Coronary artery disease in older adults with congenital heart defects: risk factors and pharmacotherapy

INTRODUCTION

With advancing age, adults with congenital heart disease (ACHD) are at a higher risk of developing atherosclerotic coronary artery disease (CAD).

OBJECTIVES

We aimed to determine the prevalence of CAD, its risk factors, and use of guideline‑directed pharmacotherapy among older patients with ACHD.  Patients and methods: We studied all ACHD patients aged 60 years or older hospitalized in our department between the years 2013 and 2020. CAD was defined as a history of acute coronary syndrome or coronary revascularization, or more than 50% diameter stenosis on coronary angiography. Data regarding the underlying heart defect, prevalence of cardiovascular risk factors, and drug prescriptions were collected.

RESULTS

A total of 198 patients with known coronary artery status (mean [SD] age, 66.2 [5.3] years; 43.3% men) were included in the analysis. Of them, 54 (27.3%) had CAD. The individuals with CAD were more often men, and they were more likely to have a mild heart defect, dyslipidemia, and a history of hypertension and tobacco use. Multivariable analysis showed that male sex (P = 0.001), dyslipidemia (P = 0.003), and hypertension (P = 0.04) were positive independent predictors of CAD, whereas overweight / obesity was identified as a negative independent predictor (P = 0.04). The proportion of CAD patients on antiplatelet and / or anticoagulant drugs was 92.6%. β‑Blockers were prescribed to 87% of the patients, and a lipid‑lowering agent to 96% of the study population.

CONCLUSIONS

CAD is common in older patients with ACHD. Our results underline the importance of identification and treatment of modifiable CAD risk factors in individuals with ACHD. The obesity paradox might also play a role in this population. The rate of guideline‑recommended pharmacotherapy implementation seems to be satisfactory.

Implantable cardioverter defibrillator use in arrhythmogenic right ventricular cardiomyopathy in North America and Europe

BACKGROUND AND AIMS

Implantable cardioverter-defibrillators (ICDs) are critical for preventing sudden cardiac death (SCD) in arrhythmogenic right ventricular cardiomyopathy (ARVC). This study aims to identify cross-continental differences in utilization of primary prevention ICDs and survival free from sustained ventricular arrhythmia (VA) in ARVC.

METHODS

This was a retrospective analysis of ARVC patients without prior VA enrolled in clinical registries from 11 countries throughout Europe and North America. Patients were classified according to whether they received treatment in North America or Europe and were further stratified by baseline predicted VA risk into low- (<10%/5 years), intermediate- (10%-25%/5 years), and high-risk (>25%/5 years) groups. Differences in ICD implantation and survival free from sustained VA events (including appropriate ICD therapy) were assessed.

RESULTS

One thousand ninety-eight patients were followed for a median of 5.1 years; 554 (50.5%) received a primary prevention ICD, and 286 (26.0%) experienced a first VA event. After adjusting for baseline risk factors, North Americans were more than three times as likely to receive ICDs {hazard ratio (HR) 3.1 [95% confidence interval (CI) 2.5, 3.8]} but had only mildly increased risk for incident sustained VA [HR 1.4 (95% CI 1.1, 1.8)]. North Americans without ICDs were at higher risk for incident sustained VA [HR 2.1 (95% CI 1.3, 3.4)] than Europeans.

CONCLUSIONS

North American ARVC patients were substantially more likely than Europeans to receive primary prevention ICDs across all arrhythmic risk strata. A lower rate of ICD implantation in Europe was not associated with a higher rate of VA events in those without ICDs.

A new model for predicting adverse outcomes in arrhythmogenic right ventricular cardiomyopathy

INTRODUCTION

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a progressive disease leading to ventricular arrhythmias and heart failure. Determining optimal time for heart transplantation (HTx) is challenging; therefore, it is necessary to identify risk factors for disease progression.

OBJECTIVES

The study aimed to identify predictors of end‑stage heart failure and to evaluate the role of biomarkers in predicting adverse outcomes in ARVC.

PATIENTS AND METHODS

A total of 91 individuals with ARVC (59 men; mean [SD] age, 47 [16] years) were included. In all patients, information on medical history was collected, electrocardiography and echocardiography were performed, and serum levels of selected biomarkers (soluble form of the ST2 protein [sST2], galectin‑3 [Gal‑3], extracellular matrix metalloproteinases [MMP‑2 and MMP‑9], N‑terminal pro-B‑type natriuretic peptide [NT‑proBNP], and high‑sensitivity troponin T [hs‑TnT]) were measured. Thereafter, the participants were followed for the primary end point of death or HTx, as well as the secondary end point of major arrhythmic events (MAEs), defined as sudden cardiac death, ventricular fibrillation, sustained ventricular tachycardia, or appropriate implantable cardioverter‑defibrillator intervention.

