ventricles respond differently to adrenergic stimulation. Isoforms of nitric oxide synthase, which plays an important role in parasympathetic function, are also distributed asymmetrically across the heart. Treatment of cardiac disease heavily relies on affecting left-sided heart targets which are thought to apply to the right ventricle as well. Functional studies of the right ventricle have often been neglected. In addition, many principles have only been investigated in animals and not in humans. Anatomical and functional heterogeneity of the cANS in human tissue or subjects is highly valuable for understanding left- and right-sided cardiac pathology and for identifying novel treatment targets and modalities. Within this perspective, we aim to provide an overview and synthesis of anatomical and functional heterogeneity of the cANS in tissue or subjects, focusing on the human heart.

Fusion cardiac resynchronization therapy in an left ventricular assist device patient from two devices and crossing leads: a case report

Background

Cardiac implanted electronic devices (CIED) have significantly improved the survival and quality of life in heart failure patients. Although implantable cardioverter-defibrillators (ICD) and cardiac resynchronization therapy (CRT) have a major role in patients with moderate to severe heart failure symptoms, the role of these devices in patients with a left ventricular assist device (LVAD) is not yet well defined. The burden of CIED-related procedures in patients with an LVAD is high. The price of lead malfunctions and pocket complications requires creative approaches to tackle CIED-related issues in this patient population.

Case summary

Here, we describe the clinical course of a 67-year-old ventricular pacing dependent LVAD patient with an ICD indication based on recurrent monomorphic ventricular tachycardias and a CRT indication due to previous deterioration of (right-sided) heart failure in the absence of biventricular pacing. We were confronted with impending right ventricular lead failure and bilateral venous access problems due to chronic subclavian vein occlusion in a patient with a total of five transvenous leads, therapeutic anticoagulation, and pronounced thoracic collaterals. We sought for a creative solution to be able to deliver effective biventricular fusion pacing with the existing leads from two contralateral pulse generators resulting in biventricular fusion pacing. This provided the solution to deliver effective CRT.

Discussion

This case illustrates the complexity of care and CIED-related decision-making in pacing dependent LVAD patients, in particularly those with an ICD and CRT indication.

The Coronary Arteries in Adults after the Arterial Switch Operation: A Systematic Review

Coronary artery status in adults long after the arterial switch operation (ASO) is unclear. We conducted a systematic review to provide an overview of coronary complications during adulthood and to evaluate the value of routine coronary imaging in adults after ASO, in light of current guidelines. Articles were screened for the inclusion of adult ASO patients and data on coronary complications and findings of coronary imaging were collected. A total of 993 adults were followed with a median available follow-up of only 2.0 years after reaching adulthood. Myocardial ischemia was suspected in 17/192 patients (8.9%). The number of coronary interventions was four (0.4%), and coronary death was reported in four (0.4%) patients. A lack of ischemia-related symptoms cannot be excluded because innervation studies indicated deficient cardiac innervation after ASO, although data is limited. Anatomical high-risk features found by routine coronary computed tomography (cCT) included stenosis (4%), acute angle (40%), kinking (24%) and inter-arterial course (11%). No coronary complications were reported during pregnancy (n = 45), although, remarkably, four (9%) patients developed heart failure. The 2020 European Society of Cardiology (ESC) guidelines state that routine screening for coronary pathologies is questionable. Based on current findings and in line with the 2018 American ACC/AHA guidelines a baseline assessment of the coronary arteries in all ASO adults seems justifiable. Thereafter, an individualized coronary follow-up strategy is advisable at least until significant duration of follow-up is available.

The significance of symptoms before and after surgery for anomalous aortic origin of coronary arteries in adolescents and adults

OBJECTIVES

The aim of this study is to describe the significance of symptoms preoperatively and at medium-term follow-up in adolescent and adult patients who underwent surgery of anomalous aortic origin of a coronary artery (AAOCA).

METHODS

Consecutive patients who underwent surgery for AAOCA in our tertiary referral centre between 2001 and 2018 were included. Clinical characteristics and symptoms were evaluated and medium-term outcomes were recorded. Symptoms were classified according to the '2019 ESC guidelines on chronic coronary syndromes'.

RESULTS

A total of 53 (55% male) patients with mean age of 44 at time of surgery underwent surgical repair of AAOCA. Data on symptoms and events ˃3 months after surgery were available in 34 patients with a median follow-up of 3 years (interquartile range 1.0-5.3). Preoperatively, only 35% patients had typical anginal complaints. After surgical correction of AAOCA, 59% of the patients were free of symptoms, compared to 6% preoperatively (P < 0.001). A total of 3 (9%) patients needed a reoperation/reintervention related to the operated AAOCA. All 3 patients presented postoperatively with novel typical anginal complaints.

