Laurence Iserin

Guidelines for pre-operative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery

The American College of Cardiology, American Heart Association, and the European Society of Cardiology are all in the process of completing updated versions of our Guidelines for Perioperative Care. nnOur respective writing committees are undertaking a careful analysis of all relevant validated studies and always incorporate appropriate new trials and meta-analyses into our evidence review. nnIn the interim, our current joint position is that the initiation of beta blockers in patients who will undergo non-cardiac surgery should not be considered routine, but should be considered carefully by each patients treating physician on a case-by-case basis. nnPlease see the expression of concern which is free to view in Eur Heart J (2013) 34 (44): 3460; doi: 10.1093/eurheartj/eht431. nnAAAn: abdominal aortic aneurysmnACCn: American College of CardiologynACEn: angiotensin-converting enzymenACSn: acute coronary syndromenAHAn: American Heart AssociationnARn: aortic regurgitationnARBn: angiotensin receptor blockernASn: aortic stenosisnAFn: atrial fibrillationnBBSAn: β-blocker in spinal anaesthesianBNPn: brain natriuretic peptidenCABGn: coronary artery bypass graftingnCARPn: coronary artery revascularization prophylaxisnCASSn: coronary artery surgery studynCIn: confidence intervalnCOX-2n: cyclooxygenase-2nCOPDn: chronic obstructive pulmonary diseasenCPETn: cardiopulmonary exercise testingnCPGn: Committee for Practice GuidelinesnCRPn: C-reactive proteinnCTn: computed tomographyncTnIn: cardiac troponin IncTnTn: cardiac troponin TnCVDn: cardiovascular diseasenDECREASEn: Dutch Echocardiographic Cardiac Risk Evaluating Applying Stress EchonDESn: drug-eluting stentnDIPOMn: Diabetes Postoperative Mortality and MorbiditynDSEn: dobutamine stress echocardiographynECGn: electrocardiographynESCn: European Society of CardiologynFEV1n: forced expiratory volume in 1 snFRISCn: fast revascularization in instability in coronary diseasenHRn: hazard rationICUn: intensive care unitnIHDn: ischaemic heart diseasenINRn: international normalized rationLMWHn: low molecular weight heparinnLQTSn: long QT syndromenLRn: likelihood rationLVn: left ventricularnMaVSn: metoprolol after surgerynMETn: metabolic equivalentnMIn: myocardial infarctionnMRn: mitral regurgitationnMRIn: magnetic resonance imagingnMSn: mitral stenosisnNICE-SUGARn: normoglycaemia in intensive care evaluation and survival using glucose algorithm regulationnNSTEMIn: non-ST-segment elevation myocardial infarctionnNT-proBNPn: N-terminal pro-brain natriuretic peptidenNYHAn: New York Heart AssociationnOPUSn: orbofiban in patients with unstable coronary syndromesnORn: odds rationPaCO2n: mixed expired volume of alveolar and dead space gasnPAHn: pulmonary arterial hypertensionnPETCO2n: end-tidal expiratory CO2 pressurenPCIn: percutaneous coronary interventionnPDAn: personal digital assistantnPOISEn: PeriOperative ISchaemic Evaluation trialnQUO-VADISn: QUinapril On Vascular ACE and Determinants of ISchemianROCn: receiver operating characteristicnSDn: standard deviationnSMVTn: sustained monomorphic ventricular tachycardianSPECTn: single photon emission computed tomographynSPVTn: sustained polymorphic ventricular tachycardianSTEMIn: ST-segment elevation myocardial infarctionnSVTn: supraventricular tachycardianSYNTAXn: synergy between percutaneous coronary intervention with taxus and cardiac surgerynTACTICSn: treat angina with aggrastat and determine cost of therapy with an invasive or conservative strategynTIAn: transient ischaemic attacknTIMIn: thrombolysis in myocardial infarctionnTOEn: transoesophageal echocardiographynUFHn: unfractionated heparinnVCO2n: carbon dioxide productionnVEn: minute ventilationnVHDn: valvular heart diseasenVKAn: vitamin K antagonistnVO2n: oxygen consumptionnVPBn: ventricular premature beatnVTn: ventricular tachycardiannGuidelines and Expert Consensus Documents aim to present management and recommendations based on the relevant evidence on a particular subject in order to help physicians to select the best possible management strategies for the individual patient suffering from a specific condition, taking into account not only the impact on outcome, but also the risk–benefit ratio of particular diagnostic or therapeutic means. Guidelines are no substitutes for textbooks. The legal implications of medical guidelines have been discussed previously.1nnA great number of Guidelines and Expert Consensus Documents have been issued in recent years by the European Society of Cardiology (ESC) and also by other organizations or related societies. Because of the impact on clinical practice, quality criteria for development of guidelines have been established in order to make all decisions transparent to the user. The recommendations for formulating and issuing ESC guidelines and Expert Consensus Documents can be found on the ESC website in the guidelines section (www.escardio.org).nnIn brief, experts in the field are selected and undertake a comprehensive review of the published evidence for management and/or prevention of a given condition. …