RESULTS

During the median (interquartile range) follow‑up of 36.4 (29.8-41.2) months, 13 patients (14%) reached the primary end point of death or HTx, and 27 (30%) experienced MAEs. The patients who achieved the primary end point had higher levels of sST2, MMP‑2, NT‑proBNP, and hs‑TnT, but not of Gal-3 and MMP-9. Three factors turned out to be independent predictors of death or HTx: higher NT‑proBNP concentration (≥890.3 pg/ml), greater right ventricular end‑diastolic area (≥39 cm2), and a history of atrial tachycardia. None of the biomarkers predicted MAEs.

CONCLUSIONS

An NT‑proBNP concentration greater than or equal to 890.3 pg/ml, right ventricular end-diastolic area of 39 cm2 or greater, and a history of atrial tachycardia were identified as risk factors for death or HTx in ARVC. Higher levels of sST2, MMP‑2, NT‑proBNP, and hs‑TnT were associated with reaching the primary end point of death or HTx. The biomarkers had no value in predicting ventricular arrhythmias.

Long-term outcomes following transcatheter pulmonary valve implantation with the sapien 3 valve: an international multicentre registry

Background

Transcatheter pulmonary valve implantation (TPVI) is indicated to treat right-ventricular outflow tract dysfunction related to congenital heart disease. Long-term outcomes following TPVI with the new-generation SAPIEN 3 valve are not well documented.

Purpose

We investigated mid-term outcomes in a large cohort of patients who underwent TPVI using the SAPIEN 3 valve.

Methods

We retrospectively analysed data from a multicentre observational registry of patients who underwent TPVI with SAPIEN 3 in 30 centres in 12 countries from Europe, the Middle East, and Canada. Patient-related, procedural, and mid-term-outcome data were assessed.

Results

We obtained data for 713 patients treated in 2014–2021. Number of procedures performed among centres varied from 1 to 190 with a median of 15. Median age was 29.4-year-old [19.0–42.8]. The most common underlying diagnosis was cono-truncal defect (68.9%), with a native or patched right-ventricular outflow tract, a bioprosthetic valve, a homograft and a conduit, in 50.8%, 19.6%, 16.5% and 13.2% patients, respectively. Pre-stenting was performed in 74.8% patients. The 20-mm, 23-mm, 26-mm, and 29-mm valves were used in 0.4%, 28.2%, 31.2%, and 40.2% of patients, respectively. Valve implantation was successful in 98.6% patients. Life-threatening peri-procedural adverse events occurred in 3.7% patients, including 0.6% peri-procedural death. Median follow-up was 1.4 years (maximum, 5.9 years; 1160 patient-years), At last follow-up, pulmonary regurgitation grade 2, 3 and 4 was noted in 6.9%, 0.9% and 0.0% patients, respectively. Median maximal gradient at last follow-up was 18 mmHg.

Six patients experienced infective endocarditis (0.5 per 100 patient-years) of whom 1 died and 2 required pulmonary valve replacement. Nine patients (0.8 per 100 patient-years) had secondary pulmonary valve replacement (including 2 by valve-in-valve TPVI; 7 patients had 23-mm and 2 had 26-mm valves). Four patients experienced pulmonary valve thrombosis (0.6 per 100 patient-year) of whom one died and 3 resolved under anticoagulation therapy.

Cumulative incidences of infective endocarditis, secondary pulmonary valve replacement and valve thrombosis were 0.7%, 1.3% and 1.3%; 0.4%, 1.3% and 4.6%; 0.5%, 0.5% and 0.8% at 1, 3 and 5 years after TPVI respectively.

Conclusion

TPVI with the SAPIEN 3 valve was feasible and safe in a wide range of patients with congenital heart defects, most of whom had large native right-ventricular outflow tracts. Mid-term outcomes were favourable.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): The study is promoted and financially supported by a Research grant of the Groupe Hospitalier Paris Saint Joseph

NT-proBNP is superior to novel plasma biomarkers for predicting adverse outcome in arrhythmogenic right ventricular cardiomyopathy

Background/Introduction

Arrhythmogenic right ventricular cardiomyopathy is a heritable heart muscle disease characterized by progressive substitution of the myocardium with fibrous and fatty tissue, which is the substrate for ventricular arrhythmia, systolic dysfunction and heart failure. Determining the optimal time for heart transplantation is challenging and, therefore, finding risk factors for disease progression is needed.

