Hypertensive disorders of pregnancy in women with structural heart disease: data from the ESC EORP Registry of Pregnancy and Cardiac disease (ROPAC)

Background

Hypertensive disorders of pregnancy (HDP) are estimated to occur in 10% of pregnancies in the general population and preeclampsia specifically in 3–5%. HDP are suggested to be more common in and less well tolerated by women with heart disease. However, the current data are conflicting and this knowledge gap impacts clinical practice guidelines.

Purpose

To harness the well characterized data of the Registry of Pregnancy and Cardiac disease (ROPAC) to examine the frequency of HDP in women with structural heart disease and its impact on maternal and perinatal outcomes.

Methods

The ROPAC registry (n=5739) is a worldwide prospective registry on pregnancies in women with heart disease, including congenital heart disease (CHD, n=3295), valvular heart disease (VHD, n=1648), cardiomyopathy (CMP, n=438), aortopathy (AOP, n=217), ischemic heart disease (IHD, n=95), and pulmonary arterial hypertension (PAH, n=45). We defined HDP as either chronic hypertension, gestational hypertension, and/or preeclampsia (including HELLP syndrome and eclampsia) and assessed the frequency of HDP in each heart disease category. Predictors of preeclampsia were identified using multivariable logistic regression. The proportion of women with adverse maternal, pregnancy, and fetal/neonatal outcomes were described among women with preeclampsia or HDP, and compared between women with and women without HDP using chi-square tests.

Results

In total, the frequency of HDP and preeclampsia was 9.3% and 2.6% in CHD, 7.5% and 2.2% in VHD, 18.7% and 7.1% in CMP, 15.7% and 2.8% AOP, 35.8% and 6.3% in IHD, and 22.2% and 11.1% in PAH. Independent predictors of preeclampsia were chronic hypertension (OR 3.06, 95% CI 2–4.69), nulliparity (2.39, 1.68–3.38), HDP in a previous pregnancy (2.29, 1.11–4.7), gestational diabetes in the current pregnancy (2.13, 1.13–4.03), pulmonary hypertension (1.71, 1.08–2.7) and age (1.04, 1.01–1.07). In women with preeclampsia and heart disease, maternal mortality was 3.5% and heart failure was 29.1%. Maternal mortality (1.4% vs 0.6%, p=0.042), heart failure (18.5% vs 10.6%), Caesarean section (61.2% vs 48.4%), preterm births (27.4% vs 16.9%), low Apgar score (9.8% vs 6.6%), small for gestational age (14.6% vs 9.7%) and neonatal mortality (1.7% vs 0.4%) were higher in women with than women without HDP (all p<0.001 except maternal mortality).

Conclusions

The frequency of HDP is increased (>10%) in CMP, AOP, IHD and PAH, but not in CHD and VHD. The high frequency of HDP is partly due to chronic hypertension, but the incidence of preeclampsia is also increased (>5%) in CMP, IHD and PAH. Among women with cardiac disease, HDP were associated with adverse maternal and perinatal outcomes. The high maternal mortality rate of 3.5% in women with heart disease and preeclampsia warrants close clinical monitoring and a better understanding of the optimal management strategies in the complex population group.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Funding from “Zabawas Foundation” and “De Hoop Foundation” in addition to the support from EORP is greatly acknowledged. Since the start of EORP, the following companies have supported the programme: Abbott Vascular Int. (2011–2021), Amgen Cardiovascular (2009–2018), AstraZeneca (2014–2021), Bayer AG (2009–2018), Boehringer Ingelheim (2009–2019), Boston Scientific (2009–2012), The Bristol Myers Squibb and Pfizer Alliance (2011–2019), Daiichi Sankyo Europe GmbH (2011–2020), The Alliance Daiichi Sankyo Europe GmbH and Eli Lilly and Company (2014–2017), Edwards (2016–2019), Gedeon Richter Plc. (2014–2016), Menarini Int. Op. (2009–2012), MSD-Merck & Co. (2011–2014), Novartis Pharma AG (2014–2020), ResMed (2014–2016), Sanofi (2009–2011), Servier (2009–2021), Vifor (2019–2022). HDP in women with heart diseaseIncidence of HDP per diagnosis group

Myocardial extracellular volume by T1 mapping: a new marker of arrhythmia in mitral valve prolapse

Funding Acknowledgements

Type of funding sources: None.

