Agnes Pasquet

Prognostic Value of Myocardial Ischemia and Viability in Patients With Chronic Left Ventricular Ischemic Dysfunction

BACKGROUNDnPrevious studies showed that thallium scintigraphy and dobutamine echocardiography were accurate, noninvasive ways of predicting contractile recovery after revascularization in patients with left ventricular (LV) dysfunction. However, the prognostic impact of such methods remains uncertain.nnnMETHODS AND RESULTSnWe prospectively studied 137 consecutive patients with coronary disease and LV dysfunction who underwent exercise-redistribution-reinjection thallium scintigraphy and dobutamine echocardiography to identify myocardial ischemia and viability. A total of 94 patients subsequently underwent revascularization, and 43 underwent medical treatment. The primary endpoint was cardiac mortality, and mean follow-up was 33+/-10 months. Twenty-four patients died of cardiac causes. By Coxs regression analysis, long-term survival was related to the extent of coronary disease, the presence of diabetes, type of treatment, the presence of ischemic myocardium as determined by thallium scintigraphy, and the presence of viable myocardium as determined by both tests. Three-year survival was greater in patients with ischemic myocardium (as determined by thallium scintigraphy) or viable myocardium (as determined by both tests) who underwent revascularization than in the other groups (P=0.018 with thallium; P<0.001 with dobutamine). Subgroup analyses indicated that among patients with 1- or 2-vessel disease, only those with ischemic or viable myocardium improved survival after revascularization, whereas in patients with 3-vessel or left main diseases, revascularization always improved survival, albeit more in the presence of ischemic or viable myocardium.nnnCONCLUSIONSnAmong the parameters commonly available in patients with LV ischemic dysfunction, the presence of ischemic myocardium (as determined by thallium scintigraphy) and that of viable myocardium (as determined by dobutamine echocardiography) are independent predictors of subsequent mortality. These observations may be useful in the preoperative selection of patients for revascularization.

Iron deficiency is associated with adverse outcome in Eisenmenger patients.

AIMSnIron deficiency is common in patients with Eisenmenger syndrome (ES). This study aimed at evaluating (i) whether iron deficiency is related with adverse outcome, (ii) the determinants of iron deficiency, and (iii) the relation between iron reserves and haemoglobin level in a contemporary cohort of ES patients.nnnMETHODS AND RESULTSnAll ES patients, older than 18 years, selected from the Belgian Eisenmenger registry, were prospectively followed using a web-based registry. Univariate Cox-regression analysis was performed to evaluate the relation with outcome, defined as all-cause mortality, transplantation, and hospitalisation due to cardiopulmonary causes. Bivariate analysis was performed where applicable. A total of 68 patients with a complete dataset (mean age 36.9 ± 14.2 years; 30.9% male) were included. During a median follow-up time of 3.1 years, 21 patients (30.9%) reached the predefined endpoint. New York Heart Association (NYHA) class ≥ III (HR 4.76; 95% CI 1.84-12.30; P = 0.001), iron deficiency (HR 5.29; 95% CI 2.04-13.76; P = 0.001), mean corpuscular volume (MCV) (HR 0.94; 95% CI 0.90-0.99; P = 0.021), and mean corpuscular haemoglobin (MCH) (HR 0.87; 95% CI 0.76-0.98; P = 0.027) were related with adverse outcome. The use of oral anticoagulation and frequent phlebotomies were independently related with iron deficiency (P = 0.005 and P = 0.008). In iron-deplete patients, MCV (R = -0.408; P= 0.014) and MCH (R = -0.437; P = 0.026) were inversely related with haematocrit. In patients with low oxygen saturation, iron reserves were related with haemoglobin levels (R = 0.587; P = 0.001).nnnCONCLUSIONSnIron deficiency was associated with a higher risk of adverse outcome. Moreover, the use of oral anticoagulation OAC and frequent phlebotomies were related to iron deficiency. Patients under anticoagulation should be monitored rigorously for iron deficiency. However, in patients with low oxygen saturations, careful iron substitution to avoid too high haemoglobin levels is suggested.

Relation of ultrasonic tissue characterization with integrated backscatter to contractile reserve in chronic left ventricular ischemic dysfunction.