Purpose

The purpose of the study was to evaluate the role of markers of myocardial fibrosis sST2, Gal-3, MMP-2 and MMP-9, as well as NT-proBNP and hsTnT, in predicting major adverse outcomes in ARVC. Moreover, we aimed to identify other risk factors for developing end-stage heart failure.

Methods

We included 91 patients with the definite diagnosis of ARVC according to the 2010 Task Force Criteria (59 males, mean age of 47±16 years). Patients were interviewed for their medical history, electrocardiography and echocardiography were performed and plasma levels of selected biomarkers were measured. Thereafter, subjects were followed for the occurrence of the composite endpoint of death or heart transplantation (HTx) and major arrhythmic events defined as ventricular fibrillation, sustained ventricular tachycardia or appropriate implantable cardioverter-defibrillator intervention.

Results

During the median follow-up of 36,4 months [29,8–41,2], 13 subjects (14%) reached the composite endpoint of death or HTx and 27 subjects (30%) experienced major arrhythmic event. Among the studied biomarkers, significantly higher levels of sST2, MMP-2, NT-proBNP and hsTnT were found in patients who achieved the composite endpoint. The remaining prognostic factors are shown in Table 1. In the multivariate analysis, three factors turned out to be significant: higher NT-proBNP levels (the cut-off point ≥890.3 pg/m), greater right ventricular end-diastolic area (the cut-off point ≥39.0 cm2) and history of atrial tachycardia. Kaplan-Meyer survival analysis depending on the number of predictors is presented in Figure 1. None of the biomarkers predicted major arrhythmic events.

Conclusions

NT-proBNP ≥890.3 pg/ml, RV area ≥39.0 cm2 and history of atrial tachycardia are independent risk factors for death or HTx in ARVC. Among the studied biomarkers, higher levels of sST2, MMP-2, NT-proBNP and hsTnT were observed in patients who reached the composite endpoint. Biomarkers had no value in predicting ventricular arrhythmias.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): National Institute of Cardiology, Warsaw, Poland

Predictors of COVID-19 outcomes in adult congenital heart disease patients - anatomy versus function

BACKGROUND

It is unclear whether patients with adult congenital heart disease (ACHD) should be considered as an increased risk population with poor outcomes when suffering from COVID-19.

AIMS

The aim of this study is to collect clinical outcome data and to identify risk factors of a complicated COVID-19 course among ACHD patients.

METHODS

Among all outpatients who came to medical attention via telemedicine or direct physician contact at our institution between September 1, 2020 until March 31, 2021 we included all with a COVID-19 diagnosis. The incidence of COVID-19 infection, a clinical course of the disease and outcome were determined.

RESULTS

One hundred and four (8.7%) out of 1 197 patients were seen at our outpatient clinic for ACHD patients met definition for a COVID-19 infection. Most of them reported a mild course of COVID-19 disease (99 [95.5%]). Five patients (4.5%) experienced severe symptoms and needed hospitalization. Two patients (1.9% of all with a confirmed diagnosis, 40% with severe infection) died. In the multivariable analysis decreased systemic ventricular systolic function and any significant valve stenosis were predictors of a complicated disease course.

CONCLUSIONS

Our study confirmed previous results showing that a physiology-based model rather than an anatomy-based model better predict COVID-19 outcomes among ACHD patients. This information is important both to patients and medical care providers facing the next wave of COVID-19 infections.

The emerging role of reassessment of genetic testing results in the diagnosis of the unexplained sudden cardiac arrest's causes

Background

The most common cause of Unexplained Sudden Cardiac Arrest (USCA) are hereditary primary arrhythmic syndromes and subclinical forms of cardiomyopathies. Both of them may be difficult to diagnose.

Objective

The aim of this study was to re-examine the role of genetic testing in patients after USCA during follow-up.

