Tricuspid regurgitation: Frequency, clinical presentation, management and outcome among patients with severe left-sided valvular heart disease in Europe. Insights from the ESC-EORP Valvular Heart Disease II survey

AIMS

Tricuspid regurgitation (TR) is commonly observed in patients with severe left-sided valvular heart disease (VHD). This study sought to assess TR frequency, management and outcome in this population.

METHODS AND RESULTS

Among 6883 patients with severe native left-sided VHD or previous left-sided valvular intervention enrolled in the EURObservational Research Programme prospective VHD II survey, moderate or severe TR was very frequent in patients with severe mitral VHD (30% when mitral stenosis, 36% when mitral regurgitation [MR]), especially in patients with secondary MR (46%), and rare in patients with severe aortic VHD (4% when aortic stenosis, 3% when aortic regurgitation). An increase in TR grade was associated with a more severe clinical presentation and a poorer 6-month survival (p < 0.0001). Rates of concomitant tricuspid valve (TV) intervention at the time of left-sided heart valve surgery were high at the time of mitral valve surgery (50% when mitral stenosis, 41% when MR). Concordance between class I indications (patients with severe TR) for concomitant TV surgery at the time of left-sided valvular heart surgery according to guidelines and real-practice decision-making was very good (88% overall, 95% in patients operated on for MR).

CONCLUSION

In this large international prospective survey among patients with severe left-sided VHD, moderate/severe TR was frequent in patients with mitral valve disease and was associated with a poorer outcome as TR grade increased. In patients with severe TR, compliance to guidelines for class I indications for concomitant TV surgery at the time of left-sided heart valve surgery was very good.

A review and recommendations for oral chaperone therapy in adult patients with Fabry disease

Fabry disease (FD) is a rare, X-linked lysosomal storage disorder affecting both males and females caused by genetic abnormalities in the gene encoding the enzyme α-galactosidase A. FD-affected patients represent a highly variable clinical course with first symptoms already appearing in young age. The disease causes a progressive multiple organ dysfunction affecting mostly the heart, kidneys and nervous system, eventually leading to premature death. Disease-specific management of FD includes enzyme replacement therapy with agalsidase α and β or pharmacological oral chaperone migalastat. Migalastat is a low-molecular-mass iminosugar, that reversibly binds to active site of amenable enzyme variants, stabilizing their molecular structure and improving trafficking to the lysosome. Migalastat was approved in the EU in 2016 and is an effective therapy in the estimated 35-50% of all patients with FD with amenable GLA gene variants. This position statement is the first comprehensive review in Central and Eastern Europe of the current role of migalastat in the treatment of FD. The statement provides an overview of the pharmacology of migalastat and summarizes the current evidence from the clinical trial program regarding the safety and efficacy of the drug and its effects on organs typically involved in FD. The position paper also includes a practical guide for clinicians on the optimal selection of patients with FD who will benefit from migalastat treatment, recommendations on the optimal selection of diagnostic tests and the use of tools to identify patients with amenable GLA mutations. Areas for future migalastat clinical research have also been identified.

Infective endocarditis in adults with congenital heart disease: Contemporary management and related outcomes in Central and South-Eastern European region

BACKGROUND

Infective endocarditis (IE) remains major cause of morbidity and mortality in adult congenital heart disease (ACHD). Limited data exists on ACHD with IE in Central and South-Eastern European (CESEE) countries. The aim of this study is to characterize contemporary management and assess outcomes of ACHD with IE in CESEE region.

METHODS

Data on ACHD patients with IE from 9 tertiary centres in 9 different CESEE countries between 2015 and 2020 was included. Baseline demographics, clinical presentation, indication for surgery, outcomes, hospital and all-cause-1-year mortality were studied.

RESULTS

A total of 295 ACHD patients (mean age 40 ± 14 years) with IE were included. Median time from symptoms onset to establishing diagnosis was 25 (11-59) days. The majority of patients (203, 68.8%) received previous empiric oral antibiotic therapy. The highest incidence of IE was observed on native and left sided valves, 194(65.8%) and 204(69.2%), respectively. More than half had a vegetation size ≥10 mm (164, 55.6%); overall 138 (46.8%) had valve complications and 119 (40.3%) had heart failure. In-hospital mortality was 26 (8.8%).

CONCLUSION

There is clear delay in establishing IE diagnosis amongst ACHD patients in CESEE countries. Adequate diagnosis is hampered by common prescription of empiric antibiotics before establishing formal diagnosis. Hence, patients commonly present with associated complications requiring surgery. Hospital treatment and survival are, nevertheless, comparable to other Western European countries. Improved awareness and education of patients and medical profession regarding IE preventive measures, risks, signs, and symptoms are urgently needed. Empiric antibiotic prescription before blood cultures are taken must be omitted.

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Tricuspid regurgitation: frequency, management and outcome among patients with severe left-sided valvular heart disease in Europe. Insights from the ESC-EORP valvular heart disease II survey

Background

Tricuspid regurgitation (TR) is frequent among patients with severe left-sided valvular heart disease (LS-VHD).

Objectives

This study sought to assess TR frequency, management and outcome in this population.

Methods

Among 6883 patients with severe LS-VHD or previous valvular intervention in the EURObservational Research Programme prospective VHD II survey, we analyzed frequency and grade of TR according to LS-VHD, and 6-month survival according to TR grade. Among 2081 patients who underwent an intervention for severe LS-VHD, we analyzed frequency and outcome of concomitant TV intervention, and concordance between Class I indications for concomitant TV surgery (patients with severe TR) and real-practice decision-making.

Results

Moderate to severe TR was very frequent among patients with severe mitral VHD (≥30%), especially in patients with secondary mitral regurgitation (46%), and rare among patients with aortic VHD (&lt;5%). Higher TR grade was associated with a poorer 6-month survival (P&lt;0.001). Rates of concomitant tricuspid valve (TV) intervention at the time of left-sided heart valve surgery were high at the time of mitral valve surgery (more than 40%). Concomitant TV intervention at the time of left-sided heart valve surgery (LS-HVS) was not associated with an increase in-hospital mortality (P=0.93). Concordance between Class I indications for concomitant TV surgery at the time of LS-HVS according to guidelines and real-practice decision-making was very good (88% overall).