CONCLUSIONS

Adolescent and adult patients with AAOCA present with varying symptoms. Only 35% have typical anginal complaints. Surgical correction of AAOCA reduces the symptoms in the vast majority of patients. One should be aware of potential lesions of the operated coronary artery in patients presenting with typical anginal complaints postoperatively.

Computed Tomography Derived Coronary Triangulated Orifice Area-Deduction of a New Parameter for Follow-up After Surgical Correction of Anomalous Aortic Origin of Coronary Arteries and Call for Validation

Introduction: Anomalous aortic origin of a coronary artery (AAOCA) from the opposite sinus of Valsalva is a rare congenital abnormality. Computed tomography angiography (CTA) is primarily used as a diagnostic tool to evaluate the anatomy and identify potentially malignant AAOCA variants. Limited data is available on the role of CTA during postoperative follow-up. We aimed to develop an objective CTA derived parameter for diagnostic evaluation and follow-up after surgical correction of AAOCA and correlate the anatomical features to the postoperative outcome.

Methods: All consecutive patients who underwent surgical repair of AAOCA from 2001 to 2018 and had pre and postoperative CTA imaging available were included. A retrospective analysis of the pre- and postoperative CTA and the outcomes was performed. The origin and course of the anomalous coronary artery and the ostial dimensions were evaluated and correlated with restenosis of operated coronary artery. To allow an accurate evaluation of the effective orifice area at diagnosis and after surgical repair we deduce and propose a new parameter—the coronary triangulated orifice area (CTOA).

Results: Out of the 54 patients who underwent surgical treatment for AAOCA, 11 fulfilled the inclusion criteria. The median follow-up was 19 months [IQR 3;42]. The mean age at surgery was 41 ± 16 years, with six patients (55%) being male. Postoperatively, the angle between the proximal coronary artery and the aortic wall increased from 20 ± 5° to 28 ± 9° (p < 0.01) and ostial diameter in the transversal plane increased from 4.1 ± 2.5 mm to 6.2 ± 2.7 mm (p < 0.01). The median CTOA increased significantly from 1.6 mm² [IQR 0.9;4.9] to 5.5 mm² [IQR 3;11.8] (p < 0.005). During follow-up, in three patients a restenosis of the operated coronary artery was suspected. In these patients, the CTOA only showed a limited postoperative increase of ≤ 1.4 mm².

Conclusions: CTA can play an important role in the evaluation of the pre- and postoperative anatomy in AAOCA patients. CTOA may be of use in conjunction with the acute angle take-off and ostial diameter order to comprehensively evaluate the operated ostium after unroofing or patch angioplasty.

Failing systemic right ventricle in a patient with dextrocardia and complex congenitally corrected transposition of the great arteries: a case report of successful transvenous cardiac resynchronization therapy

Background 

Patients with congenitally corrected transposition of the great arteries (ccTGA) are prone to the development of advanced atrio-ventricular block requiring chronic ventricular pacing. The morphological right ventricle (RV) often develops systolic dysfunction as it is unable to withstand the chronic pressure overload it is exposed to when supporting the systemic circulation.

Case summary 

A 56-year-old woman with dextrocardia and complex ccTGA with a history of dual-chamber implantable cardioverter-defibrillator (DDD-ICD, high degree atrio-ventricular-block and syncopal ventricular tachycardia), presented with progressive heart failure and symptomatic atrial arrhythmias. She underwent a successful ablation and concomitant invasive haemodynamic evaluation of potential alternative/biventricular pacing modalities. During biventricular pacing, the QRS narrowed and the systemic RV intraventricular pressure (Dp/Dt) increased with 30%. She underwent a successful transvenous upgrade to cardiac resynchronization therapy (CRT). The electrocardiogram post-implantation showed biventricular capture and patient showed subjective and objective clinical improvement.

Discussion 

Systemic RV dysfunction in ccTGA can be aggravated by chronic pacing-induced dyssynchrony, contributing to progression of heart failure in this patient group. Transvenous CRT is feasible in ccTGA anatomy and may be pursued in order to improve or preserve the functional status of pacing-dependent ccTGA patients. Invasive haemodynamic contractility evaluation can help assess the potential benefit of CRT in patients with complex anatomy.