Background

In MVP, MAD has been associated with myocardial replacement fibrosis and arrhythmia, but the importance of interstitial fibrosis remains unknown. We aimed to evaluate the relationship between mitral annular disjunction (MAD) severity and myocardial interstitial fibrosis at the left ventricular (LV) base in patients with mitral valve prolapse (MVP), and to assess the association between severity of interstitial fibrosis and the occurrence of ventricular arrhythmic events

Methods

Thirty patients with MVP and MAD (MVP-MAD) underwent Cardiac Magnetic Resonance (CMR) with assessment of MAD length, late gadolinium enhancement (LGE), and basal segments myocardial extracellular volume (ECV). The control group included 14 patients with mitral regurgitation but no MAD (MR-NoMAD) and 10 patients with normal CMR (NoMR-NoMAD). Fifteen MVP-MAD patients underwent 24h-Holter monitoring.

Results

LGE was observed in 47% of MVP-MAD patients and absent in controls. ECV was higher in MVP-MAD (30 ± 3% vs 24 ± 3% MR-NoMAD, p < 0.0001 and vs 24 ± 2% NoMR-NoMAD, p < 0.0001), even in MVP-MAD patients without LGE (29 ± 3% vs 24 ± 3%, p < 0.0001 and vs 24 ± 2%, p < 0.0001, respectively), Fig.1. MAD length was correlated with ECV (rho = 0.61, p = 0.0003), but not with LGE extent. Four patients had history of OHCA; LGE and ECV were equally performant to identify those high-risk patients (area under the ROC curve 0.81 vs 0.83, p = 0.84). Among patients with Holter, 87% had complex ventricular arrhythmia. ECV was above the cut-off value in all while only 53% had LGE.

Conclusion

Increase in ECV, a marker of interstitial fibrosis, occurs in MVP-MAD even in the absence of LGE, and was correlated with MAD length and OHCA. ECV should be part of the CMR examination of MVP patients in an effort to better assess fibrous remodelling as it may provide additional value beyond the assessment of LGE in the arrhythmic risk stratification.

Feasibility and prognostic value of adenosine stress perfusion cardiovascular magnetic resonance in patient with implantable device

Funding Acknowledgements

Type of funding sources: None.

Background

stress CMR has a limited use in patients with implantable device, in order to the possible artefacts due to the metallic component and to the risk of adenosine interaction with cardiac pacing. The aim of the study was to assess the global feasibility and to assess the prognostic value of stress perfusion CMR in patients with implantable device.

Materials and Methods

we conducted a retrospective single-center longitudinal analysis of consecutive patients with an implantable device referred for stress CMR, performed using a 1.5 Tesla unit (Siemens Healthcare,MAGNETOM Aera, Erlangen-Germany). Protocol was adapted according to current guidelines. Cardiac follow-up [6 months to 7 years] was obtained by medical records of direct contact with patient’s cardiologist referral. 

Results

44 patients were enrolled. 34 patients needed a continuous pacing during adenosine stress, that was settled in DOO in 14 (32%) and in VOO in 20 (45%). Device integrity was not compromised by CMR and not competitive atrial or ventricular stimulation was observed during examination. Image quality was good in 95% cases. 26% cases had a perfusion deficit corresponding to a previous scar, while 12% of patients had a positive stress test. All of them needed continuous pacing during stress test and underwent to a coronary angiography who confirmed the coronary stenosis.  In patients without inducible ischemia 2 patients experienced a Non-ST-elevation Myocardial Infarction after 6 and 2 years while no other cardiac symptoms or cardiac hospitalisation was remarkable during follow up.

