The impact of the multidisciplinary Endocarditis Team on the management of infective endocarditis.

BACKGROUND: In their latest guidelines for infective endocarditis (IE) (2015), the European Society of Cardiology (ESC) introduced the implementation of the Endocarditis Team (ET) to facilitate the management of IE. This study presents our experiences and the diagnostic and therapeutic impact of the ET on the management of IE. METHODS: From 2016-2020, data of all patients with suspected IE referred to the ET were prospectively collected. The final diagnosis was defined by the ET as either rejected, possible or definite IE. Diagnostic impact was scored as any change in initial diagnosis, the frequency of additional diagnostic tests advised by the ET and any change in diagnosis after these tests. Therapeutic impact was scored as any change in antibiotic therapy or change from conservative to invasive therapy or vice versa. RESULTS: A total of 321 patients (median age 67 [55-77] years, 71% male) were enrolled. The final diagnosis was rejected IE in 47 (15%), possible IE in 34 (11%) and definite IE in 240 (75%) patients. A change of initial diagnosis was seen in 53/321(17%) patients. Additional microbiological tests were advised in 69/321 (21%) patients, and additional imaging tests in 136/321 (42%) patients, which resulted in subsequent change in diagnosis in 23/321 (7%) patients. Any change in antibiotic treatment was advised in 135/321 (42%) patients, and change from initial conservative to additional surgical treatment in 15/321 (5%) patients. CONCLUSION: The ET had a clear impact on the therapeutic policy for patients with suspected IE and is useful in the management of this life-threatening disease. Broad implementation is warranted.

Mitral prolapsing volume is associated with increased cardiac dimensions in patients with mitral annular disjunction.

INTRODUCTION: In patients with mitral annular disjunction (MAD), it can be difficult to assess the severity of mitral regurgitation (MR), as they present with a prolapsing volume (i.e. volume resulting from mitral valve prolapse, blood volume shift) rather than a regurgitant jet. The influence of the mitral prolapsing volume (MPV) on cardiac dimensions is unknown. We hypothesised that the severity of MR is underestimated in these patients. Our aim was to measure MPV and to investigate its influence on cardiac dimensions in patients with MAD. METHODS: We retrospectively included 131 consecutive patients with MAD from our institution's echocardiographic database. Transthoracic echocardiography was used to assess MPV. Additionally, we established a control group of 617 consecutive patients with degenerative mitral valve disease and performed propensity score matching. RESULTS: Median MPV in the MAD group was 12 ml. MPV was an independent predictor for left ventricular end-diastolic (LVEDD) and end-systolic diameter (LVESD) and left atrial volume (all p < 0.001). In patients with large prolapsing volumes (> 15 ml), LVEDD (56 ± 6 mm vs 51 ± 6 mm, p < 0.001), LVESD [38 mm (34-41) vs 34 mm (31-39), p < 0.01] and left atrial volume [105 ml (86-159) vs 101 ml (66-123), p = 0.04] were significantly increased compared to matched patients with degenerative mitral valve disease and similarly assessed severity of MR. CONCLUSION: Due to a volume shift based on the MPV rather than an actual regurgitant jet, MR severity cannot be assessed adequately in MAD patients. Increased MPV induces ventricular and atrial enlargement. These findings warrant future studies to focus on MPV as an additional parameter for assessment of the severity of MR in MAD patients.

Implementation of the 2015 European Society of Cardiology guidelines for the management of infective endocarditis in the Netherlands.

Because the occurrence of infective endocarditis (IE) continues to be associated with high mortality, a working group was created by the Dutch Society of Cardiology to examine how the most recent European Society of Cardiology (ESC) guidelines for IE management could be implemented most effectively in the Netherlands. In order to investigate current Dutch IE practices, the working group conducted a country-wide survey. Based on the results obtained, it was concluded that most ESC recommendations could be endorsed, albeit with some adjustments. For instance, the suggested pre-operative screening and treatment of nasal carriers of Staphylococcus aureus as formulated in the ESC guideline was found to be dissimilar to current Dutch practice, and was therefore made less restrictive. The recently adapted ESC diagnostic criteria for IE were endorsed, while the practical employment of the relevant diagnostic techniques was simplified in an adapted flowchart. In addition, the presence of a multidisciplinary, so-called 'endocarditis team' in tertiary centres was proposed as a quality indicator. An adapted flowchart specifically tailored to Dutch practice for microbiological diagnostic purposes was constructed. Lastly, the working group recommended the Stichting Werkgroep Antibioticabeleid (SWAB; Dutch Working Party on Antibiotic Policy) guidelines for IE treatment instead of the antibiotic regimens proposed by the ESC.