Management of pregnancy in women with congenital heart disease

The number of women with congenital heart disease reaching childbearing age is increasing, and this group now represents the majority of women with heart disease during pregnancy. This increase raises certain issues which have already been addressed in editorials in this journal,1 2 relating to risk factors and the difficulties arising from pregnant women with severe congenital heart disease.nnAtrial and ventricular septal defects, and arterial duct, when operated on early in infancy, do not require any special treatment. Asymptomatic left-to-right shunts and moderate pulmonary stenosis are also usually well tolerated. These women should be able to give birth in non-specialist centres. The only concern is prevention of endocarditis in case of residual shunts or valvar regurgitation. Atrial septal defect is the most common congenital heart disease in adults, and in the absence of pulmonary hypertension induces barely any complications.3 nnEisenmenger reaction, major or significant aortic dilatation in Marfan syndrome, severe aortic stenosis, deep cyanosis, and heart failure put the patient at high risk of maternal death, even where there is close follow up . Eisenmenger reaction carries up to 50% mortality.1 Recent inquiries in the UK4report maternal death in the range of 2–11/100u2009000 from 1994-96. The main cardiac causes of death are …

Key issues of daily life in adults with congenital heart disease

Increasing survival rates of patients with congenital heart disease have resulted in a new and growing patient population of adults with operated congenital heart disease. Medical professionals face the specific medical needs of these patients but must also deal with their daily life issues. Adult patients with congenital heart disease report difficulties in several areas of daily life, such as sport, employment, insurability and travel or driving. Moreover, they must have a healthy lifestyle to prevent cardiovascular complications. All these issues can be addressed in a specific educational program. In this review, we discuss the different daily life issues of adults with congenital heart disease and the preventive measures that can be proposed to improve their quality of life.

Cor Triatriatum Sinister diagnosed in adult life with three dimensional transesophageal echocardiography

BackgroundCor triatriatum is a very rare congenital abnormality, usually symptomatic during childhood, diagnosis in adult age is less common.Case PresentationWe report the case of a 40 years old woman referred to our hospital for atrial flutter ablation, transthoracic cardiac bidimensional echocardiography showed an abnormal membrane bisecting the left atrium, the diagnosis of cor triatriatum was fully made via three dimensional transesophageal echocardiography. More interstingly three other cardiac anomalies were associated: ostium secundum atrial septal defect, dilated coronary sinus due probably to persistent left superior vena cava and normally functioning bicuspid aortic valve.ConclusionsCor triatriatum sinister in adult life is important to recognize because it may be easily surgically correctable when hemodynamically significant. Three Dimensional transesophageal echocardiography is a minimally invasive and highly sensitive diagnostic modality.

Pregnancy outcomes in patients with pulmonary arterial hypertension associated with congenital heart disease