Conclusion

adenosine stress CMR in patient who are pacemaker dependent during scanner is feasible, with an overall good image quality, proving an excellent diagnostic and prognostic value in a long term follow up even. Adenosine administration is safe and no the magnetic field interference with the correct functioning of the device have been shown in short or long term follow-up.

Overcoming claustrophobia in cardiovascular magnetic resonance with medical hypnosis

Funding Acknowledgements

Type of funding sources: None.

Background

the role of Cardiovascular Magnetic Resonance has gained the more and more importance in the field of cardiovascular disease. Claustrophobia remains a frequent cause of failure to complete a CMR. It is estimated that 2 million scans worldwide cannot be performed annually either due to premature termination or refusal of the patient to be scanned due to claustrophobia. In this setting, medical hypnosis may prove useful to overcome this main limitation.

Methods

we propose an observational study of consecutive patients referred to CMR and known for severe claustrophobia. Patients were proposed to undergo CMR examination with the help of medical hypnosis according to Milton H. Erickson’s method or with administration of mild sedation (lorazepam 2.5 mg).

Results

20 severe claustrophobic patients were considered in the study. 1 patient was excluded due to psychiatric condition, 1 patient undergo to general anesthesia, 5 patients refused the examination. Among the 13 patients, 10 underwent medical hypnosis while 3 patients accepted to undergo to CMR examination with the administration of lorazepam 2.5 mg. All patients treated with medical hypnosis were able to complete the examination with a great tolerance and no sign of stress or anxiety were reported. CMR protocol was performed according to clinical request and was not different form non-claustrophobic patients. None of the patients treated with lorazepam 2.5mg was able to complete the exam.

Conclusion

we prove medical hypnosis to be safe and effective in controlling patients’ anxiety, allowing optimal diagnostic imaging quality without the need to adapt the examination. Further studies in larger populations are needed to confirm our results.

Evolution of biventricular T1 values in patients with right-sided congenital heart disease

Funding Acknowledgements

Type of funding sources: None.

Background

Conflicting reports exist on the prevalence and clinical impact of interstitial fibrosis in right ventricular (RV) congenital heart disease (CHD). This study evaluates the longitudinal evolution of native myocardial T1 relaxation time (T1) in RV CHD.

Methods

On a 1.5T scanner, an ECG-triggered modified Look-Locker inversion recovery sequence (scheme 3(3)3(3)5) was acquired on a short-axis basal slice covering the RV and left ventricle (LV) on two consecutive CMR exams. Global and segmental (LV = 6, RV = 4) RV and LV T1 values  were calculated (Figure).

Results

Mean time between CMR exams for 36 included patients (age 34 ± 2y) was 22 ± 2 months. All LV segments and 81/88% of RV segments of first and second CMR could be analyzed, respectively.  T1 increased mildly but not significantly (table). There was no relationship of T1 to pulmonary regurgitation fraction, pulmonary stenosis or RV enddiastolic volume (p > 0.05). Global RV T1 of the second CMR was related to RV ejection fraction (RVEF): r = 0.353, 3.0 ± 1.4, p = 0.038. T1 of the infero-septal LV segment of first and second CMR, global LV T1 of second CMR and increase of T1 of global LV, anterior, antero-lateral and –septal LV segments, were related to age at CMR: r = 0.333 - 0.463, p < 0.05, respectively.

Conclusions

Native T1 values increased mildly in patients with stable RV CHD, which was not statistically significant probably due to the short to median follow-up. Global RV T1 appears to be related to RVEF which could be sign of increasing interstitial fibrosis whereas the relationship of LV T1 to age might be a physiological finding.