Validation and Feasibility of Echocardiographic Assessment of Systemic Right Ventricular Function: Serial Correlation With MRI

Background: Inherent to its geometry, echocardiographic imaging of the systemic right ventricle (RV) is challenging. Therefore, echocardiographic assessment of systemic RV function may not always be feasible and/or reproducible in daily practice. Here, we aim to validate the usefulness of a comprehensive range of 32 echocardiographic measurements of systemic RV function in a longitudinal cohort by serial assessment of their correlations with cardiac magnetic resonance (CMR)-derived systemic RV ejection fraction (RVEF). Methods: A single-center, retrospective cohort study was performed. Adult patients with a systemic RV who underwent a combination of both CMR and echocardiography at two different points in time were included. Off-line analysis of echocardiographic images was blinded to off-line CMR analysis and vice versa. In half of the echocardiograms, measurements were repeated by a second observer blinded to the results of the first. Correlations between echocardiographic and CMR measures were assessed with Pearson's correlation coefficient and interobserver agreement was quantified with intraclass correlation coefficients (ICC). Results: Fourteen patients were included, of which 4 had congenitally corrected transposition of the great arteries (ccTGA) and 10 patients had TGA late after an atrial switch operation. Eight patients (57%) were female. There was a mean of 8 years between the first and second imaging assessment. Only global systemic RV function, fractional area change (FAC), and global longitudinal strain (GLS) were consistently, i.e., at both time points, correlated with CMR-RVEF (global RV function: r = -0.77/r = -0.63; FAC: r = 0.79/r = 0.67; GLS: r = -0.73/r = -0.70, all p-values < 0.05). The ICC of GLS (0.82 at t = 1, p = 0.006, 0.77 at t = 2, p = 0.024) was higher than the ICC of FAC (0.35 at t = 1, p = 0.196, 0.70 at t = 2, p = 0.051) at both time points. Conclusion: GLS appears to be the most robust echocardiographic measurement of systemic RV function with good correlation with CMR-RVEF and reproducibility.

The first multicentre study on coronary anomalies in the Netherlands: MuSCAT

Background

Current guidelines on coronary anomalies are primarily based on expert consensus and a limited number of trials. A gold standard for diagnosis and a consensus on the treatment strategy in this patient group are lacking, especially for patients with an anomalous origin of a coronary artery from the opposite sinus of Valsalva (ACAOS) with an interarterial course.

Aim

To provide evidence-substantiated recommendations for diagnostic work-up, treatment and follow-up of patients with anomalous coronary arteries.

Methods

A clinical care pathway for patients with ACAOS was established by six Dutch centres. Prospectively included patients undergo work-up according to protocol using computed tomography (CT) angiography, ischaemia detection, echocardiography and coronary angiography with intracoronary measurements to assess anatomical and physiological characteristics of the ACAOS. Surgical and functional follow-up results are evaluated by CT angiography, ischaemia detection and a quality-of-life questionnaire. Patient inclusion for the first multicentre study on coronary anomalies in the Netherlands started in 2020 and will continue for at least 3 years with a minimum of 2 years of follow-up. For patients with a right or left coronary artery originating from the pulmonary artery and coronary arteriovenous fistulas a registry is maintained.

Results

Primary outcomes are: (cardiac) death, myocardial ischaemia attributable to the ACAOS, re-intervention after surgery and intervention after initially conservative treatment. The influence of work-up examinations on treatment choice is also evaluated.

Conclusions

Structural evidence for the appropriate management of patients with coronary anomalies, especially (interarterial) ACAOS, is lacking. By means of a structured care pathway in a multicentre setting, we aim to provide an evidence-based strategy for the diagnostic evaluation and treatment of this patient group.

Supplementary Information

The online version of this article (10.1007/s12471-021-01556-9) contains supplementary material, which is available to authorized users.

Clinical Course Long After Atrial Switch: A Novel Risk Score for Major Clinical Events

Background

Patients with transposition of the great arteries corrected by an atrial switch operation experience major clinical events during adulthood, mainly heart failure (HF) and arrhythmias, but data on the emerging risks remain scarce. We assessed the risk for events during the clinical course in adulthood, and provided a novel risk score for event‐free survival.

Methods and Results

This multicenter study observed 167 patients with transposition of the great arteries corrected by an atrial switch operation (61% Mustard procedure; age, 28 [interquartile range, 24–36] years) for 13 (interquartile range, 9–16) years, during which 16 (10%) patients died, 33 (20%) had HF events, defined as HF hospitalizations, heart transplantation, ventricular assist device implantation, or HF‐related death, and 15 (9%) had symptomatic ventricular arrhythmias. Five‐year risk of mortality, first HF event, and first ventricular arrhythmia increased from 1% each at age 25 years, to 6% (95% CI, 4%–9%), 23% (95% CI, 17%–28%), and 5% (95% CI, 2%–8%), respectively, at age 50 years. Predictors for event‐free survival were examined to construct a prediction model using bootstrapping techniques. A prediction model combining age >30 years, prior ventricular arrhythmia, age >1 year at repair, moderate or greater right ventricular dysfunction, severe tricuspid regurgitation, and mild or greater left ventricular dysfunction discriminated well between patients at low (<5%), intermediate (5%–20%), and high (>20%) 5‐year risk (optimism‐corrected C‐statistic, 0.86 [95% CI, 0.82–0.90]). Observed 5‐ and 10‐year event‐free survival rates in low‐risk patients were 100% and 97%, respectively, compared with only 31% and 8%, respectively, in high‐risk patients.