Objective There is growing evidence that maternal mortality in pregnant women with pulmonary arterial hypertension associated with congenital heart disease (PAH-CHD) is lower than that in available data. In order to evaluate this hypothesis, we collected data of pregnancies in women with PAH-CHD. Methods Women with PAH-CHD followed in seven French referral centres were retrospectively included from 1997 to 2015. All pregnancies were recorded. We collected data on maternal, obstetrical and neonatal outcomes. Results 28 pregnancies in 20 women (26±6u2005years old) with PAH-CHD were managed during this period. There were 18 complete pregnancies (≥20u2005weeks’ gestation (WG)), 8 abortions and 2 miscarriages. Six (33%, 95% CI (11.9 to 54.3)) patients experienced severe cardiac events. The concerned women had lower resting oxygen saturation (79.6±4.1% vs 89.3±3.8%, p<0.01). The most common cardiac complications during the complete pregnancies were heart failure (n=4) and severe hypoxaemia (n=5). Heart failure was overall severe, requiring inotropic treatment in three patients, mechanical circulatory support in one and led to one maternal death (mortality=5.0% 95% CI (0.1 to 24.9)). Obstetrical complications occurred in 25% of pregnancies. Small for gestational age was diagnosed in 39% (7/18) of fetuses. 12/18 (67%) pregnancies were delivered by caesarean section, of which 10 in emergency for obstetrical reason. Prematurity was frequent (78%), but no neonatal death occurred. Conclusions Outcome of pregnancy in women with PAH-CHD is better than previously reported, with only 5% maternal mortality in our cohort. However, because of the severity of heart failure and the high rate of neonatal complications, patients should still be advised against pregnancy.

Optimal follow-up in adult patients with congenital heart disease and chronic pulmonary regurgitation: towards tailored use of cardiac magnetic resonance imaging.

BACKGROUNDnPulmonary regurgitation (PR) is a common complication of right ventricular outflow tract (RVOT) reconstruction and leads to right ventricular (RV) dilatation and dysfunction. Although cardiac magnetic resonance (CMR) is the gold standard for evaluating PR and RV dysfunction, cost and limited availability are problems in many centres.nnnAIMSnTo determine clinical, electrocardiographic and echocardiographic predictors of these complications and optimize patient selection for their short-term follow-up by CMR.nnnMETHODSnNinety-four patients with a history of RVOT repair were prospectively included. All patients had a clinical examination, electrocardiography, echocardiography and CMR.nnnRESULTSnQRS duration, indexed end-diastolic RV (EDRV) diameter and area on echocardiography were significantly associated with RV dilatation on CMR (P<0.001). The distal localization of Doppler PR flow was the strongest echocardiographic criterion associated with severe PR (P<0.001). Arrhythmia history and high Tei index were significantly associated with low RV ejection fraction (P<0.001 and P=0.017, respectively). In multivariable analysis, grade of PR, QRS duration, arrhythmia and valvulotomy were strongly associated with severe PR and RV dilatation or systolic RV dysfunction. From these results, an approach based on a scaled scoring system for selecting patients who need short-term CMR evaluation and close follow-up was evaluated. This method should avoid 31% of CMR examinations, with a sensitivity of 97.7%.nnnCONCLUSIONnClinical, electrocardiographic and echocardiographic criteria can be used to accurately evaluate patients with RVOT repair. The combination of such features facilitates identification of patients who do or do not require close CMR evaluation.

Structure and function of the ascending aorta in palliated transposition of the great arteries

BACKGROUNDnIn transposition of the great arteries (TGA), the right ventricle (RV) is subaortic and abnormal aortic structure or function could adversely affect the capacity of the RV to supply the systemic circulation. Our aim was to assess aortic dimensions and distensibility and RV function in patients with palliated TGA using cardiovascular magnetic resonance imaging (CMR).nnnMETHODSnWe studied 29 patients (22 males; age 29±4 years) with simple TGA, who underwent an atrial switch procedure, and 29 age and sex matched controls. All subjects had cine and phase contrast CMR to evaluate aortic function and global RV function.nnnRESULTSnTGA patients had significant dilatation of the aortic annulus (21.0±3.6 mm vs. 17.6±4.1 mm, p=0.002) and the sinus of Valsalva (30.0±4 mm vs. 26.8±4.2 mm, p=0.005), compared to controls. These findings were associated with reduced distensibility of the ascending aorta in patients with TGA (3.5±1.6 vs. 5.3±2.4 mmHg(-1) x 10(-3), p=0.0009). We could not show a significant correlation between aortic stiffness indices and RV size, function, mass or presence of fibrosis.nnnCONCLUSIONnThe aortic root dilates and the ascending aorta stiffens in TGA, during young adult life. Although these proximal aortic changes did not show adverse effects on the RV in our young TGA sample, they might have important long-term physiopathological consequences in these patients.