Previous studies have shown that viable but stunned myocardium displays contractile reserve and exhibits cardiac cycle-dependent variations of integrated backscatter, whereas infarcted myocardium does not. The present study was designed to evaluate whether integrated backscatter imaging could be useful in identifying segments with recruitable inotropic reserve in patients with chronic left ventricular (LV) ischemic dysfunction. We studied 15 patients (mean age 59 +/- 10 years) with chronic coronary artery disease, anterior or inferior wall dysfunction, and depressed LV ejection fraction (35 +/- 12%), and 6 noncardiac control subjects (mean age 49 +/- 18 years). Cardiac cycle-dependent variations of integrated backscatter were measured in anterior and inferior segments during transesophageal echocardiography and compared with the contractile response (% wall thickening) of these segments to low doses of dobutamine (5 to 10 microg/kg/min). The average magnitude of cardiac cycle-dependent variations of integrated backscatter was greater among normally contracting segments of both patients and controls (5.67 +/- 0.88 and 5.64 +/- 2.26 dB, respectively, p = NS) than among dysfunctional segments (2.77 +/- 3.05 dB, p <0.01 vs control and remote segments). Dysfunctional segments were further categorized into those with and without dobutamine-induced contractile reserve. At baseline, systolic wall thickening was similar among segments responding to dobutamine than among those that did not (3.6 +/- 2.3% vs 2.9 +/- 1.6%, p = NS). During dobutamine, systolic wall thickening increased only in segments showing improvement in wall motion score (to 24.5 +/- 4.7%), whereas it remained unchanged in segments not responding to dobutamine (to 2.0 +/- 3.7%, p <0.01). The magnitude of resting cardiac cycle-dependent variations of integrated backscatter was larger in segments responding to dobutamine than in those with persistent dysfunction (5.31 +/- 2.06 vs 0.23 +/- 0.94 dB, p <0.01) and correlated significantly (r = 0.74, p <0.01) with systolic wall thickening during dobutamine. Our data demonstrate that resting cardiac cycle-dependent variations of integrated backscatter closely parallel contractile reserve in patients with chronic LV ischemic dysfunction. This suggests that tissue characterization with integrated backscatter could be a useful adjunct to the delineation of myocardial viability in these patients.

The Belgian Eisenmenger syndrome registry : implications for treatment strategies?

Objective — Pulmonary arterial hypertension (PAH), associated with congenital heart disease (CHD), usually results from a systemic-to-pulmonary shunt. Eisenmenger syndrome (ES) is characterised by severe irreversible PAH and reversal of a previous systemic-to-pulmonary shunt.A national registry of ES patients was initiated to optimise patient care and to provide epidemiological information regarding PAH and CHD in Belgium. Methods — All ES patients, older than 18 years, were selected through the local databases of ten centres in Belgium.After written informed consent, demographic, clinical, biochemical, technical, and treatment data were entered into the web-based registry. Results — Ninety-one patients were included in the registry. Mean age was 36 ± 11 years (range 18-59 years). Complete atrioventricular septal defect (N = 26, 28.6%), followed by ventricular septal defect (N = 25, 27.5%) were the commonest defects. Forty-five percent were patients with Down syndrome. Down patients were younger (32 ± 9 versus 40 ± 12 years;P = 0.039), had worse functional capacity (class II/III ratio: 15/16 versus 21/8; P = 0.035) and received significantly less specific PAH treatment (7% versus 38%;P = 0.002). Conclusion — Through the national Eisenmenger registry, 91 adult patients with ES were identified (estimated prevalence 11 per million inhabitants). Almost half of them were Down patients. Although having worse functional capacity, significantly less Down patients were receiving specific PAH treatment.

A different view on predictors of pulmonary hypertension in secundum atrial septal defect

BACKGROUND/OBJECTIVESnPulmonary arterial hypertension is an important complication in hemodynamically relevant atrial septal defects (ASD) and negatively affects outcome. This retrospective study aimed at (1) estimating the prevalence of pulmonary hypertension (PH) in patients with secundum ASD and (2) identifying predictors of PH development or persistence after ASD closure.nnnMETHODSnConsecutive patients with an isolated secundum ASD from the Belgian Registry on Adult Congenital Heart Disease were studied. Demographic, clinical, echocardiographic and invasive hemodynamic measurements were analyzed. PH was defined upon the echocardiographic PH probability (tricuspid regurgitation velocity≥2.9 m/s).nnnRESULTSnPH prevalence in the entire ASD population (295 patients, 68.8% females, mean age 46±21 years) was 15.9% compared to 13.3% in patients after ASD closure. PH after ASD closure was significantly related to mortality (p=0.001), atrial arrhythmia (p<0.001) and right heart failure (p=0.019). Age at repair was the most important predictor for PH (HR 1.11). In the highest tertile of age at repair (>55 years), PH prevalence was the highest (34%) and mean pulmonary artery pressure (mPAP) at catheterization before was related to PH after closure (HR 1.09). Twenty patients in the PH group had mPAP<25 mmHg before closure.nnnCONCLUSIONSnPH in closed secundum ASD patients is not uncommon. Its prevalence was the highest when the defect was repaired above 55 years of age. Clinical outcome was worse. PH may even develop despite normal mPAP before closure. The present findings raise the question whether the cutoff value for mPAP before closure should be age-adjusted.

