Improved Surgical Outcomes in Adults with Congenital Heart Disease and Decompensated Heart Failure: The Role of Perioperative Medical Optimization

BACKGROUND Decompensated heart failure (HF) is recognized as a significant prognostic factor for unfavorable outcomes in both the general population and adults with congenital heart diseases (ACHD). Among ACHD patients, those with advanced heart failure may be candidates for heart transplantation. However, in ACHD patients requiring heart surgery, even with reduced ejection fraction, the administration of appropriate medications can result in improved circulatory parameters, functional class, and surgical outcomes. CASE REPORT We present 5 patients who exhibited indications for open-heart surgery, advanced heart failure (HF) accompanied by congestion, and significant physical activity limitations or symptoms at rest (NYHA class III-IV). Among the patients, 40% were male, with a mean age of 47.4 years (ranging from 32 to 62 years). Three patients displayed reduced systemic ventricular ejection fraction, while 4 patients experienced arrhythmia. Congenital heart diseases (CHD) observed in the patients included repaired double-outlet right ventricle, congenitally corrected transposition of the great arteries, repaired tetralogy of Fallot, partial anomalous right pulmonary venous return, and atrial septal defect. Comprehensive heart failure medications were administered, including an angiotensin receptor neprilysin inhibitor, levosimendan, beta-blockers, phosphocreatine, and diuretics. The preoperative period ranged from 8 days to 2 months. Notably, significant clinical and hemodynamic improvements were observed in all cases, and all open-heart surgeries were successfully completed. CONCLUSIONS Advanced and decompensated HF has a high impact on surgical outcomes. Preoperative care with prescribed medical management for ACHD patients is possible and provides good early and mid-term postoperative results.

the impact of overweight and obesity on the development of systolic and diastolic myocardial dysfunction in patients with type 2 diabetes mellitus

Funding Acknowledgements

Type of funding sources: None.

OnBehalf

I.M. Sechenov First Moscow State Medical University

Background

Obesity and type 2 diabetes mellitus (DM) promote the development of systolic and diastolic myocardial dysfunction. The method of equilibrium radionuclide ventriculography (ERVG) can be used to estimate these dysfunctions.

Purpose

We conducted a comparative ERVG evidence-based analysis in patients with type 2 diabetes mellitus and varying degree of overweight. We analyzed the correlation between body mass index (BMI) and ERVG data.

Methods

The study included 42 patients (8 male and 34 female): group 1 – 12 patients with BMI 25.0-29.9 kg / m2, group 2 – 16 patients with BMI 30.0-34.9 kg / m2, group 3 – 14 patients with BMI 35.0-39.9 kg / m2. The average duration of type 2 diabetes mellitus was 11 ± 3.8 years. The average age of patients in each group was 65.8 ± 5 y.o., 57.7 ± 6 y.o., 64.6 ± 8 y.o. respectively. The groups were comparable in duration of type 2 diabetes mellitus, level of glycated hemoglobin, presence and severity of combined pathology. The patients with postinfarction cardiosclerosis and decompensated heart failure were excluded. The following ERVG indices of left ventricle (LV) and right ventricle (RV) were examined: systolic function – ejection fraction (EF), peak (PER) and average (AER) ejection rates, ejection within 1/3 of systole (ejec.1/3 s.), end-systolic volume (ESV), stroke volume (SV), diastolic function – peak filling rate (PFR), filling within 1/3 diastole (fil. 1/3 d.), end-diastolic volume (EDV).

Results

the EF of the LV in all examined patients was more than 40%. In group 2 we discovered an increase in the EDV and ESV indices of the LV, ESV of the RV compared to group 1 (123.8 ± 23.6 ml, 52.4 ± 14.5 ml, 66.3 ± 21.6 ml - in group 2 and 96.5 ± 22.7 ml, 37.9 ± 10.7 ml, 50.2 ± 16.7 ml - in group 1, respectively, p <0.05). SV of the LV in group 3 was considerably larger compared to group 1 (76.4 ± 17.8 ml vs 59.1 ± 15.6 ml, p <0.05). In all groups fil. 1/3 d. for LV and RV was below normal equal to 50% of EF. The correlation analysis revealed a negative association between fil. 1/3 d. of the RV and BMI (r = -0.46, p <0.05) in group 1.

