Dimosthenis Avramidis

Preservation of right ventricular structure and function following transatrial-transpulmonary repair of tetralogy of Fallot

OBJECTIVES Management strategy of patients with tetralogy of Fallot (TOF)-including timing, as well as surgical technique-remains a controversial topic. We sought to analyse both early and late results of our consistent policy of non-neonatal transatrial/transpulmonary (TA/TP) repair of TOF over almost 14 years, in order to assess preservation or possible deterioration of right ventricular (RV) function. METHODS All 245 consecutive patients with TOF, referred to our group for repair between September 1997 and December 2010, have been prospectively followed up. Their clinical and echocardiographic data were retrospectively analysed. All underwent complete TA/TP repair at a median age of 1.6 years (range 0.2 to 55.6 years). RESULTS Follow-up (median 8.5 years, range 0.5 to 14.6 years) was 100% completed. There was no operative death. There were three early re-operations: one for residual right ventricular outflow tract obstruction (RVOTO), one for intractable arrhythmias and one for remote second ventricular septal defect (VSD). There were three non-cardiac-related late deaths. Actuarial survival at 14 years was 98.8% (242/245). Twenty five patients required late re-operation, including 23 patients (9.4%, 23/245) who had pulmonary valve replacement (PVR). All other patients remained asymptomatic at follow-up. Mean residual right ventricular outflow tract (RVOT) pressure gradients have remained stable (6.8 ± 6.6 mmHg, 95% CI 5.9-7.6, early postoperatively, versus 7.6 ± 7.5 mmHg, 95% CI 6.6-8.6 at follow-up; P = 0.015). The mean qualitative grade of pulmonary valve insufficiency (PVI) increased (from 1.4 ± 0.9, 95% CI 1.3-1.5 at discharge to 2.1 ± 1.2, 95% CI 2-2.3 at follow-up; P < 0.001). Similarly, mean qualitative grade of tricuspid valve insufficiency (TVI) also increased (from 1 ± 0.7, 95% CI 0.9-1 at discharge to 1.5 ± 0.8, 95% CI 1.4-1.6 at follow-up; P < 0.001). However, RV function has remained normal in most patients. No significant arrhythmias have been noted. CONCLUSIONS Our management strategy of non-neonatal TA/TP repair for all patients with TOF is associated with minimal early and late mortality and morbidity, relatively low re-operation rate, preserved RV function and excellent clinical outcomes at follow-up over almost 14 years. Since many patients demonstrated progressive increase in PVI and TVI, a much longer follow-up is necessary to determine the ultimate rates of late re-operation for pulmonary valve replacement (PVR).

Atrioventricular Nodal Reentrant Tachycardia in Patients With Congenital Heart Disease: Outcome After Catheter Ablation

Background— The relationship of atrioventricular nodal reentrant tachycardia to congenital heart disease (CHD) and the outcome of catheter ablation in this population have not been studied adequately. Methods and Results— A multicenter retrospective study was performed on patients with CHD who had atrioventricular nodal reentrant tachycardia and were treated with catheter ablation. There were 109 patients (61 women), aged 22.1±13.4 years. The majority, 86 of 109 (79%), had CHD resulting in right heart pressure or volume overload. Patients were divided into 2 groups: group A (n=51) with complex CHD and group B (n=58) with simple CHD. There were no significant differences between groups in patients’ growth parameters, use of 3-dimensional imaging, and type of ablation (radiofrequency versus cryoablation). Procedure times (251±117 versus 174±94 minutes; P=0.0006) and fluoroscopy times (median 20.8 versus 16.6 minutes; P=0.037) were longer in group A versus group B. There were significant differences between groups in the acute success of ablation (82% versus 97%; P=0.04), risk of atrioventricular block (14 versus 0%; P=0.004), and need for chronic pacing (10% versus 0%; P=0.008). There was no permanent atrioventricular block in patients who underwent cryoablation. After 3.2±2.7 years of follow-up, long-term success was 86% in group A and 100% in group B (P=0.004). Conclusions— Atrioventricular nodal reentrant tachycardia can complicate the course of patients with CHD. This study demonstrates that the outcome of catheter ablation is favorable in patients with simple CHD. Patients with complex CHD have increased risk of procedural failure and atrioventricular block.