Infective endocarditis in the Netherlands: current epidemiological profile and mortality : An analysis based on partial ESC EORP collected data.

INTRODUCTION: Infective endocarditis (IE) is associated with a high in-hospital and long term mortality. Although progress has been made in diagnostic approach and management of IE, morbidity and mortality of IE remain high. In the latest European guidelines, the importance of the multi-modality imaging in diagnosis and follow up of IE is emphasized. AIM: The aim was to provide information regarding mortality and adverse events of IE, to determine IE characteristics and to assess current use of imaging in the diagnostic workup of IE. METHODS: This is a prospective observational cohort study. We used data from the EURO-ENDO registry. Seven hospitals in the Netherlands have participated and included patients with IE between April 2016 and April 2018. RESULTS: A total of 139 IE patients were included. Prosthetic valve endocarditis constituted 32.4% of the cases, cardiac device related IE 7.2% and aortic root prosthesis IE 3.6%. In-hospital mortality was 14.4% (20 patients) and one-year mortality was 21.6% (30 patients). The incidence of embolic events under treatment was 16.5%, while congestive heart failure or cardiogenic shock occurred in 15.1% of the patients. Transthoracic and transoesophageal echocardiography were performed most frequently (97.8%; 81.3%) and within 3 days after IE suspicion, followed by 18F­fluorodeoxyglucose positron emission tomography/computed tomography (45.3%) within 6 days and multi-slice computed tomography (42.4%) within 7 days. CONCLUSION: We observed a high percentage of prosthetic valve endocarditis, rapid and extensive use of imaging and a relatively low in-hospital and one-year mortality of IE in the Netherlands. Limitations include possible selection bias.

Pregnancy in women with hypertrophic cardiomyopathy: data from the European Society of Cardiology initiated Registry of Pregnancy and Cardiac disease (ROPAC).

AIMS: We report the maternal and foetal outcomes at birth and after 6 months in a cohort of pregnant women with hypertrophic cardiomyopathy (HCM). Although most women with HCM tolerate pregnancy well, there is an increased risk of obstetric and cardiovascular complications. METHODS AND RESULTS: All pregnant women with HCM entered into the prospective worldwide Registry of Pregnancy and Cardiac disease (ROPAC) were included in this analysis. The primary endpoint was a major adverse cardiovascular event (MACE), which included death, heart failure (HF), thrombo-embolic event, and arrhythmia. Baseline and outcome data were analysed and compared for patients with MACE vs. without MACE and for patients with obstructive HCM vs. non-obstructive HCM. Sixty pregnant women (mean age 30.4 ± 6.0 years) with HCM (41.7% obstructive) were included. No maternal mortality occurred in this cohort. In 14 (23%) patients at least one MACE occurred: 9 (15.0%) HF and 7 (12%) an arrhythmia (6 ventricular and 1 atrial fibrillation). MACE occurred most commonly during the 3rd trimester and postpartum period. In total, 3 (5.0%) women experienced foetal loss. Women with MACE had a higher rate of emergency Caesarean delivery for cardiac reasons (21.4% vs. 0%, P = 0.01). No significant differences in pregnancy outcome were found between women with obstructive and non-obstructive HCM. NYHA functional class of ≥II and signs of HF before pregnancy, were associated with MACE. CONCLUSION: Although most women with HCM tolerated pregnancy well, cardiovascular complications were not uncommon and predicted by pre-pregnancy status facilitating pre-pregnancy counselling and targeted antenatal care.

Validation of maternal cardiac output assessed by transthoracic echocardiography against pulmonary artery catheterization in severely ill pregnant women: prospective comparative study and systematic review.