Conclusion

TR was frequent in patients with mitral VHD and was associated with a poorer outcome as TR grade increased. Compliance to guidelines for Class I indications for concomitant TV surgery at the time of LS-HVS was very good. With the trend toward more transcatheter treatment for left-sided VHD, there is a critical need for safe and efficient tricuspid valve transcatheter treatment for patients with concomitant TR.

Funding Acknowledgement

Type of funding sources: None.

STROKE FOLLOWING PERIPHERAL ARTERIO VENIUS MALFORMATION ALCOHOL EMBOLIZATION – SHOULD WE LOOK FOR PERSISTED FORAMEN OVALE IN ADVANCE?

Stroke due to paradoxical embolism can be a complication of certain peripheral venous procedures in patients with coexisting patent foramen ovale. There is an established link between venous sclerotherapy and stroke, however there are no known reports of this complication following peripheral arteriovenous embolization.We present a case of a 36-year- old woman who experienced symptoms of disorientation and apraxia following a hypoxic event during percutaneous alcohol embolization of a large arteriovenous malformation in her right gluteal region. An MRI scan revealed multiple foci of restricted diffusion in both cerebral hemispheres corresponding to acute ischemic stroke lesions. As the subsequent work-up revealed patent foramen ovale, we speculate on the pathomechanism of stroke and conclude with a recommendation to screen for patent foramen ovale in patients undergoing peripheral venous procedures including arteriovenous malformation embolization.

First two years of reimbursed enzyme replacement therapy in the treatment of Fabry disease in Poland

Fabry disease (FD) is an ultra-rare genetic lysosomal storage disease caused by pathologic gene variants resulting in insufficient expression of α-galactosidase A. This enzyme deficiency leads to accumulation of globotriaosylceramide and globotriaosylsphingosine in plasma and in different cells throughout the body, causing major cardiovascular, renal, and nervous system complications. Until 2018, reimbursed enzyme replacement therapy (ERT) for FD was available in all European Union countries except Poland.             We present the preliminary results of the first two years of reimbursed ERT in Poland. We obtained data from the seven largest academic centers in Katowice, Cracow, Wrocław, Poznań, Gdańsk, Warsaw, and Łódź. The questionnaire included the following data: number of patients treated, number of patients qualified for ERT, and patient characteristics.             All centers returned completed questionnaires that included data for a total of 71 patients (28 men and 43 women) as of June 2021. Thirty-five patients with the diagnosis of FD confirmed by genetic testing (22 men and 13 women) had already qualified for reimbursed ERT. Mean (SD) age at the commencement of the ERT program was 39.6 (15.5) years (range 18-79 years). Mean time from the first clinical symptoms reported by the patients to the FD diagnosis was 21.1 (8.9) years, and the mean time from the final diagnosis of FD to the beginning of ERT was 4.7 (4.6) years.             FD is still underdiagnosed in Poland. To identify undiagnosed FD patients and to ensure that patients in Poland benefit fully from ERT, implementation of an effective nationwide screening strategy and close cooperation with a network of rare disease centers is advised.

First two years of reimbursed enzyme replacement therapy in the treatment of Fabry disease in Poland

Fabry disease (FD) is an ultra-rare genetic lysosomal storage disease caused by pathologic gene variants resulting in insufficient expression of α-galactosidase A. This enzyme deficiency leads to accumulation of globotriaosylceramide and globotriaosylsphingosine in plasma and in different cells throughout the body, causing major cardiovascular, renal, and nervous system complications. Until 2018, reimbursed enzyme replacement therapy (ERT) for FD was available in all European Union countries except Poland.             We present the preliminary results of the first two years of reimbursed ERT in Poland. We obtained data from the seven largest academic centers in Katowice, Kraków, Wrocław, Poznań, Gdańsk, Warszawa, and Łódź. The questionnaire included the following data: number of patients treated, number of patients qualified for ERT, and patient characteristics.             All centers returned completed questionnaires that included data for a total of 71 patients (28 men and 43 women) as of June 2021. Thirty-five patients with the diagnosis of FD confirmed by genetic testing (22 men and 13 women) had already qualified for reimbursed ERT. Mean (SD) age at the commencement of the ERT program was 39.6 (15.5) years (range 18-79 years). Mean time from the first clinical symptoms reported by the patients to the FD diagnosis was 21.1 (8.9) years, and the mean time from the final diagnosis of FD to the beginning of ERT was 4.7 (4.6) years.             FD is still underdiagnosed in Poland. To identify undiagnosed FD patients and to ensure that patients in Poland benefit fully from ERT, implementation of an effective nationwide screening strategy and close cooperation with a network of rare disease centers is advised.

OBESITY AND ATRIAL FIBRILLATION - BARIATRIC SURGERY AS A METHOD OF AF RISK DECREASE

The prevalence of obesity is growing at alarming rate worldwide. Obesity has reached the proportion of a global epidemic in both developed and developing countries. Growing number of obese patients with atrial fibrillation requires a closer look at how excessive body fat leads to AF. Excessive adipose tissue is the source of many cardiovascular diseases, like hypertension, ischemic heart disease, and arrhythmias such as atrial fibrillation. The prevalence of atrial fibrillation in the general population is estimated at 1-2%. Obesity and overweight occur in 25% of patients with AF. Pathophysiology of obesity and the relationship between atrial fibrillation, diabetes, obstructive sleep apnea and metabolicsyndrome are presented in this article as well as the benefit of bariatric surgery in qualifying patients. Paroxysmal AF and its risk factors should be carefully assessed in all patients referred for bariatric surgery. Proper diagnosis allows physicians to introduce appropriate anticoagulant prophylaxis, and significantly lower complication rate. Antiarrhythmic, respiratory, and metabolic therapy should also be considered in preoperative and postoperative care.

European Society of Cardiology Working Group on Adult Congenital Heart Disease and Study Group for Adult Congenital Heart Care in Central and South Eastern European Countries consensus paper: current status, provision gaps and investment required

AIMS

To examine the current status of care and needs of adult congenital heart disease (ACHD) services in the Central and South Eastern European (CESEE) region.

