Acquired Cardiovascular Diseases in Patients with Pulmonary Hypertension Due to Congenital Heart Disease: A Case Report.

Background: Advances in the diagnosis and treatment of congenital heart diseases (CHDs) have resulted in improved survival rates for CHD patients. Up to 90% of individuals with mild CHD and 40% with complex CHD now reach the age of 60. Previous studies have indicated an elevated risk of atherosclerotic cardiovascular disease (ASCVD) and associated risk factors, morbidity, and mortality in adults with congenital heart disease (ACHD). However, there were no comprehensive guidelines for the prevention and management of acquired cardiovascular diseases (CVDs) in ACHD populations until recently. Case presentation: A 55-year-old man with Eisenmenger syndrome and comorbidities (arterial hypertension, heart failure, dyslipidemia, hyperuricemia, and a history of pulmonary embolism (PE)) presented with progressive breathlessness. The electrocardiogram (ECG) revealed signs of right ventricle (RV) hypertrophy and overload, while echocardiography showed reduced RV function, RV overload, and severe pulmonary hypertension (PH) signs, and preserved left ventricle (LV) function. After ruling out a new PE episode, acute coronary syndrome (ACS) was diagnosed, and percutaneous intervention was performed within 24-48 h of admission. Conclusions: This case highlights the importance of increased awareness of acquired heart diseases in patients with pulmonary hypertension due to CHD.

The incremental value of myocardial viability, evaluated by 18F-fluorodeoxyglucose positron emission tomography, and cardiovascular magnetic resonance for mortality prediction in patients with previous myocardial infarction and symptomatic heart failure.

OBJECTIVES: To find the imaging mortality predictors in patients with previous myocardial infarction (MI), symptomatic heart failure (HF), and reduced left ventricle (LV) ejection fraction (EF). METHODS: for the study 39 patients were selected prospectively with prior MI, symptomatic HF, and LVEF ≤40%. All patients underwent transthoracic echocardiography (TTE), single-photon emission computed tomography myocardial perfusion imaging (SPECT MPI), 18F-FDG positron emission tomography (FDG PET). 31 patients underwent cardiovascular magnetic resonance (CMR) with late gadolinium enhancement (LGE). Patients were divided into two groups: 1 group - cardiac death; 2 group - no cardiac death. Myocardial scars were assessed on a 5-point-scale. Follow-up data was obtained. RESULTS: Imaging features disclosed significant difference (p < 0.05) of defect score (CMR and SPECT-PET), LV end-diastolic diameter (EDD) (TTE), LVEDD index (CMR), LV global longitudinal strain (CMR) and LV global circumferential strain (CMR) between the groups. Predictors of cardiac death were: LVEDD index (TTE) and LV global longitudinal strain. The cut-off values to predict cardiac death were: defect score (CMR) 25 (AUC, 79.5%; OR 1.8, 95% CI 1.2-2.7), SPECT-PET defect score 22 (AUC, 73.9%; OR 0.5, 95% CI 0.3-0.7), LVEDD (TTE) 58 mm (AUC, 88.4%; OR 23.6, 95% CI 2.6-217.7), LVEDDi 30 mm/m2 (TTE) (AUC, 73.6%; OR 22.0, 95% CI 1.9-251.5), LVEDDi 33.6 mm/m2 (CMR) (AUC, 73.6%; OR 22.0, 95% CI 1.9-251.5), LV global longitudinal strain -13.4 (AUC, 87.8%; OR 2.1, 95% CI 1.2-3.7) and LV global circumferential strain -16.3 (AUC, 76.1%; OR 1.9, 95% CI 1.2-3.0). CONCLUSIONS: Imaging features, such as defect score (CMR) >25, SPECT-PET defect score >22, LVEDD (TTE) >58 mm, LVEDDi (TTE) >30 mm/m2, LVEDDi (CMR) >33.6 mm/m2, LV global longitudinal strain -13.4 and LV global circumferential strain -16.3, may increase sensitivity and specificity of FDG PET and LGE CMR predicting of late mortality.

