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Providência R, Aali G, Zhu F, Katairo T, Ahmad M, Bray JJH, Pelone F, Khanji MY, Marijon E, Cassandra M, Celermajer DS, Shokraneh F. Handheld echocardiography for the screening and diagnosis of rheumatic heart disease: a systematic review to inform WHO guidelines. Lancet Glob Health 2024; 12:e983-e994. [PMID: 38762298 DOI: 10.1016/s2214-109x(24)00127-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 02/29/2024] [Accepted: 03/08/2024] [Indexed: 05/20/2024]
Abstract
BACKGROUND Early detection and diagnosis of acute rheumatic fever and rheumatic heart disease are key to preventing progression, and echocardiography has an important diagnostic role. Standard echocardiography might not be feasible in high-prevalence regions due to its high cost, complexity, and time requirement. Handheld echocardiography might be an easy-to-use, low-cost alternative, but its performance in screening for and diagnosing acute rheumatic fever and rheumatic heart disease needs further investigation. METHODS In this systematic review and meta-analysis, we searched Embase, MEDLINE, LILACS, and Conference Proceedings Citation Index-Science up to Feb 9, 2024, for studies on the screening and diagnosis of acute rheumatic fever and rheumatic heart disease using handheld echocardiography (index test) or standard echocardiography or auscultation (reference tests) in high-prevalence areas. We included all studies with useable data in which the diagnostic performance of the index test was assessed against a reference test. Data on test accuracy in diagnosing rheumatic heart disease, acute rheumatic fever, or carditis with acute rheumatic fever (primary outcomes) were extracted from published articles or calculated, with authors contacted as necessary. Quality of evidence was appraised using GRADE and QUADAS-2 criteria. We summarised diagnostic accuracy statistics (including sensitivity and specificity) and estimated 95% CIs using a bivariate random-effects model (or univariate random-effects models for analyses including three or fewer studies). Area under the curve (AUC) was calculated from summary receiver operating characteristic curves. Heterogeneity was assessed by visual inspection of plots. This study was registered with PROSPERO (CRD42022344081). FINDINGS Out of 4868 records we identified 11 studies, and two additional reports, comprising 15 578 unique participants. Pooled data showed that handheld echocardiography had high sensitivity (0·87 [95% CI 0·76-0·93]), specificity (0·98 [0·71-1·00]), and overall high accuracy (AUC 0·94 [0·84-1·00]) for diagnosing rheumatic heart disease when compared with standard echocardiography (two studies; moderate certainty of evidence), with better performance for diagnosing definite compared with borderline rheumatic heart disease. High sensitivity (0·79 [0·73-0·84]), specificity (0·85 [0·80-0·89]), and overall accuracy (AUC 0·90 [0·85-0·94]) for screening rheumatic heart disease was observed when pooling data of handheld echocardiography versus standard echocardiography (seven studies; high certainty of evidence). Most studies had a low risk of bias overall. Some heterogeneity was observed for sensitivity and specificity across studies, possibly driven by differences in the prevalence and severity of rheumatic heart disease, and level of training or expertise of non-expert operators. INTERPRETATION Handheld echocardiography has a high accuracy and diagnostic performance when compared with standard echocardiography for diagnosing and screening of rheumatic heart disease in high-prevalence areas. FUNDING World Health Organization. TRANSLATIONS For the Chinese, French, Italian, Persian, Portuguese, Spanish and Urdu translations of the abstract see Supplementary Materials section.
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Affiliation(s)
- Rui Providência
- Genes Health and Social Care Evidence Synthesis Unit, Institute of Health Informatics, University College London, London, UK; Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK.
| | - Ghazaleh Aali
- Cochrane Heart, Institute of Health Informatics, University College London, London, UK
| | - Fang Zhu
- Systematic Review Consultants, Nottingham, UK
| | | | - Mahmood Ahmad
- Genes Health and Social Care Evidence Synthesis Unit, Institute of Health Informatics, University College London, London, UK; Cardiology Department, Royal Free London NHS Foundation Trust, London, UK
| | - Jonathan J H Bray
- Genes Health and Social Care Evidence Synthesis Unit, Institute of Health Informatics, University College London, London, UK; Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - Ferruccio Pelone
- Genes Health and Social Care Evidence Synthesis Unit, Institute of Health Informatics, University College London, London, UK
| | - Mohammed Y Khanji
- Department of Cardiology, Barts Heart Centre, St Bartholomew's Hospital, London, UK; Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London, UK; Department of Cardiology, Newham University Hospital, Barts Health NHS Trust, London, UK
| | - Eloi Marijon
- Paris Cardiovascular Research Centre, INSERM U970, European Georges Pompidou Hospital, Paris, France
| | - Miryan Cassandra
- Cardiology Department, Hospital Dr Ayres de Menezes, São Tomé, São Tomé and Príncipe
| | - David S Celermajer
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Farhad Shokraneh
- Genes Health and Social Care Evidence Synthesis Unit, Institute of Health Informatics, University College London, London, UK; Systematic Review Consultants, Nottingham, UK
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Seitler S, Ahmad M, Ahuja SAC, Ahmed MT, Stevenson A, Schreiber TR, Sodhi PS, Diyasena HK, Ogbeide O, Arularooran S, Shokraneh F, Cassandra M, Marijon E, Celermajer DS, Khanji MY, Providencia R. Routine Antenatal Echocardiography in High-Prevalence Areas of Rheumatic Heart Disease: A WHO-Guideline Systematic Review. Glob Heart 2024; 19:39. [PMID: 38681969 PMCID: PMC11049603 DOI: 10.5334/gh.1318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 03/20/2024] [Indexed: 05/01/2024] Open
Abstract
Background Rheumatic Heart Disease (RHD) is the most common cause of valvular heart disease worldwide. Undiagnosed or untreated RHD can complicate pregnancy and lead to poor maternal and fetal outcomes and is a significant factor in non-obstetric morbidity. Echocardiography has an emerging role in screening for RHD. We aimed to critically analyse the evidence on the use of echocardiography for screening pregnant women for RHD in high-prevalence areas. Methods We searched MEDLINE and Embase to identify the relevant reports. Two independent reviewers assessed the reports against the eligibility criteria in a double-blind process. Results The searches (date: 4 April 2023) identified 432 records for screening. Ten non-controlled observational studies were identified, five using portable or handheld echocardiography, comprising data from 23,166 women. Prevalence of RHD varied across the studies, ranging from 0.4 to 6.6% (I2, heterogeneity >90%). Other cardiac abnormalities (e.g., congenital heart disease and left ventricular systolic dysfunction) were also detected <1% to 2% of cases. Certainty of evidence was very low. Conclusion Echocardiography as part of antenatal care in high-prevalence areas may detect RHD or other cardiac abnormalities in asymptomatic pregnant women, potentially reducing the rates of disease progression and adverse labor-associated outcomes. However, this evidence is affected by the low certainty of evidence, and lack of studies comparing echocardiography versus standard antenatal care. Prospective Registration PROSPERO 2022 July 4; CRD42022344081 Available from: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=344081. Research question 'In areas with a high prevalence of rheumatic heart disease, should handheld echocardiography be added to routine antenatal care?'
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Affiliation(s)
- Samuel Seitler
- Royal Free Hampstead NHS Trust, Royal Free London NHS Foundation Trust, Pond St, London NW3 2QG, UK
| | - Mahmood Ahmad
- Royal Free Hampstead NHS Trust, Royal Free London NHS Foundation Trust, Pond St, London NW3 2QG, UK
| | | | | | - Alexander Stevenson
- Department of Cardiology, High Wycombe Hospital, Queen Alexandra Rd, High Wycombe HP11 2TT, UK
| | - Tamar Rachel Schreiber
- Royal Free Hampstead NHS Trust, Royal Free London NHS Foundation Trust, Pond St, London NW3 2QG, UK
| | - Prem Singh Sodhi
- Royal Free Hampstead NHS Trust, Royal Free London NHS Foundation Trust, Pond St, London NW3 2QG, UK
| | - Hiruna Kojitha Diyasena
- Royal Free Hampstead NHS Trust, Royal Free London NHS Foundation Trust, Pond St, London NW3 2QG, UK
| | - Osarumwense Ogbeide
- Royal Free Hampstead NHS Trust, Royal Free London NHS Foundation Trust, Pond St, London NW3 2QG, UK
| | - Sankavi Arularooran
- Royal Free Hampstead NHS Trust, Royal Free London NHS Foundation Trust, Pond St, London NW3 2QG, UK
| | - Farhad Shokraneh
- GENEs health and social care evidence SYnthesiS unit, Institute of Health Informatics, University College London, UK
- Evidence Synthesis, Systematic Review Consultants LTD, Nottingham, UK
| | | | - Eloi Marijon
- Paris Cardiovascular Research Centre, INSERM U970, European Georges Pompidou Hospital, Paris, FR
- Department of Cardiology, European Georges Pompidou Hospital, Paris, FR
| | - David S. Celermajer
- The University of Sydney, Sydney, AU
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, AU
| | - Mohammed Y. Khanji
- Cardiology Department, Barts Heart Centre, Barts Health NHS Trust, London, UK
- Newham University Hospital, Barts Health NHS Trust, Glen Road, Plaistow, London E13 8SL, UK
- NIHR Barts Biomedical Research Centre, William Harvey Research Institute, Queen Mary University, London EC1A 7BE, UK
| | - Rui Providencia
- GENEs health and social care evidence SYnthesiS unit, Institute of Health Informatics, University College London, UK
- Cardiology Department, Barts Heart Centre, Barts Health NHS Trust, London, UK
- Newham University Hospital, Barts Health NHS Trust, Glen Road, Plaistow, London E13 8SL, UK
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Kearney K, Brown K, Celermajer DS, Collins N, Cordina R, Corrigan C, Dwyer N, Feenstra J, Keating D, Keogh A, Kotlyar E, Lavender M, McWilliams T, Williams T, Whitford H, Weintraub R, Wrobel J, Ellender C, Anderson J, Lau EM. Impact of Left Heart Disease Risk Factors on Outcomes in Pulmonary Arterial Hypertension Therapy. Chest 2024; 165:967-977. [PMID: 37951349 DOI: 10.1016/j.chest.2023.10.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 10/04/2023] [Accepted: 10/07/2023] [Indexed: 11/13/2023] Open
Abstract
BACKGROUND Current guidelines recommend initial monotherapy for pulmonary arterial hypertension (PAH) with cardiopulmonary comorbidities, despite limited available evidence to guide management. RESEARCH QUESTION Do left heart disease (LHD) risk factors have an impact on treatment response and influence applicability of risk assessment in a real-world cohort of patients with PAH? STUDY DESIGN AND METHODS The Ambrisentan and Tadalafil in Patients with Pulmonary Arterial Hypertension (AMBITION) trial criteria was used to define the phenotype of patients with PAH with risk factors for LHD. Treatment strategy, functional outcome, long-term survival, and risk discrimination were compared with a reference PAH cohort using the Pulmonary Hypertension Society of Australia and New Zealand Registry. RESULTS A total of 487 incident patients with PAH diagnosed between 2011 and 2020 were included. Of these, 103 (21.1%) fulfilled the definition of PAH with LHD risk factors, with 384 (78.9%) remaining as the reference group. Patients in the PAH with LHD risk factors group were older (66 ± 13 vs 58 ± 19 years; P < .001), had lower pulmonary vascular resistance (393 ± 266 vs 708 ± 391 dyn.s/cm5; P = .031), and had worse 6-min walk distance (286 ± 130 vs 327 ± 136 m; P = .005) at diagnosis. The PAH with LHD risk factors group was less likely to receive initial combination therapy (27% vs 44%; P = .02). Changes in 6-min walk distance at 12 months were similar in both groups (43 ± 77 m in the PAH with LHD risk factors group and 50 ± 90 m in the reference group; P = .50), including when stratified by initial treatment strategy (PAH with LHD risk factors group vs reference PAH group: monotherapy: 40 ± 81 vs 38 ± 95 m, P = .87; combination therapy: 53 ± 78 vs 64 ± 106 m, P = .511). Functional class improvements were also similar in both groups. REVEAL Registry 2.0 risk score effectively discriminated risk in both populations (C statistic = 0.756 for the PAH with LHD risk factors group and C statistic = 0.750 for the reference PAH group). There was no difference in survival between the two groups (log-rank test, P = .29). INTERPRETATION In a real-world cohort, patients with PAH with LHD risk factors were less likely to be exposed to initial combination therapy. Nevertheless, selected patients with PAH with LHD risk factors who were treated with initial combination therapy derived similar functional response compared with the reference group. Further studies are needed to phenotype patients with PAH with cardiopulmonary comorbidities who may benefit from initial combination therapy.
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Affiliation(s)
- Katherine Kearney
- Heart Transplant Unit, St Vincent's Hospital, Darlinghurst, NSW, Australia; School of Clinical Medicine, Faculty of Medicine and Health, UNSW, Sydney, NSW, Australia; Victor Chang Cardiac Research Institute, Darlinghurst, NSW Australia
| | - Karen Brown
- Heart Transplant Unit, St Vincent's Hospital, Darlinghurst, NSW, Australia; School of Clinical Medicine, Faculty of Medicine and Health, UNSW, Sydney, NSW, Australia
| | - David S Celermajer
- Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, Australia; Pulmonary Hypertension Service, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Nicholas Collins
- Department of Cardiology, John Hunter Hospital, Newcastle, NSW, Australia
| | - Rachael Cordina
- Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, Australia; Pulmonary Hypertension Service, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Carolyn Corrigan
- Heart Transplant Unit, St Vincent's Hospital, Darlinghurst, NSW, Australia; School of Clinical Medicine, Faculty of Medicine and Health, UNSW, Sydney, NSW, Australia
| | - Nathan Dwyer
- Department of Cardiology, Royal Hobart Hospital, Hobart, TAS, Australia
| | - John Feenstra
- Queensland Lung Transplant Service, Prince Charles Hospital, Chermside, QLD, Australia; Wesley Pulmonary Hypertension Service, Wesley Hospital, Auchenflower, QLD, Australia
| | - Dominic Keating
- Department of Respiratory Medicine, The Alfred Hospital, Melbourne, VIC, Australia; Faculty of Medicine, Nursing and Health Sciences, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Anne Keogh
- Heart Transplant Unit, St Vincent's Hospital, Darlinghurst, NSW, Australia; School of Clinical Medicine, Faculty of Medicine and Health, UNSW, Sydney, NSW, Australia; Victor Chang Cardiac Research Institute, Darlinghurst, NSW Australia
| | - Eugene Kotlyar
- Heart Transplant Unit, St Vincent's Hospital, Darlinghurst, NSW, Australia; Victor Chang Cardiac Research Institute, Darlinghurst, NSW Australia
| | - Melanie Lavender
- Advanced Lung Disease Unit, Fiona Stanley Hospital, Murdoch, WA, Australia
| | - Tanya McWilliams
- Greenlane Clinical Centre, Auckland City Hospital, Auckland, New Zealand
| | - Trevor Williams
- Department of Respiratory Medicine, The Alfred Hospital, Melbourne, VIC, Australia; Faculty of Medicine, Nursing and Health Sciences, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Helen Whitford
- Department of Respiratory Medicine, The Alfred Hospital, Melbourne, VIC, Australia; Faculty of Medicine, Nursing and Health Sciences, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Robert Weintraub
- Department of Cardiology, Royal Children's Hospital, Parkville, VIC, Australia; Murdoch Children's Research Institute and Department of Pediatrics, University of Melbourne, Melbourne, VIC, Australia
| | - Jeremy Wrobel
- Advanced Lung Disease Unit, Fiona Stanley Hospital, Murdoch, WA, Australia; Department of Medicine, University of Notre Dame Australia, Fremantle, WA, Australia
| | - Claire Ellender
- Department of Respiratory and Sleep Medicine, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - James Anderson
- Department of Respiratory Medicine, Sunshine Coast University Hospital, Birtinya, QLD, Australia
| | - Edmund M Lau
- Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, Australia; Pulmonary Hypertension Service, Royal Prince Alfred Hospital, Camperdown, NSW, Australia.
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Koemel NA, Laouali N, Senior AM, Celermajer DS, Grech A, Solon-Biet SM, Simpson SJ, Raubenheimer D, Gill TP, Skilton MR. The Relationship between Dietary Macronutrient Composition and Telomere Length Among US Adults. Adv Biol (Weinh) 2024; 8:e2300619. [PMID: 38229191 DOI: 10.1002/adbi.202300619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Indexed: 01/18/2024]
Abstract
The role of dietary macronutrients and energy intake in the aging process has been well-established. However, previous research has mainly focused on the association between leukocyte telomere length (LTL) and individual macronutrients, while the effects of macronutrient composition on LTL remain unclear. This cross-sectional analysis involved 4130 US adults (44.8 ± 17.0 years; 51% female) from the National Health and Nutrition Examination Survey during 1999-2002. A single 24-h dietary recall is used to collect dietary data. The relationship between dietary macronutrient composition and LTL is examined using three-dimensional generalized additive models. After adjustment for age, sex, ethnicity, education, physical activity, BMI, and dietary quality, a three-dimensional association of macronutrient composition with LTL (P = 0.02) is revealed. Diets lower in protein (5-10%), higher in carbohydrates (75%), and lower in fat (15-20%) are associated with the longest LTL corresponding to 7.7 years of slower biological aging. Diets lowest in protein (5%) and carbohydrate (40%), while highest in dietary fat (55%) are associated with the shortest LTL, corresponding to accelerated biological aging of 4.4 years. The associations appeared magnified with higher energy intake. These findings support a complex relationship between dietary macronutrients and biological aging independent of diet quality.
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Affiliation(s)
- Nicholas A Koemel
- Charles Perkins Centre, The University of Sydney, Sydney, 2050, Australia
- Sydney Medical School, The University of Sydney, Sydney, 2050, Australia
| | - Nasser Laouali
- Université Paris-Saclay, CESP UMR1018, UVSQ, Inserm, Gustave Roussy, Villejuif, Paris, 94805, France
- Department of Biostatistics and Epidemiology, School of Public Health and Health Sciences, University of Massachusetts, Amherst, MA, 01003, USA
- Scripps Institution of Oceanography, University of California, San Diego, CA, 92037, USA
| | - Alistair M Senior
- Charles Perkins Centre, The University of Sydney, Sydney, 2050, Australia
- School of Life and Environmental Sciences, The University of Sydney, Sydney, 2050, Australia
| | - David S Celermajer
- Sydney Medical School, The University of Sydney, Sydney, 2050, Australia
| | - Amanda Grech
- Charles Perkins Centre, The University of Sydney, Sydney, 2050, Australia
- School of Life and Environmental Sciences, The University of Sydney, Sydney, 2050, Australia
| | - Samantha M Solon-Biet
- Charles Perkins Centre, The University of Sydney, Sydney, 2050, Australia
- School of Life and Environmental Sciences, The University of Sydney, Sydney, 2050, Australia
| | - Stephen J Simpson
- Charles Perkins Centre, The University of Sydney, Sydney, 2050, Australia
- School of Life and Environmental Sciences, The University of Sydney, Sydney, 2050, Australia
| | - David Raubenheimer
- Charles Perkins Centre, The University of Sydney, Sydney, 2050, Australia
- School of Life and Environmental Sciences, The University of Sydney, Sydney, 2050, Australia
| | - Timothy P Gill
- Charles Perkins Centre, The University of Sydney, Sydney, 2050, Australia
- Sydney Medical School, The University of Sydney, Sydney, 2050, Australia
- Susan Wakil School of Nursing and Midwifery, The University of Sydney, Sydney, 2050, Australia
| | - Michael R Skilton
- Sydney Medical School, The University of Sydney, Sydney, 2050, Australia
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Shafran I, Probst V, Panzenböck A, Sadushi-Kolici R, Gerges C, Wolzt M, Segel MJ, Celermajer DS, Lang IM, Skoro-Sajer N. Asymmetric Dimethylarginine and NT-proBNP Levels Provide Synergistic Information in Pulmonary Arterial Hypertension. JACC Heart Fail 2024:S2213-1779(24)00177-X. [PMID: 38573264 DOI: 10.1016/j.jchf.2024.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 01/24/2024] [Accepted: 02/06/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND Plasma asymmetric dimethylarginine (ADMA) is elevated in pulmonary arterial hypertension (PAH) and is associated with unfavorable outcomes. OBJECTIVES The aim of this study was to assess changes in ADMA plasma levels for monitoring disease progression and outcomes during PAH-specific therapy. METHODS ADMA was measured at baseline and after at least 6 months of follow-up using enzyme-linked immunosorbent assay and high-performance liquid chromatography. Changes in ADMA were analyzed in relation to changes in established PAH markers, including hemodynamic status, N-terminal pro-brain natriuretic peptide (NT-proBNP) and risk assessment scores. Impact on survival was assessed using Kaplan-Meier curves and Cox proportional hazards models. RESULTS Between 2008 and 2019, ADMA samples were collected prospectively from 215 patients with PAH. Change in ADMA plasma level was a predictor of disease progression and survival. ΔADMA (median -0.03 μmol/L; 95% CI: -0.145 to 0.0135) was correlated with change in mean pulmonary arterial pressure (P < 0.005; rS = 0.287) but was not significantly correlated with ΔNT-proBNP (P = 0.056; rS = 0.135). Patients with decreased ADMA plasma levels at follow-up had better 3-year and 5-year survival rates (88% and 80%, respectively, vs 72% and 53% in those without decreases in ADMA) (P < 0.005; pulmonary hypertension-related mortality or lung transplantation). Patients with decreases in both ADMA and NT-proBNP had better survival rates compared with patients in whom only 1 parameter improved (P < 0.005). ΔADMA was a significant predictor of survival in Cox regression analysis and also when corrected for ΔNT-proBNP (HRs: 1.27 and 1.35, respectively; P < 0.005). CONCLUSIONS ADMA and NT-proBNP provide synergistic prognostic information for patients with PAH. ADMA could be used as an objective and distinct biomarker for monitoring treatment response in PAH.