METHODS AND RESULTS

We obtained data regarding the national ACHD status for 19 CESEE countries from their ACHD representative based on an extensive survey for 2017 and/or 2018. Thirteen countries reported at least one tertiary ACHD centre with a median year of centre establishment in 2007 (interquartile range 2002-2013). ACHD centres reported a median of 2114 patients under active follow-up with an annual cardiac catheter and surgical intervention volume of 49 and 40, respectively. The majority (90%) of catheter or surgical interventions were funded by government reimbursement schemes. However, all 19 countries had financial caps on a hospital level, leading to patient waiting lists and restrictions in the number of procedures that can be performed. The median number of ACHD specialists per country was 3. The majority of centres (75%) did not have ACHD specialist nurses. The six countries with no dedicated ACHD centres had lower Gross Domestic Product per capita compared to the remainder (P = 0.005).

CONCLUSION

The majority of countries in CESEE now have established ACHD services with adequate infrastructure and a patient workload comparable to the rest of Europe, but important gaps still exist. ACHD care is challenged or compromised by limited financial resources, insufficient staffing levels, and reimbursement caps on essential procedures compared to Western Europe. Active advocacy and increased resources are required to address the inequalities of care across the continent.

The benefit of atrial septal defect closure in the elderly patients

Objective

Closure of the atrial septal defect in the elderly patients is controversial. The aim of the study was to evaluate the outcomes of transcatheter closure of secundum atrial septal defect (ASD) in elderly patients.

Methods

From a total of 650 pts with ASD who underwent transcatheter closure 120 pts over 60 years (70 F, 50 M) with a mean age of 66.7±18.1 (60–78) were analyzed. All patients had an isolated secundum ASD with a mean Qp:Qs: 2.79±1.8 (1.5–3.9). A symptom-limited treadmill exercise tests with respiratory gas exchange analysis and transthoracic color Doppler echocardiographic study as well as Quality of life (QoL) measured using the SF36 questionnaire (SF36q) were repeated in all pts before procedure and after 12 months of follow-up.

Results

The device was successfully implanted in all pts (procedure time 30.1±9.9 (10–59) minutes, fluoroscopy time 10.1±7.2 (6–40) minutes). There were no major complications. The defect echo diameter was 19.5±15.4 (12 - 34) mm. The mean balloon stretched diameter of ASD was 22.0±7.8 (14 - 36) mm. The diameter of the implanted devices ranged 16 - 38 mm. After 12 months of ASD closure, all the pts showed a significant improvement of exercise capacity parameters. Seven QoL parameters (except mental health) improved at 12 months follow up compared to their baseline data. The mean SF36q scale increased significantly in 96 (80.2%) pts of mean 41.6±26.1 (4–71). The right ventricular dimension decreased in 101 pts (84.2%) (Table 1).

Conclusions

Closure of ASD in elderly patients caused a significant clinical and hemodynamic improvement after percutaneous treatment, which is maintained to long-term follow-up what justified this procedure in old age.

Funding Acknowledgement

Type of funding source: None

Percutaneous closure of atrial septal defect: a consensus document of the joint group of experts from the Association of Cardiovascular Interventions and the Grown-Up Congenital Heart Disease Section of the Polish Cardiac Society

Atrial septal defect is the most common congenital heart lesion in adults. Although atrial septal defect closure is recommended in those with right heart enlargement or paradoxical embolism, data informing such indications in adults are quite limited. This population has many unique characteristics and needs. In recent years, significant progress has been made with regard to diagnostic modalities that facilitate the diagnostic workup of these patients. However, the decision‑making process, especially in selected adult patients population (advanced age, various concomitant diseases, poor LV function [both systolic and diastolic], pulmonary hypertension, concomitant arrhythmias or multiple defects, or deficient rims) is still not easy. Available data are predominantly focused on imaging endpoints and short‑term morbidity and mortality rather than long‑‑term. The evidence base for outcomes with or without defect closure comes from various studies with different observation periods. Moreover, the clinical experience in diagnosing and treating that subgroup of patients is inhomogeneous between individual physicians (cardiologists, imaging specialists, operators) and between small and large experience centers. In the view of the above, the joint group of experts from the Association of Cardiovascular Interventions and the Grown‑Up Congenital Heart Disease Section of the Polish Cardiac Society developed the following consensus opinion in order to standardize the principles of diagnosis, indications for treatment, methods of performing procedures, and tenets of postoperative care in Poland.

Psychological correlates of patients' identity suffering from atrial septal defect (ASD) and patent foramen ovale (PFO)

Background

The work presents a research project carried out in hospital with participation of 100 (50 female, 50 male) patients with congenital heart defects [atrial septal defect (ASD) and patent foramen ovale (PFO)]. The aim of the study was to identify specific personality traits of patients with congenital heart defects and to check the psychological functioning of patients by examining: the level of anxiety, impulsiveness, tendency to risk-taking, empathy, neuroticism, extraversion, psychoticism and lying. The presented results and their statistical analyses showed specific personality traits of patients with congenital heart defects.

Methods

The research was conducted by psychologist Adrianna Skoczek. We performed a psychological clinical assessment and conducted the psychological tests like Eysenck Personality Questionnaire-Revised Short Version [EPQ-R(S)] and Eysenck’s Impulsivity Inventory (IVE) by Hans J. Eysenck and Sybil G. Eystenck, the State-Trait Anxiety Inventory (STAI) by C. D. Spielberger, R. L. Gorsuch, R. E. Lushene describing personality traits of patients.

Results

The level of extraversion was statistically significantly higher than the level of all other variables. The level of lies was significantly different from the level of psychoticism, which in turn was statistically significantly lower than all other. In the case of the examined women, statistically significant differences were found only between the level of psychoticism and all other analyzed variables.

Conclusions

The conducted research shows that patients suffering from ASD or PFO have specific personality traits what allow to better understanding of suffering patients.