OBJECTIVE: Most severe pregnancy complications are characterized by profound hemodynamic disturbances, thus there is a need for validated hemodynamic monitoring systems for pregnant women. Pulmonary artery catheterization (PAC) using thermodilution is the clinical gold standard for the measurement of cardiac output (CO), however this reference method is rarely performed owing to its invasive nature. Transthoracic echocardiography (TTE) allows non-invasive determination of CO. We aimed to validate TTE against PAC for the determination of CO in severely ill pregnant women. METHODS: This study consisted of a meta-analysis combining data from a prospective study and a systematic review. The prospective arm was conducted in Pretoria, South Africa, in 2003. Women with severe pregnancy complications requiring invasive monitoring with PAC according to contemporary guidelines were included. TTE was performed within 15 min of PAC and the investigator was blinded to the PAC measurements. Comparative measurements were extracted from similar studies retrieved from a systematic review of the literature and added to a database. Simultaneous CO measurements by TTE and PAC were compared. Agreement between methods was assessed using Bland-Altman statistics and intraclass correlation coefficients (ICC). RESULTS: Thirty-four comparative measurements were included in the meta-analysis. Mean CO values obtained by PAC and TTE were 7.39 L/min and 7.18 L/min, respectively. The bias was 0.21 L/min with lower and upper limits of agreement of -1.18 L/min and 1.60 L/min, percentage error was 19.1%, and ICC between the two methods was 0.94. CONCLUSIONS: CO measurements by TTE show excellent agreement with those obtained by PAC in pregnant women. Given its non-invasive nature and availability, TTE could be considered as a reference for the validation of other CO techniques in pregnant women. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd. RESUMEN OBJETIVO: Las complicaciones del embarazo más graves se caracterizan por trastornos hemodinámicos serios, debido a los cuales existe la necesidad de sistemas validados de monitorización hemodinámica para mujeres embarazadas. Aunque la cateterización de la arteria pulmonar (CAP) mediante termodilución es el patrón de referencia clínico para la medición del gasto cardíaco (GC), este método se usa con poca frecuencia debido a su naturaleza invasiva. La ecocardiografía transtorácica (ETT) permite la determinación no invasiva del GC. El objetivo de este estudio fue validar la ETT frente al CAP para determinar el GC en mujeres embarazadas gravemente enfermas. MÉTODOS: Este estudio consistió en un metaanálisis que combinó datos de un estudio prospectivo y una revisión sistemática. El estudio prospectivo se llevó a cabo en Pretoria (Sudáfrica) en 2003. Se incluyeron mujeres con complicaciones graves en el embarazo que requerían una monitorización invasiva mediante CAP según las directrices de ese momento. Se realizó una ETT en un plazo de 15 minutos de haber realizado el CAP y el investigador no tuvo acceso a las mediciones del CAP. Las mediciones comparativas se extrajeron de estudios similares obtenidos a partir de una revisión sistemática de la literatura y se añadieron a una base de datos. Se compararon las mediciones simultáneas del GC mediante ETT y CAP. La concordancia entre métodos se evaluó a través del método estadístico de Bland-Altman y de coeficientes de correlación intraclase (CCI). RESULTADOS: Se incluyeron treinta y cuatro mediciones comparativas en el metaanálisis. Los valores medios del GC obtenidos mediante CAP y ETT fueron de 7,39 l/min y 7.18 l/min, respectivamente. El sesgo fue de 0,21 l/min, siendo los límites inferior y superior de la concordancia de -1,18 l/min y 1.60 l/min; el error porcentual fue del 19,1%, y el CCI entre ambos métodos fue de 0,94. CONCLUSIONES: Las mediciones del GC en mujeres embarazadas mediante ETT muestran una excelente concordancia con las obtenidas mediante CAP. Dada su naturaleza no invasiva y su disponibilidad, la ETT podría considerarse como referencia para la validación de otras técnicas relacionadas con el GC en mujeres embarazadas. : ,。(pulmonary artery catheterization,PAC)(cardiac output,CO),,。(transthoracic echocardiography,TTE)CO。PACTTECO。 : meta。2003。PAC。PAC 15 minTTE,PAC。,。TTEPACCO。Bland-Altman(intraclass correlation coefficients,ICC)。 : meta34。PACTTECO7.39 L/min7.18 L/min。-1.18 L/min、1.60 L/min0.21 L/min,19.1%,ICC0.94。 : TTECOPACCO。,TTECO。.

Uteroplacental Doppler flow and pregnancy outcome in women with tetralogy of Fallot.