First CMR native T1 (ms) Second CMR native T1 (ms) p LV Global 1007 ± 37 1014 ± 39 0.413 LV Anterior 994 ± 53 999 ± 54 0.710 LV Antero-lateral 965 ± 63 981 ± 58 0.186 LV Infero-lateral 1000 ± 52 1004 ± 63 0.695 LV Inferior 1035 42 1037 ± 50 0.744 LV Infero-septal 1028 ± 35 1036 ± 43 0.282 LV Antero-septal 1016 ± 38 1024 ± 48 0.347 RV Global 1091 ± 90 1096 ± 85 0.410 RV Inferior 1112 ± 104 1115 ± 118 0.696 RV Infero-lateral 1061 ± 130 1077 ± 115 0.425 RV Antero-lateral 1046 ± 127 1080 ± 109 0.088 RV Anterior 1088 ± 156 1108 ± 154 0.410 Abstract Figure. Determination of biventricular T1 values

Myocardial interstitial fibrosis assessed by extracellular volume quantification is a determinant of symptoms in aortic valve regurgitation with preserved ejection fraction

Funding Acknowledgements

Type of funding sources: None.

Introduction

According to current guidelines indication for surgery is straightforward with a class I recommendation in case of severe symptomatic aortic regurgitation (AR) and/or left ventricular ejection fraction (LVEF) decrease ≤50%. However, the management of patients with asymptomatic severe AR with preserved LVEF remains debated, with a cruel lack of prognostic factors to identify patients who may benefit from early intervention. An explanation to the absence of such factors is that the determinants of symptoms, a strong prognostic parameter, have been poorly identified. Beyond LV dilation and systolic dysfunction, which are both recognized prognostic factors in chronic AR, we hypothesized that interstitial myocardial fibrosis, as an early indicator of LV remodeling, may also influence the occurrence of symptoms. Cardiovascular magnetic resonance (CMR)-based myocardial extracellular volume (ECV) quantification by T1 mapping has emerged as a valuable tool to quantify diffuse myocardial fibrosis.

Objective

To study the relationship between myocardial interstitial fibrosis quantified by T1 mapping and the symptomatic status of patients with chronic aortic valve regurgitation.

Methods

We retrospectively included 38 consecutive patients with chronic, isolated, mild to severe AR who underwent a CMR at our institution. Exclusion criteria were the presence of any other heart condition that may induce myocardial fibrosis, ≥ mild associated valve disease, AR secondary to endocarditis, genetic, inflammatory or congenital disease except bicuspid aortic valve. T1 mapping of the basal segments was performed before and after contrast administration measuring native and post-contrast T1 relaxation time and ECV.

Results

Mean age was 56 ± 20 years, 30 patients (79%) were males, and symptoms were reported in 11 patients (29%). Mean LVEF was 57 ± 9% and ≥50% in 30 patients (79%). Aortic valve regurgitation fraction (RF) was 25 ± 13%, ECV 0.27 ± 0.04%, indexed LV end-diastolic volume (LVEDVi) 98 ± 32 ml/m2, end-systolic volume (LVESVi) 46 ± 19 ml/m2, and LV mass 79 ± 21 g/m2. LVESVi (r = 0.41,p = 0.01), LVEF (r=-0.59,p = 0.0001), and ECV (r = 0.42,p = 0.008) were correlated with symptoms, whereas age (r = 0.16,p = 0.33), gender (r=-0.24,p = 0.15), LVEDVi (r = 0.28,p = 0.09), LV mass index (r = 0.08,p = 0.62), and RF (r = 0.31,p = 0.06) were not. In the subgroup of patients with preserved LVEF (≥50%), after adjustment for LVESVi and RF, only ECV remained independently associated with symptoms (p = 0.046). Interestingly, when including the patients with a reduced LVEF < 50% in the multivariable analysis only LVESVi was an independent determinant of symptoms (p = 0.04) and ECV was not (p = 0.07)

Conclusion

myocardial fibrosis quantified by ECV calculation is a determinant of symptoms in AR with preserved LVEF. Further studies are warranted to determine the prognostic value of ECV that may justify earlier intervention.

Abstract Figure. ECV in AR with preserved LVEF

2D cine vs. 3D free-breathing self-navigated whole heart for aortic root measurements in congenital heart disease

Funding Acknowledgements

Type of funding sources: None.