Atresia of the Superior Vena Cava Causing Cyanosis and Increasing Head Circumference in an Infant

We report a case of congenital atresia of the superior vena cava (SVC) with stenotic anastomoses between systemic and pulmonary veins, resulting in cyanosis and symptoms consistent with SVC syndrome in an infant.

New Developments in Cardiopulmonary Resuscitation

Percutaneous transluminal coronary angioplasty (PTCA) was introduced in the late 1970s as an alternative to coronary artery bypass graft surgery for coronary revascularization; since then, it has been accepted as a safe, reliable, and effective treatment for coronary artery disease, and its use has spread worldwide.Hyperlipidemia is a major cause of cardiovascular disease despite the availability of first-line cholesterol lowering agents such as statins. Although statin therapy is very efficient to reduce cholesterol, nearly 10-20% of individuals on statins, experience side effects, such myopathy, which hinder the drugs ability to achieve target low-density lipoprotein (LDL) cholesterol (LDL-C) levels. Statin-intolerant patients require more effective therapies for lowering LDL-C. As proprotein convertase subtilisin kexin type 9 (PCSK9) promotes the degradation of the LDL receptor (LDLR) and prevents it from recycling to the membrane, a new therapeutic approach to lowering LDL-C acts by blocking LDL-receptor degradation by serum PCSK9. Humanized monoclonal antibodies which target PCSK9 and its interaction with the LDL receptor (REGN727/SAR23653, AMG145, and RN316), as well as agents that inhibit PCSK9 synthesis, such as ALN-PCS, are now in clinical trials. The latter is a small interfering RNA (siRNA) that directs sequence-specific messenger RNA for PCSK9 leading to reduced hepatocyte-specific synthesis of PCSK9. Ongoing phase III trials’ results are awaited with great interest in order to define these agents’ long-term safety, tolerability and efficacy for reducing cardiovascular events.Sequential surgical thoracoscopic and electrophysiological (EP) ablation is gaining popularity as a novel approach for the treatment of patients with stand-alone, persistent and long standing persistent atrial fibrillation (AF).The measurement of fractional flow reserve (FFR) has been proven useful in evaluating whether or not to perform percutaneous coronary intervention (PCI), especially in the case of “intermediate” stenosis. Nowadays, the indication of its usefulness has been expanded. While coronary angiography remains the cornerstone for assessment of epicardial coronary artery lesions in the catheterization laboratory, FFR-guided coronary treatment has established its usefulness especially after FAME 1 & 2 trials.Atrial Fibrillation (AF) is associated with increased morbidity and mortality and a more severe impairment in quality of life compared with patients with congestive heart failure or myocardial infarction. Left atrial myocardial extensions, known as “myocardial sleeves”, are present in almost all pulmonary veins (PVs), and have been recognized as the main source of triggers that initiate and perpetuate AF.

Cardiopulmonary Resuscitation Update

The Takotsubo syndrome or apical ballooning, also known as “broken heart syndrome” (BHS) among a variety of suggested names, was first described by Sato et al in the Japanese population approximately 20 years ago. Since then, it has been increasingly recognized in other countries and in 2006 it was classified as a type of stress cardiomyopathy among acquired cardiomyopathies. The prevalence of the BHS is estimated to be 1-2% of patients presenting with an acute coronary syndrome but higher rates have been reported lately, due to a wider recognition of the syndrome. One of the hallmarks of the BHS is a strict predilection for postmenopausal women (over 90% in most series), whereas men account for less than 10% of cases. It has also been reported that among BHS patients, 43% had a preceding acute medical condition and 27% had a severe emotional or physical stressor associated with a “fight or flight” hypersympathetic response... (excerpt)Patients with diabetes mellitus have more advanced coronary artery disease (CAD) eith greater plaque burden, longer lesions, smaller, more diffusely diseased vessels. On the other hand, approximately 25% undergoing percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) have diabetes. Regardless of the type of revascularization, diabetic patients have worse prognosis compared to patients without diabetes. With regards to PCI, diabetic patients have a higher restenosis rate and are at greater risk for myocardial infarction and stent thrombosis than patients without diabetes... (excerpt)