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Affiliation(s)
- Inbal Shafran
- Division of Cardiology, Department of Internal Medicine II, Vienna General Hospital, Medical University of Vienna, Vienna, Austria; Pulmonary Institute, Sheba Medical Center, Tel HaShomer, Ramat Gan, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Victoria Probst
- Division of Cardiology, Department of Internal Medicine II, Vienna General Hospital, Medical University of Vienna, Vienna, Austria
| | - Adelheid Panzenböck
- Division of Cardiology, Department of Internal Medicine II, Vienna General Hospital, Medical University of Vienna, Vienna, Austria
| | - Roela Sadushi-Kolici
- Division of Cardiology, Department of Internal Medicine II, Vienna General Hospital, Medical University of Vienna, Vienna, Austria
| | - Christian Gerges
- Division of Cardiology, Department of Internal Medicine II, Vienna General Hospital, Medical University of Vienna, Vienna, Austria
| | - Michael Wolzt
- Department of Clinical Pharmacology, Vienna General Hospital, Medical University of Vienna, Vienna, Austria
| | - Michael J Segel
- Pulmonary Institute, Sheba Medical Center, Tel HaShomer, Ramat Gan, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Irene Marthe Lang
- Division of Cardiology, Department of Internal Medicine II, Vienna General Hospital, Medical University of Vienna, Vienna, Austria
| | - Nika Skoro-Sajer
- Division of Cardiology, Department of Internal Medicine II, Vienna General Hospital, Medical University of Vienna, Vienna, Austria.
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Ratwatte S, Stewart S, Strange G, Playford D, Celermajer DS. Association of Pulmonary Artery Pressures With Mortality in Adults With Reduced Left Ventricular Ejection Fraction. JACC Heart Fail 2024:S2213-1779(24)00147-1. [PMID: 38520460 DOI: 10.1016/j.jchf.2024.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 01/19/2024] [Accepted: 01/24/2024] [Indexed: 03/25/2024]
Abstract
BACKGROUND The independent effect of pulmonary hypertension (PHT) severity on mortality in those with reduced left ventricular ejection fraction (LVEF) is not well known. OBJECTIVES The authors aimed to examine the prognostic impact of increasingly elevated pulmonary pressures in a large clinical cohort of adults with reduced LVEF. METHODS The authors analyzed data from the National Echocardiography Database of Australia, a large clinical registry linking routine echocardiographic investigations to mortality. In 23,675 adults with a recorded tricuspid regurgitation peak velocity (TRV) and reduced LVEF (<50%), the authors evaluated the relationship between conventional thresholds of increasing risk of PHT and mortality during median follow-up of 2.9 years (Q1-Q3: 1.0-5.4 years). RESULTS Mean age was 70 ± 15 years, and 7,498 (31.7%) individuals were female. Overall, 8,801 (37.2%) had normal (TRV <2.5 m/s), 7,061 (29.8%) had borderline (2.5-2.8 m/s), 5,676 (24.0%) intermediate (2.9-3.4 m/s), and 2,137 (9.0%) individuals had high-risk PHT (>3.4 m/s). With increasing risk of PHT, 1- and 5-year actuarial mortality increased from 13.3% and 43.8% to 41.5% and 81.4%, respectively (P < 0.0001) from normal to severely elevated TRV. The adjusted HR of mortality increased by 1.31-fold (95% CI: 1.23-1.38), 1.82-fold (95% CI: 1.72-1.93), and 2.38-fold (95% CI: 2.21-2.56) in those with borderline, intermediate, and high risk of PHT respectively, compared with normal TRV. Further analyses suggested a distinctive threshold with a TRV reached >2.41 m/s (adjusted HR: 1.18 [95% CI: 1.04-1.33]). CONCLUSIONS The authors demonstrate the prevalence and negative prognostic impact of increasingly elevated TRV levels in individuals with reduced LVEF, with a threshold for mortality lying within the range of "borderline risk" PHT.
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Affiliation(s)
- Seshika Ratwatte
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia; University of Sydney, Faculty of Medicine and Health, Sydney, New South Wales, Australia
| | - Simon Stewart
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, United Kingdom; Institute for Health Research, The University of Notre Dame Australia, Freemantle, Western Australia, Australia
| | - Geoff Strange
- Institute for Health Research, The University of Notre Dame Australia, Freemantle, Western Australia, Australia; Heart Research Institute, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - David Playford
- Institute for Health Research, The University of Notre Dame Australia, Freemantle, Western Australia, Australia
| | - David S Celermajer
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia; University of Sydney, Faculty of Medicine and Health, Sydney, New South Wales, Australia; Heart Research Institute, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia.
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7
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Verrall CE, Tran DL, Kasparian NA, Williams T, Oxenham V, Ayer J, Celermajer DS, Cordina RL. Cognitive Functioning and Psychosocial Outcomes in Adults with Complex Congenital Heart Disease: A Cross-sectional Pilot Study. Pediatr Cardiol 2024; 45:529-543. [PMID: 38261061 PMCID: PMC10891231 DOI: 10.1007/s00246-023-03376-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 12/05/2023] [Indexed: 01/24/2024]
Abstract
Adults with complex congenital heart disease (CHD) are at risk for cognitive dysfunction. However, associations between cognitive dysfunction and psychosocial outcomes are poorly defined. Between June and November 2022, we prospectively recruited 39 adults with complex CHD who completed a computerized cognitive assessment (Cogstate) and validated psychosocial scales measuring psychological distress, health-related quality of life (HRQOL), and resilience. Participants had a mean age of 36.4 ± 11.2 years. Over half (62%) were women, most (79%) had complex biventricular CHD, and 21% had Fontan physiology. Prevalence of cognitive dysfunction was greatest in the domains of attention (29%), working memory (25%), and psychomotor speed (21%). Adjusting for age and sex, Pearson partial correlations between Cogstate z-scores and self-reported cognitive problems were small. Participants who lived in the most disadvantaged areas and those with a below-average annual household income had lower global cognitive z-scores (p = 0.02 and p = 0.03, respectively). Two-thirds (64%) reported elevated symptoms of depression, anxiety, and/or stress. Small correlations were observed between psychological distress and cognitive performance. Greater resilience was associated with lower psychological distress (r ≥ -0.5, p < 0.001) and higher HRQOL (r = 0.33, p = 0.02). Our findings demonstrate that adults with complex CHD have a high risk of cognitive dysfunction, though may not recognize or report their cognitive challenges. Lower socioeconomic status may be an indicator for those at risk of poorer cognitive functioning. Psychological distress is common though may not be a strong correlate of performance-based cognitive functioning. Formal cognitive evaluation in this patient population is essential. Optimizing resilience may be a protective strategy to minimize psychological distress and bolster HRQOL.
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Affiliation(s)
- Charlotte E Verrall
- The University of Sydney School of Medicine, Sydney, NSW, Australia.
- Heart Centre for Children, The Children's Hospital at Westmead, Sydney, NSW, Australia.
- Clinical Research Group, Heart Research Institute, Sydney, NSW, Australia.
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia.
| | - Derek L Tran
- The University of Sydney School of Medicine, Sydney, NSW, Australia
- Clinical Research Group, Heart Research Institute, Sydney, NSW, Australia
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- School of Sport, Exercise and Rehabilitation, University of Technology Sydney, Sydney, NSW, Australia
| | - Nadine A Kasparian
- Heart and Mind Wellbeing Center, Heart Institute and Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Tracey Williams
- Kids Rehab, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Vincent Oxenham
- School of Psychological Sciences, Macquarie University, Sydney, NSW, Australia
- Department of Neurology, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Julian Ayer
- The University of Sydney School of Medicine, Sydney, NSW, Australia
- Heart Centre for Children, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - David S Celermajer
- The University of Sydney School of Medicine, Sydney, NSW, Australia
- Clinical Research Group, Heart Research Institute, Sydney, NSW, Australia
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Rachael L Cordina
- The University of Sydney School of Medicine, Sydney, NSW, Australia
- Clinical Research Group, Heart Research Institute, Sydney, NSW, Australia
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
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Celermajer DS. National Standards of Care for Childhood-onset Heart Disease (CoHD)-A New Paradigm Whereby Healthcare Professionals, Governments and Consumers Work Together to Optimise Patient Care. Heart Lung Circ 2024; 33:147-149. [PMID: 38350798 DOI: 10.1016/j.hlc.2024.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2024]
Affiliation(s)
- David S Celermajer
- Faculty of Medicine and Health, University of Sydney, Sydney; Department of Cardiology, Royal Prince Alfred Hospital, Sydney; and, Heart Research Institute, Sydney, NSW, Australia.
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Lloyd LK, Nicholson C, Strange G, Celermajer DS. The burdensome logistics of data linkage in Australia - the example of a national registry for congenital heart disease. AUST HEALTH REV 2024; 48:8-15. [PMID: 38118279 DOI: 10.1071/ah23185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 11/21/2023] [Indexed: 12/22/2023]
Abstract
Objective Data linkage is a very powerful research tool in epidemiology, however, establishing this can be a lengthy and intensive process. This paper reports on the complex landscape of conducting data linkage projects in Australia. Methods We reviewed the processes, required documentation, and applications required to conduct multi-jurisdictional data linkage across Australia, in 2023. Results Obtaining the necessary approvals to conduct linkage will likely take nearly 2 years (estimated 730 days, including 605 days from initial submission to obtaining all ethical approvals and an estimated further 125 days for the issuance of unexpected additionally required approvals). Ethical review for linkage projects ranged from 51 to 128 days from submission to ethical approval, and applications consisted of 9-25 documents. Conclusions Major obstacles to conducting multi-jurisdictional data linkage included the complexity of the process, and substantial time and financial costs. The process was characterised by inefficiencies at several levels, reduplication, and a lack of any key accountabilities for timely performance of processes. Data linkage is an invaluable resource for epidemiological research. Further streamlining, establishing accountability, and greater collaboration between jurisdictions is needed to ensure data linkage is both accessible and feasible to researchers.
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Affiliation(s)
- Larissa K Lloyd
- Clinical Research Group, Heart Research Institute, Sydney, NSW, Australia; and Cardiology Department, Royal Prince Alfred Hospital, Level 6, Building 75, Missenden Road, Camperdown, Sydney, NSW 2050, Australia; and Faculty of Medicine, The University of Sydney, Sydney, NSW, Australia
| | - Calum Nicholson
- Clinical Research Group, Heart Research Institute, Sydney, NSW, Australia; and Cardiology Department, Royal Prince Alfred Hospital, Level 6, Building 75, Missenden Road, Camperdown, Sydney, NSW 2050, Australia; and Faculty of Medicine, The University of Sydney, Sydney, NSW, Australia
| | - Geoff Strange
- Clinical Research Group, Heart Research Institute, Sydney, NSW, Australia; and Cardiology Department, Royal Prince Alfred Hospital, Level 6, Building 75, Missenden Road, Camperdown, Sydney, NSW 2050, Australia; and Faculty of Medicine, The University of Sydney, Sydney, NSW, Australia
| | - David S Celermajer
- Clinical Research Group, Heart Research Institute, Sydney, NSW, Australia; and Cardiology Department, Royal Prince Alfred Hospital, Level 6, Building 75, Missenden Road, Camperdown, Sydney, NSW 2050, Australia; and Faculty of Medicine, The University of Sydney, Sydney, NSW, Australia
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Ratwatte S, Celermajer DS. Response to: Correspondence on 'Prevalence of pulmonary hypertension in aortic regurgitation and its influence on outcomes' by Michelena et al. Heart 2023; 109:1575. [PMID: 37657913 DOI: 10.1136/heartjnl-2023-323348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/03/2023] Open
Affiliation(s)
- Seshika Ratwatte
- Department of Cardiology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - David S Celermajer
- Department of Cardiology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
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11
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Figtree GA, Vernon ST, Harmer JA, Gray MP, Arnott C, Bachour E, Barsha G, Brieger D, Brown A, Celermajer DS, Channon KM, Chew NWS, Chong JJH, Chow CK, Cistulli PA, Ellinor PT, Grieve SM, Guzik TJ, Hagström E, Jenkins A, Jennings G, Keech AC, Kott KA, Kritharides L, Mamas MA, Mehran R, Meikle PJ, Natarajan P, Negishi K, O'Sullivan J, Patel S, Psaltis PJ, Redfern J, Steg PG, Sullivan DR, Sundström J, Vogel B, Wilson A, Wong D, Bhatt DL, Kovacic JC, Nicholls SJ. Clinical Pathway for Coronary Atherosclerosis in Patients Without Conventional Modifiable Risk Factors: JACC State-of-the-Art Review. J Am Coll Cardiol 2023; 82:1343-1359. [PMID: 37730292 PMCID: PMC10522922 DOI: 10.1016/j.jacc.2023.06.045] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 06/28/2023] [Indexed: 09/22/2023]
Abstract
Reducing the incidence and prevalence of standard modifiable cardiovascular risk factors (SMuRFs) is critical to tackling the global burden of coronary artery disease (CAD). However, a substantial number of individuals develop coronary atherosclerosis despite no SMuRFs. SMuRFless patients presenting with myocardial infarction have been observed to have an unexpected higher early mortality compared to their counterparts with at least 1 SMuRF. Evidence for optimal management of these patients is lacking. We assembled an international, multidisciplinary team to develop an evidence-based clinical pathway for SMuRFless CAD patients. A modified Delphi method was applied. The resulting pathway confirms underlying atherosclerosis and true SMuRFless status, ensures evidence-based secondary prevention, and considers additional tests and interventions for less typical contributors. This dedicated pathway for a previously overlooked CAD population, with an accompanying registry, aims to improve outcomes through enhanced adherence to evidence-based secondary prevention and additional diagnosis of modifiable risk factors observed.
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Affiliation(s)
- Gemma A Figtree
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia; Cardiovascular Discovery Group, Kolling Institute of Medical Research, St Leonards, New South Wales, Australia; Department of Cardiology, Royal North Shore Hospital, St Leonards, New South Wales, Australia.
| | - Stephen T Vernon
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia; Cardiovascular Discovery Group, Kolling Institute of Medical Research, St Leonards, New South Wales, Australia; Department of Cardiology, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Jason A Harmer
- Department of Cardiology, Royal North Shore Hospital, St Leonards, New South Wales, Australia; The George Institute for Global Health, Faculty of Medicine, UNSW, Sydney, New South Wales, Australia
| | - Michael P Gray
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia; Cardiovascular Discovery Group, Kolling Institute of Medical Research, St Leonards, New South Wales, Australia
| | - Clare Arnott
- The George Institute for Global Health, Faculty of Medicine, UNSW, Sydney, New South Wales, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Eric Bachour
- Consumer Representative, Agile Group Switzerland AG, Zug, Switzerland
| | - Giannie Barsha
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia; Cardiovascular Discovery Group, Kolling Institute of Medical Research, St Leonards, New South Wales, Australia
| | - David Brieger
- Department of Cardiology, Concord Repatriation General Hospital, Concord, New South Wales, Australia
| | - Alex Brown
- National Centre for Indigenous Genomics, Australian National University, Canberra, Australian Capitol Territory, Australia; Telethon Kids Institute, Nedlands, Western Australia, Australia
| | - David S Celermajer
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Keith M Channon
- British Heart Foundation Centre of Research Excellence, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Nicholas W S Chew
- Department of Cardiology, National University Heart Centre, National University Health System, Singapore
| | - James J H Chong
- Westmead Applied Research Centre, Faculty of Medicine and Health, University of Sydney, Westmead, New South Wales, Australia; Westmead Institute for Medical Research, University of Sydney, Westmead, New South Wales, Australia; Department of Cardiology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Clara K Chow
- Westmead Applied Research Centre, Faculty of Medicine and Health, University of Sydney, Westmead, New South Wales, Australia; Department of Cardiology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Peter A Cistulli
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia; Charles Perkins Centre, The University of Sydney, Camperdown, New South Wales, Australia; Department of Respiratory & Sleep Medicine, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Patrick T Ellinor
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA; Demoulas Center for Cardiac Arrhythmias, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Stuart M Grieve
- Department of Radiology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia; Imaging and Phenotyping Laboratory, Charles Perkins Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Tomasz J Guzik
- Centre for Cardiovascular Science, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, United Kingdom; Department of Internal Medicine and Omicron Medical Genomics Laboratory, Jagiellonian University Medical College, Krakow, Poland
| | - Emil Hagström
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
| | - Alicia Jenkins
- National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Camperdown, New South Wales, Australia; Diabetes and Vascular Medicine, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Garry Jennings
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Anthony C Keech
- National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Camperdown, New South Wales, Australia
| | - Katharine A Kott
- Cardiovascular Discovery Group, Kolling Institute of Medical Research, St Leonards, New South Wales, Australia; Department of Cardiology, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Leonard Kritharides
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia; Department of Cardiology, Concord Repatriation General Hospital, Concord, New South Wales, Australia; The ANZAC Research Institute, Concord Repatriation General Hospital, Concord, New South Wales, Australia
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Centre for Prognostic Research, Keele University, Keele, United Kingdom; Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Peter J Meikle
- Baker Heart and Diabetes Institute, Melbourne, Vicotria, Australia
| | - Pradeep Natarajan
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts, USA; Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA; Program in Medical and Population Genetics and the Cardiovascular Disease Initiative, Broad Institute of Harvard and Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | - Kazuaki Negishi
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia; Charles Perkins Centre, The University of Sydney, Camperdown, New South Wales, Australia; Department of Cardiology, Nepean Hospital, Kingswood, New South Wales, Australia
| | - John O'Sullivan
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia; Department of Cardiology, Royal North Shore Hospital, St Leonards, New South Wales, Australia; Charles Perkins Centre, The University of Sydney, Camperdown, New South Wales, Australia; Precision Cardiovascular Laboratory, University of Sydney, Camperdown, New South Wales, Australia; Heart Research Institute, University of Sydney, Camperdown, New South Wales, Australia
| | - Sanjay Patel
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia; Heart Research Institute, University of Sydney, Camperdown, New South Wales, Australia
| | - Peter J Psaltis
- Vascular Research Centre, Heart and Vascular Program, Lifelong Health Theme, SAHMRI, Adelaide, South Australia, Australia; Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia; Department of Cardiology, Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Julie Redfern
- The George Institute for Global Health, Faculty of Medicine, UNSW, Sydney, New South Wales, Australia; Sydney School of Health Sciences, Faculty of Medicine and Health, University of Sydney, Camperdown, New South Wales, Australia
| | - Philippe G Steg
- Université de Paris, Assistance Publique-Hôpitaux de Paris, French Alliance for Cardiovascular Trials and INSERM Unité 1148, Paris, France
| | - David R Sullivan
- Department of Chemical Pathology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Johan Sundström
- The George Institute for Global Health, Faculty of Medicine, UNSW, Sydney, New South Wales, Australia; Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Birgit Vogel
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Andrew Wilson
- Menzies Centre for Health Policy and Economics, Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Camperdown, New South Wales, Australia
| | - Dennis Wong
- Monash Cardiovascular Research Centre, Monash University, Clayton, Victoria, Australia; MonashHeart, Monash Health, Clayton, Victoria, Australia
| | - Deepak L Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai Health System, New York, New York, USA
| | - Jason C Kovacic
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Victor Chang Cardiac Research Institute, Darlinghurst, New South Wales, Australia; St Vincent's Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Stephen J Nicholls
- Victorian Heart Institute, Monash University, Clayton, Victoria, Australia
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van Dissel AC, Opotowsky AR, Burchill LJ, Aboulhosn J, Grewal J, Lubert AM, Antonova P, Shah S, Cotts T, John AS, Kay WA, DeZorzi C, Magalski A, Han F, Baker D, Kay J, Yeung E, Vonder Muhll I, Pylypchuk S, Kuo MC, Nicolarsen J, Sarubbi B, Fusco F, Jameson SM, Cramer J, Gupta T, Gallego P, O’Donnell C, Hannah J, Dellborg M, Kauling RM, Ginde S, Krieger EV, Rodriguez F, Dehghani P, Kutty S, Wong J, Wilson WM, Rodriguez-Monserrate CP, Roos-Hesselink J, Celermajer DS, Khairy P, Broberg CS. End-stage heart failure in congenitally corrected transposition of the great arteries: a multicentre study. Eur Heart J 2023; 44:3278-3291. [PMID: 37592821 PMCID: PMC10482567 DOI: 10.1093/eurheartj/ehad511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 05/19/2023] [Accepted: 07/25/2023] [Indexed: 08/19/2023] Open
Abstract
BACKGROUND AND AIMS For patients with congenitally corrected transposition of the great arteries (ccTGA), factors associated with progression to end-stage congestive heart failure (CHF) remain largely unclear. METHODS This multicentre, retrospective cohort study included adults with ccTGA seen at a congenital heart disease centre. Clinical data from initial and most recent visits were obtained. The composite primary outcome was mechanical circulatory support, heart transplantation, or death. RESULTS From 558 patients (48% female, age at first visit 36 ± 14.2 years, median follow-up 8.7 years), the event rate of the primary outcome was 15.4 per 1000 person-years (11 mechanical circulatory support implantations, 12 transplantations, and 52 deaths). Patients experiencing the primary outcome were older and more likely to have a history of atrial arrhythmia. The primary outcome was highest in those with both moderate/severe right ventricular (RV) dysfunction and tricuspid regurgitation (n = 110, 31 events) and uncommon in those with mild/less RV dysfunction and tricuspid regurgitation (n = 181, 13 events, P < .001). Outcomes were not different based on anatomic complexity and history of tricuspid valve surgery or of subpulmonic obstruction. New CHF admission or ventricular arrhythmia was associated with the primary outcome. Individuals who underwent childhood surgery had more adverse outcomes than age- and sex-matched controls. Multivariable Cox regression analysis identified older age, prior CHF admission, and severe RV dysfunction as independent predictors for the primary outcome. CONCLUSIONS Patients with ccTGA have variable deterioration to end-stage heart failure or death over time, commonly between their fifth and sixth decades. Predictors include arrhythmic and CHF events and severe RV dysfunction but not anatomy or need for tricuspid valve surgery.