Post-operative cardiac lesions after cardiac surgery in childhood

A new population of patients in cardiology has been growing steadily so that the number of grown-ups with congenital heart disease (GUCH) is almost equal to those under paediatric care. The dramatic improvement in survival should lead to a larger number of GUCH patients than children with CHD in the new millennium. Although echocardiography remains the imaging modality of choice, cross-sectional imaging techniques have a decision-aiding function for the postoperative evaluation of surgical reconstructions as well as in the preparation of complex interventional procedures. Cardiovascular CT and MRI are often complementary in providing comprehensive complex anatomical evaluation, haemodynamic assessment of residual postoperative lesions and complications of surgery. A thorough understanding of postsurgical corrections is a prerequisite for choosing the optimal imaging techniques and achieving an accurate evaluation.

Outcome of adults with Eisenmenger syndrome treated with drugs specific to pulmonary arterial hypertension: A French multicentre study

BACKGROUNDnThe relationship between pulmonary arterial hypertension-specific drug therapy (PAH-SDT) and mortality in Eisenmenger syndrome (ES) is controversial.nnnAIMSnTo investigate outcomes in patients with ES, and their relationship with PAH-SDT.nnnMETHODSnRetrospective, observational, nationwide, multicentre cohort study.nnnRESULTSnWe included 340xa0patients with ES: genetic syndrome (n=119; 35.3%); pretricuspid defect (n=75; 22.1%). Overall, 276 (81.2%) patients received PAH-SDT: monotherapy (endothelin receptor antagonist [ERA] or phosphodiesterasexa05 inhibitor [PDE5I]) 46.7%; dual therapy (ERA+PDE5I) 40.9%; triple therapy (ERA+PDE5I+prostanoid) 9.1%. Median PAH-SDT duration was 5.5xa0years [3.0-9.1xa0years]. Events (death, lung or heart-lung transplantation) occurred in 95 (27.9%) patients at a median age of 40.5xa0years [29.4-47.6]. The cumulative occurrence of events was 16.7% [95% confidence interval 12.8-21.6%] and 46.4% [95% confidence interval 38.2-55.4%] at age 40 and 60xa0years, respectively. With age at evaluation or time since PAH diagnosis as time scales, cumulative occurrence of events was lower in patients taking one or two PAH-SDTs (P=0.0001 and P=0.004, respectively), with the largest differences in the post-tricuspid defect subgroup (P<0.001 and P<0.02, respectively) versus patients without PAH-SDT. By multivariable Cox analysis, with time since PAH diagnosis as time scale, New York Heart Association/World Health Organization functional classxa0III/IV, lower peripheral arterial oxygen saturation and pretricuspid defect were associated with a higher risk of events (P=0.002, P=0.01 and P=0.04, respectively), and one or two PAH-SDTs with a lower risk of events (P=0.009).nnnCONCLUSIONSnOutcomes are poor in ES, but seem better with PAH-SDT. ES with pretricuspid defects has worse outcomes despite the delayed disease onset.

Implantable cardiac defibrillator among adults with transposition of the great arteries and atrial switch operation: case series and review of literature.

BACKGROUNDnThe experience with the implantable cardiac defibrillator (ICD) in patients with transposition of the great arteries (TGA) and history of atrial switch surgery remains limited.nnnMETHODSnRetrospective evaluation aiming to assess characteristics and outcomes of consecutive TGA patients with history of atrial switch surgery implanted with an ICD between January 2005 and June 2012 in four French centers.nnnRESULTSnOf the 12 patients (median 34 years [28, 40]; 67% male), 4 patients (33%) were implanted for secondary prevention after symptomatic documented sustained ventricular tachycardia or sudden cardiac arrest. ICDs were implanted for primary prevention in 8 patients (67%), including cardiac resynchronization in 3 patients; severe systemic ventricle dysfunction was present in all cases (median ejection fraction 27% [20, 40]). Overall, one patient died during the ICD implantation secondary to refractory cardiac arrest after defibrillation testing. Over a median follow-up of 19 months [10, 106], 6 patients out of 11 (54%) experienced worsening of congestive heart failure, including 5 who were eventually transplanted. Overall, 3 patients (27%) experienced significant ICD-related complications, whereas only one patient (primary prevention indication) developed appropriate ICD therapy (successful anti-tachycardia pacing without shock). Half of the patients presented with at least one episode of sustained (≥ 5 min) atrial arrhythmia during follow-up.nnnCONCLUSIONSnOur findings underline the key role of progressive heart failure in dictating outcomes among TGA patients with prior atrial switch repair. Our results also underline the need of better risk-stratification for sudden cardiac death in those patients.