Non-VKA Oral Anticoagulants in Adult Congenital Heart Disease: a Single-Center Study.

PURPOSE: Non-VKA oral anticoagulants (NOACs) prescription is increasing in adults with congenital heart disease (ACHD). However, data on efficacy and safety in ACHD is unclear, particularly in severe CHD. The study aimed to review the safety and efficacy of NOACs in ACHD. METHODS: Retrospective evaluation of ACHD patients started on NOACs from 2014 to 2020, with the primary endpoints of bleeding or thromboembolic events (TE). CHA2DS2-VASc and HAS-BLED scores were calculated, mortality was assessed, and risk factors for bleeding were identified. RESULTS: A total of 93 patients were included, the mean age was 52 ± 15 years, 58% were female, 55.9% had moderate CHD, and 23.7% had severe CHD (3.2% Fontan). Most (66%) had a CHA2DS2-VASc score ≥ 2 and 82% HAS-BLED ≤ 2. In a median follow-up of 41 (IQR 21) months (400.4 patient-years), there were TE in two patients. The annual risk for TE was 0.49%/patient/year. The cardiovascular mortality was 2% and all-cause mortality 5%; there were no fatal TE or bleeding events. Minor (n = 6, 6.5%) and major (n = 3, 3.2%) bleeding events were observed, a median of 12 (IQR 15) months after starting NOAC therapy. The annual risk for bleeding was 2.2%/patient/year. Renal disease (HR 14.6 [95% CI 1.23-73.6], p = 0.033) and the HAS-BLED score were predictors of major (adjusted HR 6.97 [95% CI 1.69-28.78], p = 0.007) and minor (adjusted HR 3.80 [95% CI 1.48-9.78], p = 0.006) bleeding complications. CONCLUSION: In this real-life cohort of selected ACHD, the use of NOACs was safe and effective, with a low incidence of bleeding events.

Unrepaired tetralogy of Fallot in the adult: an unexpected diagnosis.

A 40-year-old female is admitted for paroxysmal episodes of exertional dyspnoea, with associated cyanosis, improving with squatting, and a holosystolic murmur radiating to the interscapular area. Echocardiography showed a subaortic ventricular septal defect with left-to-right shunt and overriding aorta. The characteristic murmur prompted us to seek right ventricular outflow tract obstruction. Magnetic resonance was performed, confirming Tetralogy of Fallot, and corrective surgery was performed.

Infective endocarditis in a cohort of adult CHD patients.

BACKGROUND: CHD increases the risk of infective endocarditis due to the substrate of prosthetic materials and residual lesions. However, lesion-specific and mortality risks data are lacking. We sought to analyse clinical course and mortality of infective endocarditis in a cohort of adult CHD. METHODS: Retrospective analysis of all cases of proven and probable infective endocarditis (Duke's criteria) followed in our adult CHD clinic between 1970 and August, 2021. Epidemiological, clinical and imaging data were analysed. Predictors of surgical treatment and mortality were assessed using regression analysis. RESULTS: During a mean follow-up of 15.8 ± 10.9 years, 96 patients had 105 infective endocarditis episodes, half with previous cardiac surgery (corrective or palliative). The most frequent diagnoses were: ventricular septal defect, bicuspid aortic valve, Tetralogy of Fallot and pulmonary atresia. The site of infection was identified by echocardiography in 82 episodes (91%), most frequently in aortic (n = 27), tricuspid (n = 15), and mitral (n = 13) valves. Blood cultures were positive in 79% of cases, being streptococci (n = 29) and staphylococci (n = 23) the predominant pathogens. Surgery was necessary in 40% and the in-hospital mortality was 10.5%, associated with heart failure (p < 0.001; OR 13.5) and a non-surgical approach (p = 0.003; OR 5.06). CONCLUSIONS: In an adult CHD cohort, infective endocarditis was more frequent in patients with ventricular septal defect and bicuspid aortic valves, which contradicts the current guidelines that excludes them from prophylaxis. Surgical treatment is often required and mortality remains substantial. Prevention of this serious complication should be one of the major tasks in the care of adults with CHD.

Music-based interventions for people living with dementia, targeting behavioral and psychological symptoms: A scoping review.