Instantaneous wave free ratio value impact on left internal mammary artery graft patency.

OBJECTIVES: To assess whether instantaneous wave - free ratio (iFR) value is associated with left internal mammary artery (LIMA) graft failure at 12 months follow-up post coronary artery bypass graft (CABG). BACKGROUND: Data suggests bypass to a non-significant left anterior descending artery (LAD) lesion due to visual over-estimation may lead to LIMA graft failure. Implementing iFR may result in better arterial graft patency. METHODS: In iCABG (iFR guided CABG) study patients planned to undergo an isolated CABG procedure was prospectively enrolled and iFR was performed for LAD. Coronary computed tomography angiography was performed at 2 and 12 months follow-up. The primary endpoint of this study was to determine the rate of LIMA graft occlusion or hypoperfusion at 2 and 12-months follow-up. We considered a composite secondary endpoint of Major adverse cardiovascular and cerebrovascular event (MACCE) as a secondary outcome. RESULTS: In total 69 patients were included with no differences regarding age, sex and risk factors. At 2 months, 50 of LIMAs with pre-CABG iFR median 0.855 (0.785 - 0.892) were patent. Hypoperfusion was found in 8 LIMAs (median iFR 0.88 (0.842 - 0.90)). While, 7 LIMAs (median iFR 0.91 (0.88 - 0.96)) were occluded (p = 0.04). At 12 months, when iFR of LAD was >0.85: just 12 (31.6% out of all patent LIMAS) grafts were patent and 24 (100.0% out of all hypoperfused/occluded) grafts were hypoperfused or occluded (p < 0.001). In terms of MACCE, no difference (p = 1.0) was found between all 3 groups divided according to iFR value. CONCLUSIONS: Instantaneous wave - free ratio value above 0.85 in LAD is a powerful tool predicting LIMA graft failure at 1-year follow up period.

A prospective observational study on impact of epinephrine administration route on acute myocardial infarction patients with cardiac arrest in the catheterization laboratory (iCPR study).

BACKGROUND: Epinephrine is routinely utilized in cardiac arrest; however, it is unclear if the route of administration affects outcomes in acute myocardial infarction patients with cardiac arrest. OBJECTIVES: To compare the efficacy of epinephrine administered via the peripheral intravenous (IV), central IV, and intracoronary (IC) routes. METHODS: Prospective two-center pilot cohort study of acute myocardial infarction patients who suffered cardiac arrest in the cardiac catheterization laboratory during percutaneous coronary intervention. We compared the outcomes of patients who received epinephrine via peripheral IV, central IV, or IC. RESULTS: 158 participants were enrolled, 48 (30.4%), 50 (31.6%), and 60 (38.0%) in the central IV, IC, and peripheral IV arms, respectively. Peripheral IV epinephrine administration route was associated with lower odds of achieving return of spontaneous circulation (ROSC, odds ratio = 0.14, 95% confidence interval = 0.05-0.36, p < 0.0001) compared with central IV and IC administration. (There was no difference between central IV and IC routes; p = 0.9343.) The odds of stent thrombosis were significantly higher with the IC route (IC vs. peripheral IV OR = 4.6, 95% CI = 1.5-14.3, p = 0.0094; IC vs. central IV OR = 6.0, 95% CI = 1.9-19.2, p = 0.0025). Post-ROSC neurologic outcomes were better for central IV and IC routes when compared with peripheral IV. CONCLUSION: Epinephrine administration via central IV and IC routes was associated with a higher rate of ROSC and better neurologic outcomes compared with peripheral IV administration. IC administration was associated with a higher risk of stent thrombosis. Trial registration This trial is registered at NCT05253937 .

Intraoperative angiography during coronary artery bypass grafting.