Background

Cardiac magnetic resonance is considered the method of choice for determination of aortic root diameters in congenital heart disease. Usually, a cross-sectional 2D cine stack is acquired perpendicular to the vessel’s axis. However, this method requires a considerable patient collaboration and precise planning of image planes. This study compares a recently introduced free-breathing high-resolution 3D self-navigating whole heart sequence (3D self nav) to the 2D cine technique for determination of aortic root diameters.

Methods

Two observers measured on 2D cine and 3D self nav cross-sectional planes of the aortic root (figure A and B), acquired on a 1.5T scanner, cusp-commissure (CuCo) and cusp-cusp (CuCu) enddiastolic diameters (figure B and C). Asymmetry of the aortic root was evaluated by the ratio of the minimal to maximum CuCu diameter. CuCu diameters were compared to transthoracic echocardiographic (TTE) aortic root diameters.

Results

65 exams in 58 patients (mean age 32 ± 15y) were included. 2D cine and 3D self nav spatial resolution was 1.4x4.5-6mm and 1.1³mm, respectively. 3D self nav and CuCu yielded larger diameters than 2D cine and CuCo, respectively (table). Intra- and interobserver variabilities were excellent for both techniques ( bias -0.5 to 1.0 mm). Intra-observer variability of the experienced observer was better for 3D self nav (F-test p < 0.05). Aortic root asymmetry was more pronounced in patients with bicuspid aortic valve (BAV: 0.73 (0.69; 0.78) vs. 0.93 (0.9; 0.96), p < 0.001), which was associated with a larger difference of maximum CuCu to TTE diameters: 5.5 ± 3.3 vs. 3.3 ± 3.8 mm, p = 0.03.

Conclusion

Both, the 3D self nav and 2D cine techniques allow reliable determination of aortic root diameters. However, the 3D self nav technique and measurement of the CuCu diameters should be privileged to avoid underestimation of the maximum diameter, particularly in patients with asymmetric aortic roots and/or BAV

2D cine vs. 3D self nav CuCo min CuCo mid CuCo max CuCu min CuCu mid CuCu max Mean diameter 2D cine (mm) 33.5 34.8 36.2 33.4 37.6 38.5 Mean diameter 3D self nav (mm) 34.5 35.9 37.2 34.3 38.5 39.7 Mean difference (mm) -1.0 -1.1 -1.0 -0.8 -1.3 -1.2 95% Limits of agreement (mm) -5.1 to 3.2 -5.3 to 3.1 -5.5 to 3.5 -5.5 to 3.8 -4.7 to 2.0 -4.7 to 2.3 Standard deviation (mm) 3.2 2.1 2.3 2.4 1.7 1.8 Variance (mm2) 4.5 4.5 5.2 5.6 2.9 3.2 Pearson’s correlation (r) 0.952 0.954 0.945 0.944 0.972 0.951 P value (t-test) 0.003 0.001 0.006 0.005 <0.001 <0.001 Abstract Figure.

Long-term outcome of adult patients with partial anomalous pulmonary venous connection treated surgically and conservatively: data from the SACHER registry and a French center

Introduction

Partial anomalous pulmonary venous connection (PAPVC) is a rare congenital heart disease, which is characterized by one or some but not all pulmonary veins anomalously connected to the right atrium or a systemic vein. PAPVC is either an isolated shunt lesion or associated with an atrial septal defect (ASD). The only curative treatment is surgery, however the indication for surgery can be challenging. This study compares the outcome of patients treated surgically with those clinically monitored.

Method

Clinical, surgical, imaging and invasive data were retrospectively reviewed from 7 centers from the Swiss Adult Congenital HEart Registry (SACHER) and a French center.

Results

A total of 168 patients with partial anomalous pulmonary venous connection were identified. The majority (77%) of patients underwent surgery and the remaining (23%) were treated conservatively with clinical monitoring. The operated group (OG) had a significantly higher proportion of associated ASD (N=106, 82%) (p<0.001) and a higher prevalence of anomalous pulmonary veins leading to a mean Qp:Qs at 2.5±1.2 before surgery.