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Affiliation(s)
- Alexandra C van Dissel
- Department of Clinical and Experimental Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Knight Cardiovascular Institute, Oregon Health and Science University, 3181 SW Sam Jackson Pk Rd, Portland, OR 97221, USA
| | - Alexander R Opotowsky
- Department of Paediatrics, Cincinnati Children’s Hospital Medical Centre, Heart Institute, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Luke J Burchill
- Department of Medicine, Royal Melbourne Hospital, Melbourne, Australia
| | | | - Jasmine Grewal
- Division of Cardiology, St Paul’s Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Adam M Lubert
- Department of Paediatrics, Cincinnati Children’s Hospital Medical Centre, Heart Institute, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | | | | | - Timothy Cotts
- University of Michigan Medical Centre, Ann Arbor, MI, USA
| | | | | | - Christopher DeZorzi
- University of Missouri–Kansas City and Saint Luke’s Hospital, Kansas City, MO, USA
| | - Anthony Magalski
- University of Missouri–Kansas City and Saint Luke’s Hospital, Kansas City, MO, USA
| | - Frank Han
- University of Illinois, Chicago, IL, USA
| | - David Baker
- The University of Sydney and Royal Prince Alfred Hospital, Sydney, Australia
| | - Joseph Kay
- Colorado University School of Medicine, Denver, CO, USA
| | | | | | | | - Marissa C Kuo
- Emory University School of Medicine, Atlanta, GA, USA
| | | | | | | | - Susan M Jameson
- Departments of Paediatrics and Cardiovascular Medicine, School of Medicine, Stanford University, Palo Alto, CA, USA
| | - Jonathan Cramer
- Children’s Hospital, University of Nebraska Medical Centre, Omaha, NE, USA
| | | | - Pastora Gallego
- Hospital Universitario Virgen Del Rocio, Sevilla, Spain
- European Reference Network for Rare, Low Prevalence and Complex Disease of the Heart—ERN GUARD Heart
| | - 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
| | | | - Salil Ginde
- Children’s Hospital of Wisconsin, Milwaukee, WI, USA
| | - Eric V Krieger
- University of Washington Medical Centre and Seattle Children’s Hospital, Seattle, WA, USA
| | | | | | | | - Joshua Wong
- Department of Medicine, Royal Melbourne Hospital, Melbourne, Australia
| | - William M Wilson
- Department of Medicine, Royal Melbourne Hospital, Melbourne, Australia
| | | | - Jolien Roos-Hesselink
- European Reference Network for Rare, Low Prevalence and Complex Disease of the Heart—ERN GUARD Heart
- Erasmus Medical Centre, Rotterdam, The Netherlands
| | - David S Celermajer
- The University of Sydney and Royal Prince Alfred Hospital, Sydney, Australia
| | - Paul Khairy
- Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | - Craig S Broberg
- Knight Cardiovascular Institute, Oregon Health and Science University, 3181 SW Sam Jackson Pk Rd, Portland, OR 97221, USA
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13
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Celermajer DS, Baker DW, Cordina RL, Gatzoulis M, Broberg CS. Common diagnostic errors in adults with congenital heart disease. Eur Heart J 2023; 44:3217-3227. [PMID: 36527303 DOI: 10.1093/eurheartj/ehac717] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 10/07/2022] [Accepted: 11/20/2022] [Indexed: 09/08/2023] Open
Abstract
Owing to the great advances in the care for children with congenital heart disease by paediatric cardiac surgeons and cardiologists, there are ever increasing numbers of patients with congenital heart disease who reach adult life. At some stage during the late teenage years or soon after, these patients 'transition' from paediatric cardiac care to surveillance by cardiologists who look after adults. Many such specialists, however, are more familiar with commoner acquired heart problems such as coronary disease, heart failure, and arrhythmia in structurally normal hearts and less familiar with congenital heart disease. For this reason, international guidelines have suggested that the care of young adults with congenital heart disease take place in designated specialist adult congenital heart disease centres. It remains very important, however, for general cardiologists to have a good understanding of many aspects of adult congenital heart disease, including common pitfalls to avoid and, importantly, when to refer on, to a specialist centre. To help healthcare providers across the spectrum of cardiology practice to address common themes in adult congenital heart disease, this state-of-the-art review provides a series of case vignettes to illustrate frequent diagnostic problems that we have seen in our tertiary-level adult congenital heart disease centres, which are sometimes encountered in general cardiology settings. These include commonly 'missed' diagnoses, or errors with diagnosis or management, in these often very complex patients.
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Affiliation(s)
- David S Celermajer
- Sydney Medical School, University of Sydney, Sydney, NSW 2006, Australia
- Department of Cardiology, Royal Prince Alfred Hospital, Missenden Rd, Camperdown, NSW 2050, Australia
| | - David W Baker
- Sydney Medical School, University of Sydney, Sydney, NSW 2006, Australia
- Department of Cardiology, Royal Prince Alfred Hospital, Missenden Rd, Camperdown, NSW 2050, Australia
| | - Rachael L Cordina
- Sydney Medical School, University of Sydney, Sydney, NSW 2006, Australia
- Department of Cardiology, Royal Prince Alfred Hospital, Missenden Rd, Camperdown, NSW 2050, Australia
| | - Michael Gatzoulis
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton Hospital, London, UK
- National Heart and Lung Institute, Imperial College School of Medicine, London, UK
| | - Craig S Broberg
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, OR, USA
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Snir AD, Ng MK, Strange G, Playford D, Stewart S, Celermajer DS. The prognostic significance of stroke volume index in low gradient severe aortic stenosis: from the national echo database of Australia. Int J Cardiovasc Imaging 2023; 39:1719-1727. [PMID: 37300593 PMCID: PMC10520126 DOI: 10.1007/s10554-023-02886-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 05/24/2023] [Indexed: 06/12/2023]
Abstract
Approximately 50% of patients with severe aortic stenosis (AS) in clinical practice present with 'low-gradient' haemodynamics. Stroke Volume Index (SVI) is a measure of left ventricular output, with 'normal-flow' considered as > 35 ml/m2. The association between SVI and prognosis in severe low-gradient AS (LGAS) in currently not well-understood. We analysed the National Echo Database of Australia (NEDA) and identified 109,990 patients with sufficiently comprehensive echocardiographic data, linked to survival information. We identified 1,699 with severe LGAS and preserved ejection fraction (EF) (≥ 50%) and 774 with severe LGAS and reduced EF. One- and three-year survival in each subgroup were assessed (follow-up of 74 ± 43 months), according to SVI thresholds. In patients with preserved EF the mortality "threshold" was at SVI < 30 ml/m2; 1- and 3-year survival was worse for those with SVI < 30 ml/m2 relative to those with SVI > 35 ml/m2 (HR 1.80, 95% CI 1.32-2.47 and HR 1.38, 95% CI 1.12-1.70), while survival was similar between those with SVI 30-35 ml/m2 and SVI > 35 ml/m2. In patients with reduced EF the mortality "threshold" was 35 ml/m2; 1- and 3-year survival was worse for both those with SVI < 30 ml/m2 and 30-35 ml/m2 relative to those with SVI > 35 ml/m2 (HR 1.98, 95% CI 1.27-3.09 and HR 1.41, 95% CI 1.05-1.93 for SVI < 30 ml/m2 and HR 2.02, 95% CI 1.23-3.31 and HR 1.56, 95% CI 1.10-2.21 for SVI 30-35 ml/m2). The SVI prognostic threshold for medium-term mortality in severe LGAS patients is different for those with preserved LVEF (< 30 ml/m2) compared to those with reduced LVEF (< 35 ml/m2).
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Affiliation(s)
- Afik D Snir
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Martin K Ng
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- Department of Cardiology, Royal Prince Alfred Hospital, NSW, Camperdown, Australia
| | - Geoff Strange
- University of Notre Dame, Fremantle, WA, Australia
- Heart Research Institute, Newtown, NSW, Australia
| | | | - Simon Stewart
- University of Notre Dame, Fremantle, WA, Australia
- University of Glasgow, Glasgow, Scotland
| | - David S Celermajer
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia.
- Department of Cardiology, Royal Prince Alfred Hospital, NSW, Camperdown, Australia.
- Heart Research Institute, Newtown, NSW, Australia.
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Ratwatte S, Playford D, Stewart S, Strange G, Celermajer DS. Prevalence of pulmonary hypertension in aortic regurgitation and its influence on outcomes. Heart 2023; 109:1310-1318. [PMID: 37012044 DOI: 10.1136/heartjnl-2022-322187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 03/02/2023] [Indexed: 04/05/2023] Open
Abstract
OBJECTIVE Aortic regurgitation (AR) can lead to pulmonary hypertension (PHT). There is a paucity of data on the prognostic importance of PHT in these patients. We therefore aimed to describe the prevalence and prognostic importance of PHT in such patients. METHODS In this retrospective study, we analysed the National Echocardiography Database of Australia (data from 2000 to 2019). Adults with an estimated right ventricular systolic pressure (eRVSP), left ventricular ejection fraction (LVEF) >50% and with moderate or greater AR were included (n=8392). These subjects were then categorised according to their eRVSP. The relationship between PHT severity and mortality outcomes were evaluated (median follow-up of 3.1 years, IQR 1.5-5.7 years). RESULTS Subjects were aged 74±14 years and 58.4% (4901) were female. Overall, 1417 (16.9%) had no PHT, and 3253 (38.8%), 2249 (26.9%), 893 (10.6%) and 580 (6.9%) patients had borderline, mild, moderate and severe PHT, respectively. Mean eRVSP was slightly higher in females than males (41±13 vs 39±12 mm Hg, p<0.0001) and increased with age in both sexes. After adjustment for age and sex, the risk of long-term mortality increased as eRVSP increased (adjusted HR (aHR) 1.20, 95% CI 1.06 to 1.36 in borderline PHT, to aHR 3.32, 95% CI 2.85 to 3.86 in severe PHT, p<0.0001). There was a mortality threshold seen from mild PHT onwards (eRVSP 41.36-44.15 mm Hg; aHR 1.41, 95%CI 1.17 to 1.68). CONCLUSIONS In this large cohort study, we characterise the relationship between AR and PHT in adults. In patients with ≥moderate AR, PHT is associated with a progressive risk of mortality, even at mildly elevated levels.
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Affiliation(s)
- Seshika Ratwatte
- Department of Cardiology, Royal Prince Albert Hospital, Camperdown, New South Wales, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - David Playford
- Institute for Health Research, The University of Notre Dame Australia, Fremantle, Western Australia, Australia
| | - Simon Stewart
- Institute for Health Research, The University of Notre Dame Australia, Fremantle, Western Australia, Australia
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Geoff Strange
- Heart Research Institute Ltd, Newtown, New South Wales, Australia
- The University of Notre Dame Australia School of Medicine, Fremantle, Western Australia, Australia
| | - David S Celermajer
- Department of Cardiology, Royal Prince Albert Hospital, Camperdown, New South Wales, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
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Ratwatte S, Stewart S, Strange G, Playford D, Celermajer DS. Prevalence of pulmonary hypertension in aortic stenosis and its influence on outcomes. Heart 2023; 109:1319-1326. [PMID: 37012043 DOI: 10.1136/heartjnl-2022-322184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 03/21/2023] [Indexed: 04/05/2023] Open
Abstract
OBJECTIVE The significance of pulmonary hypertension (PHT) complicating aortic stenosis (AS) is poorly characterised. In a large cohort of adults with at least moderate AS, we aimed to describe the prevalence and prognostic importance of PHT in such patients. METHODS In this retrospective study, we analysed the National Echocardiography Database of Australia (data from 2000 to 2019). Adults with an estimated right ventricular systolic pressure (eRVSP), left ventricular ejection fraction (LVEF) >50% and with moderate or greater AS were included (n=14 980). These subjects were then categorised according to their eRVSP. The relationship between PHT severity and mortality outcomes were evaluated (median follow-up of 2.6 years, IQR 1.0-4.6 years). RESULTS Subjects were aged 77±13 years and 57.4% were female. Overall, 2049 (13.7%), 5085 (33.9%), 4380 (29.3%), 1956 (13.1%) and 1510 (10.1%) patients had no (eRVSP<30.00 mm Hg), borderline (30.00-39.99 mm Hg), mild (40.00-49.99 mm Hg), moderate (50.00-59.99 mm Hg) and severe PHT (>60.00 mm Hg), respectively. An echocardiographic phenotype was evident with worsening PHT, showing rising E:e' ratio and right and left atrial sizes(p<0.0001, for all). Adjusted analyses showed that the risk of long-term mortality progressively rose as eRVSP level increased (HR 1.14-2.94, borderline to severe PHT, p<0.0001 for all). A mortality threshold was identified in the 4th decile of eRVSP categories (35.01-38.00 mm Hg; HR 1.19, 95% CI 1.04 to 1.35), with risk progressively increasing through to the 10th decile (HR 2.86, 95% CI 2.54 to 3.21). CONCLUSIONS In this large cohort study, we find that PHT is common in ≥moderate AS and mortality increases as PHT becomes more severe. A threshold for higher mortality lies within the range of 'borderline-mild' PHT. TRIAL REGISTRATION NUMBER ACTRN12617001387314.
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Affiliation(s)
- Seshika Ratwatte
- Department of Cardiology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
- School of Medicine and Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Simon Stewart
- Institute for Health Research, The University of Notre Dame Australia, Fremantle, Western Australia, Australia
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Geoff Strange
- Institute for Health Research, The University of Notre Dame Australia, Fremantle, Western Australia, Australia
- Heart Research Institute Ltd, Newtown, Sydney, Australia
| | - David Playford
- Institute for Health Research, The University of Notre Dame Australia, Fremantle, Western Australia, Australia
| | - David S Celermajer
- Department of Cardiology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
- School of Medicine and Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
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Ratwatte S, Strange G, Playford D, Stewart S, Celermajer DS. Prevalence of pulmonary hypertension in mitral regurgitation and its influence on outcomes. Open Heart 2023; 10:openhrt-2023-002268. [PMID: 37280015 DOI: 10.1136/openhrt-2023-002268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 05/18/2023] [Indexed: 06/08/2023] Open
Abstract
OBJECTIVE Pulmonary hypertension (PHT) commonly coexists with significant mitral regurgitation (MR), but its prevalence and prognostic importance have not been well characterised. In a large cohort of adults with moderate or greater MR, we aimed to describe the prevalence and severity of PHT and assess its influence on outcomes. METHODS In this retrospective study, we analysed the National Echocardiography Database of Australia (data from 2000 to 2019). Adults with an estimated right ventricular systolic pressure (eRVSP), left ventricular ejection fraction >50% and with moderate or greater MR were included (n=9683). These subjects were then categorised according to their eRVSP. The relationship between PHT severity and mortality outcomes was evaluated (median follow-up of 3.2 years, IQR 1.3-6.2 years). RESULTS Subjects were aged 76±12 years, and 62.6% (6038) were women. Overall, 959 (9.9%) had no PHT, and 2952 (30.5%), 3167 (32.7%), 1588 (16.4%) and 1017 (10.5%) patients had borderline, mild, moderate and severe PHT, respectively. A 'typical left heart disease' phenotype was identified with worsening PHT, showing rising E:e', right and left atrial sizes increasing progressively, from no PHT to severe PHT (p<0.0001, for all). With increasing PHT severity, 1- and 5-year actuarial mortality increased from 8.5% and 33.0% to 39.7% and 79.8%, respectively (p<0.0001). Similarly, adjusted survival analysis showed the risk of long-term mortality progressively increased with higher eRVSP levels (adjusted HR 1.20-2.86, borderline to severe PHT, p<0.0001 for all). A mortality inflection was apparent at an eRVSP level >34.00 mm Hg (HR 1.27, CI 1.00-1.36). CONCLUSIONS In this large study, we report on the importance of PHT in patients with MR. Mortality increases as PHT becomes more severe from an eRVSP of 34 mm Hg onwards.
