Yield of echocardiographic screening of first-degree relatives of children with bicuspid aortic valve

Background

Bicuspid aortic valve (BAV) is the most common congenital heart defect, affecting 0.8% of new-borns. BAV is associated with valve dysfunction, as well as an increased risk of aortopathy. The prevalence of BAV in first-degree relatives of symptomatic BAV patients, is reported to be 5–10%. First-degree relatives also have an increased risk of aortic dilatation, independently of aortic valve morphology.

Purpose

The purpose of the study was to determine the prevalence of BAV, associated valve dysfunction and aortopathy in first-degree relatives to children diagnosed with BAV neonatally in a population-based study.

Methods

Between April 2016 and October 2018 all expecting parents at three major maternity centres were offered inclusion in a large-scale population study with focus on congenital heart disease (N≥25,000). A total of 197 children, in 196 families, were diagnosed with BAV. All first-degree relatives, including half-siblings, were offered inclusion in the follow-up study with standardized transthoracic echocardiography. Adults were also examined with transoesophageal echocardiography. Aorta diameters were measured at the AV annulus, sinuses of Valsalva, sino-tubolare junction and in the proximal ascending aorta. Aortic dilatation in children were defined as any aortic root or ascending aorta diameter ≥2 standard deviations (SD) from the expected mean, calculated as z-score using formulas from the Paediatric Heart Network Echocardiogram Database. In adults, aortic dilatation was defined as aortic root and/or ascending aorta diameters indexed to body surface area (BSA) exceeding normal reference values established by the European Association of Cardiovascular Imaging.

Results

In total, 352 first-degree relatives (242 adults [35.3 years SD 5.5] and 110 children [4.5 years, SD 3.5] were included. BAV was diagnosed in 24 relatives (6.8%). BAV could not be conclusively ruled out in 52 relatives (14.8%), who are awaiting further examination with transoesophageal echocardiography. Dilatation of the aortic root was observed in 8 adult relatives and in 17 children (7.1%). Aortic valve regurgitation was observed in 23 relatives (6.5%). In total 58 relatives (16.2%) were diagnosed with either BAV, dilated aorta, or aortic regurgitation.

Conclusion

One in fifteen first-degree relatives to children diagnosed with BAV neonatally, also had BAV, corresponding to >8 fold increase in prevalence compared with the background population. One in six relatives had BAV, dilated aorta, or aortic regurgitation. These findings are of importance for family-screening programs of BAV.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Danish Children's Heart Association

Seroprevalence of SARS-CoV-2 antibodies in social housing areas in Denmark

BACKGROUND

COVID-19 is thought to be more prevalent among ethnic minorities and individuals with low socioeconomic status. We aimed to investigate the prevalence of SARS-CoV-2 antibodies during the COVID-19 pandemic among citizens 15 years or older in Denmark living in social housing (SH) areas.

METHODS

We conducted a study between January 8th and January 31st, 2021 with recruitment in 13 selected SH areas. Participants were offered a point-of-care rapid SARS-CoV-2 IgM and IgG antibody test and a questionnaire concerning risk factors associated with COVID-19. As a proxy for the general Danish population we accessed data on seroprevalence from Danish blood donors (total Ig ELISA assay) in same time period.

RESULTS

Of the 13,279 included participants, 2296 (17.3%) were seropositive (mean age 46.6 (SD 16.4) years, 54.2% female), which was 3 times higher than in the general Danish population (mean age 41.7 (SD 14.1) years, 48.5% female) in the same period (5.8%, risk ratios (RR) 2.96, 95% CI 2.78-3.16, p > 0.001). Seropositivity was higher among males (RR 1.1, 95% CI 1.05-1.22%, p = 0.001) and increased with age, with an OR seropositivity of 1.03 for each 10-year increase in age (95% CI 1.00-1.06, p = 0.031). Close contact with COVID-19-infected individuals was associated with a higher risk of infection, especially among household members (OR 5.0, 95% CI 4.1-6.2 p < 0,001). Living at least four people in a household significantly increased the OR of seropositivity (OR 1.3, 95% CI 1.0-1.6, p = 0.02) as did living in a multi-generational household (OR 1.3 per generation, 95% CI 1.1-1.6, p = 0.003). Only 1.6% of participants reported not following any of the national COVID-19 recommendations.