Conclusions

The clinical course of patients undergoing atrial switch increasingly consists of major clinical events, especially HF. A novel risk score stratifying patients as low, intermediate, and high risk for event‐free survival provides information on absolute individual risks, which may support decisions for pharmacological and interventional management.

Potential of eHealth smart technology in optimization and monitoring of heart failure treatment in adults with systemic right ventricular failure

Aims

Patients with a systemic right ventricle (sRV) in the context of transposition of the great arteries (TGA) after atrial switch or congenitally corrected TGA are prone to heart failure and arrhythmias. This study evaluated feasibility, patient adherence, and satisfaction of a smart technology-based care pathway for heart failure treatment optimization in these patients.

Methods and results

Patients with symptomatic sRV failure eligible for initiation of sacubitril/valsartan were provided with four smartphone compatible devices (blood pressure monitor, weight scale, step counter, and rhythm monitor) and were managed according to a smart technology-based care pathway. Biweekly sacubitril/valsartan titration visits were replaced by electronical visits, patients were advised to continue measurements at least weekly after titration. Data of 24 consecutive sRV patients (median age 47 years, 50% female) who participated in the smart technology-based care pathway were analysed. Median home-hospital distance was 65 km (maximum 227 km). Most patients (20, 83.3%) submitted weekly measurements; 100% submitted prior to electronical visits. Titration conventionally occurs during a hospital visit. By implementing eHealth smart technology, 68 such trips to hospital were replaced by virtual visits facilitated by remote monitoring. An eHealth questionnaire was completed by 22 patients (92%), and 96% expressed satisfaction. After titration, 30 instances of remote adjustment of heart failure medication in addition to scheduled outpatient clinic visits occurred, one (4%) heart failure admission followed, despite ambulant adjustments. Five patients (21%) sent in rhythm registrations (n = 17), of these 77% showed sinus rhythm, whereas supraventricular tachycardia was detected in the remaining four registrations.

Conclusion

These data suggest that implementation of a smart technology-based care pathway for optimization of medical treatment sRV failure is feasible with high measurement adherence and patient satisfaction.

Clinical and economic impact of HeartLogic™ compared with standard care in heart failure patients

Aims

The implantable cardiac defibrillator/cardiac resynchronization therapy with defibrillator‐based HeartLogic™ algorithm has recently been developed for early detection of impending decompensation in heart failure (HF) patients; but whether this novel algorithm can reduce HF hospitalizations has not been evaluated. We investigated if activation of the HeartLogic algorithm reduces the number of hospital admissions for decompensated HF in a 1 year post‐activation period as compared with a 1 year pre‐activation period.

Methods and results

Heart failure patients with an implantable cardiac defibrillator/cardiac resynchronization therapy with defibrillator with the ability to activate HeartLogic and willingness to have remote device monitoring were included in this multicentre non‐blinded single‐arm trial with historical comparison. After a HeartLogic alert, the presence of HF symptoms and signs was evaluated. If there were two or more symptoms and signs apart from the HeartLogic alert, lifestyle advices were given and/or medication was adjusted. After activation of the algorithm, patients were followed for 1 year. HF events occurring in the 1 year prior to activation and in the 1 year after activation were compared. Of the 74 eligible patients (67.2 ± 10.3 years, 84% male), 68 patients completed the 1 year follow‐up period. The total number of HF hospitalizations reduced from 27 in the pre‐activation period to 7 in the post‐activation period (P = 0.003). The number of patients hospitalized for HF declined from 21 to 7 (P = 0.005), and the hospitalization length of stay diminished from average 16 to 7 days (P = 0.079). Subgroup analysis showed similar results (P = 0.888) for patients receiving cardiac resynchronization therapy during the pre‐activation period or not receiving cardiac resynchronization therapy, meaning that the effect of hospitalizations cannot solely be attributed to reverse remodelling. Subanalysis of a single‐centre Belgian subpopulation showed important reductions in overall health economic costs (P = 0.025).

Conclusion

Activation of the HeartLogic algorithm enables remote monitoring of HF patients, coincides with a significant reduction in hospitalizations for decompensated HF, and results in health economic benefits.