INTRODUCTION: Dementia care is a major public health issue worldwide. The management of behavioral and psychological symptoms (BPSD) is one of the hardest challenges in this context. Non-pharmacological strategies, like music-based interventions (Mbi), seem promising options, being considered low-risk, widely available and inclusive. This scoping review aimed at mapping all Mbi used in dementia care, targeting BPSD, and debriefing its components, structure and rationale. Music therapy and other therapeutic music activities were included. METHODS: The Arksey and O'Malley framework, Cochrane recommendations and PRISMA checklist were followed. Embase, PubMed, PsycINFO, ASSIA and Humanities Index were searched from first records until the 31st of March 2020. Snowballing process and screening of relevant journals were also undertaken. A panel of experts critically guided the evidence synthesis. RESULTS: Overall, 103 studies (34 RCT; 12 NRT; 40 Before/After studies and 17 Case Studies) met inclusion criteria. Basic elements of the Mbi, the rationale supporting its development and hypothesis tested were mostly underreported, thus hampering cross-study comparisons and generalizations. Despite this, available evidence indicates that: it is feasible to deliver Mbi to PwD at very different stages and in different settings - from community to the acute setting - even for non-music therapists; positive or neutral effects in BPSD are often reported but not without exception; individualization seems a critical factor mediating Mbi effects. CONCLUSIONS: Detailed intervention and research reporting are essential to interpretation, replication and translation into practice. Ten years after the publication of specific reporting guidelines, this goal is not yet fully achieved in music in dementia care.

Dyadic construction of dementia: meta-ethnography and behaviour-process synthesis.

OBJECTIVES: Good interaction with family caregivers helps maintain positive identity in people with dementia. However, research in this area is limited. We aimed to systematically review the dyadic experience of dementia caring. METHOD: We searched on five databases: MedLine, EMBASE, PsycInfo, ASSIA, and CINAHL. Eligible studies employed qualitative or mixed method design, reported the experience of dyads of dementia with no comorbid organic or psychiatric disorders. No restrictions were made on language, year of publication, sex or age of participants. Two independent researchers conducted the quality appraisal of studies. We synthesise data through meta-ethnography and developed a behavioural model to explain dyadic interaction. RESULTS: Seventeen studies were included in the review. The meta-ethnography generated two third-order constructs: Personal orientation and noises. When people with dementia and their carers have dyadic-oriented goals, their behavioural responses may promote positive interaction. When only one partner has dyadic goals, context-related stress may affect the interaction, because of no perceived shared understanding of the situation. CONCLUSION: Our findings suggest that unequal power distribution within dyads, can cause significant stress, when coping strategies are impaired. We discussed implications for family carers, people with dementia, and health professionals deriving from greater understanding of dyadic dynamics to care.

Prognostic power of anaerobic threshold parameters in patients with transposition of the great arteries and systemic right ventricle.

INTRODUCTION: Both transposition of the great arteries (TGA) previously submitted to a Senning/Mustard procedure and congenitally corrected TGA (cc-TGA) have the systemic circulation supported by the morphological right ventricle, thereby rendering these patients to heart failure events risk. The aim of this study was to evaluate cardiopulmonary exercise test parameters for stratifying the risk of heart failure events in TGA patients. METHODS: Retrospective evaluation of adult TGA patients with systemic circulation supported by the morphological right ventricle submitted to cardiopulmonary exercise test in a tertiary centre. Patients were followed up for at least 1 year for the primary endpoint of cardiac death or heart failure hospitalisation. Several cardiopulmonary exercise test parameters were analysed as potential predictors of the combined endpoint and their predictive power were compared (area under the curve). RESULTS: Cardiopulmonary exercise test was performed in 44 TGA patients (8 cc-TGA), with a mean age of 35.1 ± 8.4 years. The primary endpoint was reached by 10 (22.7%) patients, with a mean follow-up of 36.7 ± 26.8 months. Heart rate at anaerobic threshold had the highest area under the curve value (0.864), followed by peak oxygen consumption (pVO2) (0.838). Heart rate at anaerobic threshold ≤95 bpm and pVO2 ≤20 ml/kg/min had a sensitivity of 87.5 and 80.0% and a specificity of 82.4 and 76.5%, respectively, for the primary outcome. CONCLUSION: Heart rate at anaerobic threshold ≤95 bpm had the highest predictive power of all cardiopulmonary exercise test parameters analysed for heart failure events in TGA patients with systemic circulation supported by the morphological right ventricle.