Conclusions

As long as BMI increases in patients with type 2 diabetes mellitus, there is a significant increase in the ESV of both ventricles and EDV of the LV. The most sensitive ERVG indices during the obesity progression are ESV, EDV, and filling within 1/3 diastole. The revealed diastolic dysfunctions in absence of a significant decrease in EF are a manifestation of a myocardial stiffness. Early diagnosis of these disorders and correction of treatment can improve the prognosis of patients with type 2 diabetes mellitus and varying degree of overweight.

TRANSFORMING GROWTH FACTOR AND ARTERIAL STIFFNESS IN PATIENTS WITH UNCONTROLLED ARTERIAL HYPERTENSION

The aim of our study was to identify the relationship between TGF-β1, arterial stiffness, and target organ damage in patients with uncontrolled arterial hypertension (UAH). The study included 140 patients with hypertension: 30 people with uncontrolled hypertension (UAH), 80 people with controlled hypertension (CAH) and 30 people in the control group. All patients underwent determination of arterial stiffness using cardio-ankle vascular index (CAVI) and TGF-β1 level. The TGF-β1 level was 19,2 [17,2; 24,7] ng/ml in the CAH group. In the UAH group - 22,6 [20,6; 25,6] ng/ml. In the control group - 17.4 [11,8; 19,3] ng/ml. The maximum and minimum values of the CAVI indices were observed in the group UAH 9,2 [8,5; 9,9] and control group 7 [6,5; 7,5], respectively (p<0,05), in the CAH group there was an intermediate value of the CAVI index 7.8 [7,0; 8,5] (p<0,05). The correlation analysis revealed a significant relationship between the TGF-β1 level and CAVI for patients with hypertension (CAG r=0,777; NAG r=0,753; p<0.05). There was a significant difference in the TGF-β1 levels depending on the stage of hypertension in patients CAH (p <0,05). According to the results of the one-way regression analysis, it was revealed that in hypertensive patients with a TGF-β1 value, the most significant interactions are between myocardial mass (MM) (p<0,05), CAVI (p<0,05) and creatinine (p<0,05). An increase in the concentration of TGF-β1 and an increase of arterial stiffness were revealed in patients of the UAH group in comparison with the other groups. The relationship between TGF-β1 and arterial stiffness was also found.

VASCULAR AGE AND CARDIO-ANKLE VASCULAR INDEX IN PATIENTS WITH UNCONTROLLED ARTERIAL HYPERTENSON

Age is used in various algorithms to estimate cardiovascular risk. It is known that at the same age the health status of different patients can differ dramatically. The term vascular age (VA) was introduced in order to assess the severity of pathological process in the arterial wall. Arterial stiffness is most commonly used to estimate VA. The aim of our study was to investigate the arterial stiffness, VA in patients with uncontrolled and controlled course of arterial hypertension (AH), as well as to study the relationship between age, VA and markers of hypertension - mediated organ damage (HMOD). We put in our study 140 patients, including 80 patients with controlled course of hypertension (CH), 30 patients with uncontrolled course of hypertension (UH). 30 patients made up the control group. All groups were similar regarding age, sex, duration of hypertension and some biochemical characteristics. For all patients in our study the arterial stiffness, by means of cardio-ankle vascular index (CAVI), and VA were investigated, as well as the relationship between age, VA and markers of hypertension - mediated organ damage (HMOD) was studied. The average CAVI value in the CH group was 7,8±1,19, in the UH = 9,2+1,14, in the control group 7±0,64. The difference in CAVI values among all groups was significant (p<0,05). A positive correlation between CAVI and IMT, age and a negative correlation between CAVI and GFR was found in all three groups (p<0.05). A correlation was also found between CAVI and average daytime PBP (CH r=0.311; UH r=0, 484; p<0.05) and average night-time PBP (CH r=0.374, UN r=0.306, p<0.05) and with average night-time SBP in the group UH (r=0.349; p<0.05). VA (CH= 59[49;69], UH=71,5 [64;74], control group =54[44; 59] (p<0,05)) was significantly higher than the age of patients in the patients with AH, while in the control group no significant difference between ages was found. Significant positive correlation was found between VA and such markers of HMOD as IMT, ESV, GFR, LVPW thickness, IVS thickness. When VA was used instead of age, it was found that third of patients in CH and UH groups moved to the group of higher risk of cardiovascular (CV) events. The absence of antihypertensive therapy and target blood pressure values in patients lead to the progression of arterial stiffness and acceleration of VA in comparison to patients committed to the therapy. Use of VA in assessing the risk of CV events allows us to identify up to 30% of patients with an underestimated risk level.