INTRODUCTION: The aim of this study was to evaluate the incidence rate of technical failure of graft patency while performing intra-operative angiography after coronary artery bypass grafting. METHODS: This prospective pilot study included 50 patients with multi-vessel coronary artery disease who underwent coronary artery bypass grafting, in addition to intra-operative angiographic graft assessments, on open-chest. Overall, 144 grafts and 160 distal anastomoses were assessed in a hybrid operating room. RESULTS: Intra-operative angiography allowed the identification of 23 angiographic defects (15.9% of all grafts) in 22 patients (44%): three graft defects (2% of all grafts), 17 anastomotic defects (10.6% of all distal anastomoses), and three target artery errors (1.8% of all grafted arteries). Ten re-interventions (43.4%) were performed based on the angiographic defects detected. During the follow-up period, computed tomography angiography of the attached grafts at a mean of 224 days (range, 80-318 days) showed that all repaired grafts were patent. During surgery, the total mean dose of radiation was 1.848 ± 0.54 mSv (range, 0.78-3.4 mSv) per patient and investigation time was 19.4 ± 4.94 minute (range, 9-31 minute). CONCLUSIONS: Intra-operative angiography is a powerful tool allowing the identification of graft defects, anastomotic defects and target vessel errors. Assuming relatively low level of exposure to radiation and short investigation time, intra-operative angiography could be included in routine practice as safe procedure improving surgery quality.

Changes of biventricular function after CABG surgery: does cardioplegia type matter?

AIM: we choose to evaluate, whether type of cardioplegia is an important predictor to determine biventricular function changes after CABG. METHODS: 81 patients who underwent CABG surgery and matched inclusion criteria were enrolled in this study. The exclusion criteria were acute MI within 30 days, impaired systolic left ventricle function (LVEF ⩽35%), atrial fibrillation.TTE was performed for all patients and echocardiographic parameters of biventricular geometry and function were assessed before CABG surgery, first postoperative day and 6 months after surgery. Cardioplegia type was randomly chosen. First group consisted of 49 patients (60.5%) when CC was performed and the others 32 patients (39.5%) formed the second - BC group. RESULTS: Patients' demographic characteristics were similar in both groups, except the lower rates of AH and BSA in BC group (p = 0.015, p = 0.001 respectively). Longer duration of XCT and CBP time was observed in BC group (p = 0.019 and p = 0.028). BC group patients showed more efficient right heart chambers size reduction (p = 0.001 for RV diameter; p = 0.015 for RA diameter) and better improvement of longitudinal RV function (p = 0.02 for TAPSE; p = 0.001 for RV S') 6 months after surgery when compared with CC group patients. RV global systolic function diminished in both groups postoperatively, but the reduction was higher in CC group, although the difference was significant in comparing early postoperative measurements with the late after CABG surgery (p = 0.03). Changes of LV systolic function as well as diameter of LA did not differ between groups (p = 0.165 and p = 0.279, respectively), while diastolic function improved significantly in BC group patients at the late follow-up period: E/e' decreased (p < 0.001) and e' velocity of interventricular septum augmented significantly (p < 0.001). CONCLUSION: BC is associated with better RV reverse remodelling and improvement of longitudinal RV function, as well as LV diastolic function improvement after CABG surgery.

Correlation between Preoperative Coronary Artery Stenosis Severity Measured by Instantaneous Wave-Free Ratio and Intraoperative Transit Time Flow Measurement of Attached Grafts.