CONCLUSIONS

Danish citizens living in SH areas of low socioeconomic status had a three times higher SARS-CoV-2 seroprevalence compared to the general Danish population. The seroprevalence was significantly higher in males and increased slightly with age. Living in multiple generations households or in households of more than four persons was a strong risk factor for being seropositive. Results of this study can be used for future consideration of the need for preventive measures in the populations living in SH areas.

Testing Denmark: a Danish Nationwide Surveillance Study of COVID-19

"Testing Denmark" is a national, large-scale, epidemiological surveillance study of SARS-CoV-2 in the Danish population. Between September and October 2020, approximately 1.3 million people (age >15 years) were randomly invited to fill in an electronic questionnaire covering COVID-19 exposures and symptoms. The prevalence of SARS-CoV-2 antibodies was determined by point-of care rapid test (POCT) distributed to participants' home addresses. In total, 318,552 participants (24.5% invitees) completed the study and 2,519 (0.79%) were seropositive. Of the participants with a prior positive PCR test (n = 1,828), 29.1% were seropositive in the POCT. Although seropositivity increased with age, participants 61 years and over reported fewer symptoms and were tested less frequently. Seropositivity was associated with physical contact with SARS-CoV-2 infected individuals (risk ratio [RR] 7.43, 95% CI: 6.57-8.41), particular in household members (RR 17.70, 95% CI: 15.60-20.10). A greater risk of seropositivity was seen in home care workers (RR 2.09, 95% CI: 1.58-2.78) compared to office workers. A high degree of adherence with national preventive recommendations was reported (e.g., >80% use of face masks), but no difference were found between seropositive and seronegative participants. The seroprevalence result was somewhat hampered by a lower-than-expected performance of the POCT. This is likely due to a low sensitivity of the POCT or problems reading the test results, and the main findings therefore relate to risk associations. More emphasis should be placed on age, occupation, and exposure in local communities. IMPORTANCE To date, including 318,522 participants, this is the largest population-based study with broad national participation where tests and questionnaires have been sent to participants' homes. We found that more emphasis from national and local authorities toward the risk of infection should be placed on age of tested individuals, type of occupation, as well as exposure in local communities and households. To meet the challenge that broad nationwide information can be difficult to gather. This study design sets the stage for a novel way of conducting studies. Additionally, this study design can be used as a supplementary model in future general test strategy for ongoing monitoring of COVID-19 immunity in the population, both from past infection and from vaccination against SARS-CoV-2, however, with attention to the complexity of performing and reading the POCT at home.

Gestational Age and Neonatal Electrocardiograms

OBJECTIVES

Interpretation of the neonatal electrocardiogram (ECG) is challenging due to the profound changes of the cardiovascular system in this period. We aimed to investigate the impact of gestational age (GA) on the neonatal ECG and create GA-specific reference values.

METHODS

The Copenhagen Baby Heart Study is a prospective general population study that offered cardiac evaluation of neonates. ECGs and echocardiograms were obtained and systematically analyzed. GA, weight, height, and other baseline variables were registered.

RESULTS

We included 16 462 neonates (52% boys) with normal echocardiograms. The median postnatal age was 11 days (range 0 to 30), and the median GA was 281 days (range 238 to 301). Analyzing the ECG parameters as a function of GA, we found an effect of GA on almost all investigated ECG parameters. The largest percentual effect of GA was on heart rate (HR; 147 vs 139 beats per minute), the QRS axis (103° vs 116°), and maximum R-wave amplitude in V1 (R-V1; 0.97 vs 1.19 mV) for GA ≤35 vs ≥42 weeks, respectively. Boys had longer PR and QRS intervals and a more right-shifted QRS axis within multiple GA intervals (all P < .01). The effect of GA generally persisted after multifactorial adjustment.

