Alexandra Frogoudaki

Transvenous Pacing Leads and Systemic Thromboemboli in Patients With Intracardiac Shunts. A Multicenter Study

Background— The risk of systemic thromboemboli associated with transvenous leads in the presence of an intracardiac shunt is currently unknown. Methods and Results— To define this risk, we conducted a multicenter, retrospective cohort study of 202 patients with intracardiac shunts: Sixty-four had transvenous leads (group 1), 56 had epicardial leads (group 2), and 82 had right-to-left shunts but no pacemaker or implantable cardioverter defibrillator leads (group 3). Patient-years were accrued until the occurrence of systemic thromboemboli or study termination. Censoring occurred in the event of complete shunt closure, death, or loss to follow-up. Mean ages for groups 1, 2, and 3 were 33.9±18.0, 22.2±12.6, and 22.9±15.0 years, respectively. Respective oxygen saturations were 91.2±9.1%, 88.1±8.1%, and 79.7±6.7%. During respective median follow-ups of 7.3, 9.3, and 17.0 years, 24 patients had at least 1 systemic thromboembolus: 10 (15.6%), 5 (8.9%), and 9 (11.0%) in groups 1, 2, and 3, respectively. Univariate risk factors were older age (hazard ratio [HR], 1.05; P=0.0001), ongoing phlebotomy (HR, 3.1; P=0.0415), and an transvenous lead (HR, 2.4; P=0.0421). In multivariate, stepwise regression analyses, transvenous leads remained an independent predictor of systemic thromboemboli (HR, 2.6; P=0.0265). In patients with transvenous leads, independent risk factors were older age (HR, 1.05; P=0.0080), atrial fibrillation or flutter (HR, 6.7; P=0.0214), and ongoing phlebotomy (HR, 14.4; P=0.0349). Having had aspirin or warfarin prescribed was not protective. Epicardial leads were, however, associated with higher atrial (P=0.0407) and ventricular (P=0.0270) thresholds and shorter generator longevity (HR, 1.9; P=0.0176). Conclusions— Transvenous leads incur a >2-fold increased risk of systemic thromboemboli in patients with intracardiac shunts.

Blood Pressure Reduction and Secondary Stroke Prevention: A Systematic Review and Metaregression Analysis of Randomized Clinical Trials.

Current recommendations do not specifically address the optimal blood pressure (BP) reduction for secondary stroke prevention in patients with previous cerebrovascular events. We conducted a systematic review and metaregression analysis on the association of BP reduction with recurrent stroke and cardiovascular events using data from randomized controlled clinical trials of secondary stroke prevention. For all reported events during each eligible study period, we calculated the corresponding risk ratios to express the comparison of event occurrence risk between patients randomized to antihypertensive treatment and those randomized to placebo. On the basis of the reported BP values, we performed univariate metaregression analyses according to the achieved BP values under the random-effects model (Method of Moments) for those adverse events reported in ≥10 total subgroups of included randomized controlled clinical trials. In pairwise meta-analyses, antihypertensive treatment lowered the risk for recurrent stroke (risk ratio, 0.73; 95% confidence interval, 0.62–0.87; P<0.001), disabling or fatal stroke (risk ratio, 0.71; 95% confidence interval, 0.59–0.85; P<0.001), and cardiovascular death (risk ratio, 0.85; 95% confidence interval, 0.75–0.96; P=0.01). In metaregression analyses, systolic BP reduction was linearly related to the lower risk of recurrent stroke (P=0.049), myocardial infarction (P=0.024), death from any cause (P=0.001), and cardiovascular death (P<0.001). Similarly, diastolic BP reduction was linearly related to a lower risk of recurrent stroke (P=0.026) and all-cause mortality (P=0.009). Funnel plot inspection and Egger statistical test revealed no evidence of publication bias. The extent of BP reduction is linearly associated with the magnitude of risk reduction in recurrent cerebrovascular and cardiovascular events. Strict and aggressive BP control seems to be essential for effective secondary stroke prevention.