OBJECTIVE: Pregnancy in women with surgically corrected tetralogy of Fallot (ToF) is associated with cardiac, obstetric and neonatal complications. We compared uteroplacental Doppler flow (UDF) measurements and pregnancy outcome in women with ToF and in healthy women and aimed to assess whether a relationship exists between cardiac function and UDF in women with ToF. METHODS: We evaluated prospectively pregnant women with ToF and healthy pregnant women from the ZAHARA studies. Clinical evaluation, standardized echocardiography and UDF measurements were performed at 20 and 32 weeks' gestation. RESULTS: We included 62 women with ToF and 69 healthy controls. Cardiac complications, mostly arrhythmia, occurred in 8.1% of women with ToF. There was a higher incidence of small-for-gestational age (21.0% vs 4.4%, P = 0.004) and low birth weight (16.1% vs 2.9%, P = 0.009) in the group of women with ToF than in healthy controls. In women with ToF, early diastolic notching of uterine artery waveform at 20 and 32 weeks occurred more frequently (9.8% vs 1.5%, P = 0.034 and 7.0% vs 0%, P = 0.025, respectively) and the umbilical artery pulsatility index at 32 weeks was higher (1.02 ± 0.20 vs 0.94 ± 0.17, P = 0.015) than in healthy controls. Right ventricular function parameters prepregnancy and at 20 weeks' gestation were significantly associated with abnormal UDF. UDF parameters were associated with adverse neonatal outcome. CONCLUSION: The majority of women with surgically corrected ToF tolerate pregnancy well. However, UDF indices are more frequently abnormal in these women, suggesting impaired placentation. The association of impaired right ventricular function parameters with abnormal UDF suggests that cardiac dysfunction contributes to defective placentation or placental perfusion mismatch and may explain the increased incidence of obstetric and neonatal complications. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Echocardiographic chamber quantification in a healthy Dutch population.

AIM: For accurate interpretation of echocardiographic measurements normative data are required, which are provided by guidelines. For this article, the hypothesis was that these cannot be extrapolated to the Dutch population, since in Dutch clinical practice often higher values are found, which may not be pathological but physiological. Therefore this study aimed to 1) obtain and propose normative values for cardiac chamber quantification in a healthy Dutch population and 2) determine influences of baseline characteristics on these measurements. METHODS: Prospectively recruited healthy subjects, aged 20-72 years (at least 28 subjects per age decade, equally distributed for gender) underwent physical examination and 2D and 3D echocardiography. Both ventricles and atria were assessed and volumes were calculated. RESULTS: 147 subjects were included (age 44 ± 14 years, 50% female). Overall, feasibility was good for both linear and volumetric measurements. Linear and volumetric parameters were consistently higher than current guidelines recommend, while functional parameters were in line with the guidelines. This was more so in the older population. 3D volumes were higher than 2D volumes. Gender dependency was seen in all body surface area (BSA) corrected volumes and with increasing age, ejection fractions decreased. CONCLUSION: This study provides 2D and 3D echocardiographic reference ranges for both ventricles and atria derived from a healthy Dutch population. BSA indexed volumes are gender-dependent, age did not influence ventricular volumes and a rise in blood pressure was independently associated with increased right ventricular volumes. The higher volumes found may be indicative for the Dutch population being the tallest in the world.

Hemodynamic effects of intravenous nicardipine in severely pre-eclamptic women with a hypertensive crisis.

OBJECTIVE: Nicardipine permits rapid control of blood pressure in women with severe pre-eclampsia (PE) and hypertensive crisis. Our objective was to investigate its maternal and fetal hemodynamic effects. METHODS: Ten severely pre-eclamptic pregnant women who required intravenous nicardipine for severe hypertension were included in this prospective observational trial. Maternal macrocirculation was assessed by transthoracic echocardiography. Maternal microcirculatory perfusion was examined sublingually with the sidestream dark field imaging technique. Fetal hemodynamics were assessed by Doppler examinations of the uteroplacental and fetal circulations. Maternal cardiac output, total vascular resistance, mitral E/A ratio and capillary heterogeneity index, uterine artery pulsatility index and fetal cerebroplacental ratio were considered primary outcomes. Paired measurements, obtained before administration of nicardipine infusion and after stabilization of blood pressure, were compared. RESULTS: Administration of nicardipine significantly reduced the mean arterial blood pressure (median difference, 26 mmHg; P = 0.002) and total vascular resistance (median difference, 791 dynes × s/cm(5) ; P = 0.002) in all included women. This induced a reflex tachycardia with consequent increase in cardiac output of 1.55 L/min (P = 0.004). There were no significant changes in the other determinants of maternal or fetal hemodynamic parameters. CONCLUSIONS: Nicardipine effectively reduces blood pressure through selective afterload reduction that triggers an increase in cardiac output, without affecting maternal diastolic function, or microcirculatory, uteroplacental or fetal perfusion. This hemodynamic response is uniform and predictable. Fetomaternal cardiovascular profiling can be achieved by combining transthoracic echocardiography with obstetric Doppler.