CONCLUSIONS

GA was associated with significant differences in multiple neonatal ECG parameters. The association generally persisted after multifactorial adjustment, indicating a direct effect of GA on the developing neonatal cardiac conduction system. For HR, the QRS axis, and R-V1, the use of GA-specific reference values may optimize clinical handling of neonates.

Spontaneous closure of ventricular septal defects in newborns the first year of life

Background

Ventricular septal defect (VSD) is one of the most common congenital heart defects. Some VSDs close spontaneously while persistence of the VSD may result in heart failure and, at long term, irreversible pulmonary hypertension. Consequently, identification of factors associated with spontaneous closure are important to ensure relevant clinical follow up of those at risk of a persistent VSD.

Purpose

We aimed to assess the rate of spontaneous closure in a population-based cohort of newborns with VSD and to identify significant predictors for spontaneous closure.

Methods

The study is part of a large-scale population-based study, focusing on cardiac structure and function, including newborns born from 1st April 2016 to 31st October 2018. Newborns with a VSDs at baseline were followed with echocardiography at 3, 6 and 12 months (+30 days) of age. Cox proportional hazard model was used to determine significant predictors of spontaneous closure

Results

Based on echocardiographies of 25.750 newborn, 850 newborns (3.3%) with a VSD were identified. The majority of newborns with VSDs were born at term (88.7%) and the mean age at inclusion was 11.7±8.1 days. VSDs were more frequent in females (57.1%, p&lt;0.001). Of all VSDs, 787l (92.6%) were of a muscular type, 60 (7.0%) of perimembranous type and 3 (0.4%) were of subarterial type. Multiple VSDs were found in 98 (11.5%) cases and all were of a muscular type. Muscular VSDs were significantly smaller than perimembranous VSDs (1.9±0.7 mm vs. 3.7±1.8 mm, p&lt;0.0001). During the follow up period, seven (0.8%) children underwent surgical repair: five (5 of 56) children with perimembranous VSDs and two (two of three) children with subarterial VSDs. Follow-up was complete in 89.4% of all children. After one year 82.6% (601 of 727) VSDs had closed spontaneously. The prevalence of VSD in one-year old children was thus 0.5%. The majority of VSD closed spontaneously during the first 6 months of life (57.6% (419/727)). Muscular VSDs showed significantly higher rate of spontaneous closure compared with perimembranous VSDs (86.9% (582 /670) vs. 46.2% (25/54), p=0.0001) during the first year of life. No subarterial VSDs closed spontaneously during follow-up. Muscular type (p=0.002), size (p&lt;0.001) and presence of one VSD as opposed to multiple (p&lt;0.0025) were associated to spontaneous closure. Sex did not significantly influence spontaneous closure rate (p=0.65).

Conclusion

In a population study including more than 25,000 newborns we found that the vast majority, i.e. almost 9/10 of all VSDs, closed spontaneously during the first year of life, ultimately resulting in a prevalence of VSD in one-year old children of 0.5%. The identified factors associated with spontaneous closure – anatomical location, size and presence of multiple VSDs are of use for future management of VSDs in newborns.

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): The Danish Heart Foundation

Prevalence of mitral valve diseases in the newborn – a large population-based study of newborns

Background

Mitral valve abnormalities (MVA) include mitral valve regurgitation (MR), mitral valve prolapse (MVP), Barlow's mitral valve disease, and parachute MV. The prevalence of MVA has yet to be determined in an unselected population of newborns.

Objective

To determine the prevalence of MVA in unselected newborns and to assess the left ventricular (LV) structure and function in the neonatal heart with MR.

Methods

Transthoracic echocardiography (TTE) was performed within 28 days after birth in unselected neonates consecutively included in a prospective, multicenter, population-based study (2016–2018 (n=25,751)). TTE's were systematically reviewed for MR, MVP, Barlow's MV disease, and parachute MV. In a subgroup of 400 newborns with MR, the regurgitation was further classified as either traceable MR, mild MR, or moderate/severe MR based on the ratio of the trans-mitral jet in systole over the diastolic filling duration using M-mode in the 4-chamber view of the LV.