RoPE Score as a Predictor of Recurrent Ischemic Events After Percutaneous Patent Foramen Ovale Closure.

The benefits of patent foramen ovale (PFO) closure for cryptogenic stroke secondary prevention are still debated. The Risk of Paradoxical Embolism (RoPE) study developed a score to improve patient selection for this procedure. We proposed to assess the validity of this score to assess the prognostic impact of PFO closure.From 2000 to 2014, all consecutive patients submitted to PFO closure were included in a prospective registry in a university center. The primary endpoint was recurrent ischemic cerebrovascular events and the secondary endpoints were all-cause, neurological, and cardiac mortality rates and new-onset atrial fibrillation (NOAF) rates. In total, 403 patients were included in the study (women: 52.1%; mean age: 44.7 ± 10.9 years). The mean follow-up period was 6.4 ± 3.7 years. Immediate success was achieved in 97% patients. There were 23 (5.8%) ischemic cerebrovascular events, 8 (2.0%) deaths, and 17 (4.3%) NOAFs. The mean RoPE score was 6.10 ± 1.79. Smoker status, coronary artery disease, lower RoPE score, and higher left atrial dimensions were predictors of the primary endpoint. However, a lower RoPE score and coronary artery disease remained independent predictors in multivariate analysis.RoPE score was shown to be an independent predictor of recurrent ischemic cerebrovascular events, and a score of ≤ 6 was shown to identify patients with significantly higher risk of mortality and recurrent ischemic events.

Bicuspid aortic valve outcomes.

BACKGROUND: Bicuspid aortic valve is the most common CHD. Its association with early valvular dysfunction, endocarditis, thoracic aorta dilatation, and aortic dissection is well established. OBJECTIVE: The aim of this study was to assess the incidence and predictors of cardiac events in adults with bicuspid aortic valve. METHODS: We carried out a retrospective analysis of cardiac outcomes in ambulatory adults with bicuspid aortic valve followed-up in a tertiary hospital centre. Outcomes were defined as follows: interventional - intervention on the aortic valve or thoracic aorta; medical - death, aortic dissection, aortic valve endocarditis, congestive heart failure, arrhythmias, or ischaemic heart disease requiring hospital admission; and a composite end point of both. Kaplan-Meier curves were generated to determine event rates, and predictors of cardiac events were determined by multivariate analysis. RESULTS: A total of 227 patients were followed-up over 13±9 years; 29% of patients developed severe aortic valve dysfunction and 12.3% reached ascending thoracic aorta dimensions above 45 mm. At least one cardiac outcome occurred in 38.8% of patients, with an incidence rate at 20 years of follow-up of 47±4%; 33% of patients were submitted to an aortic valve or thoracic aorta intervention. Survival 20 years after diagnosis was 94±2%. Independent predictors of the composite end point were baseline moderate-severe aortic valve dysfunction (hazard ratio, 3.19; 95% confidence interval, 1.35-7.54; p<0.01) and aortic valve leaflets calcification (hazard ratio, 4.72; 95% confidence interval, 1.91-11.64; p<0.005). CONCLUSIONS: In this study of bicuspid aortic valve, the long-term survival was excellent but with occurrence of frequent cardiovascular events. Baseline aortic valve calcification and dysfunction were the only independent predictors of events.

The value of right ventricular longitudinal strain in the evaluation of adult patients with repaired tetralogy of Fallot: a new tool for a contemporary challenge.