The Leiden Convention coronary coding system: translation from the surgical to the universal view

Aims

The Leiden Convention coronary coding system structures the large variety of coronary anatomical patterns; isolated and in congenital heart disease. It is widely used by surgeons but not by cardiologists as the system uses a surgeons’ cranial view. Since thoracic surgeons and cardiologists work closely together, a coronary coding system practical for both disciplines is mandatory. To this purpose, the ‘surgical’ coronary coding system was adapted to an ‘imaging’ system, extending its applicability to different cardiac imaging techniques.

Methods and results

The physician takes place in the non-facing sinus of the aortic valve, oriented with the back towards the pulmonary valve, looking outward from the sinus. From this position, the right-hand sinus is sinus 1, and the left-hand sinus is sinus 2. Next, a clockwise rotation is adopted starting at sinus 1 and the encountered coronary branches described. Annotation of the normal anatomical pattern is 1R-2LCx, corresponding to the ‘surgical’ coding system. The ‘imaging’ coding system was made applicable for Computed Tomography (CT), Magnetic Resonance Imaging (MRI), echocardiography, and coronary angiography, thus facilitating interdisciplinary use. To assess applicability in daily clinical practice, images from different imaging modalities were annotated by cardiologists and cardiology residents and results scored. The average score upon evaluation was 87.5%, with the highest scores for CT and MRI images (average 90%).

Conclusion

The imaging Leiden Convention is a coronary coding system that unifies the annotation of coronary anatomy for thoracic surgeons, cardiologists, and radiologists. Validation of the coding system shows it can be easily and reliably applied in clinical practice.

Early Detection of Fluid Retention in Patients with Advanced Heart Failure: A Review of a Novel Multisensory Algorithm, HeartLogicTM

Heart failure (HF) hospitalisations due to decompensation are associated with shorter life expectancy and lower quality of life. These hospitalisations pose a significant burden on the patients, doctors and healthcare resources. Early detection of an upcoming episode of decompensation may facilitate timely optimisation of the ambulatory medical treatment and thereby prevent heart-failure-related hospitalisations. The HeartLogic^TM algorithm combines data from five sensors of cardiac implantable electronic devices into a cumulative index value. It has been developed for early detection of fluid retention in heart failure patients. This review aims to provide an overview of the current literature and experience with the HeartLogic^TM algorithm, illustrate how the index can be implemented in daily clinical practice and discuss ongoing studies and potential future developments of interest.

Sacubitril/valsartan in the treatment of systemic right ventricular failure

Objective

Pharmacological options for patients with a failing systemic right ventricle (RV) in the context of transposition of the great arteries (TGA) after atrial switch or congenitally corrected TGA (ccTGA) are not well defined. This study aims to investigate the feasibility and effects of sacubitril/valsartan treatment in a single-centre cohort of patients.

Methods

Data on all consecutive adult patients (n=20, mean age 46 years, 50% women) with a failing systemic RV in a biventricular circulation treated with sacubitril/valsartan in our centre are reported. Patients with a systemic RV ejection fraction of ≤35% who were symptomatic despite treatment with β-blocker and ACE-inhibitor/angiotensin II receptor-blockers were started on sacubitril/valsartan. This cohort underwent structural follow-up including echocardiography, exercise testing, laboratory investigations and quality of life (QOL) assessment.

Results

Six-month follow-up data were available in 18 out of 20 patients, including 12 (67%) patients with TGA after atrial switch and 6 (33%) patients with ccTGA. N-terminal pro-B-type natriuretic peptide (NT-pro-BNP) decreased significantly (950–358 ng/L, p<0.001). Echocardiographic systemic RV fractional area change and global longitudinal strain showed small improvements (19%–22%, p<0.001 and −11% to −13%, p=0.014, respectively). The 6 min walking distance improved significantly from an average of 564 to 600 m (p=0.011). The QOL domains of cognitive function, sleep and vitality improved (p=0.015, p=0.007 and p=0.037, respectively).

Conclusions

We describe the first patient cohort with systemic RV failure treated with sacubitril/valsartan. Treatment appears feasible with improvements in NT-pro-BNP and echocardiographic function. Our positive results show the potential of sacubitril/valsartan for this patient population.

The constrictive consequences of pericardial calcifications

A 53-year-old man presented with symptomatic severe pulmonary valve regurgitation. He underwent a diagnostic catheterization. A heavily calcified pericardium and the pressure tracings illustrate typical features of constrictive pericarditis physiology, including the "square root sign." This condition is important to recognize given the progressive nature and poor prognosis if untreated.