Management of valvular and structural heart diseases during the coronavirus disease 2019 pandemic: an expert opinion of the Working Group on Valvular Heart Diseases, the Working Group on Cardiac Surgery, and the Association of Cardiovascular Interventions of the Polish Cardiac Society

The ongoing pandemic of coronavirus disease 2019 (COVID‑19), caused by severe acute respiratory syndrome coronavirus 2 (SARS‑CoV‑2), represents a major challenge for healthcare. The involvement of cardiovascular system in COVID‑19 has been proven and increased healthcare system resources are redirected towards handling infected patients, which induces major changes in access to services and prioritization in the management of patients with chronic cardiovascular disease unrelated to COVID‑19. In this expert opinion, conceived by the task force involving the Working Groups on Valvular Heart Diseases and Cardiac Surgery as well as the Association of Cardiovascular Intervention of the Polish Cardiac Society, modification of diagnostic pathways, principles of healthcare personnel protection, and treatment guidelines regarding triage and prioritization are suggested. Heart Teams responsible for the treatment of valvular heart disease should continue their work using telemedicine and digital technology. Diagnostic tests must be simplified or deferred to minimize the number of potentially dangerous aerosol‑generating procedures, such as transesophageal echocardiography or exercise imaging. The treatment of aortic stenosis and mitral regurgitation has to be offered particularly due to urgent indications and in patients with advanced disease and poor prognosis. Expert risk stratification is essential for triage and setting the priority lists. In each case, an appropriate level of personal protection must be ensured for the healthcare personnel to prevent spreading infection and preserve specialized manpower, who will supply the continuing need for handling serious chronic cardiovascular disease. Importantly, as soon as the local epidemic situation improves, efforts must be made to restore standard opportunities for elective treatment of valvular heart disease and occluder‑based therapies according to existing guidelines, thus rebuilding the state ‑of ‑the ‑art cardiovascular services.

[The effectiveness of cardiovascular education in the prevention of heart disease among the inhabitants of Lesser Poland]

OBJECTIVE

Introduction: Numerous risk factors for cardiovascular disease (CVD) are modifiable, therefore understanding their effects has a significant impact on lowering the incidence and mortality. The "Małopolska Cardiovascular Preventive Intervention Study (M-CARPI)" aims to educate the inhabitants of the voivodeship regarding preventative measures for developing CVD. The aim: To examine the effectiveness of the seminars regarding preventative measures for developing CVD according to the M-CAPRI among the inhabitants of Lesser Poland.

PATIENTS AND METHODS

Material and methods: The seminars were carried out by a doctor with a specialization in cardiology, in the form of presentations, based on materials prepared by experts in accordance with European and Polish guidelines. Both initially and after the course, participants completed questionnaires regarding the subjects discussed.

RESULTS

Results: The study covered 558 people (137 men, 411 women). The analysis was based on the sub-populations of retirees and non-retirees. The knowledge of risk factors was checked, the respondents most often indicated incorrect judgment of nutrition, physical activity and smoking (45.9%, 39%, 44.2% for non-retirees and 22.8%, 27.6%, 16.5% for retirees, respectively). A significant increase in the number of people who indicated individual risk factors after the training was found (p=0,047 for HDL level and for others).

CONCLUSION

Conclusions: Educating and creating awareness towards the prevention of CVD according to the M-CAPRI survey protocol is an effective tool for prevention. Due to the limited knowledge of cardiovascular risk factors, it is necessary to carry out activities to raise awareness of the importance of cardiological disease prevention. Preventive interventions are equally effective regardless of age or profession.

PERSONALITY TRAITS OF PATIENTS SUFFERING FROM PFO AND ASD AND INFLUENCE OF COVID-19 PANDEMIC TIME FOR PATIENTS SUFFERING FROM CONGENITAL HEART DEFECTS

OBJECTIVE

Introduction: The work presents a research project carried out in John Paul II Hospital in Cracow in Clinical Department of Cardiac and Vascular Diseases with the Intensive Cardiac Supervision Subdivision, with participation of 100 (50 F, 50 M) patients with congenital heart defects. The purpose of the work is to resolve the issue of personality specifics, and thus the different characteristics of people who suffer from congenital heart defects. Therefore, the following questions should be answered: Is there a relationship between personality traits and the occurrence of a congenital heart defect? What personality traits are characteristic for patients with congenital heart defects? The aim: We aimed to assess personality traits of clients suffering from PFO and ASD. The article also talks about how coronavirus pandemic affects patients with congenital heart disease.

PATIENTS AND METHODS

Materials and methods: The research was conducted by psychologist Adrianna Skoczek. We performed a psychological clinical assessment and conducted the psychological tests like Eysenck Personality Questionnaire-Revised Short Version [EPQ-R(S)] and Eysenck's Impulsivity Inventory [IVE] by Hans J. Eysenck and Sybil G. Eysenck, the State-Trait Anxiety Inventory [STAI] by C. D. Spielberger, R. L. Gorsuch, R. E. Lushene describing personality traits of patients. Patients (F=50, M=50), with ASD (n=70) and with PFO (n=30).

RESULTS

Results: In people suffering from ASD, the level of declared empathy was statistically significantly higher than the levels of impulsiveness and tendency to risk-taking. In people suffering from PFO, a statistically significant difference was observed only between the level of psychoticism and other variables. The level of declared empathy was statistically significantly higher than the levels of impulsiveness and tendency to risk-taking, a statistically significant difference was found between the analyzed variables - anxiety as a trait and anxiety as a condition.

CONCLUSION

Conclusions: The results of the study allowed us to isolate the specific personality traits of patients suffering from congenital heart defects.

Interventional closure of patent foramen ovale in prevention of thromboembolic events. Consensus document of the Association of Cardiovascular Interventions and the Section of Grown‑up Congenital Heart Disease of the Polish Cardiac Society

The presence of patent foramen ovale (PFO) was found to be associated with a number of medical conditions, including embolic stroke and recurrent transient neurological defects. The closure of PFO remains controversial; however, in recently published guidelines from the European Association of Percutaneous Cardiovascular Interventions in collaboration with 7 other European societies, which extensively refer to the latest randomized clinical trials, it is explicitly recommended to perform percutaneous PFO closure in the prevention of recurrent thromboembolic events. In connection with the above facts and expected increasing number of PFO closure procedures, the joint expert group of the Association of Cardiovascular Interventions and the Grown‑Up Congenital Heart Disease Section of the Polish Cardiac Society developed the following consensus opinion in order to standardize the principles of diagnosis, indications, methods of performing procedures, and postoperative care in relation to Polish conditions and experiences.