OBJECTIVE: The role of right ventricular longitudinal strain for assessing patients with repaired tetralogy of Fallot is not fully understood. In this study, we aimed to evaluate its relation with other structural and functional parameters in these patients. METHODS: Patients followed-up in a grown-up CHD unit, assessed by transthoracic echocardiography, cardiac MRI, and treadmill exercise testing, were retrospectively evaluated. Right ventricular size and function and pulmonary regurgitation severity were assessed by echocardiography and MRI. Right ventricular longitudinal strain was evaluated in the four-chamber view using the standard semiautomatic method. RESULTS: In total, 42 patients were included (61% male, 32±8 years). The mean right ventricular longitudinal strain was -16.2±3.7%, and the right ventricular ejection fraction, measured by MRI, was 42.9±7.2%. Longitudinal strain showed linear correlation with tricuspid annular systolic excursion (r=-0.40) and right ventricular ejection fraction (r=-0.45) (all p<0.05), which in turn showed linear correlation with right ventricular fractional area change (r=0.50), pulmonary regurgitation colour length (r=0.35), right ventricular end-systolic volume (r=-0.60), and left ventricular ejection fraction (r=0.36) (all p<0.05). Longitudinal strain (ß=-0.72, 95% confidence interval -1.41, -0.15) and left ventricular ejection fraction (ß=0.39, 95% confidence interval 0.11, 0.67) were independently associated with right ventricular ejection fraction. The best threshold of longitudinal strain for predicting a right ventricular ejection fraction of <40% was -17.0%. CONCLUSIONS: Right ventricular longitudinal strain is a powerful method for evaluating patients with tetralogy of Fallot. It correlated with echocardiographic right ventricular function parameters and was independently associated with right ventricular ejection fraction derived by MRI.

Percutaneous occlusion of vascular malformations in pediatric and adult patients: 20-year experience of a single center.

OBJECTIVE: A case series on different vascular malformations (VM) treated with percutaneous occlusion in children and adults is presented. BACKGROUND: Percutaneous occlusion is usually the preferred treatment method for VM. Previous series have mostly focused on single types of devices and/or VM. METHODS: Retrospective analysis of all patients who underwent percutaneous occlusion of VM in a single center, from 1995 to 2014, excluding patent ductus arteriosus. Clinical and angiographic data, procedural details, implanted devices, and complications were assessed. Procedural success was defined as effective device deployment with none or minimal residual flow. Predictors of procedural failure and complications were determined by multivariate analysis. RESULTS: A total of 123 VM were intervened in 47 patients with median age of 12 years (25 days-76 years). The VM included 55 pulmonary arteriovenous fistulae, 39 aortopulmonary collaterals, 10 systemic venovenous collaterals, 8 peripheral arteriovenous fistulae, 5 Blalock-Taussig shunts, 4 coronary fistulae, and 2 Fontan fenestrations. The 143 devices used included 80 vascular plugs, 38 coils, 22 duct occluders, and 3 foramen ovale or atrial septal defect occluders. Median vessel size was 4.5 (2.0-16.0) mm and device/vessel size ratio was 1.4 (1.1-2.0). Successful occlusion was achieved in 118 (95.9%) VM, including three reinterventions. Four (3.3%) clinically relevant complications occurred, without permanent sequelae. Lower body weight was independently associated with procedural failure and complications. CONCLUSION: To our knowledge, this is the largest series on different VM occluded percutaneously in children and adults, excluding patent ductus arteriosus. Percutaneous occlusion was effective and safe, using different devices.

New-Onset Hemolytic Anemia after Percutaneous Paravalvular Leak Closure.

BACKGROUND AND AIM OF THE STUDY: Despite being usually clinically silent, paravalvular leak can present with congestive heart failure (CHF) or haemolytic anemia. Here, the case is reported of a paravalvular leak presenting with CHF, complicated by new-onset severe hemolytic anemia after percutaneous closure with a large ventricular septal duct (VSD) occlude device. METHODS: A 57-year-old patient presented with infectious endocarditis of a native mitral valve with major mitral regurgitation and was submitted for mitral valvuloplasty. However, one month later failure of the valvuloplasty forced the need for mechanical prosthetic valve implantation. Early endocarditis of the mechanical valve with CHF was noted two months later and led to mechanical valve substitution. One year later the patient presented with a major paravalvular leak and CHF recurrence. Hence, percutaneous paravalvular leak closure was proposed. RESULTS: A 16-mm VSD occluder was used, and clinical and echocardiography success was noticed. However, new-onset hemolytic anemia with acute kidney injury forced surgical re-intervention, with the successful implantation of a third mechanical valve. CONCLUSIONS: Usually, percutaneous paravalvular leak closure is a safe and successful method to treat high-risk surgical patients. However, hemolytic anemia may develop after a technically successful procedure, forcing surgical intervention. Dedicated devices are needed to overcome this important safety issue. Video 1: Periprocedural acquisition of 3-D transesophageal echocardiography showing two AVP II in the left atrium after unsuccessful deployment. Video 2: Periprocedural imaging of a muscular ventricular septal duct (mVSD) occluder (16 mm), with successful closure of the paravalvular leak.