Methods

In the years 2014–2017 we studied 44 unrelated patients (pts) (23 men (53%), mean age 36 years) after USCA. All pts underwent cardiac evaluation including ECG, Holter, echo, coronary angiography, stress exercise test and, if necessary cardiac MRI and provocative drug testing. Standard diagnostic criteria were used according to currently available ESC guidelines. We performed next generation sequencing with panel covered coding regions of &gt;4800 genes (26pts), 194 genes (5pts) and whole exome sequencing &gt;2ehab724.3204 genes (5pts). Variants of frequency no greater than 0,001 in existing variants' databases and classified as damaging by at least 3 of applied software algorithms were assessed for pathogenicity according to ACMG standards. The enrolled patients were followed up. During the follow up, the classification of rare variants according to ACMG standards was repeated.

Results

Based on applicable standards and the clinical data collected, clinical diagnosis was made in 17 (39%) probands (Long QT Syndrome 21%, Brugada Syndrome 7%, Short QT Syndrome 7%, Early Repolarization Syndrome and Catecholaminergic Polymorphic Ventricular Tachycardia 2%, both). Genetic tests were performed in 36 pts. We identified 27 rare variants in 22 pts, in genes associated with inherited arrhythmia or cardiomyopathies, of these 23 rare variants were identified in years 2014–2017. The first classification was in 2017, then only 2 variants (in FLNC) were considered pathogenic and the remaining 21 were classified as Variants of Unknown Significance (VUS). During the years 2019–2021, 23 earlier identified rare variants were reclassified according to The American College of Medical Genetics and Genomics (ACMG) standards, of these 5 VUS became pathogenic/likely pathogenic variants. In addition, we performed genetic tests in next 5 pts – we identified 4 rare variants – 3 pathogenic and 1 VUS.

Detection of certain hereditary background of SCA increased from 6,5% in years 2014–2017, to 25% in years 2019–2021.

The median follow-up period was 2366 days (interquartile range 1785–2903 days). 17/44 (39%) pts had adequate discharge of ICD. Two pts were observed with reduction of left ventricular contractility and the development of the initial stages of dilated cardiomyopathy.

Conclusion

This study shows clinical utility of extensive clinical assessment and follow-up of patient after USCA. Routine genetic testing by next generation sequencing in the patients can help in diagnosis and re-evaluation of rare variants should be made during the follow-up.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): grant of National Institute of Cardiology, Warsaw, Poland

Pathogenic variants in plakophilin-2 gene (PKP2) are associated with better survival in arrhythmogenic right ventricular cardiomyopathy

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is mainly caused by mutations in genes encoding desmosomal proteins. Variants in plakophilin-2 gene (PKP2) are the most common cause of the disease, associated with conventional ARVC phenotype. The study aims to evaluate the prevalence of PKP2 variants and examine genotype-phenotype correlation in Polish ARVC cohort. All 56 ARVC patients fulfilling the current criteria were screened for genetic variants in PKP2 using denaturing high-performance liquid chromatography or next-generation sequencing. The clinical evaluation involved medical history, electrocardiogram, echocardiography, and follow-up. Ten variants (5 frameshift, 2 nonsense, 2 splicing, and 1 missense) in PKP2 were found in 28 (50%) cases. All truncating variants are classified as pathogenic/likely pathogenic, while the missense variant is classified as variant of uncertain significance. Patients carrying a PKP2 mutation were younger at diagnosis (p = 0.003), more often had negative T waves in V1-V3 (p = 0.01), had higher left ventricular ejection fraction (p = 0.04), and were less likely to present symptoms of heart failure (p = 0.01) and left ventricular damage progression (p = 0.04). Combined endpoint of death or heart transplant was more frequent in subgroup without PKP2 mutation (p = 0.03). Pathogenic variants in PKP2 are responsible for 50% of ARVC cases in the Polish population and are associated with a better prognosis. ARVC patients with PKP2 mutation are less likely to present left ventricular involvement and heart failure symptoms. Combined endpoint of death or heart transplant was less frequent in this group.

Pregnancy-related, nonelective cardiac hospitalizations and pregnancy outcomes: a tertiary referral cardiac center experience

BACKGROUND

Pregnant women with cardiovascular diseases (CVD) and their offspring are at increased morbidity and mortality.

AIMS

To provide data on pregnancy outcomes among women with different typesof CVD requiring non-elective cardiac hospitalization in atertiary referral cardiac center.

METHODS

We identified all records of non-elective hospitalizations of pregnant women hospitalized between January 2009 through March 2018, at our institution-a tertiary referral cardiaccentre. The incidence and type of cardiac complications during pregnancy as well as the pregnancy and offspring outcomeswere determined.

