Ju Ryoung Moon

Outcomes of Pregnancy in Women with Congenital Heart Disease: A Single Center Experience in Korea

Pregnancy outcomes in patients with congenital heart disease have not been fully assessed in Korea. Forty-nine pregnancies that occurred in 34 women with congenital heart disease who registered at our hospital between September 1995 and April 2006 were reviewed. Spontaneous abortions occurred in two pregnancies at 6+1 and 7 weeks, and another two underwent elective pregnancy termination. One maternal death in puerperium occurred in a woman with Eisenmenger syndrome. Maternal cardiac complications were noted in 18.4%, pulmonary edema in 16.3%, symptomatic arrhythmia in 6.1%, deterioration of New York Heart Association (NYHA) functional class by ≥2 in 2.0%, and cardiac death in 2.0%. Independent predictors of adverse maternal cardiac events were an NYHA functional class of ≥3 (odds ratio [OR], 20.3), right ventricular dilation (OR, 21.2), and pulmonary hypertension (OR, 21.8). Neonatal complications occurred in 22.4% of pregnancies and included preterm delivery (16.3%), small for gestational age (12.2%), and neonatal death (2.0%). Independent predictors of adverse neonatal events were pulmonary hypertension (OR, 6.8) and NYHA functional class ≥3 (OR, 23.0). Pregnancy in women with congenital heart disease was found to be significantly associated with maternal cardiac and neonatal complications. Pre-pregnancy counseling and multidisciplinary care involving cardiologists and obstetricians are recommended for women with congenital heart disease contemplating pregnancy.

A comparison of the Ghent and revised Ghent nosologies for the diagnosis of Marfan syndrome in an adult Korean population.

Recently, a revised Ghent nosology has been established for the diagnosis of Marfan syndrome (MFS) that puts more weight on the aortic root aneurysm and ectopia lentis. We compared the application of the Ghent and revised Ghent nosologies in adult Korean patients for whom there is suspicion of MFS. From January 1995 to June 2010, we enrolled 106 patients older than 20 years for whom there was suspicion of MFS, and who had undergone genetic analysis of the fibrillin‐1 gene (FBN1). Of 106 patients, 86 patients (81%) fulfilled the criteria of the Ghent nosology, and 84 patients (79%) met the criteria of the revised Ghent nosology. The two patients who met the Ghent nosology criteria, but not the criteria of the revised Ghent nosology were diagnosed with Loeys–Dietz syndrome and MASS phenotype. The level of agreement between both nosologies was very high (κ = 0.94, 95% confidence interval: 0.86 to 1.0). Marfan‐like syndromes were diagnosed in 30% (6/20 patients) with negative Ghent and revised Ghent criteria and no FBN1 mutations. These results suggest that adult Korean patients who fulfill the old Ghent criteria almost all fulfill the new criteria for the diagnosis of MFS.

Factors influencing depression in adolescents with congenital heart disease

OBJECTIVE This study was designed to identify variables associated with depression in adolescents who underwent operation for congenital heart disease (CHD). METHODS Data were collected from 231 adolescents, aged 13 to 18 years with CHD, during outpatient clinic follow-up after open heart surgery in 3 major cardiac centers in Korea. Adolescents completed measures of resilience, depression, and parental attitude. Their New York Heart Association functional class, CHD functional index, and noninvasive saturation of arterial oxygen were also measured. RESULTS There were significantly positive relations between depression and the 3 variables: older age, worse New York Heart Association functional class, and higher CHD functional index. Negative relations were found between depression and higher saturation of arterial oxygen, higher academic achievements, affectionate parental attitude, and higher resilience. The multiple regression analysis also showed that 62% of the variance in depression in adolescents with CHD could be explained by resilience and parental attitude. CONCLUSION This study demonstrated that adolescents with higher resilience and an affectionate parent were less depressed.

Clinical and genetic analysis of Korean patients with Marfan syndrome: possible ethnic differences in clinical manifestation

Yoo E‐H, Woo H, Ki C‐S, Lee HJ, Kim D‐K, Kang I‐S, Park P, Sung K, Lee CS, Chung T‐Y, Moon JR, Han H, Lee S‐T, Kim J‐W. Clinical and genetic analysis of Korean patients with Marfan syndrome: possible ethnic differences in clinical manifestation.