Permanent pacemaker implantation after alcoholic septal ablation induced complete heart block: Long-term impact.

INTRODUCTION AND OBJECTIVES: Patients with hypertrophic obstructive cardiomyopathy (HOCM) that remain symptomatic despite optimized medical therapy often undergo alcohol septal ablation (ASA). One of the most frequent complications is complete heart block (CHB), requiring a permanent pacemaker (PPM) in variable rates of up to 20% of patients. The long-term impact of PPM implantation in these patients remains unclear. This study aimed to evaluate the long-term clinical outcomes in patients who implant PPM after ASA. METHODS: Patients who underwent ASA at a tertiary center were consecutively and prospectively enrolled. Patients with previous PPM or implantable cardio-defibrillator were excluded from this analysis. Patients with and without PPM implantation after ASA were compared based on their baseline characteristics, procedure data and three-year primary endpoint of composite of all-cause mortality and hospitalization and secondary endpoint of composite of all-cause mortality and cardiac cause hospitalization. RESULTS: Between 2009 and 2019, 109 patients underwent ASA, 97 of whom were included in this analysis (68% female, mean age 65.2 years old). 16 patients (16.5%) required PPM implantation for CHB. In these patients, no vascular access, pacemaker pocket or pulmonary parenchyma complications were noted. The baseline characteristics of comorbidities, symptoms, echocardiographic and electrocardiographic findings were identical in the two groups, with higher mean age (70.6±10.0 years vs. 64.1±11.9 years) and lower beta-blocker therapy rate (56% vs. 84%) in the PPM group. Procedure-related data showed higher creatine kinase (CK) peaks in the PPM group (1692 U/L vs. 1243 U/L), with no significant difference in the alcohol dose. At three years after ASA procedure, there were no differences in the primary and secondary endpoints between the two groups. CONCLUSIONS: Permanent pacemaker after ASA induced CHB do not affect long term prognosis in hypertrophic obstructive cardiomyopathy patients.

A Preliminary Psychometric Case Study of the Music in Dementia Assessment Scales: European Portuguese Version (Midas-PT).

INTRODUCTION: Music in Dementia Assessment Scales (MiDAS) is a standardized outcome measure aiming to capture the effects of music-based interventions in patients with dementia. It is a unique instrument regarding its specificity, with the potential to enhance research in the field of music in dementia care. The aim of this study was to report a preliminary psychometric study of the translated and adapted instrument to European Portuguese (MiDAS-PT). MATERIAL AND METHODS: Care home residents with dementia attended bi-weekly group music-based interventions, for five weeks. Intervention coordinators and care home staff completed MiDAS ratings at every session and the Quality-of-Life Scale (QoL-AD) at three time-points. Inter-rater reliability, test-retest reliability, internal consistency, concurrent validity (QoL-AD) and construct validity were evaluated. RESULTS: A total of 529 forms were completed (staff = 235, therapist = 294). Low therapist inter-rater and test-retest reliability, good internal consistency, low concurrent validity, and good construct validity were found. There were high factor loadings between the five MiDAS items (Interest, Response, Initiation, Involvement, and Enjoyment). CONCLUSION: This preliminary investigation indicated acceptable psychometric properties on a range of attributes, but more research is needed in order to definitely establish the psychometric value of the scale.

Single puncture approach guided by transesophageal echocardiography for atrial fibrillation ablation in a patient with prior percutaneous septal closure: case report.