RESULTS

161 out of 328 pregnancy-related hospitalizations in140 pregnancies were non-elective. Cardiac complications occurred in 62 (44%) of pregnancies, with the most frequent being: episodesof arrhythmia (22.1% pregnancies), followed by heart failure exacerbations(6.4% pregnancies). Maternal mortality reached 2.1% and affected only women with primary cardiomyopathies (CMP). Offspring mortality was 2.8%. Newborns of mothers with cardiac complications had significantly lower Apgar scoresand gestational age at delivery,compared to mothers without cardiac complications.

CONCLUSIONS

In our series mortality and morbidity among pregnant women with CVD hospitalizations werehigh. An unfavorable maternal outcome mainly affected women with CMP. Offspringof mothers with cardiovascular complications are prone to have a lowergestational age and Apgar score.

Galectin-3 plasma levels in adult congenital heart disease and the pressure overloaded right ventricle: reason matters

Aim: To assess galectin-3 (Gal-3) levels and their relationship with clinical status and right ventricular (RV) performance in adults with RV pressure overload of various mechanisms due to congenital heart disease. Materials & methods: A cross-sectional study was conducted. Patients underwent clinical examination, blood testing and transthoracic echocardiography. Results: The study included 63 patients with congenitally corrected transposition of the great arteries, 41 patients with Eisenmenger syndrome and 20 healthy controls. Gal-3 concentrations were higher in patients compared with controls (7.83 vs 6.11 ng/ml; p = 0.002). Biomarker levels correlated with age, New York Health Association class, N-terminal probrain natriuretic peptide and RV function only in congenitally corrected transposition of the great arteries patients. Conclusion: Gal-3 profile in congenital heart disease patients and pressure-overloaded RV differs according to the cause of pressure overload.

A Recurrent Exertional Syncope and Sudden Cardiac Arrest in a Young Athlete with Known Pathogenic p.Arg420Gln Variant in the RYR2 Gene

Catecholaminergic polymorphic ventricular tachycardia (CPVT) is one of causes of sudden cardiac death in the young, especially in athletes. Diagnosis of CPVT may be difficult since all cardiological examinations performed at rest are usually normal, and exercise stress test-induced ventricular tachycardia is not commonly present. The identification of a pathogenic mutation in RYR2 or CASQ2 is diagnostic in CPVT. We report on a 20-year-old athlete who survived two sudden cardiac arrests during swimming. Moreover, he suffered repeated syncopal spells on exercise. The diagnosis was made only following genetic testing using a multi-gene panel, and the p.Arg420Gln RYR2 variant was identified. We present diagnostic and therapeutic issues in this young athlete with CPVT.

Factors associated with the need for pulmonary valve replacement in asymptomatic patients with isolated pulmonary regurgitation after repair of tetralogy of Fallot: a cardiac magnetic resonance study

BACKGROUND

Pulmonary regurgitation (PR) is the most common late complication in patients after repair of tetralogy of Fallot (TOF). Most patients remain asymptomatic over years, but eventually, the compensatory mechanisms fail, leading to right ventricular (RV) dilation and dysfunction, limited exercise capacity, ventricular arrhythmia, and sudden death.

AIMS

We aimed to evaluate associations between cardiac magnetic resonance (CMR) parameters and the need for either surgical or percutaneous pulmonary valve replacement (PVR) in asymptomatic patients with significant PR after repair of TOF.

METHODS

Of 209 patients with repaired TOF who had undergone a CMR study, we selected 61 asymptomatic patients with moderate‑to‑severe PR and followed them for up to 4 years (mean [SD], 21.4 [13.7] months). We excluded patients with residual ventricular septal defect, a peak RV outflow tract gradient of 30 mm Hg or higher, or at least moderate tricuspid regurgitation.

RESULTS

Receiver operating characteristic curve analyses revealed that the ratio of RV to left ventricular (LV) volume (RV/ LV ratio; threshold >2.4) and PR fraction (PRF; threshold >33%) had acceptable discriminatory capacity to differentiate between patients requiring PVR and those treated conservatively. The Cox proportional hazards regression and the Kaplan–Meier curves revealed that the RV / LV ratio and PRF was significantly associated with the need for PVR. The combination of the RV / LV ratio and PRF provided significant discrimination in terms of survival without PVR (P <0.001; log‑rank test for trend).