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Affiliation(s)
- Seshika Ratwatte
- Department of Cardiology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Geoff Strange
- Institute for Health Research, The University of Notre Dame Australia, Fremantle, Western Australia, Australia
- Heart Research Institute Ltd, Newtown, New South Wales, Australia
| | - David Playford
- Institute for Health Research, The University of Notre Dame Australia, Fremantle, Western Australia, Australia
| | - Simon Stewart
- Institute for Health Research, The University of Notre Dame Australia, Fremantle, Western Australia, Australia
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - David S Celermajer
- Department of Cardiology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
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Lloyd LK, Nasir R, Nicholson C, Strange G, Celermajer DS. Obstacles in establishing a national disease registry in Australia: lessons from the development of the CHAANZ Congenital Heart Disease Registry. AUST HEALTH REV 2023:AH23063. [PMID: 37188545 DOI: 10.1071/ah23063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 04/26/2023] [Indexed: 05/17/2023]
Abstract
ObjectivesTo provide insights into the obstacles which pose challenges to the set-up of any National Registry in Australia.MethodsAn analysis of our experience in executing a Multi-Institutional Agreement (MIA) and obtaining ethics and governance approvals, post-award of a large Medical Research Futures Fund grant in June 2020.ResultsFrom July 2020, our timeline to an executed MIA was 283 days, despite full-time staff working towards this goal. Subsequently, after lead site ethics approval, time to site governance approvals ranged from 9 to 291 days. A total of 214 emails were sent during the MIA development and signing. There were 11-71 emails sent to individual governance offices and the number of requested points of additional information ranged from 0 to 31 queries.ConclusionsThere were considerable time delays in executing the initial (pre-research) stages of a National Federal Government funded Registry project which required substantial time and resources. We report a wide variation in requirements between different states and institutions. We propose several strategies which could be implemented to facilitate a more streamlined approach to research ethics and governance. This centralised approach would allow for better use of funding and facilitate better progress in medical research.
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Nicholson C, Hanly M, Celermajer DS. An interactive geographic information system to inform optimal locations for healthcare services. PLOS Digit Health 2023; 2:e0000253. [PMID: 37155602 PMCID: PMC10166531 DOI: 10.1371/journal.pdig.0000253] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Accepted: 04/11/2023] [Indexed: 05/10/2023]
Abstract
Large health datasets can provide evidence for the equitable allocation of healthcare resources and access to care. Geographic information systems (GIS) can help to present this data in a useful way, aiding in health service delivery. An interactive GIS was developed for the adult congenital heart disease service (ACHD) in New South Wales, Australia to demonstrate its feasibility for health service planning. Datasets describing geographic boundaries, area-level demographics, hospital driving times, and the current ACHD patient population were collected, linked, and displayed in an interactive clinic planning tool. The current ACHD service locations were mapped, and tools to compare current and potential locations were provided. Three locations for new clinics in rural areas were selected to demonstrate the application. Introducing new clinics changed the number of rural patients within a 1-hour drive of their nearest clinic from 44·38% to 55.07% (79 patients) and reduced the average driving time from rural areas to the nearest clinic from 2·4 hours to 1·8 hours. The longest driving time was changed from 10·9 hours to 8·9 hours. A de-identified public version of the GIS clinic planning tool is deployed at https://cbdrh.shinyapps.io/ACHD_Dashboard/. This application demonstrates how a freely available and interactive GIS can be used to aid in health service planning. In the context of ACHD, GIS research has shown that adherence to best practice care is impacted by patients' accessibility to specialist services. This project builds on this research by providing opensource tools to build more accessible healthcare services.
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Affiliation(s)
- Calum Nicholson
- Central Clinical School, University of Sydney Faculty of Medicine and Health, Darlington, New South Wales, Australia
- Clinical Research Group, Heart Research Institute, Newtown, New South Wales, Australia
- Cardiology Department, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Mark Hanly
- Centre for Big Data Research in Health, University of New South Wales, Kensington, New South Wales, Australia
| | - David S Celermajer
- Central Clinical School, University of Sydney Faculty of Medicine and Health, Darlington, New South Wales, Australia
- Clinical Research Group, Heart Research Institute, Newtown, New South Wales, Australia
- Cardiology Department, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
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James NL, Milijasevic Z, Ujhazy A, Huber D, Rotne R, Edwards G, Jermyn K, Celermajer DS. Safety evaluation of the guardian device on the common carotid artery in sheep. Heliyon 2023; 9:e14909. [PMID: 37064446 PMCID: PMC10102196 DOI: 10.1016/j.heliyon.2023.e14909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 03/15/2023] [Accepted: 03/21/2023] [Indexed: 03/28/2023] Open
Abstract
Background Pulse pressure intensity in middle-aged adults is a risk factor for dementia. The Guardian device (The Brain Protection Company, Sydney, Australia) has been developed to reduce pulse pressure, as a potential therapy. Objectives The aim of this study was to evaluate the safety of the Guardian, a novel pulse modulation device designed to reduce the intensity of the pulse pressure that penetrates into the cerebral small vessels. The Guardian is a helix that gently wraps around the common carotid artery (CCA) to slightly change its shape, to absorb pulsatility, without lowering flow. Methods The Guardian was implanted bilaterally on the CCAs of 10 mature sheep for chronic implant periods of 3, 6 or 8 months. The ratio of internal device diameter to outer diameter of the CCA varied from 63% to 92% (n = 20). The implant position on the vessel was marked surgically at implant. Gross pathology and histopathology of the CCA were examined at 3- and 6-months post explant. Most devices were explanted using open surgery, however minimally invasive surgical explant techniques were examined in 2 animals to assess the potential of this approach for explant in humans if required. Results The Guardian was successfully implanted with no adverse events, and minimally invasive explant appeared to be viable for removal. Following implant, the device was surrounded by a thin fibrous capsule, with similar pathology at 3- and 6-months. Minimal or no movement was observed. CCA sections appeared histologically normal, with no evidence of thrombosis, stenosis, fibrosis, chronic inflammatory response, or vessel degeneration. Conclusions The feasibility of surgical implantation and biomaterial safety of the Guardian was confirmed over 8 months. Minimally invasive explant of the Guardian has the potential to be viable. Further work is required to demonstrate efficacy in vitro and/or in vivo before evaluation in humans.
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Moonen A, Ng MKC, Playford D, Strange G, Scalia GM, Celermajer DS. Atrial functional mitral regurgitation: prevalence, characteristics and outcomes from the National Echo Database of Australia. Open Heart 2023; 10:openhrt-2022-002180. [PMID: 36792312 PMCID: PMC9933756 DOI: 10.1136/openhrt-2022-002180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 01/30/2023] [Indexed: 02/17/2023] Open
Abstract
AIMS Atrial functional mitral regurgitation (AFMR) is characterised by left atrial and consequent mitral annular dilatation causing mitral regurgitation. AFMR is likely to become more common with population ageing, alongside increases in atrial fibrillation and heart failure with preserved ejection fraction; conditions causing atrial dilatation. Here, we aim to define the prevalence and characterise the patient and survival characteristics of AFMR in the National Echocardiographic Database of Australia (NEDA). METHODS AND RESULTS 14 004 adults with moderate or severe FMR were identified from NEDA. AFMR or ventricular FMR (VFMR) was classified by LA size, LV size and LVEF. AFMR was found in 40% (n=5562) and VFMR in 60% (n=8442). Compared with VFMR, the AFMR subgroup were significantly older (mean age 78±11 years), with a higher proportion of females and of AF. Participants were followed up for a median of 65 months (IQR 36-116 months). After adjustment for age, sex, AF, and pulmonary hypertension, the prognosis for VFMR was significantly worse than for AFMR (HR 1.57, 95% CI 1.47 to 1.68 for all-cause and 1.73, 95% CI 1.60 to 1.88, p<0.001 for both). After further adjustment for LVEF, mortality rates were similar in VFMR and AFMR patients (HR 0.93, p=NS), though advancing age and pulmonary hypertension remained independently associated with prognosis. CONCLUSIONS AFMR is a common cause of significant functional MR that predominantly affects elderly female patients with AF. Advancing age and pulmonary hypertension independently associated with survival in FMR. Prognosis was better in AFMR compared with VFMR; however, this difference was accounted for by LV systolic impairment and not by MR severity.
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Affiliation(s)
- Avalon Moonen
- School of Medicine, The University of Sydney, Sydney, New South Wales, Australia
| | - Martin K C Ng
- School of Medicine, The University of Sydney, Sydney, New South Wales, Australia,Department of Cardiology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - David Playford
- School of Medicine, The University of Notre Dame Australia, Fremantle, Western Australia, Australia
| | - Geoff Strange
- School of Medicine, The University of Notre Dame Australia, Fremantle, Western Australia, Australia
| | - Gregory M Scalia
- The University of Queensland, Saint Lucia, Queensland, Australia,Department of Cardiology, The Prince Charles Hospital, Chermside, Queensland, Australia
| | - David S Celermajer
- School of Medicine, The University of Sydney, Sydney, New South Wales, Australia .,Department of Cardiology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
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Offen S, Puranik R, Baker D, Cordina R, Chard R, Celermajer DS. Prevalence and determinants of tricuspid regurgitation after repair of tetralogy of Fallot. Int J Cardiol 2023; 372:55-59. [PMID: 36436685 DOI: 10.1016/j.ijcard.2022.11.039] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 11/16/2022] [Accepted: 11/22/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND The prevalence and determinants of tricuspid regurgitation (TR) in patients with repaired Tetralogy of Fallot (rTOF) remain incompletely understood. OBJECTIVES To explore the prevalence of and factors associated with TR in patients with rTOF, specifically, the relationship of right ventricular (RV) dilatation with TR severity. METHODS Patients (≥17 yrs) with rTOF referred to our service (2000-2019) were identified. Those with severe pulmonary stenosis, significant shunt, or previous tricuspid valve surgery were excluded. Using standard cardiac MRI protocols, RV, right atrial (RA) and tricuspid valve (TV) parameters were measured and compared. RESULTS 68 consecutively eligible patients with rTOF were included in the study (27 ± 9 yrs., 35% female). Despite substantial RV volume overload (mean RVEDVi 153 mL/m2), the majority of the cohort (78%) had no or only mild TR. RA volumes, tenting height/area and annular diameter were normal (4.9 ± 2.0 mm, 1.1 ± 1.0 cm2 and 32.4 ± 6.2 mm, respectively). There was no significant correlation of TR fraction with RVEDVi (r = 0.13; p = 0.30), RVEF (r = 0.09; p = 0.44) or tricuspid annular diameter (r = 0.07; p = 0.62). Only RAVi showed a weak but significant correlation with TR fraction (0.29; p = 0.03). In a pooled cohort analysis, including both rTOF patients and adults with a dilated RV from pre-tricuspid shunt lesions, only rTOF was independently associated with higher TR fraction (p = 0.017). CONCLUSION Despite substantial RV dilatation in a cohort with rTOF, there was surprisingly little TR. We found poor correlation between RVEDVi, RA volumes, tricuspid annular dilatation and the presence of significant TR. These findings question commonly held notions regarding the pathophysiology of functional TR in these patients.
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Affiliation(s)
- Sophie Offen
- Faculty of Medicine and Health, University of Sydney, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Australia
| | - Raj Puranik
- Faculty of Medicine and Health, University of Sydney, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Australia
| | - David Baker
- Department of Cardiology, Royal Prince Alfred Hospital, Australia
| | - Rachael Cordina
- Faculty of Medicine and Health, University of Sydney, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Australia
| | - Richard Chard
- Department of Cardiology, Westmead Hospital, Australia
| | - David S Celermajer
- Faculty of Medicine and Health, University of Sydney, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Australia; Heart Research Institute, Australia.
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Kwok CYT, Poon YKP, Chook P, Guo DS, Lin CQ, Yin YH, Celermajer DS, Woo KS. A Potential Strategy for Atherosclerosis Prevention in Modernizing China - Hyperhomocysteinemia, MTHFR C677T Polymorphism and Air Pollution (PM2.5) on Atherogenesis in Chinese Adults. J Nutr Health Aging 2023; 27:134-141. [PMID: 36806868 DOI: 10.1007/s12603-023-1889-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Atherosclerosis is one of the most important global health hazards and air pollution (AP, PM2.5) has been implicated. In addition to traditional risk factors hyperhomocysteinemia (HC) has been recognized in many parts of China related to risk of stroke. METHODS To evaluate the impact of HC (homocysteine >14μmol/l) and PM2.5 air pollution on atherogenesis in modernizing China, we studied 756 asymptomatic Chinese in China from 1998-2007. PM2.5 exposure, HC, folate, and methylenetetrahydrofolate reductase (MTHFR) C/T genotype were evaluated. Brachial flow-mediated dilation (FMD) and carotid intima-media thickness (IMT) were measured by ultrasound. Locations were categorized as zones 1, 2 and 3, with increasing PM2.5 exposure. RESULTS HC was higher (19.4±13.1 and 27.1±25.1μmol/l) in high PM2.5-polluted zones 2 and 3 than in zone 1 (9.7±4.5μmol/l, p<0.0015). The top HC tertile was characterized by lower folate and vitamin B12, but a higher proportion of the MTHFR TT genotype, Metabolic Syndrome (MS) and PM2.5 level (p=0.0018). FMD was significantly lower (7.3±2.3%) and carotid IMT thicker (0.63±0.12mm) in the top HC tertile, compared with low HC tertile (8.4±2.5%, p<0.0001; 0.57±0.1mm, p<0.0001 respectively). Similar differences in FMD and IMT were seen in zones 2 and 3, compared with zone 1 (p<0.0001). On multivariate regression, HC was related to male gender (beta=0.106, p=0.021), MTHFR-TT (beta=0.935, p<0.0001), locations (beta=0.230, p<0.0001) and folate-MTHFR interaction (beta=-0.566, p<0.0001). FMD was related to age (beta= -0.221; p<0.0001), male gender (beta= -0.194, p=0.001) PM2.5 and location (beta=-0.285 to -0.303, p<0.0001). Carotid IMT was related to PM2.5 (beta=0.173, p<0.0001), HC (0.122, p=0.006) but not to MTHFR or location, independent of age, gender, MS, and LDL-C. No significant HC-PM2.5 interaction effect on FMD and IMT was observed. CONCLUSION HC and PM2.5 pollution but not MTHFR genotype were both related to carotid IMT, independent of other traditional risk factors. This has potential implications in dietary and AP strategies for atherosclerosis prevention in China.
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Affiliation(s)
- C Y T Kwok
- Prof KS Woo, Department of Medicine and Therapeutics, Tsang Shiu Tim Building, United College, The Chinese University of Hong Kong, Shatin NT, Hong Kong, Phone: (852) 2647 4966, Fax: (852) 2647 4966, E-mail:
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Karimi Galougahi K, Zhang Y, Kienzle V, Liu C, Quek L, Patel S, Lau E, Cordina R, Figtree GA, Celermajer DS. β3 adrenergic agonism: A novel pathway which improves right ventricular-pulmonary arterial hemodynamics in pulmonary arterial hypertension. Physiol Rep 2023; 11:e15549. [PMID: 36597221 PMCID: PMC9810839 DOI: 10.14814/phy2.15549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 11/29/2022] [Accepted: 12/01/2022] [Indexed: 06/17/2023] Open
Abstract
Efficacy of therapies that target the downstream nitric oxide (NO) pathway in pulmonary arterial hypertension (PAH) depends on the bioavailability of NO. Reduced NO level in PAH is secondary to "uncoupling" of endothelial nitric oxide synthase (eNOS). Stimulation of β3 adrenergic receptors (β3 ARs) may lead to the recoupling of NOS and therefore be beneficial in PAH. We aimed to examine the efficacy of β3 AR agonism as a novel pathway in experimental PAH. In hypoxia (5 weeks) and Sugen hypoxia (hypoxia for 5 weeks + SU5416 injection) models of PAH, we examined the effects of the selective β3 AR agonist CL316243. We measured echocardiographic indices and invasive right ventricular (RV)-pulmonary arterial (PA) hemodynamics and compared CL316243 with riociguat and sildenafil. We assessed treatment effects on RV-PA remodeling, oxidative stress, and eNOS glutathionylation, an oxidative modification that uncouples eNOS. Compared with normoxic mice, RV systolic pressure was increased in the control hypoxic mice (p < 0.0001) and Sugen hypoxic mice (p < 0.0001). CL316243 reduced RV systolic pressure, to a similar degree to riociguat and sildenafil, in both hypoxia (p < 0.0001) and Sugen hypoxia models (p < 0.03). CL316243 reversed pulmonary vascular remodeling, decreased RV afterload, improved RV-PA coupling efficiency and reduced RV stiffness, hypertrophy, and fibrosis. Although all treatments decreased oxidative stress, CL316243 significantly reduced eNOS glutathionylation. β3 AR stimulation improved RV hemodynamics and led to beneficial RV-PA remodeling in experimental models of PAH. β3 AR agonists may be effective therapies in PAH.
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Affiliation(s)
- Keyvan Karimi Galougahi
- Heart Research InstituteSydneyAustralia
- Royal Prince Alfred HospitalSydneyAustralia
- Sydney Medical SchoolFaculty of Medicine and HealthUniversity of SydneySydneyAustralia
| | | | | | - Chia‐Chi Liu
- Heart Research InstituteSydneyAustralia
- Sydney Medical SchoolFaculty of Medicine and HealthUniversity of SydneySydneyAustralia
- Kolling Institute for Medical ResearchSydneyAustralia
| | - Lake‐Ee Quek
- Charles Perkins CenterUniversity of SydneySydneyAustralia
| | - Sanjay Patel
- Heart Research InstituteSydneyAustralia
- Royal Prince Alfred HospitalSydneyAustralia
- Sydney Medical SchoolFaculty of Medicine and HealthUniversity of SydneySydneyAustralia
| | - Edmund Lau
- Sydney Medical SchoolFaculty of Medicine and HealthUniversity of SydneySydneyAustralia
- Department of Respiratory MedicineRoyal Prince Alfred HospitalSydneyAustralia
| | - Rachael L. Cordina
- Royal Prince Alfred HospitalSydneyAustralia
- Sydney Medical SchoolFaculty of Medicine and HealthUniversity of SydneySydneyAustralia
| | - Gemma A. Figtree
- Sydney Medical SchoolFaculty of Medicine and HealthUniversity of SydneySydneyAustralia
- Kolling Institute for Medical ResearchSydneyAustralia
- Department of CardiologyRoyal North Shore HospitalSydneyAustralia
| | - David S. Celermajer
- Heart Research InstituteSydneyAustralia
- Royal Prince Alfred HospitalSydneyAustralia
- Sydney Medical SchoolFaculty of Medicine and HealthUniversity of SydneySydneyAustralia
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Chami J, Strange G, Baker D, Cordina R, Grigg L, Celermajer DS, Nicholson C. Algorithmic complexity stratification for congenital heart disease patients. International Journal of Cardiology Congenital Heart Disease 2022. [DOI: 10.1016/j.ijcchd.2022.100430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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Lawley CM, Tanous D, O'Donnell C, Anderson B, Aroney N, Walters DL, Shipton S, Wilson W, Celermajer DS, Roberts P. Ten Years of Percutaneous Pulmonary Valve Implantation in Australia and New Zealand. Heart Lung Circ 2022; 31:1649-1657. [PMID: 36038469 DOI: 10.1016/j.hlc.2022.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 04/28/2022] [Accepted: 07/12/2022] [Indexed: 12/27/2022]
Abstract
OBJECTIVE This study sought to investigate the characteristics, morbidity (including the rate of infective endocarditis and valve replacement) and mortality of individuals undergoing percutaneous pulmonary valve implantation in Australia and New Zealand since the procedure has been performed. BACKGROUND The outcomes of percutaneous pulmonary valve implantation in Australia and New Zealand have not been evaluated. Recent international data, including patients from New Zealand, suggests the rate of infective endocarditis is not insignificant. METHODS A retrospective multi-site cohort study was undertaken via medical record review at the centres where percutaneous pulmonary valve implantation has been performed. All procedures performed from 2009-March 2018 were included. Individuals were identified from local institution databases. Data was collected and analysed including demographics, details at the time of intervention, haemodynamic outcome, post procedure morbidity and mortality. Multi-site ethics approval was obtained. RESULTS One hundred and seventy-nine (179) patients attended the cardiac catheter laboratory for planned percutaneous pulmonary valve implantation. Of these patients, 172 underwent successful implantation. Tetralogy of Fallot and pulmonary atresia were the most common diagnoses. The median age at procedure was 19 years (range 3-60 yrs). There was a significant improvement in the acute haemodynamics in patients undergoing percutaneous pulmonary valve implantation for stenosis. Seven (7) patients (3.9%) experienced a major procedural/early post procedure complication (death, conversion to open procedure, cardiac arrest), including two deaths. The annualised rates of infective endocarditis and valve replacement were 4.6% and 3.8% respectively. There was one death related to infective endocarditis in follow-up. CONCLUSIONS Percutaneous pulmonary valve replacement is a relatively safe method of rehabilitating the right ventricular outflow tract.