Percutaneous left atrial appendage closure in a patient with atrial fibrillation and osler-weber-rendu disease

We present a case report of a 79-year-old woman with permanent atrial fibrillation and Osler-Weber-Rendu disease who underwent percutaneous closure of left atrial appendage. The patient had a history of small bowel resection due to mesenteric embolism and recurrent episodes of gastrointestinal bleeding, epistaxis and hemarthrosis. Bleeding episodes were exacerbated by anticoagulation therapy causing severe anemia that required repeated red blood cells transfusions. Left atrial appendage occlusion with Watchman 30 mm LAA Device was successfully performed. In long-term observation no thromboembolic event, epistaxis or severe bleeding have occurred.

P1800The benefit of atrial septal defect closure in patients with borderline shunt

Objective

Closure of atrial septal defect in patients with borderline shunt is controversial. The aim of the study was to evaluate the outcomes of transcatheter closure of secundum atrial septal defect (ASD) in the patients with the borderline shunt.

Methods

215 pts (126 F,89 M) with a mean age of 31.9±18.2 (16–58) years with a small ASD who underwent transcatheter closure were analyzed. All patients had an isolated secundum ASD with pulmonary to systemic blood flow Qp:Qs ratio≤1.5, mean 1.2±0.6 (1.1–1.5).

A symptom-limited treadmill exercise test with respiratory gas exchange analysis, transthoracic color Doppler echocardiographic study and Quality of life (QoL) (using the SF36 questionnaire (SF36q)) were repeated in all pts before and 36 months after the procedure.

Results

The device was successfully implanted in all pts (procedure time 19.1±5.2 (8–38) minutes, fluoroscopy time 8.1±4.4 (6–13) minutes). There were no major complications. The defect echo diameter was 7.7±3.9 (5 - 15) mm. The diameter of the implanted devices ranged from 6 to 18 mm.

After 36 months of ASD closure, all the pts showed a significant improvement of exercise capacity. 7 QoL parameters (except mental health) improved at 36 months of follow-up compared with baseline. The mean SF36q scale increased in 168 (78.1%) pts of mean 40.2±20.1 (9–72). The right ventricular dimension decreased in 173 pts (80.4%) (Table 1).

Table 1 Parameter Before ASD closure 36 months after ASD closure p value Time of exercise (min) 12.1±5.2 18.6±4.3 <0.001 VO2 peak (ml/kg/min) 10.2±4.7 14.8±4.2 <0.001 SF36q scale 0–100 37.3±22.3 79±29.5 <0.001 Right atrial area (cm2) 20.1±1.7 14.7±1.5 <0.001 Right ventricular area (cm2) 18.1±1.4 12.2±1.5 <0.001

Conclusions

ASD closure in patients with borderline shunt resulted in a significant and long-term clinical and hemodynamic improvement after percutaneous treatment.

Transcatheter closure of atrial septal communication: Impact on quality of life in mid-term follow-up

BACKGROUND

Atrial septal defect (ASD) and patent foramen ovale (PFO) are specific types of atrial septal communications (ASC).

OBJECTIVES

We aimed to assess quality of life (QoL) in patients before and after percutaneous closure of ASC and determine the factors influencing QoL in this group of patients.

MATERIAL AND METHODS

We performed a clinical assessment and conducted an SF-36 questionnaire, electrocardiography and echocardiography studies in patients before and 6 months after percutaneous ASC closure.

RESULTS

Patients with ASD (n = 56) had a lower SF-36 total score than those with PFO (n = 73), before and after percutaneous ASC occlusion (both p < 0.001). After the procedure, the improvement of SF-36 total score in patients with ASD or atrial fibrillation was greater (p < 0.001 and p = 0.005, respectively). We observed correlations between improvement of QoL and baseline supraventricular extrasystolic beats (rs = 0.28; p = 0.002), but not ventricular extrasystolic beats (rs = 0.03; p = 0.76). Quality of life improvement was predicted in patients with ASD by higher baseline tricuspid annular plane systolic excursion (TAPSE) and right ventricular longitudinal dimension R2 = 0.38; p < 0.001. However, in patients with PFO, this was predicted by TAPSE, lack of arterial hypertension and usage of angiotensin-converting enzyme inhibitors, R2 = 0.30; p < 0.001.

CONCLUSIONS

Patients with ASD have lower QoL than those with PFO before and after percutaneous ASC occlusion. Six months after the procedure, the improvement of QoL in patients with ASD was higher than in those with PFO. The change in QoL self-assessed by patients after the procedure was associated with episodes of arrhythmia and was predicted with echocardiographic and clinical parameters.

Clinical classification of rare cardiac arrhythmogenic and conduction disorders, and rare arrhythmias

INTRODUCTION Rare cardiovascular diseases and disorders (RCDDs) constitute an important clinical problem, and their proper classification is crucial for expanding knowledge in the field of RCDDs. OBJECTIVES The aim of this paper is to provide an updated classification of rare arrhythmogenic and conduction disorders, and rare arrhythmias (RACDRAs). METHODS We performed a search for RACDRAs using the Orphanet inventory of rare diseases, which includes diseases with a prevalence of no more than 5 per 10 000 in the general population. We supplemented this with a search of PubMed and Scopus databases according to a wider definition proposed by the European Parliament and the Council of the European Union. RESULTS RACDRAs are categorized into 2 groups, primary electrical disorders of the heart and arrhythmias in specific clinical settings. The first group is further divided into subgroups of major clinical presentation: disorders predisposing to supraventricular tachyarrhythmias, ventricular tachyarrhythmias, bradyarrhythmias, and others. The second group includes iatrogenic arrhythmias or heart rhythm disturbances related to medical treatment, arrhythmias associated with metabolic disorders, and others. We provide a classification of RACDRAs and supplement them with respective RCDDs codes. CONCLUSION The clinical classification of RACDRAs may form a basis to facilitate research and progress in clinical practice, both in diagnostic and therapeutic approaches.

[Przezskórne zamknięcie ubytku w przegrodzie międzyprzedsionkowej: wpływ na prawy przedsionek, dyspersję załamka P i zaburzenia rytmu serca w obserwacji średnioterminowej]

The size of the right atrium (RA) reduces after transcatheter closure of the atrial septal defect (ASD). Inverse structural and electrical remodeling is observed.