CONCLUSIONS

The RV/ LV ratio and PRF were significantly associated with the need for PVR in asymptomatic patients with isolated moderate‑to‑severe PR after repair of TOF.

P2826Clinical and genetic yield of familiar screening after sudden death of young patients

Background

In Europe, approximately 9000 patients under the age of 45 die suddenly every year. In this group the predominant reasons of sudden death (SD) are channelopathies, cardiomyopathies, myocarditis and substance abuse. The main challenge is the identification of the cause of an unexpected death, especially when the autopsy was not done routinely.

Objective

The aim of the study was to investigate the value of clinical and genetic screening in relatives of subjects who died suddenly under the age of 45.

Methods

In the years 2017–2018 we evaluated 53 relatives (41 1st degree) of 25 young SD subjects. Clinical screening included a review of medical history, clinical examination, ECG, transthoracic echocardiogram, 24- hour EKG Holter monitoring, stress test and, cardiac MRI, provocative drug tests, if necessary. Standard diagnostic criteria were used according to currently available ESC guidelines. The most affected 1st degree relative of the SD victim was named as proband.

DNA samples from 25 probands were examined by next generation sequencing (NGS) using a custom panel which included 174 genes associated with 17 cardiac diseases-TruSight Cardio (TSC) panel. Variants identified with NGS were followed-up in probands and other relatives with Sanger sequencing.

Baseline analysis of NGS results was based on searching for genetic variants with very low frequency (<0.001) with high bioinformatic prediction scores with special regard to phenotypically consistent genes. The frequencies of variants were compared with the GnomAD database, Phase 3 of 1000 Genomes, NHLBI GO Exome Sequencing Project (ESP) 6500. For the bioinformatic prediction scores we used data summarized in VarSome database. The clinical significance of the variants was based on ClinVar database.

Results

Based on comprehensive clinical evaluation of relatives the diagnosis was made in 16/25 (64%) families, namely long QT syndrome (n=7/16; 43,75%), hypertrophic cardiomyopathy (n=5/16; 31,25%), Brugada syndrome (1/16; 6,25%), arrhythmogenic right ventricular cardiomyopathy (n=1/16; 6,25%), thoracic aortic aneurysm (n=1/16; 6,25%) and complete heart block (n=1/16; 6,25%). In 9/25 families (36%) exams showed minor abnormalities, but definite diagnosis could not be made.

We found pathogenic variants in 11/25 (44%) probands. We identified 9 variants in a subgroup of probands with diagnosis (frameshift in MYBPC3 and PKP2, missense variants in KCNQ1, SCN3B, SCN5A,MYH7,TPM1, SCN2B, KCNH2 genes) and 2 variants in a subgroup of probands without diagnosis (frameshift in TTN gene and a missense in KCNH2 gene).

Conclusion

This study shows that clinical and genetic familial screening after sudden death of young patients may be effective, helps in identifying individuals at risk and allows to implement an adequate treatment to prevent subsequent sudden death.

Acknowledgement/Funding

Institute of Cardiology in Anin 2.9/II/17

Coincidence of Andersen-Tawil syndrome and Marfan syndrome: A case report

We report on a 44-year-old woman with coincidence of two genetic disorders: Andersen-Tawil syndrome and Marfan syndrome. In both, life-threatening arrhythmias could occur. A 44-year-old woman presented acute ascending aortic dissection with aortic arch involvement and chronic thoracic descending and abdominal aortic dissection. Clinical and genetic examination confirmed Marfan syndrome (MFS) diagnosis. Due to repolarization disorder in ECG and premature ventricular contractions in Holter ECG, the sequencing data were analyzed again and mutation in KCNJ2 gene was identified. The case showed that coincidence of Andersen-Tawil syndrome (ATS) and MFS did not provoke life-threatening arrhythmias. Complication was rather caused by expression of FBN1 mutation.