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Affiliation(s)
- Claire M Lawley
- The Heart Centre for Children, The Children's Hospital at Westmead, Sydney Children's Hospitals Network, Sydney, NSW, Australia; The University of Sydney Children's Hospital Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.
| | - David Tanous
- The Heart Centre for Children, The Children's Hospital at Westmead, Sydney Children's Hospitals Network, Sydney, NSW, Australia; Department of Cardiology, Westmead Hospital, Sydney, NSW, Australia
| | - Clare O'Donnell
- Green Lane Paediatric and Congenital Cardiac Service, Starship/Auckland City Hospitals, Starship Children's Hospital, Auckland, New Zealand
| | - Benjamin Anderson
- Queensland Paediatric Cardiac Service, Queensland Children's Hospital, Brisbane, Qld, Australia
| | - Nicholas Aroney
- Department of Cardiology, The Prince Charles Hospital, Brisbane, Qld, Australia
| | - Darren L Walters
- Department of Cardiology, The Prince Charles Hospital, Brisbane, Qld, Australia; The University of Queensland, Brisbane, Qld, Australia
| | - Stephen Shipton
- Children's Cardiac Centre, Perth Children's Hospital, Perth, WA, Australia
| | - William Wilson
- Department of Cardiology, The Royal Melbourne Hospital, Melbourne, Vic, Australia
| | - David S Celermajer
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Philip Roberts
- The Heart Centre for Children, The Children's Hospital at Westmead, Sydney Children's Hospitals Network, Sydney, NSW, Australia
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Stanton KM, Wylie L, Kotchetkova I, Coy A, Carroll G, LA Gerche A, Celermajer DS. Soldiers' Heart: A Prospective Study of Cardiac Remodeling in Soldiers Undergoing Progressive Intensity Exercise Training. Med Sci Sports Exerc 2022; 54:2011-2019. [PMID: 35881923 DOI: 10.1249/mss.0000000000003006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
PURPOSE Most studies reporting cardiac changes with exercise have been cross sectional. The few available longitudinal studies have lacked standardization for environmental confounders. We prospectively assessed the relationship between increasing exercise intensity and cardiac remodeling in a highly standardized cohort of healthy young army soldiers. METHODS Sixty-three male army recruits (22 ± 3 yr) underwent a 12-wk moderate-intensity mixed strength and endurance exercise program, followed by a further 15-wk high-intensity exercise program, with highly controlled exercise, diet, and sleep patterns. Fitness (multistage fitness test), anthropometry, and 2D echocardiography were assessed. RESULTS Moderate-intensity exercise was associated with increased fitness and decreased body fat % (both P < 0.01). There was no significant incremental change in these parameters after high-intensity exercise. By contrast, both moderate- and high-intensity exercises were associated with dose-dependent increases in left atrial and left ventricular (LV) volumes, LV mass, and right ventricular (RV) size (all P < 0.01). At the end of high-intensity training, 51% had a dilated LV and 59% had a dilated RV compared with published normal ranges. Almost all had normal LV systolic function and strain before and after exercise training. A small number of soldiers had mildly decreased RV systolic function at baseline and after moderate-intensity exercise (3% and 6%, respectively). CONCLUSIONS We describe "soldiers' heart," which is characterized by balanced chamber dilatation, normal LV mass, and largely normal systolic function and myocardial strain. This prospective and highly controlled longitudinal study also found that increasing intensity exercise was associated with increasing chamber dimensions, which paralleled an increase in fitness after moderate-intensity exercise. After high-intensity exercise, however, cardiac chamber size continued to increase, but fitness did not increase further.
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Affiliation(s)
| | - Laura Wylie
- Heart Research Institute Sydney, Newtown, New South Wales, AUSTRALIA
| | | | - Amy Coy
- Heart Research Institute Sydney, Newtown, New South Wales, AUSTRALIA
| | - Gerard Carroll
- Wagga Wagga Base Hospital, Wagga Wagga, New South Wales, AUSTRALIA
| | - André LA Gerche
- Baker Heart and Diabetes Research Institute, Melbourne, Victoria, AUSTRALIA
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Figtree GA, Adamson PD, Antoniades C, Blumenthal RS, Blaha M, Budoff M, Celermajer DS, Chan MY, Chow CK, Dey D, Dwivedi G, Giannotti N, Grieve SM, Hamilton-Craig C, Kingwell BA, Kovacic JC, Min JK, Newby DE, Patel S, Peter K, Psaltis PJ, Vernon ST, Wong DT, Nicholls SJ. Noninvasive Plaque Imaging to Accelerate Coronary Artery Disease Drug Development. Circulation 2022; 146:1712-1727. [PMID: 36441819 DOI: 10.1161/circulationaha.122.060308] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 08/29/2022] [Indexed: 11/30/2022]
Abstract
Coronary artery disease (CAD) remains the leading cause of adult mortality globally. Targeting known modifiable risk factors has had substantial benefit, but there remains a need for new approaches. Improvements in invasive and noninvasive imaging techniques have enabled an increasing recognition of distinct quantitative phenotypes of coronary atherosclerosis that are prognostically relevant. There are marked differences in plaque phenotype, from the high-risk, lipid-rich, thin-capped atheroma to the low-risk, quiescent, eccentric, nonobstructive calcified plaque. Such distinct phenotypes reflect different pathophysiologic pathways and are associated with different risks for acute ischemic events. Noninvasive coronary imaging techniques, such as computed tomography, positron emission tomography, and coronary magnetic resonance imaging, have major potential to accelerate cardiovascular drug development, which has been affected by the high costs and protracted timelines of cardiovascular outcome trials. This may be achieved through enrichment of high-risk phenotypes with higher event rates or as primary end points of drug efficacy, at least in phase 2 trials, in a manner historically performed through intravascular coronary imaging studies. Herein, we provide a comprehensive review of the current technology available and its application in clinical trials, including implications for sample size requirements, as well as potential limitations. In its effort to accelerate drug development, the US Food and Drug Administration has approved surrogate end points for 120 conditions, but not for CAD. There are robust data showing the beneficial effects of drugs, including statins, on CAD progression and plaque stabilization in a manner that correlates with established clinical end points of mortality and major adverse cardiovascular events. This, together with a clear mechanistic rationale for using imaging as a surrogate CAD end point, makes it timely for CAD imaging end points to be considered. We discuss the importance of global consensus on these imaging end points and protocols and partnership with regulatory bodies to build a more informed, sustainable staged pathway for novel therapies.
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Affiliation(s)
- Gemma A Figtree
- Kolling Institute of Medical Research, Sydney, Australia (G.A.F., S.T.V.)
- Department of Cardiology, Royal North Shore Hospital, Northern Sydney Local Health District, Australia (G.A.F., S.T.V.)
- Charles Perkins Centre (G.A.F., C.K.C.), University of Sydney, Australia
- Faculty of Medicine and Health (G.A.F., D.S.C., N.G., S.P., S.T.V.), University of Sydney, Australia
| | - Philip D Adamson
- Christchurch Heart Institute, University of Otago Christchurch, New Zealand (P.D.A.)
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (P.D.A., D.E.N.)
| | - Charalambos Antoniades
- Acute Vascular Imaging Centre (C.A.), Radcliffe Department of Medicine, University of Oxford, UK
- Division of Cardiovascular Medicine (C.A.), Radcliffe Department of Medicine, University of Oxford, UK
| | - Roger S Blumenthal
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, MD (R.S.B., M. Blaha)
| | - Michael Blaha
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, MD (R.S.B., M. Blaha)
| | | | - David S Celermajer
- Faculty of Medicine and Health (G.A.F., D.S.C., N.G., S.P., S.T.V.), University of Sydney, Australia
- Departments of Cardiology (D.S.C., S.P.), Royal Prince Alfred Hospital, Sydney, Australia
| | - Mark Y Chan
- Department of Cardiology, National University Heart Centre, Singapore (M.Y.C.)
| | - Clara K Chow
- Westmead Applied Research Centre (C.K.C.), University of Sydney, Australia
- Charles Perkins Centre (G.A.F., C.K.C.), University of Sydney, Australia
| | - Damini Dey
- Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA (D.D.)
| | - Girish Dwivedi
- Harry Perkins Institute of Medical Research, University of Western Australia (G.D.)
- Department of Cardiology, Fiona Stanley Hospital, Perth, Australia (G.D.)
| | - Nicola Giannotti
- Faculty of Medicine and Health (G.A.F., D.S.C., N.G., S.P., S.T.V.), University of Sydney, Australia
| | - Stuart M Grieve
- Imaging and Phenotyping Laboratory (S.M.G.), University of Sydney, Australia
- Radiology (S.M.G.), Royal Prince Alfred Hospital, Sydney, Australia
| | - Christian Hamilton-Craig
- Faculty of Medicine and Centre for Advanced Imaging, University of Queensland and School of Medicine, Griffith University Sunshine Coast, Australia (C.H.-C.)
| | | | - Jason C Kovacic
- Victor Chang Cardiac Research Institute, Darlinghurst, Australia (J.C.K.)
- St Vincent's Clinical School, University of NSW, Australia (J.C.K.)
- Cardiovascular Research Institute, Icahn School of Medicine at Mount Sinai, New York, NY (J.C.K.)
| | | | - David E Newby
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (P.D.A., D.E.N.)
| | - Sanjay Patel
- Faculty of Medicine and Health (G.A.F., D.S.C., N.G., S.P., S.T.V.), University of Sydney, Australia
- Departments of Cardiology (D.S.C., S.P.), Royal Prince Alfred Hospital, Sydney, Australia
| | - Karlheinz Peter
- Baker Heart and Diabetes Institute, Melbourne, Australia (K.P.)
- Department of Cardiology, The Alfred Hospital, Melbourne, Australia (K.P.)
| | - Peter J Psaltis
- Lifelong Health, South Australian Health and Medical Research Institute, Adelaide (P.J.P.)
- Department of Cardiology, Royal Adelaide Hospital, Australia (P.J.P.)
| | - Stephen T Vernon
- Kolling Institute of Medical Research, Sydney, Australia (G.A.F., S.T.V.)
- Department of Cardiology, Royal North Shore Hospital, Northern Sydney Local Health District, Australia (G.A.F., S.T.V.)
- Faculty of Medicine and Health (G.A.F., D.S.C., N.G., S.P., S.T.V.), University of Sydney, Australia
| | - Dennis T Wong
- Monash Heart, Clayton, Australia (D.T.W., S.J.N.)
- Victorian Heart Institute, Monash University, Melbourne, Australia (D.T.W., S.J.N.)
| | - Stephen J Nicholls
- Monash Heart, Clayton, Australia (D.T.W., S.J.N.)
- Victorian Heart Institute, Monash University, Melbourne, Australia (D.T.W., S.J.N.)
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29
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Gallagher R, Chow CK, Parker H, Neubeck L, Celermajer DS, Redfern J, Tofler G, Buckley T, Schumacher T, Hyun K, Boroumand F, Figtree G. The effect of a game-based mobile app 'MyHeartMate' to promote lifestyle change in coronary disease patients: a randomized controlled trial. Eur Heart J Digit Health 2022; 4:33-42. [PMID: 36743873 PMCID: PMC9890079 DOI: 10.1093/ehjdh/ztac069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 10/12/2022] [Indexed: 11/26/2022]
Abstract
Aims Secondary prevention reduces coronary heart disease (CHD) progression. Traditional prevention programs including cardiac rehabilitation are under-accessed, which smartphone apps may overcome. To evaluate the effect of a game-based mobile app intervention (MyHeartMate) to improve cardiovascular risk factors and lifestyle behaviours. Methods and results Single-blind randomized trial of CHD patients in Sydney, 2017-2021. Intervention group were provided the MyHeartMate app for 6 months. Co-designed features included an avatar of the patient's heart and tokens earned by risk factor work (tracking, challenges, and quizzes). The control group received usual care. Primary outcome was self-reported physical activity [metabolic equivalents (METs), Global Physical Activity Questionnaire] and secondary outcomes included lipid levels, blood pressure (BP), body mass index, and smoking. Pre-specified sample size was achieved (n = 390), age 61.2 ± 11.5 years; 82.5% men and 9.2% current smokers. At 6 months, adjusted for baseline levels, the intervention group achieved more physical activity than control (median difference 329 MET mins/wk), which was not statistically significant (95% CI -37.4, 696; P = 0.064). No differences occurred between groups on secondary outcomes except for lower triglyceride levels in the intervention [mean difference -0.3 (95% CI -0.5, -0.1 mmoL/L, P = 0.004)]. Acceptability was high: 94.8% of intervention participants engaged by tracking exercise or BP and completing missions; 26.8% continued to engage for ≥30 days. Participants (n = 14) reported the app supported tracking behaviours and risk factors, reinforcing and improving self-care confidence, and decreasing anxiety. Conclusion A game-based app proved highly acceptable for patients with CHD but did not improve risk factors or lifestyle behaviours other than triglyceride levels.
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Affiliation(s)
| | - Clara K Chow
- Westmead Applied Research Centre, Faculty of Medicine and Health, University of Sydney, 176 Hawkesbury Road, Westmead, New South Wales 2006, Australia,Department of Cardiology, Westmead Hospital, 176 Hawkesbury Road, Westmead, New South Wales 2145, Australia
| | - Helen Parker
- Charles Perkins Centre, University of Sydney, Building D17 Johns Hopkins Drive, Sydney, New South Wales 2006, Australia,School of Health Sciences, Faculty of Medicine and Health, University of Sydney, Susan Wakil Health Building, Western Ave, Camperdown, New South Wales 2006, Australia
| | - Lis Neubeck
- The Centre for Cardiovascular Health, School of Health and Social Care, Edinburgh Napier University, 9 Sighthill Close, Sighthill, EH11 4QD, UK
| | - David S Celermajer
- Faculty of Medicine and Health, Central Clinical School, University of Sydney, John Hopkins Drive, Camperdown, New South Wales 2006, Australia,Department of Cardiology, Royal Prince Alfred Hospital, John Hopkins Drive, Camperdown, New South Wales 2050, Australia,Clinical Research Group, The Heart Research Institute, 7 Eliza Street, Newtown, New South Wales 2042, Australia
| | - Julie Redfern
- School of Health Sciences, Faculty of Medicine and Health, University of Sydney, Susan Wakil Health Building, Western Ave, Camperdown, New South Wales 2006, Australia
| | - Geoffrey Tofler
- Department of Cardiology, Royal North Shore Hospital, Reserve Road St, Leonards, New South Wales 2065, Australia,Faculty of Medicine and Health, Northern Clinical School, University of Sydney, Reserve Road St, Leonards, New South Wales 2006, Australia
| | - Thomas Buckley
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, Building D17 Johns Hopkins Drive, Sydney, New South Wales 2006, Australia,Cardiovascular Discovery Group, Kolling Institute of Medical Research, Reserve Road St, Leonards, New South Wales 2065, Australia
| | - Tracy Schumacher
- Priority Research Centre for Physical Activity and Nutrition, University of Newcastle, Ring Road, Callaghan, New South Wales 2308, Australia
| | - Karice Hyun
- School of Health Sciences, Faculty of Medicine and Health, University of Sydney, Susan Wakil Health Building, Western Ave, Camperdown, New South Wales 2006, Australia
| | - Farzaneh Boroumand
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, Building D17 Johns Hopkins Drive, Sydney, New South Wales 2006, Australia,School of Health Sciences, Faculty of Medicine and Health, University of Sydney, Susan Wakil Health Building, Western Ave, Camperdown, New South Wales 2006, Australia,School of Mathematical and Physical Sciences, Macquarie University, Herring Road, North Ryde, New South Wales 2109, Australia
| | - Gemma Figtree
- Department of Cardiology, Royal North Shore Hospital, Reserve Road St, Leonards, New South Wales 2065, Australia,Faculty of Medicine and Health, Northern Clinical School, University of Sydney, Reserve Road St, Leonards, New South Wales 2006, Australia,Cardiovascular Discovery Group, Kolling Institute of Medical Research, Reserve Road St, Leonards, New South Wales 2065, Australia
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Koemel NA, Senior AM, Celermajer DS, Grech A, Gill TP, Raubenheimer D, Simpson SJ, Skilton MR. Associations of dietary macronutrient composition with cardiometabolic health: data from the National Health and Nutrition Examination Survey (NHANES) 1999–2014. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Human nutrition is a leading modifiable risk factor for the prevention of cardiometabolic diseases. However, most nutritional research focuses on the role of specific nutrients rather than compositional analysis of the diet.
Purpose
We aimed to assess the association of dietary macronutrient composition with various markers of cardiometabolic health.
Methods
This study was undertaken using 24-hour food recall data from the National Health and Nutrition Examination Survey from years 1999–2014 (n=36,637). Participants included both males and females ≥20 years of age (49.8±18.3 years; 53% Female). Caloric outliers for males (<800 kcal/day or >4200 kcal/day) and females (<600 kcal/day or >3500 kcal/day) were removed from the analysis (n=1844). Cardiometabolic health markers were collected via mobile examination center and included triglycerides (n=16,444), total cholesterol (n=31,155), LDL cholesterol (n=15,798), HDL cholesterol (n=33,435), blood pressure (n=34,121), body fat percentage (n=4269), body mass index (n=35,187), glucose (n=17,208), insulin (n=16,273), oral glucose tolerance test (n=8280), and HbA1c (n=27,288). Associations of dietary macronutrients with cardiometabolic health markers were assessed using 3-dimensional general additive models (Protein; Carbohydrate; Fat) with adjustment for age, sex, misreporting, ethnicity, education level, household income, physical activity, alcohol intake, and smoking. Response surfaces on right-angled mixture triangles were generated as predictions from absolute macronutrient intake at the 50th percentile of total energy intake. Macronutrient intakes were transformed to a percentage of energy to visualize and interpret associations compositionally.
Results
There was a complex 3-way interactive non-linear association of macronutrient composition with lipid profile (Figure A-D; all p<0.04), blood pressure (Figure E-F; all p<0.001), body fat percentage (Figure G; p<0.001), body mass index (Figure H; p<0.001), and all markers of glycemic control (Figure I-L; all p<0.001). Diets comprised of high protein coupled with low fat were associated with higher triglycerides but generally more favorable total cholesterol, blood pressure, and body fatness. Conversely, diets composed of high protein coupled with high fat were associated with higher HDL cholesterol but worse total cholesterol, body fatness, body mass index, and glycemic control.
Conclusions
These findings display a complex relationship between dietary macronutrient composition and cardiometabolic health. Future research is needed to evaluate how dietary source and quality may modify the observed associations.
Funding Acknowledgement
Type of funding sources: Private company.
