Coronary artery disease in older adults with congenital heart defects: risk factors and pharmacotherapy.

INTRODUCTION: With advancing age, adults with congenital heart disease (ACHD) are at a higher risk of developing atherosclerotic coronary artery disease (CAD). OBJECTIVES: We aimed to determine the prevalence of CAD, its risk factors, and use of guideline­directed pharmacotherapy among older patients with ACHD.  Patients and methods: We studied all ACHD patients aged 60 years or older hospitalized in our department between the years 2013 and 2020. CAD was defined as a history of acute coronary syndrome or coronary revascularization, or more than 50% diameter stenosis on coronary angiography. Data regarding the underlying heart defect, prevalence of cardiovascular risk factors, and drug prescriptions were collected. RESULTS: A total of 198 patients with known coronary artery status (mean [SD] age, 66.2 [5.3] years; 43.3% men) were included in the analysis. Of them, 54 (27.3%) had CAD. The individuals with CAD were more often men, and they were more likely to have a mild heart defect, dyslipidemia, and a history of hypertension and tobacco use. Multivariable analysis showed that male sex (P = 0.001), dyslipidemia (P = 0.003), and hypertension (P = 0.04) were positive independent predictors of CAD, whereas overweight / obesity was identified as a negative independent predictor (P = 0.04). The proportion of CAD patients on antiplatelet and / or anticoagulant drugs was 92.6%. ß­Blockers were prescribed to 87% of the patients, and a lipid­lowering agent to 96% of the study population. CONCLUSIONS: CAD is common in older patients with ACHD. Our results underline the importance of identification and treatment of modifiable CAD risk factors in individuals with ACHD. The obesity paradox might also play a role in this population. The rate of guideline­recommended pharmacotherapy implementation seems to be satisfactory.

Human Health and Christianity in the Context of the Dilemma of Forgiveness.

This article argues that Christianity has the potential to strengthen people's health when solving the forgiveness dilemma. However-paradoxically-the starting point for the analysis is the presumption that a hasty and imprudent decision to forgive may negatively impact the health of the decision-maker, and that Christianity may contribute to people making unconsidered decisions by prompting them to forgive. In the first part of the analysis, the concept of health and its biblical understanding are discussed. The second part includes both a reflection on forgiveness-related dilemmas and the tension between the decision to forgive and the feeling of regret that may negatively influence health. In the third part, the Christian concept of forgiveness with reference to the aforementioned issues is discussed.

Educating students during a pandemic in the light of research.

The topic of this article is the research that was carried out at the Opole University of Management and Administration during the pandemic. The aim of the research was to answer the question whether and to what extent the COVID-19 pandemic affected the completion of studies by students of the Opole University of Management and Administration. The analysis included the assessment of students from the last semester in the academic year 2018/2019 (before the COVID-19 pandemic) and 2019/2020 (during the COVID-19 pandemic), as well as the results from the diploma examination, the coefficient of similarity of the works to others in the uniform anti-plagiarism system and the planned date of taking the final examination. The research was conducted using the data analysis method. The results showed that the students who were supposed to graduate in the time when the pandemic started, much more often than their predecessors did not take the final examination and were not able to finish writing their diploma papers. Additionally, they had lower grades in their practical subjects.

The burden of cardiovascular risk factors among seniors with congenital heart disease: A single tertiary center experience.

BACKGROUND: The number of adults with congenital heart disease (ACHD) surviving to old age is increasing worldwide. Acquired cardiovascular comorbidities may complicate the course and treatment of the underlying congenital disease and worsen the prognosis. AIMS: The study aimed to assess the burden of cardiovascular (CV) risk factors among elderly patients with ACHD. METHODS: A retrospective analysis of data on all patients ≥60 years of age hospitalized in a tertiary clinic for ACHD was performed from July 2013 to March 2020. We collected information on smoking status, body mass index, and the presence of dyslipidemia, systemic hypertension, and diabetes. RESULTS: The most common CV risk factors among 322 patients ≥60 years of age (median age 66 years; 34% men) were: being overweight/obesity (65.5%), dyslipidemia (64.9%), and arterial hypertension (60.6%). Over 21% of patients suffered from diabetes, and 25.8% were smokers. Over 54% of patients had two or 3 CV risk factors. Patients above 70 years of age were healthier in terms of being overweight/obesity, dyslipidemia, and smoking status. Patients with mild ACHD were more likely hypertensive compared to individuals with complex defects. The highest CV burden was noted in younger men with mild ACHD. CONCLUSIONS: We demonstrated a high burden of CV risk factors in seniors with ACHD. Special attention should be paid to the identification and control of classical CV risk factors in order to prevent acquired CV disease in this population.