Background and Objectives: To assess the correlation between the degree of target coronary artery stenosis measured by instantaneous wave-free ratio (iFR) and the intraoperative transit time flow measurement (TTFM) of attached grafts as well as evaluate flow competition between the native coronary artery and the attached graft according to the severity of stenosis. Materials and Methods: In total, 89 grafts were subjected to intraoperative transit time flow measurement after coronary artery bypass grafting (CABG) in 25 patients with multivessel coronary artery disease (CAD). The iFR was evaluated for all coronary arteries with grafts. The coronary artery stenoses were divided into three groups based on the iFR value: iFR < 0.86 (group 1); iFR 0.86-0.90 (group 2); and iFR > 0.90 (group 3). Results: The mean graft flow (MGF) was 46.9 ± 18.4 mL/min for group 1, 45.3 ± 20.9 mL/min for group 2, and 31.3 ± 18.5 mL/min for group 3. A statistically significant difference was confirmed between groups 1 and 3 (p = 0.002) and between groups 2 and 3 (p = 0.025). The pulsatility index (PI) was 2.49 ± 1.20 for group 1, 2.66 ± 2.13 for group 2, and 4.70 ± 3.66 for group 3. A statistically significant difference was found between groups 1 and 3 (p = 0.006) and between groups 2 and 3 (p = 0.032). Backward flow was detected in 7.5% of grafts for group 1, in 16.6% of grafts for group 2, and in 16% of grafts for group 3. A statistically significant difference was found between groups 1 and 2 (p = 0.025) and between groups 1 and 3 (p = 0.029). Conclusions: The iFR is a useful tool for predicting the impact of competitive flow observed between a native artery and an attached graft. The effect of competitive flow significantly increases when the graft is attached to a vessel with mild coronary stenosis. In a coronary artery where the iFR was not hemodynamically significant, the MGF was lower, the PI was higher, and a larger proportion of grafts with backward flow (BF) was detected compared to when there was significant stenosis (iFR < 0.86).

Early and long-term results of aortic valve sparing aortic root reimplantation surgery for bicuspid and tricuspid aortic valves.

INTRODUCTION: To evaluate early and long-term clinical outcomes following aortic valve sparing aortic root reimplantation surgery in patients with leaking bicuspid and tricuspid aortic valves. METHODS: The study consisted of 92 consecutive adult patients (tricuspid aortic valve group = 63 and bicuspid aortic valve group = 29) who underwent aortic valve sparing aortic root reimplantation surgery with or without aortic cusp repair for dilatation of the aortic root and/or aortic valve regurgitation at our institution from April 2004 to October 2016. Clinical outcomes were investigated using Kaplan-Meier and log-rank tests between groups. RESULTS: The follow-up was 100% complete with a mean time of 5.3 ± 3.3 years. The 30-day in-hospital mortality was 3.1% in tricuspid aortic valve group and 3.4% in bicuspid aortic valve group patients. The overall survival rates at 10 years did not differ between bicuspid aortic valve and tricuspid aortic valve patient groups (96.6 ± 3.3% vs. 90.3 ± 4.2%, p = 0.3). Freedom from recurrent aortic valve regurgitation (>2+) at 10 years was 90.5 ± 4.1% in tricuspid aortic valve group and 75.7 ± 8.7% in bicuspid aortic valve group (p = 0.06). Freedom from aortic valve reoperation at 10 years was 100% in tricuspid aortic valve group and 83.9 ± 7.4% in bicuspid aortic valve group (p = 0.002). CONCLUSION: Aortic valve sparing aortic root reimplantation surgery is a safe and efficient technique, providing acceptable long-term survival with low rates of valve-related complications in both tricuspid aortic valve and bicuspid aortic valve patient groups. However, aortic valve reoperation rates at 10 years follow-up were higher in bicuspid aortic valve group patients compared to tricuspid aortic valve group patients.

Changes in right ventricular longitudinal function: primary mitral and concomitant tricuspid valve repair.