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Affiliation(s)
- N A Koemel
- University of Sydney, Charles Perkins Centre, Sydney Medical School , Sydney , Australia
| | - A M Senior
- University of Sydney, Charles Perkins Centre, School of Life and Environmental Sciences , Sydney , Australia
| | - D S Celermajer
- University of Sydney, Sydney Medical School , Sydney , Australia
| | - A Grech
- University of Sydney, Charles Perkins Centre, School of Life and Environmental Sciences , Sydney , Australia
| | - T P Gill
- University of Sydney, Charles Perkins Center, Sydney Medical School, Susan Wakil School of Nursing and Midwifery , Sydney , Australia
| | - D Raubenheimer
- University of Sydney, Charles Perkins Centre, School of Life and Environmental Sciences , Sydney , Australia
| | - S J Simpson
- University of Sydney, Charles Perkins Centre, School of Life and Environmental Sciences , Sydney , Australia
| | - M R Skilton
- University of Sydney, Charles Perkins Centre, Sydney Medical School , Sydney , Australia
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Marshall KH, d'Udekem Y, Winlaw DS, Dalziel K, Woolfenden SR, Zannino D, Costa DSJ, Bishop R, Celermajer DS, Sholler GF, Kasparian NA. The Australian and New Zealand Fontan Registry Quality of Life Study: Protocol for a population-based assessment of quality of life among people with a Fontan circulation, their parents, and siblings. BMJ Open 2022; 12:e065726. [PMID: 36127092 PMCID: PMC9490616 DOI: 10.1136/bmjopen-2022-065726] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Advances in the care of patients with single-ventricle congenital heart disease have led to a new generation of individuals living with a Fontan circulation. For people with Fontan physiology, physical, psychological and neurodevelopmental challenges are common. The objective of this study is to describe and develop a deeper understanding of the factors that contribute to quality of life (QOL) among children, adolescents and adults living with a Fontan circulation across Australia and New Zealand, their parents and siblings. METHODS AND ANALYSIS This article presents the protocol for the Australian and New Zealand Fontan Registry (ANZFR) QOL Study, a cross-sectional, population-based study designed to examine QOL among people of all ages with a Fontan circulation, their parents and siblings. Study eligibility criteria includes (1) individuals with a Fontan circulation aged ≥6 years, at least 12 months post-Fontan procedure and enrolled in the ANZFR; (2) parents of individuals enrolled in the ANZFR; and (3) siblings aged ≥6 years of an individual enrolled in the ANZFR. A novel, online research platform is used to distribute personalised assessments tailored to participant age and developmental stage. A suite of validated psychometric self-report and parent-proxy report instruments capture potential correlates and predictors of QOL, including symptoms of psychological distress, personality attributes, coping and cognitive appraisals, family functioning, healthcare experiences and costs, access to emotional support and socioeconomic factors. Clinical characteristics are captured via self-report and parent-proxy report, as well as the ANZFR. Descriptive analyses and multilevel models will be used to examine QOL across groups and to investigate potential explanatory variables. ETHICS AND DISSEMINATION Approval has been obtained from all relevant Human Research Ethics Committees (HRECs), including the Sydney Children's Hospitals Network and the Royal Children's Hospital Melbourne HRECs. Study findings will be published in peer-reviewed journals and presented at national and international meetings and seminars.
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Affiliation(s)
- Kate H Marshall
- Heart Centre for Children, The Sydney Children's Hospitals Network, Sydney, New South Wales, Australia
- Discipline of Paediatrics and Child Health, School of Clinical Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Yves d'Udekem
- The Division of Cardiovascular Surgery, Children's National Heart Institute, Washington, D.C, USA
| | - David S Winlaw
- Cardiothoracic Surgery, The Heart Institute, Cincinnati Children's Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Kim Dalziel
- Health Economics Unit, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Susan R Woolfenden
- Discipline of Paediatrics and Child Health, School of Clinical Medicine, University of New South Wales, Sydney, New South Wales, Australia
- Sydney Institute for Women, Children and their Families, Sydney Local Health District, Camperdown, New South Wales, Australia
| | - Diana Zannino
- Heart Research Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Daniel S J Costa
- School of Psychology, The University of Sydney, Sydney, New South Wales, Australia
| | - Rachel Bishop
- Australian and New Zealand Fontan Registry, Melbourne, Victoria, Australia
| | - David S Celermajer
- Department of Cardiology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
- Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Gary F Sholler
- Heart Centre for Children, The Sydney Children's Hospitals Network, Sydney, New South Wales, Australia
- Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Nadine A Kasparian
- Center for Heart Disease and Mental Health, Heart Institute and Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Stanton KM, Kienzle V, Dinnes DLM, Kotchetkov I, Jessup W, Kritharides L, Celermajer DS, Rye KA. Moderate- and High-Intensity Exercise Improves Lipoprotein Profile and Cholesterol Efflux Capacity in Healthy Young Men. J Am Heart Assoc 2022; 11:e023386. [PMID: 35699182 PMCID: PMC9238648 DOI: 10.1161/jaha.121.023386] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background Exercise is associated with a reduced risk of cardiovascular disease. Increased high‐density lipoprotein cholesterol (HDL‐C) levels are thought to contribute to these benefits, but much of the research in this area has been limited by lack of well‐controlled subject selection and exercise interventions. We sought to study the effect of moderate and high‐intensity exercise on HDL function, lipid/lipoprotein profile, and other cardiometabolic parameters in a homogeneous population where exercise, daily routine, sleep patterns, and living conditions were carefully controlled. Methods and Results Male Army recruits (n=115, age 22±0.3 years) completed a 12‐week moderate‐intensity exercise program. A subset of 51 subsequently completed a 15‐week high‐intensity exercise program. Fitness increased and body fat decreased after moderate‐ and high‐intensity exercise (P<0.001). Moderate‐intensity exercise increased HDL‐C and apolipoprotein A‐I levels (6.6%, 11.6% respectively), and decreased low‐density lipoprotein cholesterol and apolipoprotein B levels (7.2%, 4.9% respectively) (all P<0.01). HDL‐C and apolipoprotein A‐I levels further increased by 8.2% (P<0.001) and 6.3% (P<0.05) after high‐intensity exercise. Moderate‐intensity exercise increased ABCA‐1 (ATP‐binding cassette transporter A1) mediated cholesterol efflux by 13.5% (P<0.001), which was sustained after high‐intensity exercise. In a selected subset the ability of HDLs to inhibit ICAM‐1 (intercellular adhesion molecule‐1) expression decreased after the high (P<0.001) but not the moderate‐intensity exercise program. Conclusions When controlling for exercise patterns, diet, and sleep, moderate‐intensity exercise improved HDL function, lipid/lipoprotein profile, fitness, and body composition. A sequential moderate followed by high‐intensity exercise program showed sustained or incremental benefits in these parameters. Improved HDL function may be part of the mechanism by which exercise reduces cardiovascular disease risk.
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Affiliation(s)
- Kelly M Stanton
- Heart Research Institute Sydney New South Wales Australia.,The University of Sydney New South Wales Australia.,Royal Brisbane and Women's Hospital Herston Queensland Australia
| | - Vivian Kienzle
- Heart Research Institute Sydney New South Wales Australia
| | | | | | - Wendy Jessup
- The ANZAC Research Institute Concord New South Wales Australia
| | - Leonard Kritharides
- Heart Research Institute Sydney New South Wales Australia.,The ANZAC Research Institute Concord New South Wales Australia
| | - David S Celermajer
- Heart Research Institute Sydney New South Wales Australia.,The University of Sydney New South Wales Australia.,Royal Prince Alfred Hospital Sydney New South Wales Australia
| | - Kerry-Anne Rye
- The University of New South Wales Sydney New South Wales Australia
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34
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Tran DL, Kamaladasa Y, Munoz PA, Kotchetkova I, D'Souza M, Celermajer DS, Maiorana A, Cordina R. Estimating exercise intensity using heart rate in adolescents and adults with congenital heart disease: Are established methods valid? International Journal of Cardiology Congenital Heart Disease 2022. [DOI: 10.1016/j.ijcchd.2022.100362] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
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35
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Daley M, Buratto E, King G, Grigg L, Iyengar A, Alphonso N, Bullock A, Celermajer DS, Ayer J, Robertson T, d'Udekem Y, Konstantinov IE. Impact of Fontan Fenestration on Long-Term Outcomes: A Propensity Score-Matched Analysis. J Am Heart Assoc 2022; 11:e026087. [PMID: 35621213 PMCID: PMC9238726 DOI: 10.1161/jaha.122.026087] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The long-term impact of fenestration at the time of Fontan operation remains unclear. We aimed to review the early and long-term impact of Fontan fenestration in the Australia and New Zealand cohort. Methods and Results We reviewed 1443 patients (621 fenestrated, 822 nonfenestrated) from the Australia and New Zealand Fontan registry. Data were collected on preoperative demographics, operative details, and follow-up. Propensity-score matching was performed to account for the various preoperative and operative differences and risk factors. Primary outcomes were survival and freedom from failure. Median follow-up was 10.6 years. After propensity-score matching (407 matched pairs), there was no difference in survival (87% versus 90% at 20 years; P=0.16) or freedom from failure (73% versus 80% at 20 years; P=0.10) between patients with and without fenestration, respectively. Although patients with fenestration had longer bypass and cross-clamp times (P<0.001), there was no difference in hospital length of stay or prolonged pleural effusions (P=0.80 and P=0.46, respectively). Freedom from systemic and Fontan circuit thromboembolism was higher in the nonfenestrated group (89%; 95% CI, 88%-95%) than the fenestrated group (84%; 95% CI, 77%-89%; P=0.03). There was no difference in incidence of plastic bronchitis, protein-losing enteropathy, New York Heart Association Class III/IV symptoms, or Fontan takedown. Conclusions In the propensity score-matched analysis we have demonstrated no difference in long-term survival or freedom from Fontan failure in patients with and without fenestration. There was a higher incidence of long-term thromboembolic events in patients with fenestration. Overall, it appears that fenestration in Fontan circulation does not bring long-term benefits.
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Affiliation(s)
- Michael Daley
- Department of Cardiac Surgery Royal Children's Hospital Melbourne Australia.,Department of Paediatrics University of Melbourne Melbourne Australia.,Heart Research Group Murdoch Children's Research Institute Melbourne Australia
| | - Edward Buratto
- Department of Cardiac Surgery Royal Children's Hospital Melbourne Australia.,Department of Paediatrics University of Melbourne Melbourne Australia.,Heart Research Group Murdoch Children's Research Institute Melbourne Australia
| | - Gregory King
- Department of Cardiac Surgery Royal Children's Hospital Melbourne Australia.,Department of Paediatrics University of Melbourne Melbourne Australia.,Heart Research Group Murdoch Children's Research Institute Melbourne Australia
| | - Leeanne Grigg
- Department of Cardiology Royal Melbourne Hospital Melbourne Australia
| | - Ajay Iyengar
- Green Lane Paediatric and Congenital Cardiac Service Starship Children's Health Auckland New Zealand.,Department of Surgery University of Auckland Auckland New Zealand
| | - Nelson Alphonso
- Department of Cardiac Surgery Queensland Children's Hospital Brisbane Australia.,Queensland Paediatric Cardiac ResearchChild Health Research CentreUniversity of Queensland Brisbane Australia
| | - Andrew Bullock
- Department of Cardiology Perth Children's Hospital Perth Australia.,Adult Congenital Cardiology Division Cardiovascular Medicine Sir Charles Gardiner Hospital Perth Australia
| | - David S Celermajer
- Department of Medicine The University of Sydney Sydney Australia.,Department of Cardiology Royal Prince Alfred Hospital Sydney Australia
| | - Julian Ayer
- The Heart Centre for Children The Children's Hospital at Westmead Sydney Australia.,Discipline of Paediatrics and Child Health The University of Sydney Sydney Australia
| | - Terry Robertson
- Department of Cardiology, Women and Children's Hospital Adelaide Australia
| | - Yves d'Udekem
- The Division of Cardiovascular Surgery Children's National Heart InstituteChildren's National Hospital Washington DC
| | - Igor E Konstantinov
- Department of Cardiac Surgery Royal Children's Hospital Melbourne Australia.,Department of Paediatrics University of Melbourne Melbourne Australia.,Heart Research Group Murdoch Children's Research Institute Melbourne Australia
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36
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Borlaug BA, Blair J, Bergmann MW, Bugger H, Burkhoff D, Bruch L, Celermajer DS, Claggett B, Cleland JGF, Cutlip DE, Dauber I, Eicher JC, Gao Q, Gorter TM, Gustafsson F, Hayward C, van der Heyden J, Hasenfuß G, Hummel SL, Kaye DM, Komtebedde J, Massaro JM, Mazurek JA, McKenzie S, Mehta SR, Petrie MC, Post MC, Nair A, Rieth A, Silvestry FE, Solomon SD, Trochu JN, Van Veldhuisen DJ, Westenfeld R, Leon MB, Shah SJ. Latent Pulmonary Vascular Disease May Alter the Response to Therapeutic Atrial Shunt Device in Heart Failure. Circulation 2022; 145:1592-1604. [PMID: 35354306 PMCID: PMC9133195 DOI: 10.1161/circulationaha.122.059486] [Citation(s) in RCA: 49] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND In REDUCE LAP-HF II (A Study to Evaluate the Corvia Medical, Inc IASD System II to Reduce Elevated Left Atrial Pressure in Patients With Heart Failure), implantation of an atrial shunt device did not provide overall clinical benefit for patients with heart failure with preserved or mildly reduced ejection fraction. However, prespecified analyses identified differences in response in subgroups defined by pulmonary artery systolic pressure during submaximal exercise, right atrial volume, and sex. Shunt implantation reduces left atrial pressures but increases pulmonary blood flow, which may be poorly tolerated in patients with pulmonary vascular disease (PVD). On the basis of these results, we hypothesized that patients with latent PVD, defined as elevated pulmonary vascular resistance during exercise, might be harmed by shunt implantation, and conversely that patients without PVD might benefit. METHODS REDUCE LAP-HF II enrolled 626 patients with heart failure, ejection fraction ≥40%, exercise pulmonary capillary wedge pressure ≥25 mm Hg, and resting pulmonary vascular resistance <3.5 Wood units who were randomized 1:1 to atrial shunt device or sham control. The primary outcome-a hierarchical composite of cardiovascular death, nonfatal ischemic stroke, recurrent HF events, and change in health status-was analyzed using the win ratio. Latent PVD was defined as pulmonary vascular resistance ≥1.74 Wood units (highest tertile) at peak exercise, measured before randomization. RESULTS Compared with patients without PVD (n=382), those with latent PVD (n=188) were older, had more atrial fibrillation and right heart dysfunction, and were more likely to have elevated left atrial pressure at rest. Shunt treatment was associated with worse outcomes in patients with PVD (win ratio, 0.60 [95% CI, 0.42, 0.86]; P=0.005) and signal of clinical benefit in patients without PVD (win ratio, 1.31 [95% CI, 1.02, 1.68]; P=0.038). Patients with larger right atrial volumes and men had worse outcomes with the device and both groups were more likely to have pacemakers, heart failure with mildly reduced ejection fraction, and increased left atrial volume. For patients without latent PVD or pacemaker (n=313; 50% of randomized patients), shunt treatment resulted in more robust signal of clinical benefit (win ratio, 1.51 [95% CI, 1.14, 2.00]; P=0.004). CONCLUSIONS In patients with heart failure with preserved or mildly reduced ejection fraction, the presence of latent PVD uncovered by invasive hemodynamic exercise testing identifies patients who may worsen with atrial shunt therapy, whereas those without latent PVD may benefit.
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Affiliation(s)
- Barry A. Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | | | | | | | - Dan Burkhoff
- Cardiovascular Research Foundation, New York NY, USA
| | | | | | | | - John GF Cleland
- Robertson Centre for Biostatistics and Glasgow Clinical Trials Unit, Institute of Health and Wellbeing, Glasgow, and National Heart & Lung Institute, Imperial College London, United Kingdom
| | | | - Ira Dauber
- South Denver Cardiology Associates/Centura Health. Denver, CO, USA
| | | | - Qi Gao
- Baim Clinical Research Institute, Boston, MA
| | - Thomas M. Gorter
- University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Finn Gustafsson
- Rigshospitalet, University ofCopenhagen, Copenhagen, Denmark
| | | | | | - Gerd Hasenfuß
- Heart Center, University Medical Center, Göttingen, Germany
| | - Scott L Hummel
- University of Michigan, Ann Harbor, MI and VA Ann Arbor Health System, Ann Arbor, MI
| | | | | | | | | | | | - Shamir R. Mehta
- McMaster University and Hamilton Health Sciences, Hamilton, Canada
| | | | - Marco C. Post
- Departments of Cardiology, St. Antonius Hospital Nieuwegein and University Medical Center Utrecht, The Netherlands
| | | | - Andreas Rieth
- Kerckhoff Heart and Thoraxcenter, Bad Nauheim, Germany
| | | | | | - Jean-Noël Trochu
- Nantes Université, CHU Nantes, CNRS, INSERM, l’institut du thorax, F-44000 Nantes, France
| | - Dirk J. Van Veldhuisen
- University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Ralf Westenfeld
- Division of Cardiology, Pulmonology, and Vascular Medicine Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany
| | | | - Sanjiv J. Shah
- Northwestern University Feinberg School of Medicine, Chicago, IL USA
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37
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Lim MS, Portelli SS, Padang R, Bannon PG, Hambly BD, Jeremy RW, Celermajer DS, Robertson EN. Novel insights into bicuspid aortic valve (BAV) aortopathy: Long non-coding RNAs TUG1 and MIAT are differentially expressed in BAV ascending aortas. Cardiovasc Pathol 2022; 60:107433. [PMID: 35588998 DOI: 10.1016/j.carpath.2022.107433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Revised: 05/10/2022] [Accepted: 05/10/2022] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Whilst a combination of genetically mediated vulnerability and haemodynamic insult is suspected to contribute to bicuspid aortic valve (BAV) aortopathy, the underlying pathophysiological mechanisms are poorly understood. METHODS Utilising RT-qPCR, we compared the expression of 28 potentially relevant long non-coding RNA (lncRNA) in aortic tissue from BAV patients undergoing aortic surgery for aortopathy, to healthy controls. Relative lncRNA expression was measured using ΔΔCT, with fold-change calculated as RQ=2-ΔΔCT. RESULTS When comparing samples from BAV patients (n=29, males n=25; median age 58 years, Q1-Q3 51-65, maximum aortic dimension 50±5mm) with healthy controls (n=7; males n=4, p=0.12; median age 39 years, Q1-Q3 18-47, p=0.001), there were two differentially expressed lncRNA: TUG1 expression was significantly lower in BAV aortic tissue (RQ 0.59, 95% CI 0.50-0.69, p=0.02), whilst MIAT expression was significantly higher (RQ 2.87, 95% CI 1.96-4.20, p=0.01). Sensitivity analysis including only patients with normal BAV function showed similar trends of differential expression of TUG1 (RQ 0.69, 95% CI 0.50-0.90, p=0.29) and MIAT (RQ 2.55, 95% CI 1.21-5.36, p=0.29) compared to controls. CONCLUSIONS LncRNA TUG1 and MIAT are differentially expressed in BAV aortopathy compared to healthy controls, independent of BAV haemodynamics. Aberrant lncRNA expression may be involved in the pathogenesis of BAV aortopathy.