Results

Of 25,751 included newborns, we found a prevalence of MVA of 26.7%. (6,883/ 25,751). The prevalence of MR was 26.2%, MVP was 0.35%, Barlow's disease was 0.13%, and parachute mitral valve was 0.027%. MR was more frequent in females compared to males (50.4 vs 48.2%, p&lt;0.01). Newborns with MR had enlarged left atrial diameter (11.91±2.03 mm vs 11.53±2.02 mm, p&lt;0.01) and LV end-diastolic and end-systolic diameter (LVIDd 19.98±1.88 mm vs 19.87±1.83 mm, p&lt;0.01, LVIDs 13.48±1.47 mm vs 13.31±1.41 mm, p&lt;0.01), thicker LV posterior wall (2.19±0.60 mm vs 2.05±0.52 mm, p&lt;0.01), increased early and atrial mitral inflow velocities (MV E velocity (0.65±0.14 m/sec vs 0.61±0.13 m/sec, p&lt;0.01), MV A velocity (0.60±0.13 m/sec vs 0.57±0.13 m/sec, p&lt;0.01)), but lower fractional shortening (32.54±4.22% vs. 32.96±4.17%, p&lt;0.01) as compared to newborns without MVA.

In subgroup analysis MR severity was classified as traceable in 44% (175/400) of cases, mild MR in 52% (209/400) of cases and moderate/severe MR in 4% (16/400) of cases. Comparing traceable MR with moderate/severe MR (19.48±1.88 mm vs 20.96±2.64 mm, p=0.01) and comparing mild MR with moderate/severe MR (19.85±1.92 mm vs 20.96±2.64 mm, p=0.04) showed significant increases in LV end-diastolic diameter.

Conclusion

Over one fourth of all newborns had a MV abnormality of which mitral regurgitation accounted for the vast majority. The presence of MR was associated with asymmetric LV remodeling and discrete changes in LV function. Subgroup analysis revealed that increment in MR severity was primarily associated with an increase in LV end-diastolic diameter.

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): Herlev-Gentofte Hospital

Relationship between patient presentation and morphology of coronary atherosclerosis by quantitative multidetector computed tomography

Aims

Quantitative computed tomography (QCT) allows assessment of morphological features of coronary atherosclerosis. We aimed to test the hypothesis that clinical patient presentation is associated with distinct morphological features of coronary atherosclerosis.

Methods and results

A total of 1652 participants, representing a spectrum of clinical risk profiles [787 asymptomatic individuals from the general population, 468 patients with acute chest pain without acute coronary syndrome (ACS), and 397 patients with acute chest pain and ACS], underwent multidetector computed tomography. Of these, 274 asymptomatic individuals, 254 patients with acute chest pain without ACS, and 327 patients with acute chest pain and ACS underwent QCT to assess coronary plaque volumes and proportions of dense calcium (DC), fibrous, fibro fatty (FF), and necrotic core (NC) tissue. Furthermore, the presence of vulnerable plaques, defined by plaque volume and tissue composition, was examined. Coronary plaque volume increased significantly with worsening clinical risk profile [geometric mean (95% confidence interval): 148 (129–166) mm3, 257 (224–295) mm3, and 407 (363–457) mm3, respectively, P < 0.001]. Plaque composition differed significantly across cohorts, P < 0.0001. The proportion of DC decreased, whereas FF and NC increased with worsening clinical risk profile (mean proportions DC: 33%, 23%, 23%; FF: 50%, 61%, 57%; and NC: 17%, 17%, 20%, respectively). Significant differences in plaque composition persisted after multivariable adjustment for age, gender, body surface area, hypertension, statin use at baseline, diabetes, smoking, family history of ischaemic heart disease, total plaque volume, and tube voltage, P < 0.01.

Conclusion

Coronary atherosclerotic plaque volume and composition are strongly associated to clinical presentation.

Functional effects of losartan in hypertrophic cardiomyopathy-a randomised clinical trial

OBJECTIVE

There is a lack of disease-modifying treatments in hypertrophic cardiomyopathy (HCM). The aim of this randomised, placebo-controlled study was to assess if losartan could improve or ameliorate deterioration of cardiac function and exercise capacity.