Echocardiographic findings associated with mortality ortransplant in patients with pulmonary arterial hypertension:A systematic review and meta-analysis.

BACKGROUND: Identification of patients at risk of deterioration is essential to guide clinical management in pulmonary arterial hypertension (PAH). This study aims to provide a comprehensive overview of well-investigated echocardiographic findings that are associated with clinical deterioration in PAH. METHODS: MEDLINE and EMBASE databases were systematically searched for longitudinal studies published by April 2015 that reported associations between echocardiographic findings and mortality, transplant or clinical worsening. Meta-analysis using random effect models was performed for echocardiographic findings investigated by four or more studies. In case of statistical heterogeneity a sensitivity analysis was conducted. RESULTS: Thirty-seven papers investigating 51 echocardiographic findings were included. Meta-analysis of univariable hazard ratios (HRs) and sensitivity analysis showed that presence of pericardial effusion (pooled HR 1.70; 95 % CI 1.44-1.99), right atrial area (pooled HR 1.71; 95 % CI 1.38-2.13) and tricuspid annular plane systolic excursion (TAPSE; pooled HR 1.72; 95 % CI 1.34-2.20) were the most well-investigated and robust predictors of mortality or transplant. CONCLUSIONS: This meta-analysis substantiates the clinical yield of specific echocardiographic findings in the prognostication of PAH patients in day-to-day practice. In particular, pericardial effusion, right atrial area and TAPSE are of prognostic value.

Tachyarrhythmia in patients with congenital heart disease: inevitable destiny?

The prevalence of patients with congenital heart disease (CHD) has increased over the last century. As a result, the number of CHD patients presenting with late, postoperative tachyarrhythmias has increased as well. The aim of this review is to discuss the present knowledge on the mechanisms underlying both atrial and ventricular tachyarrhythmia in patients with CHD and the advantages and disadvantages of the currently available invasive treatment modalities.

Endovascular catheter ablation of ventricular tachycardia in a patient with a surgically repaired congenital left ventricular aneurysm.

We present a patient with a congenital left ventricular aneurysm who visited our outpatient clinic for a routine check-up and, during this visit, lost consciousness due to sustained ventricular tachycardia. In our patient, endocardial mapping revealed extensive conduction abnormalities, and successful ablation was accomplished at the endocardial surface.

Atrial fibrillation: to map or not to map?

Isolation of the pulmonary veins may be an effective treatment modality for eliminating atrial fibrillation (AF) episodes but unfortunately not for all patients. When ablative therapy fails, it is assumed that AF has progressed from a trigger-driven to a substrate-mediated arrhythmia. The effect of radiofrequency ablation on persistent AF can be attributed to various mechanisms, including elimination of the trigger, modification of the arrhythmogenic substrate, interruption of crucial pathways of conduction, atrial debulking, or atrial denervation. This review discusses the possible effects of pulmonary vein isolation on the fibrillatory process and the necessity of cardiac mapping in order to comprehend the mechanisms of AF in the individual patient and to select the optimal treatment modality.

Cardiologist and cardiac surgeon view on decision-making in prosthetic aortic valve selection: does profession matter?

AIMS: Assess and compare among Dutch cardiothoracic surgeons and cardiologists: opinion on (1) patient involvement, (2) conveying risk in aortic valve selection, and (3) aortic valve preferences. METHODS AND RESULTS: A survey among 117 cardiothoracic surgeons and cardiologists was conducted. Group responses were compared using the Mann-Whitney U test. Most respondents agreed that patients should be involved in decision-making, with surgeons leaning more toward patient involvement (always: 83 % versus 50 % respectively; p < 0.01) than cardiologists. Most respondents found that ideally doctors and patients should decide together, with cardiologists leaning more toward taking the lead compared with surgeons (p < 0.01). Major risks of the therapeutic options were usually discussed with patients, and less common complications to a lesser extent. A wide variation in valve preference was noted with cardiologists leaning more toward mechanical prostheses, while surgeons more often preferred bioprostheses (p < 0.05). CONCLUSION: Patient involvement and conveying risk in aortic valve selection is considered important by cardiologists and cardiothoracic surgeons. The medical profession influences attitude with regard to aortic valve selection and patient involvement, and preference for a valve substitute. The variation in valve preference suggests that in most patients both valve types are suitable and aortic valve selection may benefit from evidence-based informed shared decision-making.