Latest follow-up was 12 years after surgery. Mean age was 40±17 years. Patients in the non-operated group (NOG) were significantly more dyspneic than the OG (p=0.002). However, the need for medical treatment did not differ between groups: 58% of the NOG and 48% in the OG (p=0.203).

Right ventricular (RV) ejection fraction did not differ between groups despite a significantly larger RV end-diastolic volume and a higher Qp:Qs on cardiac magnetic resonance (CMR) in the NOG (table).

On echocardiography, the NOG showed a significantly better right ventricular longitudinal function and a higher systolic pulmonary artery pressure than the OG (table). The prevalence of significant valvulopathies did not differ between groups (table).

Both groups had normal exercise capacity and with no differences between groups (table).

Eighteen (14%) OG patients required a re-intervention either for residual shunt and/or stenosis of the pulmonary veins, superior and inferior vena cava.

Conclusion

PAPVC patients after surgical correction, show a favorable outcome in terms of imaging parameters and exercise capacity, however, a significant number presents with symptoms. PAPVC patients treated conservatively with small left to right shunting, have similar outcome justifying a conservative approach.

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Unrestricted grant from Actelion, Switzerland

Long-term outcome of adult patients with total anomalous pulmonary venous connection: data from the SACHER registry and a French center

Introduction

Total anomalous pulmonary venous connection is a rare cyanotic congenital heart disease, where all pulmonary veins aberrantly connect to a systemic vein or the right atrium. The only curative treatment is surgery allowing the patients to reach adulthood. This study describes the long-term outcome of these individuals focusing on arrhythmias.

Methods

Clinical, surgical, imaging and invasive data were retrospectively reviewed from 7 centers participating in the Swiss Adult Congenital Heart disease Registry (SACHER) and one French center.

Results

A total of 57 patients were identified and analyzed 22±8 years after surgery.

At last follow-up, 21% of patients presented cardiac symptoms, mainly palpitations. No patient had pulmonary hypertension or a relevant valvulopathy. Echocardiography revealed in 5 (8.8%) patients a dilated right ventricle (RV) and in 3 (5.3%) patients a diminished RV systolic function. Exercise capacity was normal in most patients (table). Cardiac magnetic resonance imaging found in 2 (4%) had a residual shunt with an mean Qp:Qs of 1.25, due to a single anomalously connected pulmonary vein.

Holter recordings revealed arrhythmias in 23% of patient. Ten (17.5%) had atrial fibrillation, flutter or tachycardia. Three (5%) patients presented ventricular arrhythmias: two patients showed non-sustained ventricular tachycardia and one patient complex ventricular extrasystoles. Four patients (7%) were on antiarrhythmic medication for supraventricular arrhythmias. Three patients (5%) underwent an electrophysiological study with a mean time since surgery of 20 years. Three (5%) patients underwent pacemaker implantation within 3 weeks to 36 months after surgical correction, which were removed in 2 patients after 7 years.

Age and the presence of a valvulopathy at follow-up predicted tachyarrhythmia on binomial logistic regression analysis (p<0.03).

Conclusions

In adult survivors after TAPVC repair, supraventricular but also ventricular arrhythmias are frequently observed which appears to be related to age and valvular lesions at follow-up. This study underlies the importance of long-term follow-up as some of the patients currently without arrhythmia will probably develop rhythm disorders in the future.

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Unrestricted grant by Actelion SA, Switzerland

Prevalence of arrhythmias on the long term of adult patients with partial anomalous pulmonary venous connection treated surgically and conservatively: data from the SACHER registry and a French center

Introduction

Partial anomalous pulmonary venous connection (PAPVC) is a rare congenital heart disease, characterized by one or some but not all pulmonary veins anomalously connected to the right atrium or a systemic vein. PAPVC is either an isolated shunt lesion or associated with an atrial septal defect (ASD). This study compares the arrhythmic outcome of patients treated surgically with those clinically monitored.

Method

Clinical, surgical, imaging and invasive data of PAPVC patients were retrospectively reviewed from 7 centers from the Swiss Adult Congenital HEart disease Registry (SACHER) and one French center.