Sudden cardiac arrest in patients without overt heart disease: a limited value of next generation sequencing

INTRODUCTION Unexplained sudden cardiac arrest (SCA), occurs in up to 10% of patients and is often attributed to an inherited arrhythmia syndrome. Family screening and genetic testing may help clarify the cause of unexplained SCA. OBJECTIVES We aimed to assess the usefulness of clinical evaluation and genetic testing in patients after unexplained SCA and in their families. PATIENTS AND METHODS In the years 2014-2017, we studied 44 unrelated patients after unexplained SCA and 96 of their relatives. All patients and relatives underwent comprehensive cardiac evaluation. In 31 patients with SCA, next generation sequencing (NGS) was performed. The Kaplan-Meier survival curve was constructed to compare the event-free survival depending on clinical diagnosis or genotype. An adverse event was defined as an adequate implantable cardioverter-defibrillator discharge. RESULTS Based on the clinical evaluation, diagnosis was established in 39% of probands (long QT syndrome 21%; short QT syndrome 7%; Brugada syndrome 7%; catecholaminergic polymorphic ventricular tachycardia, 2%; and early repolarization syndrome, 2%). Ventricular arrhythmia was identified in the relatives of 19% of probands. In 18 of the 31 probands (54.8%), 23 rare gene variants were identified, of which only 2 were classified as pathogenic. The event-free survival over a median of 4.5 years was similar in patients with or without clinical diagnosis and in carriers and noncarriers of a rare genetic variant. CONCLUSIONS This study shows the significance of an extensive clinical assessment in unexplained SCA victims and their relatives. Routine genetic testing by NGS has low diagnostic and prognostic value.

Pregnancy After Transcatheter Pulmonary Valve Implantation

Transcatheter pulmonary valve implantation (TPVI) is a relatively new method of treating patients with significant pulmonary regurgitation or pulmonary stenosis, or both, after reconstruction of the right ventricular outflow tract. It is an attractive alternative to conduit replacement in this group of patients, who are typically young and active. This report includes 4 young women who after successful TPVI became pregnant and gave birth. Transthoracic echocardiography, cardiopulmonary exercise testing, and cardiac magnetic resonance imaging were performed in all patients. The results suggest that pregnancy and delivery after successful TPVI is safe when the appropriate precautions have been taken.

Are heart rate monitors valuable tools for diagnosing arrhythmias in endurance athletes?

Millions of physically active individuals worldwide use heart rate monitors (HRMs) to control their exercise intensity. In many cases, the HRM indicates an unusually high heart rate (HR) or even arrhythmias during training. Unfortunately, studies assessing the reliability of these devices to help control HR disturbances during exercise do not exist. We examined 142 regularly training endurance runners and cyclists, aged 18-51 years, with unexplained HR abnormalities indicated by various HRMs to assess the utility of HRMs in diagnosing exertion-induced arrhythmias. Each athlete simultaneously wore a Holter electrocardiogram (ECG) recorder and an HRM during typical endurance training in which they had previously detected "arrhythmias" to verify the diagnosis. Average HRs during exercise were precisely recorded by all types of HRMs. No signs of arrhythmia were detected during exercise in approximately 39% of athletes, and concordant HRs were recorded by the HRMs and Holter ECG. HRMs indicated surprisingly high short-term HRs in 45% of athletes that were not detected by the Holter ECG and were artifacts. In 15% of athletes, single ventricular/supraventricular beats were detected by the Holter ECG but not by the HRM. We detected a serious tachyarrhythmia in the HRM and Holter ECG data with concomitant clinical symptoms in only one athlete, who was forced to cease exercising. We conclude that the HRM is not a suitable tool for monitoring heart arrhythmias in athletes and propose an algorithm to exclude the suspicion of exercise-induced arrhythmia detected by HRMs in asymptomatic, physically active individuals.

Assessment of systemic right ventricular function in adult overweight and obese patients with congenitally corrected transposition of the great arteries

BACKGROUND

In congenitally corrected transposition of the great arteries the right ventricle (RV) supports systemic circulation, and patients are prone to develop heart failure over time. Chronic volume overload secondary to obesity may contribute to premature dysfunction of the systemic RV.

AIM

The aim of our study was to assess the systemic RV function in overweight/obese adult patients with congenitally corrected transposition of the great arteries.

METHODS

Transthoracic echocardiographic studies and laboratory testing (N-terminal pro-B-type natriuretic peptide [NT-proBNP] assessment) were performed in patients with congenitally corrected transposition, who were scheduled for a routine examination, and the body mass index was calculated for each patient.

RESULTS

We studied 56 adults (31 men; mean age 33.9 years); 22 of whom were overweight (body mass index [BMI] of 25-29.9 kg/m²) or obese (BMI of 30 kg/m² or more), and 34 of whom were normal weight (BMI below 25 kg/m²). Age, gender, heart rate, and blood pressure were similar in both groups. The mean NT-proBNP levels were not significantly different. On echocardiography, the overweight/obese patients had a decreased systemic RV fractional area change (0.38) compared to normal weight patients (0.43); p = 0.02. Moreover, a significant reduction in the global longitudinal strain in the overweight/obese group was observed (-15.3% vs. -18.3%; p = 0.01).