Pregnancy in Patients with the Fontan Operation.

Improved survival rates for patients with a Fontan circulation has allowed more women with this complex cardiac physiology to contemplate pregnancy. However, pregnancy in women with a Fontan circulation is associated with a high risk of adverse maternal and fetal outcomes, high rates of miscarriage and preterm delivery. Factors associated with a successful pregnancy outcome are: younger age, normal body weight, absence of significant functional limitation, no Fontan-related complications, and well-functioning single ventricle physiology. Appropriate care with timely preconception counselling and regular, frequent clinical reviews by a multidisciplinary team based at a tertiary centre, improves the chance of a successful pregnancy. Empowerment of patients with education on their specific congenital cardiac condition and its projected trajectory, helps them make informed choices regarding their health, reproductive choices and assists them to achieve their life goals.

Pregnancy in adult congenital heart disease.

Cardiac disease in pregnancy is a challenging health care problem. The number of cases and their complexity is increasing, such that heart disease is now the leading cause of maternal mortality in developed countries. Numerically, women with congenital heart disease (CHD) make up the majority of cases and although maternal mortality is infrequent, a good outcome is only achieved though meticulous care, which starts pre-pregnancy and continues for months after the pregnancy has ended. All women with CHD should be assessed and counseled before pregnancy and carefully monitored during pregnancy, the delivery and in the puerperium. In most cases, pregnancy is well tolerated but in some conditions, such as pulmonary hypertension or severe dilatation of the aorta, pregnancy is extremely high risk and should be advised against.

Ebstein's anomaly may be caused by mutations in the sarcomere protein gene MYH7.

Ebstein's anomaly is a rare congenital heart malformation characterised by adherence of the septal and posterior leaflets of the tricuspid valve to the underlying myocardium. Associated abnormalities of left ventricular morphology and function including left ventricular noncompaction (LVNC) have been observed. An association between Ebstein's anomaly with LVNC and mutations in the sarcomeric protein gene MYH7, encoding ß-myosin heavy chain, has been shown by recent studies. This might represent a specific subtype of Ebstein's anomaly with a Mendelian inheritance pattern. In this review we discuss the association of MYH7 mutations with Ebstein's anomaly and LVNC and its implications for the clinical care for patients and their family members.

Prevalence and development of aortic dilation and dissection in women with Turner syndrome: a systematic review and meta-analysis.

OBJECTIVES: Women with Turner syndrome (TS) have an increased risk of aortic disease, reducing life-expectancy. This study aimed to systematically review the prevalence of thoracic aortic dilatation, aortic dimensions and growth, and the incidence of aortic dissection. METHODS: A systematic literature search was conducted up to July 2022. Observational studies with an adult TS population were included, and studies including children aged <15 years old or specific TS populations were excluded. RESULTS: In total 21 studies were included. The pooled prevalence of ascending aortic dilatation was 23% (95% CI 19-26) at a mean pooled age of 29 years (95% CI 26-32), while the incidence of aortic dissection was 164 per 100.000 patient-years (95% CI 95-284). Three reporting studies showed aortic growth over time to be limited. Risk factors for aortic dilation or dissection were older age, bicuspid aortic valve, aortic coarctation, and hypertension. CONCLUSION: In adult TS women, ascending aortic dilatation is common and the hazard of aortic dissection increased compared to the general population, whereas aortic growth is limited. Conventional risk markers do not explain all aortic dissection cases; therefore, new imaging parameters and blood biomarkers are needed to improve prediction, allowing for patient-tailored follow-up and surgical decision-making.

Reproductive health in adults with congenital heart disease: a review on fertility, sexual health, assisted reproductive technology and contraception.

INTRODUCTION: Due to the improved survival in individuals with congenital heart disease (CHD), considering their reproductive health has become more important. Currently, this topic is still underexplored. AREAS COVERED: We discuss fertility, sexuality, assisted reproductive technology (ART), and contraception in adults with CHD. EXPERT OPINION: Timely counseling regarding fertility, sexuality, pregnancy, and contraception is necessary, preferably during teenage years. Due to a lack of data, whether or not to perform ART in adults with CHD is almost always based on expert opinion and follow-up in an expert center is recommended. Future research is necessary to fill the gaps in knowledge on the risks and frequency of complications of ART in adults with CHD, but also to be able to differentiate the relative risks in the different types of CHD. Only then will we be able to counsel adults with CHD correctly and not unjustly deprive someone of a chance of pregnancy.