Right Ventricular Function in Patients With Eisenmenger Syndrome

To evaluate (1) whether right ventricular (RV) dysfunction, evaluated using tricuspid annular plane systolic excursion (TAPSE) is associated with a worse outcome in patients with the Eisenmenger syndrome, (2) which variables are related to RV dysfunction, and (3) whether differences exist among simple pretricuspid, simple post-tricuspid, and combined shunt lesions. Patients with Eisenmenger syndrome, aged >18 years, who underwent echocardiography, were selected from the Belgian Eisenmenger registry and prospectively followed up using a Web-based registry. Cox regression analysis was performed to evaluate the relation to outcomes, defined as all-cause mortality, transplantation, and hospitalization for cardiopulmonary causes. Comparative and bivariate analysis was performed, where applicable. A total of 58 patients (mean age 35.1 ± 13.2 years, 32.8% men) were included. During a mean follow-up of 3.2 years, 22 patients (37.9%) reached the predefined end point. Only TAPSE (hazard ratio 0.820, 95% confidence interval 0.708 to 0.950; p = 0.008) was related to the adverse outcomes on multivariate analysis. Patients with pretricuspid shunt lesions were older (p <0.0001) had greater left (p <0.0001) and right atrial (p <0.0001) dimensions, greater RV dimensions (p = 0.002), and more tricuspid regurgitation (p = 0.012) compared to patients with post-tricuspid lesions. Lower TAPSE was related to the presence of pulmonary artery thrombosis (R = -0.378; p = 0.006). In conclusion, in patients with Eisenmenger syndrome, RV dysfunction, evaluated using TAPSE, is related to worse outcomes. Patients with Eisenmenger syndrome with pretricuspid shunt lesions were older and had greater left atrial, right atrial, and RV dimensions compared to patients with post-tricuspid lesions, indicating a difference in the RV response. Lower TAPSE was associated with the presence of pulmonary artery thrombosis.

Worsening in oxygen saturation and exercise capacity predict adverse outcome in patients with Eisenmenger syndrome

OBJECTIVESnTo evaluate (1) changes in clinical, biochemical and echocardiographic parameters, (2) whether deterioration in exercise capacity and resting oxygen saturation (SatO2-rest) are related with adverse outcome and (3) its additional value in predicting outcome in Eisenmenger patients.nnnMETHODSnSeventy-seven (36 ± 14 years, 30% male) patients were included and prospectively followed. Changes between baseline and final visit were evaluated. Clinical deterioration was defined as a deterioration in exercise capacity or SatO2-rest. Univariate and multivariate analyses were performed to evaluate predictors of outcome defined as the need for hospitalization due to right heart failure, transplantation, or all-cause mortality. Finally, the additional prognostic value of deterioration in exercise capacity and SatO2-rest was evaluated.nnnRESULTSnDuring a mean follow-up period of 4.0 ± 2.1 years, 27 (35%) events occurred. Patients in the event-group presented with an deterioration in NYHA class (P<0.0001), 6 minute walk distance (P=0.006) and SatO2-rest (P<0.0001). After adjustment for baseline variables, multivariate Cox regression analysis indicated that clinical deterioration was independently associated with adverse outcome.nnnCONCLUSIONSnClinical deterioration, defined as a deterioration in exercise capacity or SatO2-rest was associated with adverse outcome in Eisenmenger patients. Moreover, these parameters provided additional information on which patients would develop an event and may benefit from initiation or escalation of disease targeting therapy.

