Jaspal Dua

Benefit of endovascular stenting for aortic coarctation on systemic hypertension in adults.

BACKGROUND Endovascular stenting is a recognised treatment strategy for aortic coarctation (CoA) in adults. We assessed systemic hypertension control and the need for antihypertensive therapy after CoA stenting in adults. METHODS Data were collected prospectively on 54 patients (36 men; mean age: 34 ± 16 years) who underwent endovascular stenting for CoA over a 7-year period. Five patients were excluded as they did not attend follow-up appointments. Patients underwent clinical examination, including right arm systolic blood pressure (SBP) and 24-hour ambulatory blood pressure monitoring at baseline, 6-12 weeks and 9-12 months. RESULTS There was a significant fall in mean peak-to-peak systolic gradient (PG) across the CoA after stenting (26 ± 11 mmHg vs. 5 ± 4 mmHg; P<0.01). There were successive reductions in right arm SBP and ambulatory SBP at baseline, 6-12 weeks and 9-12 months post-procedure (right arm: 155 ± 18 mmHg vs. 137 ± 17 mmHg vs. 142 ± 16 mmHg, respectively; all P-values <0.01; ambulatory: 142 ± 14 mmHg vs. 132 ± 16 mmHg vs. 131 ± 15 mmHg, respectively; all P-values <0.01). Twenty-four patients had severe CoA (PG >25 mmHg before stenting); baseline SBP was significantly higher in severe versus non-severe patients (160 mmHg vs. 148 mmHg; P=0.02). The absolute reduction in PG after stenting was significantly higher in the severe group (31 ± 7 mmHg vs. 14 ± 5 mmHg; P<0.0001), but there was no significant difference in SBP between groups at 6-12 weeks (141 mmHg vs. 135 mmHg; P=0.21) or 9-12 months (139 mmHg vs. 139 mmHg; P=0.96). CONCLUSION Endovascular stenting of CoA results in a significant reduction in SBP at 6-12 weeks, which is sustained at 9-12 months, with similar outcomes in severe and non-severe CoA groups.

Cardiopulmonary exercise testing in the evaluation of liver disease in adults who have had the Fontan operation

BACKGROUND Liver disease (LD) is a long-term complication in patients with a single ventricle who have had the Fontan operation. A decline in cardiopulmonary exercise testing (CPET) variables is associated with increased risk of hospitalization, but its association with LD is unknown. AIM To determine the association between CPET variables and LD in adults who have had the Fontan operation. METHODS We retrospectively reviewed the medical records from two tertiary institutions. RESULTS We identified 114 adults (≥18 years; mean 30.9±7.4 years) who had undergone the Fontan operation: 56% were women; 63% had total cavopulmonary connection; 66% had New York Heart Association (NYHA) class I status; 42% had arrhythmias; 22% had systemic right ventricle; and 35% had ventricular dysfunction. Of 81 patients with liver-imaging data, 41% had LD (i.e. imaging evidence of cirrhosis, with or without portal hypertension, splenomegaly or varices). There were no differences in clinical or echocardiographic variables between those with and without LD. Among the 58 patients with CPET data, mean peak oxygen consumption (VO2) was 18.6±5.7mL/kg/min, per-cent-predicted peak VO2 was 53.9±15.5%, peak oxygen pulse was 9.3±2.9mL/beat and per-cent-predicted peak oxygen pulse was 82.6±21.5%. Of the 44 patients with liver and CPET data, each standard deviation decrease in per-cent-predicted peak VO2 (16%) and per-cent-predicted peak oxygen pulse (22%) was associated with a 2.3-fold increase in the odds of LD, after adjusting for NYHA, institution and Fontan type (P=0.04). Similarly, each standard deviation decrease in per-cent-predicted peak VO2 and oxygen pulse was associated with an estimated 5.9-year and 4.9-year earlier onset of LD, respectively (P>0.05). CONCLUSIONS Decline in per-cent-predicted peak VO2 and oxygen pulse was associated with increased odds of LD in adults who had undergone the Fontan operation. Our study supports more rapid hepatic evaluation among patients with abnormal or worsening CPET variables.