OBJECTIVES: To evaluate the impact of concomitant tricuspid valve (TV) repair on the right ventricular (RV) function postoperatively and within the 6 months following degenerative mitral valve (MV) repair. METHODS: The prospective study included 37 patients (mean age 57.32 ± 2.13 years) with severe MV regurgitation due to primary MV prolapse. Nineteen underwent successful MV repair (TV(-) group). Additional TV repair due to moderate-to-severe TV regurgitation was performed in 18 (TV(+) group). Two-dimensional (2D) speckle-tracking and tissue Doppler echocardiography was performed for all patients before surgery and 7 days and 6 months after surgery. RESULTS: Preoperative dimensions and indices of RV longitudinal function did not differ between the groups (right ventricle end-diastolic diameter (RVEDD) was 33.53 ± 0.94 mm vs. 34.67 ± 1.72 mm, tricuspid annular systolic motion (S') was 15.06 ± 0.85 cm/s vs. 16.0 ± 1.27 cm/s, tricuspid annular plane systolic excursion (TAPSE) was 24.02 ± 1.06 mm vs. 22.4 ± 1.36 mm, respectively; p>0.05). RVEDD decreased significantly and did not change within the follow-up in the TV(-) group. In the TV(+) group, RVEDD decreased early after surgery and more markedly six months later in comparison to the TV(-) group. Indices of RV systolic longitudinal function decreased early after surgery and had a tendency to increase after six months in both groups. Regional longitudinal strains of the lateral RV wall decreased early after surgery and improved within the six months in the TV(-) group and did not change significantly in the TV(+) group. CONCLUSIONS: Additional TV repair in degenerative MV repair more markedly reduces RV dimensions and does not have a negative impact on RV systolic function in comparison to an isolated MV repair although these conclusions are of limited value due to the lack of a control group.

Takotsubo cardiomyopathy: the challenging diagnosis in clinical routine.

Takotsubo cardiomyopathy is rapidly reversible heart failure syndrome that usually mimics the symptoms of acute myocardial infarction with the characteristic regional wall-motion abnormalities (classically with a virtual apical ballooning caused by hypokinetic or akinetic apical or midventricular myocardium and hypercontraction of the basal segments) and absence of obstructive coronary artery disease. TC is usually associated with identifiable emotional, psychological or physical stress event and most commonly appears in postmenopausal women. The certain pathophysiological mechanism remains unknown. However, the central hypothesis is supported by the excess of catecholamines and hyperactivity of nervous system. In the last decades the frequency of the TC diagnosis is increasing rapidly but at the initial presentation the diagnosis remains challenging due to the close similarities between TC and ST elevation myocardial infarction clinical presentations that consider TC as an important part of differential diagnosis in acute coronary syndrome.

Determinants of reduced tricuspid annular plane systolic excursion in patients with severe systolic left ventricular dysfunction.

OBJECTIVE: Right ventricular (RV) dysfunction is associated with poor exercise tolerance and prognosis, regardless of left ventricular (LV) function. Tricuspid annular plane systolic excursion (TAPSE) is a non-invasive parameter of RV longitudinal function which can predict outcome in heart failure (HF) patients (pts). Our aim was to investigate the relation of TAPSE to clinical and echocardiographic parameters in severe LV dysfunction. METHODS AND RESULTS: The study included 119 pts with non-ischaemic dilated cardiomyopathy (n = 46) and ischaemic heart disease (n = 73) in stable HF with severe LV systolic dysfunction (LV ejection fraction (EF) < 30%). In pts with different LV dysfunction severity the higher NYHA class correlated with lower TAPSE dimensions: NYHA class IV 12.7 +/- 2.9 mm vs. NYHA class III 15.9 +/- 4.2 mm and NYHA class II 18.8 +/- 4.2 mm, P < 0.001. The presence of atrial arrhythmias in 16% of pts was related to lower values of TAPSE (12.9 +/- 3.6 mm vs. 15.4 +/- 4.2 mm, P < 0.05). Pts with non-ischaemic HF aetiology were found to have lower values of TAPSE compared to ischaemic aetiology (12.5 +/- 2.8 mm vs. 16.6 +/- 4.1 mm, P = 0.001) and increased odds of low TAPSE (< or = 14 mm)--odds ratio (OR) [95% confidence interval] = 9.8 [3.8-25.6], P < 0.001. Multivariate analysis revealed that LVEF, deceleration time (DT) of early mitral inflow E wave and the RV end-diastolic diameter are independent determinants of reduced TAPSE (< or = 14 mm) in pts with severe LV systolic dysfunction. CONCLUSION: The lower TAPSE values are related to higher NYHA functional class, presence of atrial arrhythmias and non-ischaemic aetiology in HF pts. The LVEF, DT of LV filling and RV end-diastolic diameter are independent predictors of reduced TAPSE (< or = 14 mm) in pts with severe systolic LV dysfunction.