Exercise intolerance in patients with congenitally corrected transposition of the great arteries relates to right ventricular filling pressures

BACKGROUND Patients with congenitally corrected transposition of the great arteries (ccTGA) have significantly reduced exercise tolerance. Progressive right ventricular (RV) dysfunction with tricuspid regurgitation (TR) and other haemodynamic lesions are common among them. We hypothesised that interaction of these factors may result in increased systemic RV filling pressure, which in turn impact on exercise capacity. METHODS Patients with ccTGA in functional class I or II, able to perform treadmill exercise and without resting cyanosis were enrolled. All patients underwent cardiopulmonary exercise testing and transthoracic echocardiographic examination. RV filling pressure was estimated using tissue Doppler imaging (TDI) techniques by measuring early annular diastolic velocity (Ea) and the ratio of the transtricuspid inflow to the early annular diastolic velocity (E/Ea). RESULTS A total of 27 patients (mean age 41 years, 48% female) were assessed, the majority (63%) asymptomatic. Many patients had coexistent haemodynamic lesions including shunts, pulmonary stenosis, TR and systemic ventricular dysfunction. Average percentage predicted peak oxygen consumption, VE/VCO(2) slope and heart rate reserve were abnormal in this population. Patients with moderately/severely impaired exercise capacity (≤ 60% predicted peak VO(2)) had significantly higher E/Ea ratios compared to those with normal/mildly impaired exercise capacity (septal E/Ea = 17.1 ± 9.7 vs 8.8 ± 1.6 and lateral E/Ea = 11.5 ± 5.8 vs 6.6 ± 1.3, p = 0.007 and 0.01 respectively). CONCLUSION Reduced exercise capacity is common in adults with ccTGA even among asymptomatic patients and relates to increased RV filling pressures assessed by TDI. This index could potentially be used to optimize therapy or prognosticate adverse events in ccTGA patients.

Clinical and prognostic implications of plasma NGAL and NT-proBNP in adult patients with congenital heart disease.

BACKGROUND Prognostic value of NT-proBNP is well established in patients with congenital heart disease. Growing evidence suggests that plasma NGAL is elevated in heart failure but data is limited in congenital heart disease. This study investigates the combined prognostic value of plasma NGAL with plasma NT-proBNP in adult patients with congenital heart disease. METHODS Plasma levels of NT-proBNP and NGAL were measured in 76 consecutive adult patients (33 men, mean age 31.7 ± 14 yrs) with congenital heart disease and normal values of serum creatinine. Patients were divided in three groups: A: simple cardiac lesions, B: complex cardiac lesions and C: cyanotic lesions. Patients were also monitored for long-term major cardiovascular events: death, hospitalization, NYHA class worsening, new onset of arrhythmias, surgical or percutaneous intervention. RESULTS NGAL value was significantly different between groups: In group A median NGAL value was 64.5 ± 36.7 ng/ml, in group B median NGAL value was 88.77 ± 36.17 ng/ml and in group C median NGAL value was 121 ± 40 ng/ml (group A vs. group B: p = 0.048, group B vs. group C: p = 0.037, group A vs. group C: p = 0.003). Plasma NT-proBNP predicted all events (HR = 1.001, CI = 1.001-1.002, p = 0.0006) as well as cardiovascular death alone (HR = 1.001, CI = 1.001-1.002, p = 0.0004); plasma NGAL was the only predictor of cardiovascular death (HR = 1.017, CI = 1.001-1.033, p = 0.037). CONCLUSION Plasma NGAL levels were lower in patients with simple congenital disease compared to patients with complex congenital heart disease and cyanotic congenital heart disease. Plasma NGAL levels correlated with NT-proBNP and could predict cardiovascular death in this small cohort of patients.

Left Main Coronary Artery to Left Atrial Fistula Causing Mild Pulmonary Hypertension

A 73-year-old man with a 6-month history of exertional chest tightness and dyspnea was referred for evaluation. No risk factors for coronary atherosclerosis were present. Left cardiac catheterization revealed coronary arteries without significant stenoses and mildly impaired left ventricular function (ejection fraction, 55%). A fistula from the main stem …

Shortness of Breath and Lower Limb Edema in a 54-Year-Old Woman, Is There Any Cure?