AIM

The aim of study was to analyze the parameters predisposing to the lack of normalization of enlarged RA after transcatheter closure of ASD during 6-month follow-up.

MATERIALS AND METHODS

A prospective study included 56 consecutive adult patients (12 men) aged from 23 to 76 years (49.8±13.3 years) with ASD, in whom transcatheter ASD closure was performed. Each patient was assessed before and 6 months after the treatment using standard 12-lead resting electrocardiogram (ECG), 24-hour Holter monitoring and echocardiography.

RESULTS

Before the procedure in 37 patients with ASD enlarged RA was observed, while after transcatheter ASD closure in 24 patients normalization of enlarged RA was noted. Patients in whom 6 months after the procedure there was no normalization of the enlarged RA were older, characterized by higher right ventricular systolic pressure (RVSP), pulmonary to systemic blood flow ratio (Qp/Qs), larger size of the occluder, interatrial septal defect, longer fluoroscopy time and lower left ventricular ejection fraction. P-wave dispersion (Pdysp) was found to be a destimulant i.e. increased Pdysp (>67 ms, P<0.000) decreased the chance of RA normalization after procedure. On the other hand, minimum P-wave duration (Pmin) was a stimulant, therefore, increased Pmin (>72ms, P<0.000) increased the chance of RA normalization. A significant association was found between the reduction of supraventricular extrasystolic beats and RA area normalization (P<0.001), and there was no association between the incidence of atrial fibrillation episodes and RA area normalization.

CONCLUSIONS

Evaluation of the duration of the P-wave and its dispersion may help to assess the prognosis of the right atrium size normalization in the mid-term follow-up after transcatheter closure of ASD. There is a significant relationship between normalization of the right atrium size and reduction of supraventricular extrasystolic beats.

Personality traits of patients suffering from congenital heart defects

OBJECTIVE

Introduction: Personality traits of patients suffering from congenital heart defects The work presents a research project carried out in John Paul II Hospital, The Clinical Department of Cardiac and Vascular Diseases with the Intensive Cardiac Surgeon Division Institute of Cardiology, Collegium Medicum of the Jagiellonian University in Cracow, with participation of patients with congenital heart defects. We aimed to assess personality traits of clients suffering from congenital heart defects, in a group of women and men, younger, under 40 years old and older than 40 years old, with PFO and ASD before and after surgery. The aim: identify specific personality traits of patients with congenital heart defects and to check the psychological functioning of patients by examining: the level of anxiety, impulsiveness, tendency to risk-taking, empathy, neuroticism, extraversion, psychoticism and lying.

PATIENTS AND METHODS

Material and methods: We performed a psychological clinical assessment and conducted the psychological tests like EPQ-R(S) by Hans J. Eysenck and Sybil G. Eysenck, IVE by Hans J. Eysenck and Sybil G. Eystenck, STAI by C. D. Spielberger, R. L. Gorsuch, R. E. Lushene describing personality traits of patients.

RESULTS

Results: Patients (F=29, M=21), adult, with ASD and with PFO, with the level of education: basic, vocational, secondary, incomplete higher, higher; inhabiting: village, city up to 40 thousand residents, a city with a population of 41-61 thousand, and a city with a population of 60 thousand; civil status: single, married, divorced, widow/widower, separated; being: students, unemployed persons, working persons, pensioners, retirees.

CONCLUSION

Conclusions: The presented results and their statistical analyses showed specific personality traits of patients with congenital heart defects.

[Elimination of the left atrial appendage in the prevention of thromboembolic events in patients with atrial fibrillation]

Atrial fibrillation (AF) is the most common cardiac arrhythmia in the adult population. Thromboembolic events are one of the reson of increased mortality in this group of patients. Oral anticoagulation therapy significantly reduces the risk of complications, however every tenth patient has contraindications to this treatment. Percutaneous left atrial appendage occlusion (LAAO) is effective, non-pharmacological method of treatment through elimination the source of thromi. This procedure is dedicated to patients with high risk of thromboembolism events and contraindications to anticoagulation.

Serum rantes, transforming growth factor-β1 and interleukin-6 levels correlate with cardiac muscle fibrosis in patients with aortic valve stenosis

Regulated on Activation Normal T Expressed and Secreted (RANTES) chemokine is involved in the initiation of inflammation and immune-cell recruitment. Interleukin -6 (IL-6) is used as a general index of severity of the chronic inflammatory process. Finally, transforming growth factor-β (TGF-β) is an immune biomarker potentially involved in the regulation of valve fibrosis and calcification. The aim of this study was to analyze selected biomarkers associated with the different stages of immune-pathogenesis in aortic stenosis. Forty consecutive patients with moderate to severe aortic stenosis (AS) and without previous myocardial infarction history were included in the study and divided into two groups. Two imaging techniques, echocardiography and magnetic resonance, were used to estimate the degree of AS and left ventricular muscle function. Inflammatory biomarker serum levels including CCL5/RANTES, IL-6, and TGF-β1 were determined based on ELISA measurements. Mean levels of RANTES, IL-6, and TGF-β1 did not significantly differ between both groups. A negative correlation was found between RANTES serum level and left ventricle (LV) mass as assessed by MRI (r = -0.3358, P = 0.0341). A positive correlation (r = 0.3283, P = 0.0387) was found between IL-6 serum levels and LV mass as measured by MRI. In addition, a positive correlation (r = 0.6803, P = 0.01) was seen between IL-6 serum levels and LV muscle mass with positive late gadolinium enhancement (LGE). There was a positive correlation between TGF-β1 serum level and ejection fraction as measured by echocardiography (r = 0.3217, P = 0.043). The relationship between selected inflammatory biomarkers, LV ejection fraction, LV mass, and LV muscle mass with LGE appeared to be independent of valvular pathobiologic process severity, as we did not observe differences in IL-6, RANTES, or TGF-β1 between groups differing in severity. On the contrary, these markers appear to be linked to myocardial function and remodeling, which may provide valuable insights into the pathobiology of AS and provide a basis for future detection strategies of AS.