The impact of pulmonary regurgitation on right ventricular size and function in patients with repaired tetralogy of Fallot and additional haemodynamic abnormalities.

PURPOSE: Right ventricular (RV) outflow tract obstruction (RVOTO) was demonstrated to be protective against RV dilatation in patients with repaired tetralogy of Fallot and chronic pulmonary regurgitation (PR). We hypothesised that the presence of additional haemodynamic abnormalities (more than mild tricuspid regurgitation, residual ventricular septal defect) reduces this protective association. Accordingly, we aimed to assess the impact of PR on RV size and function in this population. MATERIAL AND METHODS: Consecutive patients with additional haemodynamic abnormalities after tetralogy of Fallot (TOF) repair, who had undergone cardiovascular magnetic resonance, were included. RESULTS: Out of 90 patients studied, 18 individuals (mean age 32.5 ± 10.7 years, 72.2% males) met the inclusion criteria. There were no differences in RV volumes and ejection fraction between patients with and without RVOTO. Neither PR fraction (PRF) nor PR volume (PRV) correlated with RV end-diastolic volume (r = 0.36; p = 0.15 and r = 0.37; p = 0.14, respectively, for PRF and PRV) or RV end-systolic volume (r = 0.2; p = 0.42 and r = 0.19; p = 0.45, respectively, for PRF and PRV). Similarly, no significant correlations were observed between PRF or PRV and RV ejection fraction (r = -0.04; p = 0.87 and r = -0.03; p = 0.9, respectively). CONCLUSIONS: Additional haemodynamic abnormalities are associated with the abolition of the protective effect of RVOTO on RV size. There was no significant relationship between measures of PR and RV volumes in patients after TOF repair with concomitant haemodynamic abnormalities. These abnormalities acted as confounding factors in the assessment of the impact of pulmonary regurgitation on RV size and function.

The coronary sinus interatrial connection with total unroofing coronary sinus discovered late after correction of secundum atrial septal defect.

A coronary sinus (CS) interatrial connection is a rare congenital anomaly which can be in various types from atrial septal defect type unroofing CS to the total absence of the CS. The pathology usually accompanies the left superior caval vein (LSCV) draining to CS and in case of its absence directly to the left atrium (LA). We present a 53-year-old woman after surgical correction of a secundum atrial septal defect in 1974, with a CS interatrial connection and paroxysmal atrial fibrillation (PAF). She gave a history of PAF and was admitted to our clinic due to progressive exertional intolerance, peripheral edema, and mild hypoxia (SatO2 92%) with subsequent cyanosis. Transthoracic echocardiography showed a left-to-right shunt in the posteroinferior part of the atrial septum. Computed tomography revealed a persistent LSCV draining directly into the LA, the absence of the CS, and cardiac veins draining into the LA. The right atrium (RA) and the LA were connected via a tunnel with a visible contrast passage from the left to the right side-the persisting mouth of the coronary sinus. The patient was qualified for surgical correction. A glutaraldehyde-treated autologous pericardial patch was used to construct the tunnel connecting the LSVC and the RA. The second part of the patch was used to close the atrial communication at the inferior vena cava level. The patient had an uncomplicated postoperative course and is now classified in New York Heart Association Class II.

Systemic right ventricle in elderly patients with congenitally corrected transposition of the great arteries: Clinical profile, cardiac biomarkers, and echocardiographic parameters.