Reliability and validity of the Korean version of the Minnesota Living with Heart Failure Questionnaire

OBJECTIVE The aim of this study was to verify the reliability and validity of the Korean language version of the Minnesota Living with Heart Failure Questionnaire (MLHFQ) before using this version in clinical practice to assess the quality of care in patients with heart failure in a cardiology clinic. METHODS The Korean versions of the MLHFQ, 36-Item Short Form Health Survey, and Center for Epidemiologic Studies Depression Scale were administered to evaluate the psychometric properties among 154 patients with heart failure in a major cardiac center in Korea. Cardiac function was assessed by evaluating left ventricular ejection fraction values, N-terminal pro-brain natriuretic peptide levels, and New York Heart Association classifications. RESULTS The questionnaire content and construct validity were supported by factor analysis. Three factors explained 70.7% of the variance. Total and subtotal scales had correlations with the mental and physical component scores of the 36-Item Short Form Health Survey and Center for Epidemiologic Studies Depression Scale, supporting the convergent validity of the Korean version of the MLHFQ. We also found that the New York Heart Association classification was associated with the MLHFQ score. The internal consistency of both total and subtotal scales was greater than .80. CONCLUSION The Korean version of the MLHFQ demonstrated excellent psychometric properties. These results support the use of the MLHFQ in Korean patients with heart failure. Further studies are recommended to assess the responsiveness to change of the Korean version of the MLHFQ.

Analysis of Cardiovascular Risk Factors in Adults with Congenital Heart Disease.

Background and Objectives The objective of this study was to analyze cardiovascular risk factors in adults with congenital heart disease (ACHD). Subjects and Methods The subjects for this study comprised 135 patients, aged 18 years and above, who visited the ACHD clinic at the Samsung Medical Center and 135 adults with a structurally normal heart who were randomly selected from the Center for Health Promotion during the same period. For the analysis, the ACHD group was further divided into an ACHD group that underwent correction by cardiac surgery and a cyanotic group. Results The mean (standard diviation) age (years) of patients in the surgically corrected group was 48.4 (10.9) years, while that of patients in the cyanotic group was 43.1 (9.0) years and that of patients in the control group was 47.1 (10.3) years (p=0.042). The adjusted odds ratios (ORs) for past smoking, hypertension, diabetes mellitus, hypercholesterolemia, obesity, and metabolic syndrome were significantly higher in the surgically corrected patients than in the controls. However, the ORs for all variables excluding past smoking were significantly lower in the cyanotic group compared with the control group. After adjustment for age, gender, smoking, alcohol use, and exercise, the ORs for metabolic syndrome were 0.46 (0.35-0.57, p<0.001) and 1.48 (1.14-1.92, p=0.003) in the cyanotic and surgically corrected groups, respectively. Conclusion Cardiovascular risk factors need to be considered in surgically corrected ACHD patients as well as in adults with a structurally normal heart. A further study with a long-term follow-up is needed for developing guidelines for prevention.

The Center for Epidemiologic Studies Depression Scale is an adequate screening instrument for depression and anxiety disorder in adults with congential heart disease

BackgroundThe Center for Epidemiological Studies Depression Scale (CES-D) is an instrument that is commonly used to screen for depression in patients with chronic disease, but the characteristics of the CES-D in adults with congenital heart disease (CHD) have not yet been studied. The aim of this study was to investigate the criterion validities and the predictive powers of the CES-D for depression and anxiety disorders in adults with CHD.MethodsTwo hundred patients were screened with the CES-D and secondarily interviewed with a diagnostic instrument, i.e., the Mini International Neuropsychiatric Instrument. The sensitivity and specificity values of the CES-D were calculated by cross-tabulation at different cutoff scores. Receiver operating characteristic (ROC) curves were used to assess the optimal cutoff point for each disorder and to assess the predictive power of the instrument.ResultsThe CES-D exhibited satisfactory criterion validities for depression and for all combinations of depression and/or anxiety. With a desired sensitivity of at least 80%, the optimal cutoff scores were 18. The predictive power of the CES-D in the patients was best for major depression and dysthymia (area under the ROC curve: 0.92) followed by the score for any combination of depression and/or anxiety (0.88).ConclusionThe use of CES-D to simultaneously screen for both depression and anxiety disorders may be useful in adults with CHD. Trial registration: CESDEP 212. Registered 2 March 2014 (retrospectively registered).