Systolic Anterior Motion Obstructing the Pulmonary Outflow Tract After Tricuspid Valve Replacement

A patient with congenitally corrected transposition of the great arteries who presented with shortness of breath was found to have severe tricuspid regurgitation and right ventricular impairment. After uneventful mechanical systemic tricuspid atrioventricular valve replacement, the patient was extubated within 12 hours. On the first postoperative day, he developed episodes of profound hypotension lasting a few seconds. A transesophageal echocardiogram demonstrated displacement of the interventricular septum that caused systolic anterior motion of the mitral valve into the subpulmonic left ventricle. Mitral valve replacement resolved this complication, and the patient proceeded to do well at discharge.

P27 An evaluation of patient outcomes following percutaneous pulmonary valve implantation from a single centre

Background Congenital right ventricular outflow tract (RVOT) dysfunction can now be treated percutaneously. There is demonstrable evidence that percutaneous pulmonary valve implantation PPVI effectively restores conduit graft viability with a consequent improvement in right ventricular pressures and exercise tolerance. Aim This study evaluates early and late peri-procedural factors in patients with RVOT dysfunction, following PPVI using Medtronic Melody (MM) and Edwards SAPIEN (ES) valves. Methodology This was a single-centre retrospective study of a cohort of 41 consecutive men (n = 18) and women (n = 23), mean age 26.1 ± 10.2 (±SD) years who underwent PPVI between December 2007 and November 2014. Indications for PPVI were significant homograft dysfunction in the context of previously corrected pulmonary atresia (n = 10), pulmonary stenosis (PS) or regurgitation (Ross procedure, n = 9), Transposition of Great arteries (n = 4), Tetralogy of Fallot (n = 15), and truncus arteriosus (n = 3). Patients were categorised as having pulmonary stenosis (44%), regurgitation (34%) or mixed pulmonary valve disease (22%). Invasive haemodynamic, echocardiographic, electrocardiographic (ECG) and cardiopulmonary exercise test (CPET) parameters were assessed pre and post-procedure, at 1, 6 and 12 months (and at 2 or 3 years respectively in some patients). Differences between the measurements were tested by ANOVA or with χ2 test for proportions. Abstract P27 Figure 1 Trends in maximal main pulmonary artery pressure gradient over time. Results PPVI significantly reduced the mean baseline RVOT gradients in stenosis (45 vs18.4 mmHg); regurgitation (19.2 vs. 7.6 mmHg) and mixed disease (32.5 vs. 12mmHg). Mean right ventricular (RV) systolic pressures fell (61.6 ± 2.3 vs. 41.9 ± 2mmHg, p < 0.001) and RV diastolic pressures decreased by about 60% (14.3 ± 1.1 vs. 8.6 ± 1.4mmHg, p < 0.001). Echocardiography showed a clear improvement in pulmonary and tricuspid valve velocities (p for trend <0.01). Furthermore, there was consistent reduction in the main pulmonary artery maximum pressure gradient measured pre- procedure (Figure 1). No significant changes in duration of PR, QRS or QTc were apparent on follow-up ECGs. No changes were observed in CPET performance during follow-up. Discussion Implantation of MM and ES valves in patients with pulmonary stenosis, regurgitation or mixed pulmonary diseases appear to be effective. Immediate improvement in right ventricular pressures and functional improvements demonstrated by echocardiography suggest PPVI is a worthwhile treatment option for patients with dysfunctional RVOT homografts. Multi-centre collaborations are essential to further determine long-term effects of PPVI on cardiac function, exercise tolerance and quality of life in RVOT dysfunction.

Recurrent thrombosis despite a therapeutic international normalised ratio

There has been significant progress in the management of venous thromboembolism in recent years, with increased awareness and adequate thromboprophylaxis proving successful in reducing the morbidity and mortality associated with this condition. Most hospitals in the UK have specialists who run an anticoagulation clinic and ensure the adequate monitoring of, and compliance with, agents such as warfarin. In this Lesson of the Month, we describe an individual with treated congenital heart disease who developed extensive thrombosis while his warfarin control was considered to be in the therapeutic range.