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Affiliation(s)
- M S Lim
- The University of Sydney, Sydney Medical School, Faculty of Medicine and Health, Camperdown, New South Wales, Australia; Royal Prince Alfred Hospital, Department of Cardiology, Camperdown, New South Wales, Australia.
| | - S S Portelli
- The University of Sydney, Sydney Medical School, Faculty of Medicine and Health, Camperdown, New South Wales, Australia
| | - R Padang
- The University of Sydney, Sydney Medical School, Faculty of Medicine and Health, Camperdown, New South Wales, Australia; Royal Prince Alfred Hospital, Department of Cardiology, Camperdown, New South Wales, Australia
| | - P G Bannon
- The University of Sydney, Sydney Medical School, Faculty of Medicine and Health, Camperdown, New South Wales, Australia; Royal Prince Alfred Hospital, Department of Cardiothoracic Surgery, Camperdown, New South Wales, Australia
| | - B D Hambly
- The University of Sydney, Sydney Medical School, Faculty of Medicine and Health, Camperdown, New South Wales, Australia
| | - R W Jeremy
- The University of Sydney, Sydney Medical School, Faculty of Medicine and Health, Camperdown, New South Wales, Australia; Royal Prince Alfred Hospital, Department of Cardiology, Camperdown, New South Wales, Australia
| | - D S Celermajer
- The University of Sydney, Sydney Medical School, Faculty of Medicine and Health, Camperdown, New South Wales, Australia; Royal Prince Alfred Hospital, Department of Cardiology, Camperdown, New South Wales, Australia; Heart Research Institute, Sydney, Australia
| | - E N Robertson
- The University of Sydney, Sydney Medical School, Faculty of Medicine and Health, Camperdown, New South Wales, Australia; Royal Prince Alfred Hospital, Department of Cardiology, Camperdown, New South Wales, Australia
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Lim MS, Cordina R, Kotchetkova I, Celermajer DS. Late complication rates after aortic coarctation repair in patients with or without a bicuspid aortic valve. Heart 2022; 108:855-859. [PMID: 34535439 DOI: 10.1136/heartjnl-2021-319969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Accepted: 08/27/2021] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVE Patients with previously repaired aortic coarctation (CoA) are at risk of developing late surgical complications. Many patients with CoA also have a bicuspid aortic valve (BAV). We sought to determine in patients with repaired CoA whether the presence of BAV is associated with more cardiovascular reinterventions during follow-up. METHODS Adults with previously repaired simple CoA were recruited from our Adult Congenital Heart Disease database (Sydney, Australia). The incidence of complications relating to the 'CoA-site' (descending aortic aneurysm or dissection, or recoarctation) and the 'AV/AscAo' (aortic valve or ascending aortic pathology) that required intervention was compared between those with BAV ('CoA-BAV') and without BAV ('CoA-only'). RESULTS Of 146 patients with repaired CoA, 101 (69%) had BAV. Age at CoA repair was similar (median 6.0 (IQR 0.5-14.0) years vs 5.0 (IQR 0.5-11.0) years, p=0.44), as was the distribution of repair types, with end-to-end repair the most common in both groups (45.9% vs 45.6%). At a median of 28 years following initial repair, a significantly higher proportion of patients with CoA-BAV required cardiovascular reintervention (45.5% vs 20.0%, p=0.003). Whereas 'CoA-site' complications were more common than 'AV/AscAo' complications in patients with CoA only (13.3% and 0%, respectively), patients with CoA-BAV had a high prevalence of both 'CoA-site' as well as 'AV/AscAo' complications (19.8% and 21.8%, respectively). Overall survival was similar (p=0.42). CONCLUSION In adults with repaired CoA, patients with CoA-BAV are more than twice as likely to require cardiovascular reintervention by early-to-mid-adult life compared with those with CoA alone. Despite this, no difference in survival outcomes was observed.
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Affiliation(s)
- Michelle S Lim
- Central Clinical School, The University of Sydney Faculty of Medicine and Health, Sydney, New South Wales, Australia .,Cardiology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Rachael Cordina
- Central Clinical School, The University of Sydney Faculty of Medicine and Health, Sydney, New South Wales, Australia.,Cardiology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Irina Kotchetkova
- Cardiology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - David S Celermajer
- Central Clinical School, The University of Sydney Faculty of Medicine and Health, Sydney, New South Wales, Australia.,Cardiology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
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Offen S, Playford D, Strange G, Stewart S, Celermajer DS. Adverse Prognostic Impact of Even Mild or Moderate Tricuspid Regurgitation: Insights from The National Echocardiography Database of Australia. J Am Soc Echocardiogr 2022; 35:810-817. [PMID: 35421545 DOI: 10.1016/j.echo.2022.04.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 04/01/2022] [Accepted: 04/02/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND The prevalence and prognostic impact of tricuspid regurgitation (TR) remains incompletely characterized. METHODS The distribution of TR severity was analyzed in 439,558 adults (mean age 62.1 ±17.8 years, 51.5% men) being investigated for heart disease, from 2000-2019, by 25 centers contributing to the National Echocardiography Database of Australia. Survival status and cause of death were ascertained, in all adults, from the National Death Index of Australia. The relationship between TR severity and mortality was examined. RESULTS Of those studied, 311,604 (70.9%) had no/trivial TR; 94,172 (21.4%) mild TR; 26,056 (5.9%) moderate TR; and 7,726 (1.8%) severe TR. During a median 4.1 years (interquartile range 2.2-7.0 years) follow up, 109,004 died (49% from cardiovascular causes). Moderate or greater TR was associated with older age and female sex (p<0.001). Individuals with moderate and severe TR had a 2.0- to 3.2-fold increased risk of all-cause long-term mortality after adjustment for age and sex, compared to those with no/trivial TR (p<0.001 for both comparisons). Even those with mild TR had a significantly increased risk for mortality (HR 1.29, 95% CI 1.27-1.31). In fully adjusted models, including for RV systolic pressure, atrial fibrillation and significant left-heart disease, there remained a 1.24 to 2.65-fold increased risk of mortality with mild (HR 1.24, 95% CI 1.23-1.26), moderate (HR 1.72, 95% CI 1.68-1.75) or severe TR (HR 2.65, 95% CI 2.57-2.73), compared to those with no/trivial TR (p<0.001 for all). CONCLUSIONS TR is a common condition in adults referred for echocardiography. Moreover, even in the presence of other cardiac disease, increasing grades of TR are independently associated with increasing risks of CV and all-cause mortality. Furthermore, we show that even mild TR is independently associated with a significant increase in mortality.
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Affiliation(s)
- Sophie Offen
- Faculty of Medicine and Health, University of Sydney, NSW, Australia; Dept of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - David Playford
- The University of Notre Dame Australia, Fremantle, WA, Australia
| | - Geoff Strange
- Heart Research Institute, Sydney, NSW, Australia; The University of Notre Dame Australia, Fremantle, WA, Australia
| | - Simon Stewart
- Torrens University Australia, Adelaide, SA, Australia; University of Glasgow, Glasgow, Scotland
| | - David S Celermajer
- Faculty of Medicine and Health, University of Sydney, NSW, Australia; Dept of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia; Heart Research Institute, Sydney, NSW, Australia.
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Stanton KM, Liu H, Kienzle V, Bursill C, Bao S, Celermajer DS. The Effects of Exercise on Plaque Volume and Composition in a Mouse Model of Early and Late Life Atherosclerosis. Front Cardiovasc Med 2022; 9:837371. [PMID: 35419434 PMCID: PMC8995971 DOI: 10.3389/fcvm.2022.837371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 02/17/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundExercise is associated with a less atherogenic lipid profile; however, there is limited research on the effect of exercise on atherosclerotic plaque composition and markers of plaque stability.MethodsA total of 110 apolipoprotein (apo)E−/− mice were placed on a chow diet and randomly assigned to control or exercise for a period of 10 weeks, commencing either at 12 weeks of age (the early-stage atherosclerosis, EA group) or at 40 weeks of age (the late-stage atherosclerosis, LA group). At the end of the exercise period, blood was assayed for lipids. Histologic analysis of the aortic sinus was undertaken to assess plaque size and composition that includes macrophage content, monocyte chemoattractant protein (MCP)-1, matrix metalloproteinase-2 (MMP-2), and tissue inhibitors of metalloproteinase 1 and 2 (TIMP-1 and 2).ResultsA total of 103 mice (38 EA, 65 LA) completed the protocol. In the EA group, exercise reduced plasma total cholesterol (TC) (−16%), free cholesterol (−13%), triglyceride (TG) (−35%), and phospholipid (−27%) levels, when compared to sedentary control mice (p < 0.01). In the EA group, exercise also significantly reduced plaque stenosis (−25%, p < 0.01), and there were higher levels of elastin (3-fold increase, p < 0.0001) and collagen (11-fold increase, p < 0.0001) in plaques, compared to control mice. There was an increase in plaque MMP-2 content in the exercise group (13% increase, p < 0.05) but no significant difference in macrophage or MCP-1 content. In the LA group, exercise reduced plaque stenosis (−18%, p < 0.05), but there was no significant difference in plaque composition. There was no difference in macrophage, MCP-1, or MMP-2 content in the LA groups. TIMP-1 was lower with exercise in both the EA and LA groups (−59%, p < 0.01 and −51%, p < 0.01 respectively); however, there was no difference in TIMP-2 levels.ConclusionA 10-week exercise period reduces atherosclerotic plaque stenosis when commenced at both early- and late-stage atherosclerosis. Intervening earlier with exercise had a greater beneficial effect on lipids and plaque composition than when starting exercise at a later disease stage.
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Affiliation(s)
- Kelly M. Stanton
- Clinical Research Group, Heart Research Institute, Sydney, NSW, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- *Correspondence: Kelly M. Stanton
| | - Hongjuan Liu
- Discipline of Pathology and School of Medical Science, University of Sydney, Sydney, NSW, Australia
| | - Vivian Kienzle
- Clinical Research Group, Heart Research Institute, Sydney, NSW, Australia
| | - Christina Bursill
- Clinical Research Group, Heart Research Institute, Sydney, NSW, Australia
- Vascular Research Centre, South Australian Health and Medical Research Institute, Adelaide, SA, Australia
- Faculty of Health and Medical Science, University of Adelaide, Adelaide, SA, Australia
| | - Shisan Bao
- Discipline of Pathology and School of Medical Science, University of Sydney, Sydney, NSW, Australia
| | - David S. Celermajer
- Clinical Research Group, Heart Research Institute, Sydney, NSW, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
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King G, Buratto E, Celermajer DS, Grigg L, Alphonso N, Robertson T, Bullock A, Ayer J, Iyengar A, d’Udekem Y, Konstantinov IE. Natural and Modified History of Atrioventricular Valve Regurgitation in Patients With Fontan Circulation. J Am Coll Cardiol 2022; 79:1832-1845. [DOI: 10.1016/j.jacc.2022.02.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 01/28/2022] [Accepted: 02/17/2022] [Indexed: 12/26/2022]
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Chami J, Nicholson C, Strange G, Baker D, Cordina R, Celermajer DS. Hospital discharge codes and substantial underreporting of congenital heart disease. International Journal of Cardiology Congenital Heart Disease 2022. [DOI: 10.1016/j.ijcchd.2022.100320] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Kott KA, Bishop M, Yang CHJ, Plasto TM, Cheng DC, Kaplan AI, Cullen L, Celermajer DS, Meikle PJ, Vernon ST, Figtree GA. Biomarker Development in Cardiology: Reviewing the Past to Inform the Future. Cells 2022; 11:cells11030588. [PMID: 35159397 PMCID: PMC8834296 DOI: 10.3390/cells11030588] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 01/27/2022] [Accepted: 02/05/2022] [Indexed: 12/29/2022] Open
Abstract
Cardiac biomarkers have become pivotal to the clinical practice of cardiology, but there remains much to discover that could benefit cardiology patients. We review the discovery of key protein biomarkers in the fields of acute coronary syndrome, heart failure, and atherosclerosis, giving an overview of the populations they were studied in and the statistics that were used to validate them. We review statistical approaches that are currently in use to assess new biomarkers and overview a framework for biomarker discovery and evaluation that could be incorporated into clinical trials to evaluate cardiovascular outcomes in the future.
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Affiliation(s)
- Katharine A. Kott
- Cardiovascular Discovery Group, Kolling Institute of Medical Research, University of Sydney, St Leonards 2065, Australia; (K.A.K.); (S.T.V.)
- Department of Cardiology, Royal North Shore Hospital, St Leonards 2065, Australia
- Sydney Medical School, University of Sydney, Camperdown 2050, Australia; (C.H.J.Y.); (T.M.P.); (D.C.C.); (A.I.K.); (D.S.C.)
| | - Michael Bishop
- School of Medicine and Public Health, University of Newcastle, Kensington 2033, Australia;
| | - Christina H. J. Yang
- Sydney Medical School, University of Sydney, Camperdown 2050, Australia; (C.H.J.Y.); (T.M.P.); (D.C.C.); (A.I.K.); (D.S.C.)
| | - Toby M. Plasto
- Sydney Medical School, University of Sydney, Camperdown 2050, Australia; (C.H.J.Y.); (T.M.P.); (D.C.C.); (A.I.K.); (D.S.C.)
| | - Daniel C. Cheng
- Sydney Medical School, University of Sydney, Camperdown 2050, Australia; (C.H.J.Y.); (T.M.P.); (D.C.C.); (A.I.K.); (D.S.C.)
| | - Adam I. Kaplan
- Sydney Medical School, University of Sydney, Camperdown 2050, Australia; (C.H.J.Y.); (T.M.P.); (D.C.C.); (A.I.K.); (D.S.C.)
| | - Louise Cullen
- Emergency and Trauma Centre, Royal Brisbane and Women’s Hospital, Herston 4029, Australia;
| | - David S. Celermajer
- Sydney Medical School, University of Sydney, Camperdown 2050, Australia; (C.H.J.Y.); (T.M.P.); (D.C.C.); (A.I.K.); (D.S.C.)
- Department of Cardiology, Royal Prince Alfred Hospital, Camperdown 2050, Australia
- The Heart Research Institute, Newtown 2042, Australia
| | - Peter J. Meikle
- Baker Heart and Diabetes Institute, Melbourne 3004, Australia;
| | - Stephen T. Vernon
- Cardiovascular Discovery Group, Kolling Institute of Medical Research, University of Sydney, St Leonards 2065, Australia; (K.A.K.); (S.T.V.)
- Department of Cardiology, Royal North Shore Hospital, St Leonards 2065, Australia
- Sydney Medical School, University of Sydney, Camperdown 2050, Australia; (C.H.J.Y.); (T.M.P.); (D.C.C.); (A.I.K.); (D.S.C.)
| | - Gemma A. Figtree
- Cardiovascular Discovery Group, Kolling Institute of Medical Research, University of Sydney, St Leonards 2065, Australia; (K.A.K.); (S.T.V.)
- Department of Cardiology, Royal North Shore Hospital, St Leonards 2065, Australia
- Sydney Medical School, University of Sydney, Camperdown 2050, Australia; (C.H.J.Y.); (T.M.P.); (D.C.C.); (A.I.K.); (D.S.C.)
- Correspondence: ; Tel.: +61-(2)-9926-4915
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Vernon ST, Kott KA, Hansen T, Finemore M, Baumgart KW, Bhindi R, Yang J, Hansen PS, Nicholls SJ, Celermajer DS, Ward MR, van Nunen SA, Grieve SM, Figtree GA. Immunoglobulin E Sensitization to Mammalian Oligosaccharide Galactose-α-1,3 (α-Gal) Is Associated With Noncalcified Plaque, Obstructive Coronary Artery Disease, and ST-Segment-Elevated Myocardial Infarction. Arterioscler Thromb Vasc Biol 2022; 42:352-361. [PMID: 35045730 DOI: 10.1161/atvbaha.121.316878] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Treating known risk factors for coronary artery disease (CAD) has substantially reduced CAD morbidity and mortality. However, a significant burden of CAD remains unexplained. Immunoglobulin E sensitization to mammalian oligosaccharide galactose-α-1,3-galactose (α-Gal) was recently associated with CAD in a small observational study. We sought to confirm that α-Gal sensitization is associated with CAD burden, in particular noncalcified plaque. Additionally, we sort to assess whether that α-Gal sensitization is associated with ST-segment-elevated myocardial infarction (STEMI) Methods: We performed a cross-sectional analysis of participants enrolled in the BioHEART cohort study. We measured α-Gal specific-immunoglobulin E antibodies in serum of 1056 patients referred for CT coronary angiography for suspected CAD and 100 selected patients presenting with STEMI, enriched for patients without standard modifiable risk factors. CT coronary angiograms were assessed using coronary artery calcium scores and segmental plaque scores. RESULTS α-Gal sensitization was associated with presence of noncalcified plaque (odds ratio, 1.62 [95% CI, 1.04-2.53], P=0.03) and obstructive CAD (odds ratio, 2.05 [95% CI, 1.29-3.25], P=0.002), independent of age, sex, and traditional risk factors. The α-Gal sensitization rate was 12.8-fold higher in patients with STEMI compared with matched healthy controls and 2.2-fold higher in the patients with STEMI compared with matched stable CAD patients (17% versus 1.3%, P=0.01 and 20% versus 9%, P=0.03, respectively). CONCLUSIONS α-Gal sensitization is independently associated with noncalcified plaque burden and obstructive CAD and occurs at higher frequency in patients with STEMI than those with stable or no CAD. These findings may have implications for individuals exposed to ticks, as well as public health policy. Registration: URL: https://www.anzctr.org.au; Unique identifier: ACTRN12618001322224.
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Affiliation(s)
- Stephen T Vernon
- Cardiovascular Discovery Group, Kolling Institute of Medical Research (S.T.V., K.A.K., T.H., M.F., G.A.F.) University of Sydney, Australia.,Northern Clinical School, Faculty of Medicine and Health (S.T.V., K.A.K., T.H., M.F., R.B., P.S.H., M.R.W., S.A.v.N., G.A.F.) University of Sydney, Australia.,Department of Cardiology, Royal North Shore Hospital, Australia (S.T.V., K.A.K., T.H., R.B., P.S.H., M.R.W., G.A.F.)
| | - Katharine A Kott
- Cardiovascular Discovery Group, Kolling Institute of Medical Research (S.T.V., K.A.K., T.H., M.F., G.A.F.) University of Sydney, Australia.,Northern Clinical School, Faculty of Medicine and Health (S.T.V., K.A.K., T.H., M.F., R.B., P.S.H., M.R.W., S.A.v.N., G.A.F.) University of Sydney, Australia.,Department of Cardiology, Royal North Shore Hospital, Australia (S.T.V., K.A.K., T.H., R.B., P.S.H., M.R.W., G.A.F.)
| | - Thomas Hansen
- Cardiovascular Discovery Group, Kolling Institute of Medical Research (S.T.V., K.A.K., T.H., M.F., G.A.F.) University of Sydney, Australia.,Northern Clinical School, Faculty of Medicine and Health (S.T.V., K.A.K., T.H., M.F., R.B., P.S.H., M.R.W., S.A.v.N., G.A.F.) University of Sydney, Australia.,Department of Cardiology, Royal North Shore Hospital, Australia (S.T.V., K.A.K., T.H., R.B., P.S.H., M.R.W., G.A.F.)
| | - Meghan Finemore
- Cardiovascular Discovery Group, Kolling Institute of Medical Research (S.T.V., K.A.K., T.H., M.F., G.A.F.) University of Sydney, Australia.,Northern Clinical School, Faculty of Medicine and Health (S.T.V., K.A.K., T.H., M.F., R.B., P.S.H., M.R.W., S.A.v.N., G.A.F.) University of Sydney, Australia
| | | | - Ravinay Bhindi
- Northern Clinical School, Faculty of Medicine and Health (S.T.V., K.A.K., T.H., M.F., R.B., P.S.H., M.R.W., S.A.v.N., G.A.F.) University of Sydney, Australia.,Department of Cardiology, Royal North Shore Hospital, Australia (S.T.V., K.A.K., T.H., R.B., P.S.H., M.R.W., G.A.F.)
| | - Jean Yang
- Charles Perkins Centre (J.Y., S.M.G., G.A.F.) University of Sydney, Australia.,School of Mathematics and Statistics (J.Y.) University of Sydney, Australia
| | - Peter S Hansen
- Northern Clinical School, Faculty of Medicine and Health (S.T.V., K.A.K., T.H., M.F., R.B., P.S.H., M.R.W., S.A.v.N., G.A.F.) University of Sydney, Australia.,Department of Cardiology, Royal North Shore Hospital, Australia (S.T.V., K.A.K., T.H., R.B., P.S.H., M.R.W., G.A.F.)
| | - Stephen J Nicholls
- Monash Cardiovascular Research Centre, Victorian Heart Institute, Monash University, Australia (S.J.N.)
| | - David S Celermajer
- Sydney Medical School (D.S.C.) University of Sydney, Australia.,Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia (D.S.C.)
| | - Michael R Ward
- Northern Clinical School, Faculty of Medicine and Health (S.T.V., K.A.K., T.H., M.F., R.B., P.S.H., M.R.W., S.A.v.N., G.A.F.) University of Sydney, Australia.,Department of Cardiology, Royal North Shore Hospital, Australia (S.T.V., K.A.K., T.H., R.B., P.S.H., M.R.W., G.A.F.)
| | - Sheryl A van Nunen
- Northern Clinical School, Faculty of Medicine and Health (S.T.V., K.A.K., T.H., M.F., R.B., P.S.H., M.R.W., S.A.v.N., G.A.F.) University of Sydney, Australia.,Northern Beaches Hospital, Sydney, Australia (S.A.v.N.)
| | - Stuart M Grieve
- Charles Perkins Centre (J.Y., S.M.G., G.A.F.) University of Sydney, Australia.,Imaging and Phenotyping Laboratory, Charles Perkins Centre, Faculty of Medicine and Health (S.M.G.), University of Sydney, Australia.,Department of Radiology, Royal Prince Alfred Hospital, Sydney, Australia (S.M.G.)
| | - Gemma A Figtree
- Cardiovascular Discovery Group, Kolling Institute of Medical Research (S.T.V., K.A.K., T.H., M.F., G.A.F.) University of Sydney, Australia.,Northern Clinical School, Faculty of Medicine and Health (S.T.V., K.A.K., T.H., M.F., R.B., P.S.H., M.R.W., S.A.v.N., G.A.F.) University of Sydney, Australia.,Charles Perkins Centre (J.Y., S.M.G., G.A.F.) University of Sydney, Australia.,Department of Cardiology, Royal North Shore Hospital, Australia (S.T.V., K.A.K., T.H., R.B., P.S.H., M.R.W., G.A.F.)