Natural Course of Adult Ebstein Anomaly When Treated according to Current Recommendation

The objectives of this study were to assess the clinical outcomes of adults with Ebstein Anomaly (EA) according to their treatment modalities. All adult EA patients diagnosed between October 1994 and October 2014 were retrospectively evaluated by medical record review. Total 60 patients were categorized into 3 groups according to their treatment strategy, i.e. non-operative treatment (Group I, n = 23), immediate operative treatment (Group II, n = 27), and delayed operative treatment (Group III, n = 10). A composite of major adverse cardiac and cerebrovascular events (MACCE) and factors associated with MACCE were assessed in each treatment group. MACCE occurred in 13.0% patients in Group I, 55.6% patients in Group II and 50% in Group III (P = 0.006). Event free survivals at 5 years were 90% in Group I, 52.7% in Group II, 50.0% in Group III (P = 0.036). Post-operatively, most patients showed improvement on clinical symptoms. However, event free survival rate was lower in patients with operation compared to those with non-operative treatment (58.7% vs. 90.9%; P = 0.007). Major arrhythmic event occurred more frequently even after surgical ablation (50.0% vs. 20.0%; P = 0.034). Re-operation was more frequent in patients underwent delayed surgery compared to those with immediate surgery (50.0% vs. 18.5%; P = 0.001). Current guideline to decide patient’s treatment strategy appeared to be appropriate in adult patients with EA. However, surgical ablation for arrhythmia was not enough so that concomitant medical treatment should be considered. Therefore, attentive risk stratification and cautious decision of treatment strategy by experienced cardiac surgeon are believed to improve clinical outcome.

The Relationship between Parental Rearing Behavior, Resilience, and Depressive Symptoms in Adolescents with Congenital Heart Disease

Objectives Parental rearing behavior is one factor that influences the strength of resilience. In turn, resilience influences depression. However, it is unclear whether resilience has a mediating effect on the relationship between parental rearing and depression in adolescents with congenital heart disease (CHD). Therefore, the associations between parental rearing behavior and resilience and between rearing behavior and symptoms of depression were investigated with respect to age, gender and disease severity. Subjects and methods Patients completed a parental rearing behavior questionnaire, a resilience scale and the Children’s Depression Inventory during a routine clinic visit. Structural equation modeling with maximum likelihood estimation was used to analyze the data. Results The median age of the 180 patients included in the study was 17.8 years, and 64% were male. Lower resilience was found to be associated with overprotection, punishment, rejection, and control. There was a strong relationship between resilience and symptoms of depression. Resilience varied according to gender, age group, and disease severity. Conclusion Parental rearing behaviors such as emotional warmth, rejection, punishment, control, and overprotection have a significant influence on adolescent’s resilience. When developing intervention programs to increase resilience and reduce depression in adolescents with CHD, parenting attitudes, gender, age, and CHD severity should be considered.

Clinical and Prognostic Value of Depressive Symptoms and N-Terminal Pro-B-Type Natriuretic Peptide in Patients With Eisenmenger Syndrome.

Objectives Eisenmenger syndrome (ES) is commonly associated with depressive symptoms and elevated N-terminal pro–B-type natriuretic peptide (NT-proBNP). We investigated the predictive value of depressive symptoms and NTproBNP levels for long-term outcomes in patients with ES. Methods Blood was drawn to measure NT-proBNP, and depressive symptoms were measured using the Korean version of the Beck Depression Inventory (BDI) in an outpatient clinic sample of 64 patients with ES (67% female; median age = 41.5 years [range, 21.0–74.8 years]). Cardiac events (hospitalization, emergency department visits, and cardiac death) were monitored during 3 years of follow-up. Results During the follow-up period, 15 (23.4%) patients experienced a cardiac event. The combination of depressive symptoms and NT-proBNP levels better predicted future cardiac events than either variable alone. Patients with NT-proBNP > 510 pg/ml and a total BDI score > 10 had a 9.6 times higher risk for cardiac events than did patients with NT-proBNP ⩽ 510 pg/ml or total BDI score ⩽ 10 (p < .001). Conclusions Depressive symptoms and NT-proBNP levels are both associated with adverse clinical outcomes in ES.