Ischemic Versus Non-Ischemic (Neurogenic) Myocardial Contractility Impairment in Acute Coronary Syndromes: Prevalence and Impact on Left Ventricular Systolic Function Recovery

BACKGROUND Neurogenic mechanism is believed to contribute to left ventricular (LV) systolic dysfunction in acute coronary syndromes (ACS); its extreme form is known as takotsubo cardiomyopathy. However, the magnitude of neurogenic contribution to LV dysfunction in all-comer first-time ACS remains unknown. MATERIAL AND METHODS In 120 consecutive patients with first-time ACS (age 66.3±12.3years, 40 women) coronary angiograms were individually matched to the echocardiographic left ventricular (LV) segments (17-segment model). Baseline contractility impairment was classified as ischemic (I): confined to the stenotic artery(ies) supply area(s), neurogenic (N): in absence of attributable coronary stenosis, or partially ischemic/partially neurogenic (I&N). Echocardiography was repeated at 6 months to determine LV systolic function recovery. RESULTS Neurogenic component (NC) contribution to myocardial contractility impairment was present in 24.2% of ACS patients, with pure N in 6.7% and I&N in 17.5%. Diabetes/pre-diabetes was present in 38.5% vs. 33.5% vs. 0% (I vs. I&N vs. N; p=0.02). Major stressor preceding symptom onset was reported in 3.3% in I, 9.5% in I&N, and 25.0% in N (p=0.03). The number of LV segments with contractility impairment was 2±4 in I, 17±11 in I&N, and 3±16 in N (p<0.05). NC presence was independently associated with better recovery of global LV systolic function (OR 2.99, 95% CI: 1.16-7.76; p=0.024). CONCLUSIONS Novel findings from this study are: (1) NC may contribute to myocardial contractility impairment in 1 in every 4 first-time ACS patients, (2) NC contribution to contractility impairment in ACS is blunted in diabetes or pre-diabetes, and (3) LV systolic function recovery is better in patients with NC.

Long-Term Effects of Percutaneous Fenestration Following the Fontan Procedure in Adult Patients with Congenital Univentricular Heart

Background

The Fontan procedure, performed for univentricular heart, may also include the technique of percutaneous fenestration to create a small atrial septal defect (ASD) and a right-to-left shunt. The aim of this study was to evaluate the long-term effects of fenestration in adult patients who had a Fontan procedure for univentricular heart.

Material/Methods

Fontan surgery was performed in 39 patients, including 19 (49%) patients with fenestration (Group I), and 20 (51%) patients without the fenestration procedure (Group II). Laboratory tests in both groups included echocardiography, plethysmography, cardiopulmonary exercise testing, and 24-hour Holter monitoring.

Results

Compared with patients in Group I, patients in Group II had a significantly increased level of N-terminal pro-brain natriuretic peptide (NT-proBNP) (p=0.04), alkaline phosphatase (ALP) (p=0.01) and a significant increase in frequency of atrial fibrillation (p=0.04). Patients in Group I had a significantly increased systemic ventricular ejection fraction (SVEF) (p=0.05) and increased heart rate (HR) (p=0.006), heart rate reserve (HRR) (p=0.02), ventilatory equivalent (VE) (p=0.01), and VO₂ peak (p=0.05) on cardiopulmonary exercise testing (CPET). Renal, hematologic, and ventilatory parameters, and incidence of thromboembolism showed no significant differences between the groups.

Conclusions

Long-term follow-up of patients who underwent Fontan procedures with percutaneous fenestration had improved single ventricular function, lower NT-proBNP levels, improved exercise capacity, and reduced ALP levels. These findings indicate that percutaneous fenestration closure should be considered for adult patients who have undergone Fontan procedure for univentricular heart.

Improvement of physical capacity in patients undergoing transcatheter closure of atrial septal defects

INTRODUCTION

Atrial septal defect (ASD) is the most common congenital cardiac anomaly diagnosed in adults. It often remains asymptomatic until the fourth or fifth decade of life. Significant left-to-right interatrial shunting is associated with the risk of heart failure, pulmonary hypertension and atrial fibrillation. Percutaneous ASD closure is a recognized method of treatment.

AIM

To evaluate the clinical outcomes and physical capacity in patients undergoing transcatheter closure of ostium secundum ASD.

MATERIAL AND METHODS

One hundred and twenty adult patients (75 females and 45 males) with a mean age of 43.1 ±13.3 (17-78) years who underwent transcatheter device closure of ostium secundum ASD were analyzed. Clinical evaluation and transthoracic color Doppler echocardiographic study were repeated in all patients before as well as 1 and 24 months after the procedure. To assess the physical capacity symptom-limited treadmill exercise tests with respiratory gas-exchange analysis were performed in all patients before the procedure and after 24 months of follow-up.

RESULTS

The devices were successfully implanted in all patients. During 24 months of follow-up all patients showed significant clinical and spiroergometric improvement of exercise capacity, and a significant decrease of right heart chamber overload features on echocardiography.

CONCLUSIONS

Transcatheter closure of ASD in patients with significant shunt resulted in significant clinical and hemodynamic improvement regardless of the baseline functional class.

[Personality traits of perpetrators of various types of crimes]

This study was conducted in Nowy Wiśnicz, with prisoners sentenced for: murders, sex crimes, theft and robbery, maintenance, bullying. A Polish adaptation of PAI test, made by the author of the study, was used. The study results and its statistical analysis showed characteristic personality features of particular criminal groups can be used in rehabilitation of disturbed people, addicts, and become the basis for preparing actions reducing frequency of committing crimes.