OBJECTIVE: The number of patients with congenitally corrected transposition of the great arteries (ccTGA) surviving to old age is increasing. This study therefore sought to characterize 'geriatric' systemic right ventricle (sRV) in terms of clinical profile, cardiac biomarkers, and echocardiography-derived function when compared with findings in younger patients. METHODS: A single-center cross-sectional study of adults with ccTGA was performed. Patients underwent clinical assessment; transthoracic echocardiography; and venous blood sampling including N-terminal pro-B-type natriuretic peptide (NTproBNP), galectin-3, and soluble suppression of tumorgenicity 2 (sST2) measurements. In the echocardiographic study, the sRV function was assessed using fractional area change (FAC), tricuspid annular plane systolic excursion (TAPSE), systolic pulsed-wave Doppler velocity (s'), and longitudinal strain (LS). RESULTS: Ten patients with ccTGA aged 60 years or older and 53 patients younger than 60 years of age were included. There were significantly more individuals with hypertension (40% vs. 5.7%), dyslipidaemia (50% vs. 5.7%), and atrial fibrillation (70% vs. 20.7%) in the older group; similarly, we found higher NTproBNP (2706 pg/mL vs. 784.7 pg/mL; p<0.001), and galectin-3 (10.15 ng/mL vs. 7.24 ng/mL; p=0.007) concentrations in elderly ccTGA individuals, while sST2 content did not vary significantly according to age. Upon echocardiographic assessment, lower sRV FAC (28.6% vs. 36.1%; p=0.028) and LS (-12% vs. -15.5%; p=0.017) values were observed in patients aged 60 years or older. TAPSE and s' did not differ between the age groups. CONCLUSION: Careful screening for acquired comorbidities, particularly atrial fibrillation, in elderly ccTGA patients is warranted. Examining selected cardiac biomarkers and echocardiography-derived parameters are useful in the assessment of the aging sRV.

Prolonged left ventricular contraction duration in apical segments as a marker of arrhythmic risk in patients with long QT syndrome.

AIMS: Long QT syndrome (LQTS) is an inherited cardiac ion channelopathy predisposing to life-threatening ventricular arrhythmias and sudden cardiac death. The aim of this study was to investigate left ventricular mechanical abnormalities in LQTS patients and establish a potential role of strain as a marker of arrhythmic risk. METHODS AND RESULTS: We included 47 patients with genetically confirmed LQTS (22 LQT1, 20 LQT2, 3 LQT3, and 2 SCN3B) and 25 healthy controls. A history of cardiac events was present in 30 LQTS subjects. Tissue Doppler and speckle tracking echocardiography were performed and contraction duration was measured by radial and longitudinal strain. The radial strain characteristic was subdivided into two planes - the basal and the apical. Left ventricular ejection fraction and global longitudinal strain were normal in LQTS patients. Mean contraction duration was longer in LQTS patients compared with controls in regard to basal radial strain (491 ± 57 vs. 437 ± 55 ms, P < 0.001), apical radial strain (450 ± 53 vs. 407 ± 53 ms, P = 0.002), and longitudinal strain (445 ± 34 vs. 423 ± 43 ms, P = 0.02). Moreover, contraction duration obtained from apical radial strain analysis was longer in symptomatic compared with asymptomatic LQTS mutation carriers (462 ± 49 vs. 429 ± 55 ms, P = 0.024), as well as in subject with mutations other than LQT1 considered to be at higher risk (468 ± 50 vs. 429 ± 49 ms, P = 0.01). CONCLUSION: Myocardial contraction duration is prolonged for both radial and longitudinal directions in LQTS patients. Regional left ventricular function analysis may contribute to risk stratification. Apical radial deformation seems to select subjects at higher risk of arrhythmic events.

Single ventricle systolic function and cardiopulmonary exercise performance in adult patients with Fontan circulation.

OBJECTIVE: We employed echocardiographic tissue characterization for the assessment of single ventricle systolic function and examined its relationship with cardiopulmonary exercise testing (CPET) performance in the Fontan circulation. METHODS: 40 consecutive adult Fontan patients (16 female, 24 male; mean age 26.3 ± 5.9) were enrolled in our prospective cross-sectional study. All patients underwent echocardiographic assessment including tissue characterization and CPET within 3 days from each other. RESULTS: LAPSE (lateral annular plane systolic excursion) was higher in patients with a dominant left ventricle compared to a dominant right ventricle (12.3 + -2.6 vs 9.8 + -1.1 mm, p = .008) and in patients with AP (right atrium-pulmonary artery) connection than with lateral tunnel or extracardiac conduits (13.9 ± 1.7 vs 11.3 ± 2.6 and 10.9 ± 2.2 mm, p = .014 and p = .014, respectively). Maximal oxygen pulse (O2 pulse max) was significantly higher in patients with a dominant left or common ventricle compared to patients with a dominant right ventricle (10.3 and 12.0 vs 6.6 ml/beat, p = .002 and p = .032, respectively). There was a positive correlation between O2 pulse max and LAPSE (r = 0.442, p = .009), atrioventricular valve annulus systolic velocity (S') (r = 0.606, p < .0001), lateral wall basal segment systolic velocity (bas vel s) (r = 0.469, p = .009) and lateral wall mid segment systolic velocity (mid vel s) (r = 0.452, p = .012). In the multivariable regression model, S' (r = 0.606, p < .0001) remained predictive of O2 pulse max. CONCLUSIONS: LAPSE and S' are suitable parameters for the assessment of systolic function in Fontan patients. Subclinical systolic dysfunction of longitudinal fibers is associated with worse CPET performance. O2 pulse max seems to be the best parameter reflecting Fontan patients' physical performance.