The importance of pulmonary artery pressures on late atrial arrhythmia in transcatheter and surgically closed ASD type secundum

AIMSnAtrial fibrillation and flutter remain an important cause of morbidity in adults with atrial septal defect (ASD). This study aimed at investigating predictors for late (≥ 1 month after repair) atrial arrhythmia.nnnMETHODSnPatients who underwent ASD closure after the age of 18 years, were selected through the databases of three medical centres in Belgium. Preprocedural, periprocedural and follow-up data were extracted. Univariate and multivariate Cox-regression analysis was performed. Kaplan-Meier analysis was performed for any independent predictor of late atrial arrhythmia.nnnRESULTSnA total of 155 patients (38 men and 117 women) was included. Twenty-four patients (median age 48.3 years, range 19.9-79.8) underwent surgical and 131 (median age 57.6 years, range 18.2-86.9) underwent transcatheter closure. Thirty-nine patients (25.2%) presented with late atrial arrhythmia. Male gender (P = 0.008), creatinine (P = 0.002), atrial arrhythmia before (P < 0.0001) and within 1 month after repair (P = 0.001) and a mean pulmonary artery pressure (mPAP) ≥ 25 mmHg (P < 0.0001) correlated with late atrial arrhythmia in univariate Cox-regression analysis. Multivariate analysis showed that mPAP ≥ 25 mm Hg (HR 3.72; 95%CI 1.82-7.59; P < 0.0001) and the presence of atrial arrhythmia before (HR 3.22; 95%CI 1.56-6.66; P = 0.002) and within 1 month after repair (HR 2.08; 95%CI 2.08-15.92; P = 0.001) were predictive of late atrial arrhythmia. Kaplan-Meier analysis showed that patients with a mPAP ≥ 25 mm Hg had a higher risk at developing late atrial arrhythmia (P < 0.0001).nnnCONCLUSIONnIn patients with ASD type secundum, a mPAP ≥ 25 mmHg is an independent predictor of late atrial arrhythmia. The presence of pulmonary hypertension before repair should raise awareness for atrial arrhythmias and may be used to guide therapy.

Practical recommendations on the use of echocardiography to assess pulmonary arterial hypertension--a Belgian expert consensus endorsed by the Working Group on Non-Invasive Cardiac Imaging.

Pulmonary hypertension (PH) is defined by a sustained increase in mean pulmonary arterial pressure > 25 mmHg. Due to its widespread availability, echocardiography (ECHO) is used as the first-line imaging modality to detect pulmonary PH and assess right ventricular (RV) function in daily routine. As such, ECHO is the key examination to detect the presence of PH, to provide valuable prognostic information and to give an orientation to therapeutic strategies. In addition to detection and screening, ECHO also provides clues for the differential diagnosis of PH. The present document, based on a consensus of experts, provides practical recommendations for the use of ECHO in the evaluation of PH and of its consequences on the right ventricle.

Predictive model for late atrial arrhythmia after closure of an atrial septal defect

OBJECTIVESnTo develop a quantitative event-free prediction model of late atrial arrhythmia after atrial septal defect (ASD) repair.nnnBACKGROUNDnThe clinical management of ASD is driven by risk factors that determine the occurrence of late atrial arrhythmia.nnnMETHODSnData from ASD type secundum patients, included in the Belgian Congenital Heart Disease Registry, were analyzed. Based on review of the literature, age at repair, gender, pulmonary hypertension, atrial arrhythmia before and within one month after repair were included in the model. Using Cox-regression analysis, a weighted risk score was derived, which was validated using the Brier score.nnnRESULTSnA total of 155 patients (117 women; median age at follow-up 53.9 years, range 18.0-78.8) having 349 follow-up years was included. Thirty-nine patients (25.2%) presented with late atrial arrhythmia. Multivariate analysis showed that a mPAP ≥ 25 mmHg (HR 4.39; 95%CI 2.17-9.09; P<0.0001), the presence of atrial arrhythmia before (HR 3.52; 95%CI 1.75-7.14; P=0.002) and ≤ 1month after repair (HR 6.62; 95%CI 2.38-20.00; P<0.0001) and gender (HR 2.18 95%CI 1.11-4.35) were associated with late atrial arrhythmia. A risk score (0 to 28 points) to predict atrial arrhythmia free survival was derived for follow-up times ranging from one to 5 years. Mean Brier score for the model was 0.10.nnnCONCLUSIONSnWe formulated a well validated risk model to predict arrhythmia-free survival in ASD patients undergoing ASD repair. Further research is needed whether this model can be used for individual clinical risk stratification and whether the model can be adapted for application in other congenital heart defects.