Background: Atrial septal defect (ASD) is associated with a risk of developing atrial fibrillation (AF) higher than in the general population, even after percutaneous or surgical septal closure. Catheter ablation is an effective treatment strategy for preventing recurrences and reducing the AF burden. However, electrophysiologists are faced with technical difficulties and the risk of complications with the left atrium access in patients with prior ASD percutaneous closure. Case summary: We report a case of a patient with highly symptomatic paroxysmal AF, with an ASD, closed percutaneously many years before, who underwent a successful catheter AF ablation, using a single transeptal (TSP) approach guided by transesophageal echocardiography (TEE). Discussion: In patients with ASD and an occluder device implanted, there is a potential risk for septal tear during the TSP passage, device dislodgement, or thrombus formation on the device. Atrial fibrillation ablation in this subset of patients has often been protracted and scarcely reported. TEE and intra-cardiac echocardiography have been increasingly used for interventional procedure guidance during AF ablation. As described here, AF ablation using a simplified single TSP guided by TEE is feasible, safe, and effective after device ASD closure.

Ventricular Septal Rupture-The Resurgence of a Post-Myocardial Infarction Dreadful Complication during COVID-19 Pandemic.

In the midst of the coronavirus disease-2019 (COVID-19) pandemic, an 84-year-old female patient was admitted due to non-exertional syncope preceded by retrosternal pain. She had experienced a prolonged episode of oppressive chest pain 6 days before her presentation, but due to the concern of contracting COVID-19, she did not present for medical care. Upon admission to the emergency department, the patient was in circulatory shock, with her physical examination being remarkable for the presence of a holosystolic murmur. Admission electrocardiogram revealed an inferior ST-segment elevation with Q waves with extension to the posterior wall, consistent with subacute infarct in the right coronary artery (RCA) territory, and the patient was transferred for primary percutaneous coronary intervention. Upon arrival to the catheterization laboratory, a summary transthoracic echocardiogram was performed, which revealed inferior wall and infero-septal akinesia with an 18 mm ventricular septal rupture. Coronary angiography documented occlusion of the proximal segment of a dominant RCA. Due to a high perioperative risk, the patient underwent successful retrograde percutaneous closure with a 24 mm MemoPart™ device, with mild to moderate residual shunt. Despite an immediate clinical improvement, the patient died 12 hours after the procedure due to refractory cardiogenic shock.

Multimodality imaging of a cardiac angiosarcoma presenting with atrial flutter.

A 39-year-old female patient presents to the emergency department with palpitations and dyspnoea, with the admission electrocardiogram revealing atrial flutter. Step-by-step multimodality imaging techniques, including transthoracic echocardiography, computed tomography, cardiac magnetic resonance imaging, and intracardiac echocardiography-guided tissue biopsy, led to the final diagnosis of a right atrial angiosarcoma.

Intracardiac echocardiography-guided left atrial appendage occlusion: The path to independence.

INTRODUCTION AND OBJECTIVES: Transesophageal echocardiography (TEE) has been the standard method for guiding left atrial appendage occlusion (LAAO) procedures. Recently, intracardiac echocardiography (ICE) has emerged as an alternative to TEE due to several advantages, particularly the avoidance of general anesthesia. This analysis aims to assess the safety, feasibility and efficacy of ICE-guided LAAO procedures. METHODS: We performed a retrospective analysis of ICE-guided LAAO procedures, including a comparison of embolic and bleeding events with the predicted standard scores and a comparison with TEE-guided procedures. RESULTS: A total of 88 patients underwent echocardiography-guided percutaneous LAAO (43 patients with TEE and 45 with ICE), mean age 74.9 years, 68.2% male. In the ICE-guided population, the technical success rate was 93% and the major complication rate was 8.8%. During follow-up, yearly stroke and major bleeding rates were 1.4% and 8.4%, respectively, compared to the 4.0% and 8.7% predicted by the CHA2DS2-VASc and HAS-BLED scores. In the TEE versus ICE analysis (similar baseline characteristics), no statistically significant differences were seen regarding technical success (95.3% vs. 93.3%), procedure-related complications (14.0% vs. 8.9%), device thrombus (2.3% vs. 0%), residual minor peridevice leaks (14.0% vs. 24.4%), one-year all-cause mortality (9.3% vs. 4.4%), stroke (9.3% vs. 2.2%) or major bleeding events (9.3% vs. 11.1%). CONCLUSION: ICE-guided LAAO was a safe and effective therapeutic strategy in a high embolic and bleeding risk population, compared to the event rates predicted by the CHA2DS2-VASc and HAS-BLED scores. The ICE-guided procedure compared well to TEE-guided procedures regarding procedure feasibility, safety, and efficacy.