Transcatheter pulmonary valve implantation in 100 patients: a 10-year single-center experience.

Introduction: Transcatheter pulmonary valve implantation (TPVI) is a non-surgical method of treatment for patients with right ventricular outflow tract (RVOT) dysfunction after surgical repair of congenital heart defects (CHD). Aim: To evaluate the long-term results of TPVI performed in a single center.Material and methods: Over 10 years, TPVI was performed in 100 patients (mean age: 26.4 ±8.1 years), using Melody Medtronic or Sapien Edwards valves. Results: The initial success rate of TPVI was 93%. In 7 cases (5 urgent), a switch to surgical intervention was necessary due to periprocedural complications (all patients survived). Following TPVI, none of the 93 patients had severe pulmonary regurgitation. The pulmonary gradient decreased from 49.0 ±37.8 before to 27.6 ±14.9 mm Hg directly after TPVI (p < 0.0001). Right ventricular end-diastolic volume decreased, while NYHA class and pVO2 uptake significantly improved in 1 year after TPVI. Freedom from reintervention was 100% in 1 year. Freedom from serious adverse events was 86% in mean 5.5 years of observation. The main reason for reintervention was infective endocarditis (IE) (1.6% patients/year). Increased risk of IE was associated with severe PS before valve implantation and the suboptimal result of TPVI. The incidence of IE seems to be lower in patients treated permanently with antiplatelet therapy (1.8% vs. 0.9% patients/year, NS). Conclusions: TPVI is a safe and effective method of treatment in patients with RVOT dysfunction after surgical correction of CHD. To achieve a good outcome, precise patient selection and rigorous IE prevention are necessary.

Is there any role for computed tomography imaging in anticipating the functional status in adults late after total cavopulmonary connection? A retrospective evaluation.

BACKGROUND: The Fontan procedure is performed in patients with congenital heart diseases and abnormal anatomy of the heart, which preclude intracardiac repair involving a separation of the systemic and pulmonary circulations. The role of computed tomography (CT) in assessing patients' clinical status after the total cavopulmonary connection (TCPC) procedure is not well defined. AIMS: To determine a potential role and diagnostic capability of CT in the functional assessment of adults with the TCPC. METHODS: Data obtained from 18 patients (10 women; mean [SD] age, 27.9 [6.3] years) with the TCPC were analyzed retrospectively. All patients underwent biochemical evaluation, cardiopulmonary exercise test, transthoracic echocardiography, and CT. Upon CT examination, the dimensions of the left and right pulmonary arteries, superior and inferior venae cavae, all pulmonary veins, and extracardiac conduits were measured. The measurements acquired by CT were correlated with the results of transthoracic echocardiography, cardiopulmonary exercise test, and biochemical analysis. RESULTS: The mean (SD) time after the TCPC was 18.5 (6.5) years. The area and circumference of the inferior vena cava significantly correlated with age (r = 0.503, P <0.05). A significant positive correlation was found between the area and circumference of a conduit and the predicted maximal oxygen uptake (r = 0.664, P <0.01). The area (ß = 0.746, R2 = 0.556, P <0.01) and the circumference (ß = 0.757, R2 = 0.572, P <0.01) of a conduit were considered significant predictors in estimating the value of maximal oxygen uptake. CONCLUSIONS: Our study showed an association between the dimensions of an extracardiac conduit and patient functional status, time elapsed since the procedure, and age of adults who underwent the TCPC in childhood. These findings support a more extensive use of CT in patients with TCPC, complemented by the measurements of the superior and inferior venae cavae and the conduit.

Clozapine-induced myocarditis during co-administration of valproate: A case report. / Zapalenie miesnia sercowego indukowane klozapina w trakcie leczenia pochodnymi kwasu walproinowego: opis przypadku.