Public Access Defibrillation

The present case report describes a patient who sustained an acute inferior wall myocardial infarction, but initially remained clinically stable, then he underwent a successful coronary angioplasty and stenting procedure of a totally occluded right coronary artery, subsequently developing a dramatic clinical course with cardiogenic shock and cardiac arrest due to acute stent thrombosis which was successfully managed with repeat coronary angioplasty. We attributed this discrepant clinical manifestation of acute coronary occlusion to coronary collaterals, initially being present and then disappearing following the recanalization procedure, as being responsible for the dramatic clinical picture following the stent thrombosis.Aim: The purpose of this investigation was to collect data on the appropriate nursing care to patients supported with an intra-aortic balloon pump (IABP).Patients: All 39 patients who were supported with an IABP during the year 2006 (23 men ??? 16 women) took part in this investigation. They received nursing and medical care in the Intensive Care Cardiovascular Unit (ICCU) of Evagelismos General Hospital of Athens.Πeριγράφeται η πeρίπτωση eνός ασθeνούς, 66 eτών, που παρουσιάσθηκe μe πολλαπλά eπeισόδια eμμένουσας μονόμορφης κοιλιακής ταχυκαρδίας 30 και 14 έτη μeτά δύο eμφράγματα του κατωτέρου και του προσθίου τοιχώματος του μυοκαρδίου. Αφού η ηλeκτρική θύeλλα κατeστάλη μe ένα μeικτό σχήμα τριπλής αντιαρρυθμικής αγωγής, ο ασθeνής υπeβλήθη σe eνδοκαρδιακή κατάλυση της αρρυθμιογόνου eστίας μe τη βοήθeια του ηλeκτροανατομικού συστήματος χαρτογράφησης στο ηλeκτροφυσιολογικό eργαστήριο. Ακολούθησe η eμφύτeυση eνός αντιταχυκαρδιακού βηματοδότου απινιδωτού που στους eπακόλουθους 30 μήνeς παρακολούθησης κινητοποιήθηκe αθόρυβα σe ένα μοναδικό στιγμιότυπο αντιταχυκαρδιακής βηματοδότησης.Ο όρος οξύ στeφανιαίο σύνδρομο ( ACS ) αναφέρeται σe ένα φάσμα τριών πιθανών κλινικών eκδηλώσeων της στeφανιαίας νόσου, την ασταθή στηθάγχη (UA), το έμφραγμα χωρίς ανάσπαση του ST (NSTEM) και το έμφραγμα μe ανάσπαση του ST (STEMI). Η διάκριση αυτή eίναι χρήσιμη στην ανάπτυξη θeραπeυτικών στρατηγικών. Το Αμeρικανικό κολλέγιο καρδιολογίας ( ACC ) και η Αμeρικανική καρδιολογική eταιρία ( AHA ), από κοινού δημοσιeύουν κατeυθυντήριeς οδηγίeς για την αντιμeτώπιση των οξέων στeφανιαίων συνδρόμων. Η τeλeυταία αναθeώρηση των προτeινόμeνων κατeυθυντήριων οδηγιών έγινe το 2007. Η ασταθής στηθάγχη ( UA ) και το NSTEMI έμφραγμα eίναι δύο δυσδιάκριτeς μeταξύ τους οντότητeς και η διαφορά τους έγκeιται στο γeγονός ότι το NSTEMI χαρακτηρίζeται από πeρισσότeρο eκτeταμένη μυοκαρδιακή βλάβη, μe απeλeυθέρωση στην κυκλοφορία τροπονίνης (TnT ή TnI ) ή CK-MB. Eίναι σημαντικό στην αντιμeτώπιση της ασταθούς στηθάγχης/NSTEMI να eπιλέξουμe πρώιμα ανάμeσα σe eπeμβατική ή συντηρητική θeραπeυτική στρατηγική. Η eπιλογή γίνeται μe βάση στοιχeία από το ιστορικό, την κλινική eικόνα και τα eργαστηριακά eυρήματα του ασθeνούς ... (excerpt)Despite primary and secondary methods for the prevention of acute coronary syndromes, there is still poor patient and physician understanding of the importance of smoking cessation. Cardiovascular risk decreases significantly after smoking cessation, however, there is a paucity of counseling programs regarding this issue after hospitalization. Such programs have proved to be cost effective and should be provided as standard care.