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Offen SM, Baker D, Puranik R, Celermajer DS. Right ventricular volume and its relationship to functional tricuspid regurgitation. Int J Cardiol Heart Vasc 2022; 38:100940. [PMID: 35024430 PMCID: PMC8728462 DOI: 10.1016/j.ijcha.2021.100940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 11/14/2021] [Accepted: 12/22/2021] [Indexed: 11/12/2022]
Abstract
Background Significant right ventricular (RV) dilatation has long been considered integral to the pathogenesis of functional tricuspid regurgitation (FTR). Objectives To explore the relationship of RV dilatation and FTR in patients with ‘pure’ RV volume overload. Methods Patients (>17yrs) with RV dilatation due to pre-tricuspid shunts (atrial septal defect; ASD and/or partial anomalous pulmonary venous drainage; PAPVD) referred to our service (2000–2019) were retrospectively identified. Those with pulmonary hypertension, primum ASD or left-heart disease were excluded. Using standard cardiac MRI protocols, RV, right atrial and TV parameters were measured and compared. Results Of 52 consecutively eligible patients (42 ± 15yrs, 25 males), 25 had ASDs, 13 had PAPVD and 14 had both conditions. All were in sinus rhythm and none had pulmonary regurgitation. Left and right ventricular ejection fractions were normal (LVEF 63 ± 8%, RVEF 56 ± 8%). Indexed RV end-diastolic volumes (RVEDVi) were moderately increased (males 148 ± 33 mL/m2 and females 141 ± 42 mL/m2, range 95–267 mL/m2). Despite substantial RV volume overload, no patients had severe tricuspid regurgitation (TR). Only two had > mild TR. There was a weak correlation between tricuspid annular diameter and both degree of RV dilatation (r = 0.37; p = 0.01) and degree of TR (r = 0.38; p = 0.006). There was a similarly poor correlation between right atrial dimensions and the degree of TR (r = 0.34; p = 0.02). Conclusion When RV dilatation is simply due to volume overload, we find that significant TR is extremely rare. This gives an important and novel insight; that RV dilatation per se does not result in FTR.
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Affiliation(s)
- Sophie M Offen
- Faculty of Medicine and Health, University of Sydney, Australia.,Department of Cardiology, Royal Prince Alfred Hospital, Australia
| | - David Baker
- Department of Cardiology, Royal Prince Alfred Hospital, Australia
| | - Raj Puranik
- Faculty of Medicine and Health, University of Sydney, Australia.,Department of Cardiology, Royal Prince Alfred Hospital, Australia
| | - David S Celermajer
- Faculty of Medicine and Health, University of Sydney, Australia.,Department of Cardiology, Royal Prince Alfred Hospital, Australia.,Heart Research Institute, Australia
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Tran DL, Celermajer DS, Ayer J, Grigg L, Clendenning C, Hornung T, Justo R, Davis GM, d'Udekem Y, Cordina R. The "Super-Fontan" Phenotype: Characterizing Factors Associated With High Physical Performance. Front Cardiovasc Med 2021; 8:764273. [PMID: 34950712 PMCID: PMC8688538 DOI: 10.3389/fcvm.2021.764273] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 11/09/2021] [Indexed: 12/28/2022] Open
Abstract
Background: People with a Fontan circulation usually have moderately impaired exercise performance, although a subset have high physical performance ("Super-Fontan"), which may represent a low-risk phenotype. Methods: People with a "Super-Fontan" phenotype were defined as achieving normal exercise performance [≥80% predicted peak oxygen uptake (VO2) and work rate] during cardiopulmonary exercise testing (CPET) and were identified from the Australian and New Zealand Fontan Registry. A Fontan control group that included people with impaired exercise performance (<80% predicted VO2 or work rate) was also identified based on a 1:3 allocation ratio. A subset of participants were prospectively recruited and completed a series of physical activity, exercise self-efficacy, and health-related quality of life questionnaires. Results: Sixty CPETs ("Super-Fontan", n = 15; control, n = 45) were included. A subset ("Super-Fontan", n = 10; control, n = 13) completed a series of questionnaires. Average age was 29 ± 8 years; 48% were males. Exercise capacity reflected by percent predicted VO2 was 67 ± 17% in the entire cohort. Compared to the "Super-Fontan" phenotype, age at Fontan completion was higher in controls (4.0 ± 2.9 vs. 7.2 ± 5.3 years, p = 0.002). Only one (7%) person in the "Super-Fontan" group had a dominant right ventricle compared to 15 (33%) controls (p = 0.043). None of those in the "Super-Fontan" group were obese, while almost a quarter (22%) of controls were obese based on body mass index (p = 0.046). Lung function abnormalities were less prevalent in the "Super-Fontan" group (20 vs. 70%, p = 0.006). Exercise self-efficacy was greater in the "Super-Fontan" group (34.2 ± 3.6 vs. 27.9 ± 7.2, p = 0.02). Self-reported sports participation and physical activity levels during childhood and early adulthood were higher in the "Super-Fontan" group (p < 0.05). The total average time spent participating in structured sports and physical activity was 4.3 ± 2.6 h/wk in the "Super-Fontan" group compared to 2.0 ± 3.0 h/wk in controls, p = 0.003. There were no differences in self-reported current total physical activity score or health-related quality of life between groups (p ≥ 0.05). Conclusions: The "Super-Fontan" phenotype is associated with a healthy weight, lower age at Fontan completion, better exercise self-efficacy, and higher overall levels of sport and physical activity participation during physical development.
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Affiliation(s)
- Derek L Tran
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Central Clinical School, The University of Sydney School of Medicine, Sydney, NSW, Australia.,Charles Perkins Centre, Heart Research Institute, Sydney, NSW, Australia
| | - David S Celermajer
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Central Clinical School, The University of Sydney School of Medicine, Sydney, NSW, Australia.,Charles Perkins Centre, Heart Research Institute, Sydney, NSW, Australia
| | - Julian Ayer
- Heart Centre for Children, The Sydney Children's Hospital Network, Sydney, NSW, Australia.,The Children's Hospital at Westmead Clinical School, Sydney, NSW, Australia
| | - Leeanne Grigg
- Department of Cardiology, The Royal Melbourne Hospital, Melbourne, VIC, Australia.,The University of Melbourne School of Medicine, Melbourne, VIC, Australia
| | | | - Tim Hornung
- Green Lane Paediatric and Congenital Cardiac Service, Starship Hospital, Auckland, New Zealand
| | - Robert Justo
- Paediatric Cardiac Service, Queensland Children's Hospital, Brisbane, QLD, Australia.,The University of Queensland School of Medicine, Brisbane, QLD, Australia
| | - Glen M Davis
- Discipline of Exercise and Sports Science, Sydney School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Yves d'Udekem
- The George Washington University School of Medicine and Health Sciences, Washington, DC, United States.,Division of Cardiovascular Surgery, Children's National Hospital, Washington, DC, United States
| | - Rachael Cordina
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Central Clinical School, The University of Sydney School of Medicine, Sydney, NSW, Australia.,Charles Perkins Centre, Heart Research Institute, Sydney, NSW, Australia.,Murdoch Children's Research Institute, Melbourne, VIC, Australia
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Snir AD, Ng MK, Strange G, Playford D, Stewart S, Celermajer DS. Prevalence and Outcomes of Low-Gradient Severe Aortic Stenosis-From the National Echo Database of Australia. J Am Heart Assoc 2021; 10:e021126. [PMID: 34719256 PMCID: PMC8751961 DOI: 10.1161/jaha.121.021126] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The prevalence and outcomes of the different subtypes of severe low‐gradient aortic stenosis (AS) in routine clinical cardiology practice have not been well characterized. Methods and Results Data were derived from the National Echocardiography Database of Australia. Of 192 060 adults (aged 62.8±17.8 [mean±SD] years) with native aortic valve profiling between 2000 and 2019, 12 013 (6.3%) had severe AS. Of these, 5601 patients (47%) had high‐gradient and 6412 patients (53%) had low‐gradient severe AS. The stroke volume index was documented in 2741 (42.7%) patients with low gradient; 1750 patients (64%) with low flow, low gradient (LFLG); and 991 patients with normal flow, low gradient. Of the patients with LFLG, 1570 (89.7%) had left ventricular ejection fraction recorded; 959 (61%) had paradoxical LFLG (preserved left ventricular ejection fraction), and 611 (39%) had classical LFLG (reduced left ventricular ejection fraction). All‐cause and cardiovascular‐related mortality were assessed in the 8162 patients with classifiable severe AS subtype during a mean±SD follow‐up of 88±45 months. Actual 1‐year and 5‐year all‐cause mortality rates varied across these groups and were 15.8% and 49.2% among patients with high‐gradient severe AS, 11.6% and 53.6% in patients with normal‐flow, low‐gradient severe AS, 16.9% and 58.8% in patients with paradoxical LFLG severe AS, and 30.5% and 72.9% in patients with classical LFLG severe AS. Compared with patients with high‐gradient severe AS, the 5‐year age‐adjusted and sex‐adjusted mortality risk hazard ratios were 0.94 (95% CI, 0.85–1.03) in patients with normal‐flow, low‐gradient severe AS; 1.01 (95% CI, 0.92–1.12) in patients with paradoxical LFLG severe AS; and 1.65 (95% CI, 1.48–1.84) in patients with classical LFLG severe AS. Conclusions Approximately half of those patients with echocardiographic features of severe AS in routine clinical practice have low‐gradient hemodynamics, which is associated with long‐term mortality comparable with or worse than high‐gradient severe AS. The poorest survival was associated with classical LFLG severe AS.
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Affiliation(s)
- Afik D Snir
- Faculty of Medicine and Health University of Sydney Australia
| | - Martin K Ng
- Faculty of Medicine and Health University of Sydney Australia.,Department of Cardiology Royal Prince Alfred Hospital Camperdown Australia
| | - Geoff Strange
- Heart Research Institute Newtown Australia.,School of Medicine University of Notre Dame Fremantle Australia
| | - David Playford
- School of Medicine University of Notre Dame Fremantle Australia
| | - Simon Stewart
- Torrens University Australia Adelaide Australia.,University of Glasgow Scotland
| | - David S Celermajer
- Faculty of Medicine and Health University of Sydney Australia.,Department of Cardiology Royal Prince Alfred Hospital Camperdown Australia.,Heart Research Institute Newtown Australia
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Snir A, Wilson MK, Ju AL, Wong S, Khor L, Naoum C, Wong K, Keech A, Celermajer DS, Ng MK. Novel pressure-regulated deployment strategy for improving the safety and efficacy of balloon-expandable transcatheter aortic valves. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.2166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
The optimal method for balloon-expandable transcatheter heart valve (THV) deployment remains unknown. Current implantation protocols are volume-dependent and rely on ad-hoc filling of the deployment apparatus without accounting for annular wall tension during prosthesis expansion, predisposing patients to inconsistent clinical outcomes. During THV deployment, the annular wall tension exerted by the expanding prosthesis is determined by prosthesis diameter and balloon pressure (Laplace's Law).
Objective
We proposed and tested a novel method for balloon-expandable THV deployment, aimed at controlling balloon pressure and the resulting annular wall tension to allow optimal prosthesis-annulus apposition while preventing significant tissue injury.
Methods
330 consecutive patients with severe native aortic stenosis who underwent balloon-expandable THV implantation between 2015–2020 were included. 106 patients were considered high-risk for annular rupture. THVs were deployed until reaching a pre-determined balloon pressure; 4–4.5atm in earlier cases to establish experience and safety, later increasing to 5–6.5atm in most cases. Post-dilatation was performed to reduce >mild angiographic regurgitation (PVR). Using a biomechanical model, annular wall stress (tension) was estimated for each case and assessed against recorded rates of post-dilatation, ≥mild paravalvular regurgitation (PVR) on TTE, new PPM or LBBB and annular rupture.
Results
Patients with wall stress >3MPa (n=184) had reduced post-dilatation rate (p<0.001) and final PVR (≥mild, p=0.014). Annular rupture occurred in 2/3 high-risk cases with wall stress >3.5MPa; no rupture occurred in 102 high-risk cases with wall stress ≤3.5MPa. Based on these results, we defined target deployment wall stress levels (3–3.5MPa) and associated deployment pressure per THV size. Patients within this target range (n=136) had 8.1% new PPM, 12.5% new LBBB, 12.7% mild PVR with no cases of ≥moderate PVR. Importantly, there was an inconsistent relationship between deployment balloon volume and resulting annular wall stress.
Conclusion
Pressure-regulated THV deployment is a simple, easily reproducible, safe and effective method, regardless of high-risk anatomical complexities.
Funding Acknowledgement
Type of funding sources: None. Annular wall stress and PVRModel, stress vs volume and new strategy
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Affiliation(s)
- A Snir
- University of Sydney, Faculty of Medicine and Health, Sydney, Australia
| | - M K Wilson
- Macquarie University Hospital, Sydney, Australia
| | - A L Ju
- University of Sydney, Faculty of Engineering, Sydney, Australia
| | - S Wong
- Macquarie University Hospital, Sydney, Australia
| | - L Khor
- Macquarie University Hospital, Sydney, Australia
| | - C Naoum
- Macquarie University Hospital, Sydney, Australia
| | - K Wong
- Royal Prince Alfred Hospital, Sydney, Australia
| | - A Keech
- Royal Prince Alfred Hospital, Sydney, Australia
| | | | - M K Ng
- Royal Prince Alfred Hospital, Sydney, Australia
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Snir A, Ng MK, Playford D, Strange G, Stewart S, Celermajer DS. Relative prevalence and outcomes of low gradient severe aortic stenosis in routine clinical practice. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.1672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
The prevalence and outcomes of low-gradient severe aortic stenosis (AS), in particular low-flow low-gradient (LFLG) severe AS, have not been well characterized.
Objectives
We sought to delineate the relative prevalence and outcomes of patients with low-gradient severe AS in routine clinical cardiology practice.
Methods
Data were derived from the National Echocardiography Database of Australia (NEDA), a national multicentre clinical registry with data linkage to mortality. A total of 192,060 adults with native aortic valve profiling from 2000–2019 were identified, of whom 12,013 (6.3%) had severe AS (aged 75.3±13.1 years, 53.5% men). Severe AS subtypes were determined using standard echocardiographic criteria. All-cause and cardiovascular-related mortality were assessed on an adjusted basis (age and sex) in 8,162 patients with classifiable severe AS subtypes, during mean follow-up of 88±45 months. Additionally, rates of recorded Aortic Valve Replacement (AVR) during follow-up were compared between AS groups.
Results
5,601 patients (47%) had high-gradient and 6,412 patients (53%) had low-gradient severe AS. In the low-gradient group, Stroke Volume Index data was recorded in 2,741 patients; 1,750 (64%) had LFLG and 991 (36%) had normal-flow low-gradient (NFLG). For LFLG patients, 1,570 had LV ejection fraction recorded; 959 (61%) had paradoxical LFLG and 651 (39%) had classical LFLG. Adjusted 5-year cardiovascular mortality rates were 28% in high-gradient, 24% in NFLG, 27% in paradoxical LFLG and 50% in classical LFLG patients (p<0.001). Rates of recorded AVR per mean follow-up years were 5.2% for high-gradient, 4.0% for NFLG, 3.1% for classical LFLG and 2.4% for paradoxical LFLG severe AS (p<0.001).
Conclusions
Approximately half the subjects with echocardiographic features of severe AS in routine clinical practice have low-gradient haemodynamics, associated with long-term mortality comparable to or worse than high-gradient severe AS. The poorest survival was associated with classical LFLG severe AS.
Funding Acknowledgement
Type of funding sources: None. Summary illustration5 year mortality curves
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Affiliation(s)
- A Snir
- University of Sydney, Faculty of Medicine and Health, Sydney, Australia
| | - M K Ng
- Royal Prince Alfred Hospital, Sydney, Australia
| | - D Playford
- University of Notre Dame, Fremantle, Australia
| | - G Strange
- University of Notre Dame, Fremantle, Australia
| | - S Stewart
- Torrens University Australia, Adelaide, Australia
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Snir A, Ng MK, Strange G, Playford D, Stewart S, Celermajer DS. Cardiac damage staging classification and prognosis in low flow low gradient severe aortic stenosis. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.1673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
There are currently no established prognostic models for low-flow, low-Gradient (LFLG) severe aortic stenosis (AS). The Cardiac Damage Staging Classification, has been validated as a clinically useful prognostic tool in high-gradient severe AS, but not specifically in LFLG severe AS.
Objective
To assess and confirm the prognostic utility of the Cardiac Damage Staging Classification, in LFLG severe AS patients.
Methods
We analysed data from the National Echocardiography Database of Australia (NEDA), a national multicentre registry with individual data linkage to mortality. Of 192,060 adults (aged 62.8±17.8 years) with comprehensive ultrasound profiling of the native aortic valve studied between 2000–2019, 12,013 (6.3%) had severe AS. Based on standard echocardiographic parameters, 611 classical and 959 paradoxical LFLG patients were identified. Mean follow-up was 70±41 months. All-cause and cardiovascular-related mortality were assessed for each LFLG group on an adjusted basis (age and sex), according to cardiac damage classification staging.
Results
Paradoxical LFLG patients were younger (mean age 74.3 vs 76.2, p=0.006) and more often female (62.8% vs 36.3%, p<0.001). Classical LFLG patients had greater associated cardiac damage at diagnosis (76% vs. 49%, for Stage ≥2, p<0.001). Compared to Stage 0 paradoxical LFLG patients, adjusted 1- and 5-year cardiovascular-related mortality was 200% (HR 2.82, 95% CI 1.12–7.11) and 120% (HR 2.42, 95% CI 1.46–4.02) higher in Stage 2 patients and 350% (HR 4.23, 95% CI 1.68–10.63) and 175% (HR 3.18, 95% CI 1.90–5.34) higher in Stage 3/4 patients, respectively. Compared to Stage 1 classical LFLG patients, adjusted 1- and 5-year cardiovascular-related mortality was 58% (HR 1.66, 95% CI 0.95–2.90) and 24% (HR 1.35, 95% CI 0.91–1.99) higher in Stage 2 patients and 125% (HR 2.48, 95% CI 1.43–4.28) and 52% (HR 1.87, 95% CI 1.26–2.78) higher in Stage 3/4 patients, respectively.
Conclusion
In patients with LFLG severe AS identified by echocardiography, increasing severity denoted by the cardiac damage staging classification is strongly associated with increasing medium- to long-term mortality.
Funding Acknowledgement
Type of funding sources: None. Stages + Classical LFLG 5 year mortalityParadoxical LFLG 5 year mortality curves
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Affiliation(s)
- A Snir
- University of Sydney, Faculty of Medicine and Health, Sydney, Australia
| | - M K Ng
- Royal Prince Alfred Hospital, Sydney, Australia
| | - G Strange
- University of Notre Dame, Fremantle, Australia
| | - D Playford
- University of Notre Dame, Fremantle, Australia
| | - S Stewart
- Torrens University Australia, Adelaide, Australia
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