Clozapine, atypical antipsychotic drug, is widely used in patients with schizophrenia, for whom previous therapy was inadequate or not tolerated. Clozapine-induced myocarditis (CIM) is a relatively rare but potentially life-threatening complication of clozapine therapy; however, the underlying mechanism has not been so far well elucidated. Factors predisposing to CIM include a rapid dose titration, advanced age and co-administration of sodium valproate. In this paper, we present a case of a 22-year-old male patient with refractory schizophrenia who developed CIMduring low-dose clozapine treatment with co-administration of valproate and risperidone. On the basis of our case and literature review, we point out that during the first weeks of clozapine treatment patients should be actively, daily monitored for the presence of symptoms suggesting CIM. The low dose of clozapine and concurrent use of valproate are unique aspects of the report, adding new information to the discussion on safety of concomitant use of clozapine and valproate. Further investigation is required to better understand the role of co-administration of valproate and risperidone in the pathogenesis of CIM.

High-Sensitive Cardiac Troponin T and Systemic Right Ventricular Area Predict Outcomes in Adults With Congenitally Corrected Transposition.

BACKGROUND: Congenitally corrected transposition of the great arteries (ccTGA) is a rare clinical condition in which the morphologically right ventricle sustains systemic circulation. This congenital heart anomaly exposes patients with ccTGA to adverse events over time. Strategies to identify persons who are at high risk of clinical events will be crucial for improving patient outcomes. Thus the aim of this study was to identify screening tools that enable morbidity and mortality risk stratification in adults with ccTGA. METHODS: This was a prospective observational study. Electrocardiography, laboratory testing, echocardiography, and cardiopulmonary exercise testing were performed at baseline. A Cox proportional hazards regression analysis was conducted to establish determinants of composite clinical endpoints, including death, heart transplantation, systemic ventricular device assist implantation, worsening of heart failure, vascular events, tricuspid valve regurgitation requiring intervention, and clinically relevant arrhythmias. RESULTS: Fifty-one patients-30 male and 21 female-with a mean age of 36 years were studied. During a median follow-up period of 3.15 years, 19 patients experienced 39 clinical events. Detectable high-sensitivity troponin T (hsTnT) combined with echocardiography-derived systemic right ventricular end-diastolic (sRVED) area were the best predictors of adverse outcomes (hazard ratio [HR] = 6.25, P = 0.02 and HR = 1.05, P = 0.02, respectively). CONCLUSIONS: A combination of detectable hsTnT and an increased sRVED area are the best predictors of adverse clinical events in adults with ccTGA. This observation may be useful to guide follow-up, as both risk determinants are widely available and simple to obtain in everyday practice.

Differences in regional diastolic function between restrictive and normal right ventricular physiology in adult patients late after tetralogy of Fallot repair.

BACKGROUND: Restrictive right ventricular physiology (RRVP) is a common finding in adult patients after tetralogy of Fallot (TOF) repair. Despite many attempts to relate this phenomenon to various factors, its clinical importance and the underlying myocardial pathologies are still enigmatic. AIM: We sought to evaluate the regional diastolic right ventricular (RV) function in patients after TOF repair with and without RRVP. METHODS: A group of 112 consecutive patients with repaired TOF underwent transthoracic echocardiography with tissue Doppler imaging, cardiopulmonary exercise test, cardiac magnetic resonance, and laboratory test. Of them, 83 patients met the inclusion criteria. Regional deformations of the RV and interventricular septum (IVS) in patients with and without RRVP were compared. RESULTS: Tetralogy of Fallot patients demonstrated an inhomogeneous pattern of strain rate (SR) values in the atrial contraction phase (A wave) of the RV free wall compared to healthy volunteers. Patients with RRVP had significantly lower values of A wave curves of IVS segments (velocities and SR) and higher values of RV free wall SR during early filling (E wave) and atrial contraction phases compared to patients without RRVP. In multiple factor analysis RRVP was correlated with lower values of end-diastolic IVS velocities (A wave) and higher values of RV SR A waves. CONCLUSIONS: Tissue Doppler imaging may show diastolic abnormalities in patients with RRVP. This group of patients demonstrated a deterioration in IVS diastolic function as measured by SR A waves. The diastolic function of RV free wall segments was better in patients with RRVP compared to patients without restriction of the RV measured by SR.