Results

A total of 168 patients with PAPVC were identified. Most (77%) patients underwent surgery, while the remaining (23%) ones were treated conservatively with clinical monitoring. The operated group (OG) had a significantly higher number of associated ASD (N=106, 82%) (p<0.001) and a higher number of anomalous pulmonary veins leading to a mean Qp:Qs at 2.5±1.2 before surgery (table). Moreover, the majority of patients in the OG had cardiac symptoms (N=78, 60%) and were diagnosed at a significantly younger age (table). Mean age at operation was 27±20 years.

Age did not differ at latest follow-up (table). Holter recordings revealed a higher prevalence of arrhythmia in the OG (p=0.031), mainly of supraventricular tachyarrhythmias (table). The occurrence of ventricular non-sustained tachycardia and of bradyarrhythmia did not statistically differ between groups. Patients in the OG required more often medical treatment for arrhythmias: 12 (9%) needed electrophysiological study in the OG and none in the NOG (p=0.057). The amount of patients requiring a pacemaker implantation in the OG (11%) was significantly higher than that of NOG (0%) (p=0.039).

Conclusion

Patients after PAPVC repair present with a significant higher burden of arrhythmia than conservatively treated patients, either due to a larger shunt pre-operatively and/or as a late complication of the corrective surgery itself.

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Unrestricted grant from Actelion, Switzerland

Hypnosis and superficial cervical anesthesia for total thyroidectomy in a high-risk patient - A case report

•

Total thyroidectomy can be challenging in high-risk patients.

•

Local superficial anesthesia combined with a hypnosis-analgesia technique instead of intravenous sedation.

•

Because of difficulties controlling the thyrotoxic state.

•

Given the multiple cardiac and large vessel malformations, a possible variant of the inferior laryngeal nerve was expected.

•

Locoregional deep cervical anesthesia can be associated with breathing problems when performed bilaterally.

Introduction

Total thyroidectomy can be challenging in high-risk patients. Local cervical anesthesia with sedation is an alternative to general anesthesia.

Case presentation

A 33-year old male patient with cyanotic congenital heart disease due to unrepaired tricuspid atresia type Ic and associated pulmonary arterial hypertension presented with tachycardic atrial fibrillation and amiodarone-induced thyrotoxicosis resulting in recurrent hemodynamic instability. Because of difficulties controlling the thyrotoxic state, the indication for total thyroidectomy was established. Total thyroidectomy was subsequently performed using local anesthesia combined using a hypnosis-analgesia technique instead of intravenous sedation. The intervention and the post-operative course were uneventful.

Discussion

A well-established therapist-patient relationship is crucial for a successful induction of hypnosis. Patient motivation and expectations are equally important for a successful implementation of this approach.

Conclusion

We conclude that hypnosis combined with local anesthesia provides an effective alternative in selected patients with very high anesthesiological risk.

1047 Increased interstitial fibrosis in patients with mitral valve prolapse and mitro-annular dysjunction

Background

in patients with myxomatous mitral valve prolapse (MVP), mitral annular disjunction (MAD) has been associated with the presence of late gadolinium enhancement (LGE) at papillary muscle level and the risk of sudden cardiac death. However, patients with MAD but no detectable LGE still may have arrhythmia. We investigated the relation between MAD and the presence of interstitial fibrosis in the basal inferior left ventricular myocardium.

Methods

28 patient with MVP and associated MAD underwent Cardiovascular Magnetic Resonance imaging (CMR) at 1.5 T scanner (Aera, Siemens Medical Solutions, Erlangen, Germany). Exclusion criteria were ischemic heart disease, infiltrative cardiomyopathy and contraindication to CMR. 12 patients with mitral valve regurgitation but no MAD and 10 patients without mitral disease served as the control group. MAD severity was measured from LA wall-posterior MV leaflet junction to the top of the LV infero-basal wall during end systole. Insterstitial fibrosis was assessed by calculating the extracellular volume (ECV) from T1 mapping of the left ventricular basal slice acquired before and after Gadolinium injection.