Introduction: Pulmonary hypertension is common among patients with hyperthyroidism, and Graves’ disease constitutes the most common cause of thyrotoxicosis. Case Presentation: We report the case of a female patient admitted to the cardiology department with shortness of breath and pretibial myxedema. The diagnostic work-up revealed combined pre- and post-capillary pulmonary hypertension due to Graves’ disease superimposed on left ventricular diastolic dysfunction. Restoration of thyroid function led to normalization of the pulmonary pressure and symptom resolution. Conclusions: Thyroid disease is a cause of reversible pulmonary hypertension and thus should be appropriately considered in the diagnostic algorithm in patients with dyspnea, clinical signs of hyperthyroidism and elevated pulmonary pressure.

Pathophysiology and Causes of Heart Failure in Adult Congenital Heart Disease

Congenital heart disease (CHD) predisposes patients to numerous types of heart failure (HF) including systolic and diastolic myocardial dysfunction. There are multiple causes of HF including genetics, arrhythmia, cyanosis, ischemia, and residual hemodynamic lesions. Initial diagnosis, cardiac morphology, and type of surgical repair set the seeds for late-onset heart failure in the adult patient. This chapter will focus on the complex pathophysiology of heart failure in this population and will examine both left and right ventricular disease.

Blood Pressure Reduction and Secondary Stroke PreventionNovelty and Significance: A Systematic Review and Metaregression Analysis of Randomized Clinical Trials

Current recommendations do not specifically address the optimal blood pressure (BP) reduction for secondary stroke prevention in patients with previous cerebrovascular events. We conducted a systematic review and metaregression analysis on the association of BP reduction with recurrent stroke and cardiovascular events using data from randomized controlled clinical trials of secondary stroke prevention. For all reported events during each eligible study period, we calculated the corresponding risk ratios to express the comparison of event occurrence risk between patients randomized to antihypertensive treatment and those randomized to placebo. On the basis of the reported BP values, we performed univariate metaregression analyses according to the achieved BP values under the random-effects model (Method of Moments) for those adverse events reported in ≥10 total subgroups of included randomized controlled clinical trials. In pairwise meta-analyses, antihypertensive treatment lowered the risk for recurrent stroke (risk ratio, 0.73; 95% confidence interval, 0.62–0.87; P<0.001), disabling or fatal stroke (risk ratio, 0.71; 95% confidence interval, 0.59–0.85; P<0.001), and cardiovascular death (risk ratio, 0.85; 95% confidence interval, 0.75–0.96; P=0.01). In metaregression analyses, systolic BP reduction was linearly related to the lower risk of recurrent stroke (P=0.049), myocardial infarction (P=0.024), death from any cause (P=0.001), and cardiovascular death (P<0.001). Similarly, diastolic BP reduction was linearly related to a lower risk of recurrent stroke (P=0.026) and all-cause mortality (P=0.009). Funnel plot inspection and Egger statistical test revealed no evidence of publication bias. The extent of BP reduction is linearly associated with the magnitude of risk reduction in recurrent cerebrovascular and cardiovascular events. Strict and aggressive BP control seems to be essential for effective secondary stroke prevention.

Cardiac Issues in Adolescents with Congenital Heart Disease

The number of adult patients is continuously growing. However, although improving surgical and interventional techniques in childhood, a substantial number of patients carry persistent or residual lesions for the rest of their life. These lesions might predispose for late electrical, mechanical, or haemodynamic complications: arrhythmia, heart failure (HF), infective endocarditis, pulmonary hypertension, and re-interventions. Therefore, life-long follow-up is needed for most patients.

1131-147 Thoracic aorta atherosclerosis burden index predicts coronary artery disease in patients undergoing transesophageal echocardiography

AIMS The severity of thoracic aortic atherosclerosis (TAA) is associated with the extent of coronary artery disease (CAD). The aim of this study is to quantitative this relationship by developing a novel atherosclerotic index. METHODS AND RESULTS Two hundred and forty six consecutive patients underwent transesophageal echocardiography (TEE) and coronary angiography. A grading system was used to define the extent of TAA for individual segment of the thoracic aorta. TAA burden index (TAABI) was defined as the sum of the grading for each segment. Of the derived values TAABI had the greatest specificity and sensitivity in predicting CAD. A TAABI of greater than 6 was associated with 16-fold increase in the probability of CAD with a specificity of 88% and a sensitivity of 81%. The positive predictive value was 77% and the negative predictive value 90%. CONCLUSION A TAABI value of greater than 6 accurately predicts the presence of CAD. Patients with no or mild TAA are at low risk of having angiographically significant CAD.