METHODS

Echocardiography, exercise test and MRI or CT were performed at baseline and after 12 months in 133 patients (52±13 years, 35% female) randomly allocated to losartan (100 mg/day) or placebo.

RESULTS

Losartan had no effect on systolic function compared with placebo (mean difference for left ventricular ejection fraction (LVEF) 0% (95% CI -3% to 4%), p=0.84 or global longitudinal strain 0.7% (95% CI -0.2% to 1.6%), p=0.13). Neither Doppler measures of diastolic function, left atrial volume (mean difference 2 mL/m(2) (95% CI -4 to 8 mL/m(2)) p=0.53) nor exercise capacity (mean difference -0.3 metabolic equivalents (METS) (95% CI -1.0 to 0.3 METS), p=0.28) differed between the treatment groups. At follow-up, there was further progression of disease, with the most prominent impairment being an increase in left atrial volume of 6 mL/m(2) (95% CI 3 to 9 mL/m(2), p<0.0001) in both groups combined. LVEF decreased (mean change -2%, (95% CI -3% to -1%), p=0.037) and 4% of patients had end-stage HCM with a LVEF of less than 50% at the end of the study.

CONCLUSION

Treatment with losartan had no effect on cardiac function or exercise capacity compared with placebo. Losartan fail to improve myocardial performance and failed to alter the progression of the disease. These findings do not support the use of angiotensin II receptor blockers as disease modifiers in adult patients with overt HCM.

TRIAL REGISTRATION NUMBER

NCT01447654-results.

Efficacy and safety of the angiotensin II receptor blocker losartan for hypertrophic cardiomyopathy: the INHERIT randomised, double-blind, placebo-controlled trial

BACKGROUND

No medical treatment has been reliably shown to halt or reverse disease progression in hypertrophic cardiomyopathy, but the results of several pilot studies have suggested beneficial effects of angiotensin II receptor blockers on left ventricular hypertrophy and fibrosis, which are predictive of an adverse outcome. We aimed to assess the effect of the angiotensin II receptor blocker losartan on left ventricular hypertrophy and fibrosis in patients with hypertrophic cardiomyopathy.

METHODS

In this single-centre, randomised, double-blind, placebo-controlled trial, adult patients (aged 18 years and older) with obstructive or non-obstructive hypertrophic cardiomyopathy were randomly assigned via computer-based system to losartan (100 mg per day) or placebo for 12 months. Patients and investigators were masked to assigned treatment. The primary endpoint was change in left ventricular mass as assessed by cardiac magnetic resonance imaging (CMR) or CT. Efficacy analyses were done in the modified intention-to-treat population (all patients with data available at the 12-month follow-up). The trial is registered with ClinicalTrials.gov, number NCT01447654.

FINDINGS

Between Dec 1, 2011, and May 1, 2013, 318 patients were screened. 133 patients (mean age 52 years [SD 13], 35% women) consented and were randomly assigned to placebo (n=69) or losartan (n=64). 124 (93%) patients completed the study and were included in the modified intention-to-treat analysis for the primary endpoint. After 12 months we noted no significant difference in the change in left ventricular mass between the placebo group and the losartan group (mean difference 1 g/m(2), 95% CI -3 to 6; p=0·60). A decrease in systolic blood pressure in the losartan group (from mean 127 mm Hg [SD 12] to 121 mm Hg [14]; p=0·0001) confirmed drug compliance; blood pressure did not decrease in the placebo group. Two (2%) patients, both in the placebo group, died from sudden cardiac death during follow-up. In the losartan group, one (1%) patient had angioedema, one (1%) had deterioration of renal function, and one (1%) had hyperkalaemia. Treatment was well tolerated by patients with left ventricular outflow obstruction at baseline.

INTERPRETATION

Our findings challenge the generally held view that angiotensin II receptor blockers reduce cardiac hypertrophy. Treatment with losartan was safe, suggesting that it can be used for other indications in patients with hypertrophic cardiomyopathy, irrespective of obstructive physiology. Additional studies are needed to assess the effect of angiotensin II receptor blockers in preclinical hypertrophic cardiomyopathy-eg, in genotype-positive but phenotype-negative individuals.