Pregnancy outcomes in women with Ebstein's anomaly: data from the Registry of Pregnancy And Cardiac disease (ROPAC).

OBJECTIVE: Ebstein's anomaly is a rare congenital cardiac condition and data regarding pregnancy outcomes in this patient group are scarce. We evaluated the maternal and perinatal risks of pregnancy in 81 women with Ebstein's anomaly. METHODS: The Registry of Pregnancy and Cardiac disease is a prospective global registry of pregnancies in women with structural cardiac disease. Pregnancy outcomes in women with Ebstein's anomaly were examined. The primary outcome was the occurrence of a major adverse cardiac event (MACE) defined as maternal mortality, heart failure, arrhythmia, thromboembolic event or endocarditis. Secondary endpoints were obstetric and perinatal outcomes and the influence of pregnancy on tricuspid valve regurgitation as well as right atrial and ventricular dimensions. RESULTS: In the 81 women with Ebstein's anomaly (mean age 29.7±6.1 years, 46.9% nulliparous), MACE occurred in 8 (9.9%) pregnancies, mostly heart failure (n=6). There were no maternal deaths. Prepregnancy signs of heart failure were predictive for MACE. Almost half of the women were delivered by caesarean section (45.7%) and preterm delivery occurred in 24.7%. Neonatal mortality was 2.5% and 4.9% of the infants had congenital heart disease. In the subgroup in which prepregnancy and postpregnancy data were available, there was no difference in tricuspid valve regurgitation grade or right atrial and ventricular dimensions before and after pregnancy. CONCLUSIONS: Most women with Ebstein's anomaly tolerate pregnancy well, but women with prepregnancy signs of heart failure are at higher risk for MACE during pregnancy and should be counselled accordingly.

[Right atrial aneurysm after chest trauma: late presentation]. / Aneurisma da aurícula direita após traumatismo torácico: apresentação tardia.

We report the case of a 59-year-old patient, with a history of severe chest trauma with rib fractures at the age of 20 and recent onset of fatigue and palpitations, who was diagnosed with atrial tachycardia, which was converted pharmacologically. Cor triatriatum or Ebstein's anomaly were suspected on initial imaging studies (transthoracic echocardiography and MRI). Due to recurrence of arrhythmia, he subsequently underwent repeat echocardiographic evaluation, which established a diagnosis of right atrial aneurysm. The arrhythmia was converted electrically. The patient has remained asymptomatic during 18 months of follow-up, without arrhythmia recurrence, medicated with carvedilol (after an initial period with amiodarone) and warfarin.

Analysing the use of music to facilitate social interaction in care home residents with dementia: Narrative synthesis systematic review.

INTRODUCTION: Individuals with dementia residing in care homes can rely heavily on care staff to access activities and meaningful interactions. Previous research suggests that care home interactions can be short, fragmented and task-orientated due to staff workload and residents' language impairments. However, music has the potential to be an alternative communication form that remains intact in the later stages of dementia. This systematic review aims to explore how care home music interventions can facilitate social interactions. METHODS: A narrative synthesis was conducted to explore the mechanisms behind how and why care home music intervention facilitate social interactions. The four-element framework guided analysis; (1) Developing a theory, (2) Developing a preliminary synthesis, (3) Exploring relationships, (4) Assessing robustness. FINDINGS: The final synthesis included 23 articles. The studies consisted of music therapy sessions, personalised music listening, structured music singing or instrument playing sessions and music therapeutic care. Despite the difference in music interventions, most studies reported an increase in residents' sociable verbal and non-verbal communication and a decrease in unsociable communication. Music interventions allowed residents to reminisce, express themselves, focus and connect with others. DISCUSSION: The studies highlighted music interventions are accessible to all residents with dementia despite their impairments. The adaptability allows individuals to continue to connect and express themselves even when language deteriorates. More research is needed into the enablers and barriers to implementing interventions into practice, as this systematic review has highlighted that some form of music intervention for all residents can be highly beneficial. Care homes use of music could increase social interactions and meaningful activities.