Chemokine RANTES is increased at early stages of coronary artery disease

Cardiovascular diseases, and in particular coronary artery disease (CAD), are the leading causes of death in Europe and represent around 50% of overall mortality. Numerous cardiovascular markers have been proposed in relation to cardiovascular risk prediction, in relation to cardiac and vascular and cerebral events. Chemokines which regulate immune cell vascular chemotaxis, including CCL5/RANTES are points of great interest. We hypothesized that chemokine RANTES level measured in peripheral blood may be associated with severity of atherosclerosis in patients with stable angina undergoing coronary angiography. RANTES and interleukin 18 (IL-18) levels were measured by ELISA. Classical and novel cardiovascular risk factors like brachial flow mediated dilation and intima-media thickness were analyzed in the context of chemokine levels and severity of atherosclerosis. Study included 62 consecutive patients with coronary atherosclerosis demonstrated by coronary angiography, (mean age 59.3 years (S.D. = 7.4)), divided into two groups: group I with lower severity of atherosclerosis, (n = 45) and group 2 with severe CAD (n = 17) based on coronary angiography. Groups were well balanced for classic risk factors for atherosclerosis. Mean RANTES level were significantly higher in patients in group I (67.9 ng/ml, S.E.M. = 3.97) than in group II (50.5 ng/ml, S.E.M. = 7.49; P = 0.03). In contrast, IL-18 levels were similar in both groups (255 pg/ml in group I and 315 pg/ml, S.E.M. = 40.91 in group I, P = 0.12), as well as hsCRP concentration (3.45 S.E.M. = 2.66 ng/ml and 4.69 ng/ml S.E.M.= 1.64 ng/ml respectively; P = 0.47). Flow-mediated dilatation (FMD) values have been significantly lower in group II than in group I (6.31; S.E.M. = 0.61; vs 4.41; S.E.M. = 0,56, respectively, P = 0.026), while nitroglycerine-mediated dilatation (NMD) did not differ, indicating more pronounced endothelial dysfunction. No significant correlations between chemokine RANTES levels and intima-media thickness (IMT), FMD measurements have been found in the total population studied. Chemokine RANTES level could become a useful marker of severity of coronary artery disease. Its lower levels were observed in patients with more diffuse disease. Elevated level of chemokine RANTES in patients with stable angina pectoris may evaluate patients to high risk group in plaque formation at early stages of atherosclerosis.

Conduction abnormality and arrhythmia after transcatheter closure of atrial septal defect

BACKGROUND

The aim of this study was to prospectively perform ambulatory 24-h ECG monitoring to assess the effects of transcatheter closure of atrial septal defect (ASD).

METHODS AND RESULTS

A total of 235 consecutive subjects (female, n=163; male, n=72; age, 44.6±14.4 years) were enrolled in the study, who were due undergo ASD closure. Holter monitoring was performed before procedure and at 1, 6 and 12 months of follow-up. During the procedure transient supraventricular arrhythmia occurred in 8 patients (3.4%), and bradycardia in 3 (1.3%). In 3 patients (1.3%) an episode of atrial fibrillation occurred in the first hour after the procedure. In 8 patients (3.4%) transient first-degree atrioventricular block was noted. A significant increase in number of supraventricular extrasystoles (SVES)/24 h was noted 1 month after the procedure (P<0.001). On multiple forward stepwise regression analysis, device size and fluoroscopy time had an influence on increase in number of SVES seen 1 month after the procedure (P<0.001).

CONCLUSIONS

Transcatheter closure of ASD is associated with a transient increase in supraventricular premature beats and a small risk of conduction abnormalities and paroxysmal atrial fibrillation in early follow-up. Transcatheter closure of ASD does not reduce arrhythmia that appears prior to ASD closure. Larger device size and longer procedure time are associated with increased risk of supraventricular arrhythmia on early follow-up.

Conduction Abnormality and Arrhythmia After Transcatheter Closure of Atrial Septal Defect

Background:The aim of this study was to prospectively perform ambulatory 24-h ECG monitoring to assess the effects of transcatheter closure of atrial septal defect (ASD).Methods and Results:A total of 235 consecutive subjects (female, n=163; male, n=72; age, 44.6±14.4 years) were enrolled in the study, who were due undergo ASD closure. Holter monitoring was performed before procedure and at 1, 6 and 12 months of follow-up. During the procedure transient supraventricular arrhythmia occurred in 8 patients (3.4%), and bradycardia in 3 (1.3%). In 3 patients (1.3%) an episode of atrial fibrillation occurred in the first hour after the procedure. In 8 patients (3.4%) transient first-degree atrioventricular block was noted. A significant increase in number of supraventricular extrasystoles (SVES)/24 h was noted 1 month after the procedure (P<0.001). On multiple forward stepwise regression analysis, device size and fluoroscopy time had an influence on increase in number of SVES seen 1 month after the procedure (P<0.001).Conclusions:Transcatheter closure of ASD is associated with a transient increase in supraventricular premature beats and a small risk of conduction abnormalities and paroxysmal atrial fibrillation in early follow-up. Transcatheter closure of ASD does not reduce arrhythmia that appears prior to ASD closure. Larger device size and longer procedure time are associated with increased risk of supraventricular arrhythmia on early follow-up.

Elevated level of plasma endothelin-1 in patients with atrial septal defect

Background

The study aimed to assess the level of plasma Endothelin-1 (ET-1) in patients before and after transcatheter closure of atrial septal defect (ASD) and to evaluate the usefulness of measuring ET-1 levels for the diagnosis and selection of candidates for ASD closure.

Methods

80 patients (55 F, 25 M), mean age 42,2 ± 11,5 years were enrolled for an attempt at ASD closure. A group of 19 healthy volunteers, (12 F, 7 M) mean age 39.2 ± 9.15 served as controls. All ASD patients underwent: clinical and echocardiographic study and cardiopulmonary exercise test. ET-1 levels were measured before and after closure. Whole blood was collected from femoral artery and vein and from pulmonary artery during cardiac catheterization.

Results

ET-1 levels at peripheral artery and vein in ASD patients were significantly higher than in the volunteers (p < 0.0001). The ASD subjects with highest ET-1 level presented the larger area of right ventricle and right atrium and higher pulmonary artery systolic pressure(p < 0.05). The ASD subjects with lower ET-1 level demonstrated longer time of exercise and higher peak oxygen consumption (p < 0.05). There was a decrease of ET-1 at peripheral artery (5.128 ± 8.8 vs. 2.22 ± 6.2; p < 0.001) and at peripheral vein (4.401 ± 3.33 vs. 2.05 ± 1.35; p < 0.001) within 48 hours after ASD closure, as compared to the baseline data. After 6 and 12 months farther drop in ET-1 level was observed.

Conclusions

1. The level of ET-1 in ASD patients is elevated in compare to healthy subject.

2. The significant reduction of ET-1 level is observed after percutaneous closure of ASD.

3. Elevated level of ET-1 in patients with ASD is associated with right heart enlargement.

4. Measurements of ET-1 may be a supplemental diagnostic tool and may be helpful in establishing indications for defect closure.