Functional and haemodynamic assessment of mild-to-moderate pulmonary valve stenosis at rest and during exercise.

OBJECTIVE: In adult patients with mild-to-moderate pulmonary valve (PV) stenosis, exercise capacity and haemodynamics have not been extensively studied, although regular exercise is recommended. Therefore, we aimed to assess exercise capacity to study the increase in PV gradient during exercise and to evaluate the impact of this increased pressure load on the RV. METHODS: Nineteen patients (8 female; 29±6.4 years) with isolated mild-to-moderate PV stenosis and no prior cardiac interventions were consecutively enrolled from the outpatient clinic of adult congenital heart disease. All patients underwent cardiopulmonary exercise testing, transthoracic echocardiography and bicycle stress echocardiography. Results for exercise testing were compared with age-matched and gender-matched control patients. RESULTS: In the studied population, resting heart rate (89±11 vs 75±14 bpm; p=0.001), peak power (199±66 vs 263±68 W; p=0.006); peak VO2 (31.2±9.9 vs 39±7.4 mL/kg/min; p=0.011); oxygen uptake efficiency slope (2430±913 vs 3292±943(mL/min)/(L/min); p=0.007) and VE/VCO2 slope (26.8±5.2 vs 22.6±4.3; p=0.01) differed significantly from controls. A linear increase of peak PV gradient with increasing flow was observed in the pooled dataset (Pearson's R=0.947; p<0.0001) and slopes identical as for control patients were obtained for the oxygen pulse-workload relationship. Right heart morphology and function were preserved in the studied patients. CONCLUSIONS: Patients with mild-to-moderate PV stenosis have decreased exercise capacity. A linear increase in PV gradient with flow suggests a fixed valve area throughout the exercise. Although systolic RV pressure load increases during exercise, good ventricular performance was observed without signs of functional or morphological changes of the right heart. CLINICAL TRIAL NUMBER: NCT01444222.

Intra-cardiac echocardiography in atrial septal interventions: impact on hospitalization costs.

OBJECTIVE: Intra-cardiac echocardiography (ICE) is used to guide percutaneous interventions on the atrial septum. However, ICE catheters are expensive. We questioned the impact of the use of ICE catheters on hospitalization costs for patent foramen ovale (PFO) or atrial septal defect (ASD) closure. METHODS AND RESULTS: Patients, scheduled for atrial septal closure, were randomly selected to use the AcuNav catheter (Biosense Webster Inc, Diamond Bar, CA, US) on top of the standard procedure (three or two days of hospitalization, procedure with transoesophageal echocardiography (TEE) and general anaesthesia). The AcuNav catheter was provided for free and the total hospitalization cost for each patient was calculated by verification of the bills, sent to the patient and the national health insurance. This was compared with a fictive hospitalization cost when ICE alone would have been used (three or two days of hospitalization, procedure without TEE, and local anaesthesia). Feasibility and safety were also evaluated. Three PFOs and two ASDs were successfully closed (3F/2M, age 55 +/- 12 years). The total hospitalization cost for a standard closing procedure was EUR 9345 +/- 132 and EUR 9303 +/- 132 for three and two days of hospitalization, respectively. With a free ICE catheter and no general anaesthesia, hospitalization cost lowered to EUR 8464 +/- 131 and EUR 8422 +/-131, respectively. Cost saving would be EUR 881 +/- 3, but the price of a single-use ICE catheter varies between EUR 2000 and 2500. In all patients, adequate images were obtained and no complications related to the ICE catheter occurred. CONCLUSIONS: Single-use ICE catheters remain expensive in percutaneous ASD or PFO closure. However, general anaesthesia might be avoided, which could open a discussion on cost savings.