CONCLUSIONS

Overweight/obesity in adult patients with congenitally corrected transposition of the great arteries is associated with impaired systemic RV function.

Determinants of left- and right‑ventricular ejection fractions in patients with repaired tetralogy of Fallot: a cardiac magnetic resonance imaging study

INTRODUCTION

There are inconsistent data regarding the factors affecting left ventricular ejection fraction (LVEF) and right ventricular ejection fraction (RVEF) in patients after tetralogy of Fallot (TOF) repair.

OBJECTIVES

The aim of the study was to assess the determinants of LVEF and RVEF in a large cohort of patients with repaired TOF.

PATIENTS AND METHODS

The study comprised 122 patients with repaired TOF (median age, 24.2 years; interquartile range, 20.3-30.9; men, 60.6%) who had undergone cardiac magnetic resonance imaging study. Predictors of LVEF, RVEF, and RVEF corrected for shunting or regurgitations (cRVEF) were identified with the use of linear regression analyses.

RESULTS

There was a weak correlation between RVEF and LVEF (r = 0.39, P <0.0001). A multiple regression analysis revealed the following independent predictors of LVEF: positive predictor - RVEF (P = 0.0002); negative predictors - pulmonary regurgitation fraction (PRF, P = 0.01) and male sex (P = 0.001). RVEF was predicted independently by positive predictors such as LVEF (P <0.0001) and LV end‑diastolic volume (LVEDV, P = 0.04) and negative predictors such as right ventricular mass (P <0.0001) and number of previous cardiothoracic surgery interventions (P = 0.005). In the model predicting cRVEF, only left ventricular mass was a positive predictor of cRVEF (P <0.0001), while right ventricular mass (P <0.0001), PRF (P <0.0001), male sex (P <0.0001), and RV late gadolinium enhancement score (P = 0.008) were negative predictors of cRVEF.

CONCLUSIONS

Because PRF was inversely and independently correlated with LVEF, and LVEDV showed a positive and independent correlation with RVEF, left ventricular disease (low LVEF and LVEDV due to left ventricular compression) may be used as a marker of the severity of right ventricular disease (pulmonary regurgitation severity and its consequences). Further studies are needed to evaluate the role of LVEF and LVEDV in supporting patient selection for pulmonary valve replacement.

The ratio of right ventricular volume to left ventricular volume reflects the impact of pulmonary regurgitation independently of the method of pulmonary regurgitation quantification

BACKGROUND

Previous studies have advocated quantifying pulmonary regurgitation (PR) by using PR volume (PRV) instead of commonly used PR fraction (PRF). However, physicians are not familiar with the use of PRV in clinical practice. The ratio of right ventricle (RV) volume to left ventricle volume (RV/LV) may better reflect the impact of PR on the heart than RV end-diastolic volume (RVEDV) alone. We aimed to compare the impact of PRV and PRF on RV size expressed as either the RV/LV ratio or RVEDV (mL/m(2)).

METHODS

Consecutive patients with repaired tetralogy of Fallot were included (n=53). PRV, PRF and ventricular volumes were measured with the use of cardiac magnetic resonance.

RESULTS

RVEDV was more closely correlated with PRV when compared with PRF (r=0.686, p<0.0001, and r=0.430, p=0.0014, respectively). On the other hand, both PRV and PRF showed a good correlation with the RV/LV ratio (r=0.691, p<0.0001, and r=0.685, p<0.0001, respectively). Receiver operating characteristic analysis showed that both measures of PR had similar ability to predict severe RV dilatation when the RV/LV ratio-based criterion was used, namely the RV/LV ratio>2.0 [area under the curve (AUC)(PRV)=0.770 vs AUC(PRF)=0.777, p=0.86]. Conversely, with the use of the RVEDV-based criterion (>170mL/m(2)), PRV proved to be superior over PRF (AUC(PRV)=0.770 vs AUC(PRF)=0.656, p=0.0028].

CONCLUSIONS

PRV and PRF have similar significance as measures of PR when the RV/LV ratio is used instead of RVEDV. The RV/LV ratio is a universal marker of RV dilatation independent of the method of PR quantification applied (PRF vs PRV).