Results

Mean age was 47,5+\-23,3 years and 60% were male. ECV was higher in patients with MVP compared with controls (basal septum: 0.27 ± 0.04 vs 0.23 ± 0.03 p = 0.006; basal inferoposterior wall 0.28 ± 0.03 vs 0.23 ± 0.02 p = 0.003) and there was a significant correlation between MAD severity and ECV of the basal inferior wall (spearman rho 0.68, p < 0.0001) (Figure 1). Among MVP patients, ECV of the basal inferoposterior wall was higher in patients positive for LGE in the papillary muscles (ECV 0.31 ± 0.03 vs 0.27 ± 0.03 p 0,004).

Conclusion

In MVP patients, MAD severity was associated with a higher amount of interstitial fibrosis even in the absence of detectable macroscopic fibrosis in the papillary muscle region.

Abstract 1047 Figure 1

[Congenital heart disease: from childhood to adulthood]

With the improvement of congenital heart surgery, most children with congenital heart disease will survive into adulthood with a good quality of life. Regular cardiac follow-up is recommended for all patients. The adolescent period coincides often with medium and long term consequences and complications and repeat surgery or catheter interventions might be needed. It is therefore of prime importance to begin the transition process early and to pursue it well into adulthood. We have elaborated a formal transition program adapted to youngsters with congenital heart disease.

[Cardiac MR in development: the large multicenter CMR studies in 2012]

The results of several large multicenter CMR studies were reported in 2012, thus, constantly corroborating the evidence on CMR performance. In this review, we present results of the MR-IMPACT programme and the CE-MARC study, which demonstrated the superiority of perfusion-CMR over gated SPECT for the workup of suspected CAD, the currently available data from the European CMR registry, comprising almost 30,000 patients from 57 participating centers in 15 European countries, and finally, the results of the Advisa-MRI study, which documented the safety of a MRI-compatible pacemaker system. These large trials and others set the basis for the recommendations in the new European guidelines on heart failure to use CMR as a first line method if echocardiographic quality is inadequate or the etiology of heart failure is unclear.

[Adults with congenital heart diseases: a growing population, a multidisciplinary approach]

Untill recently, congenital heart disease was considered as a childhood's disease. With improvement in pediatric survival, adults with a congenital heart disease (ACHD) represent an emerging group of patients who need specialized medical care. In 2010, the ESC published newguidelines on global and specific management of adults with congenital heart disease. ACHD centers organize appropriate medical care for these patients, promote specialist training and national scientific research in collaboration with other national ACHD centers.

Acetylcholine release in human heart atrium: influence of muscarinic autoreceptors, diabetes, and age

BACKGROUND

An imbalance of sympathetic and parasympathetic drive to the heart is an important risk factor for cardiac death in patients with coronary heart disease, diabetes, and renal insufficiency. The amount of neurotransmitter released from peripheral autonomic nerves is modulated by presynaptic receptor systems. In analogy to alpha-autoreceptors on sympathetic nerves, muscarinic autoreceptors activated by endogenous acetylcholine may exist on parasympathetic nerves in the human heart.

METHODS AND RESULTS

We developed a technique to study acetylcholine release from human atria and investigated muscarinic autoreceptor function. A pharmacological and molecular approach was used to characterize the subtype involved. Of the 5 muscarinic receptor subtypes cloned, only mRNA encoding for M(2)- and M(3)-receptors were detected. Potencies of several muscarinic antagonists against the release-inhibiting effect of the nonselective muscarinic agonist carbachol at the cardiac autoreceptor were correlated with published data for human cloned M(1)- through M(5)-receptors.

CONCLUSIONS

This analysis clearly indicates that acetylcholine release in human atria is controlled by muscarinic M(2)-receptors. Blockade of these receptors by atropine doubles the amount of acetylcholine released at a stimulation frequency of 5 Hz. In atria of patients >70 years of age and patients with late diabetic complications, acetylcholine release is reduced. Locally impaired cardiac acetylcholine release may therefore represent a pathophysiological link to sudden cardiac death in elderly and diabetic patients.