Univentricular hearts not undergoing Fontan: the type of palliation matters.

INTRODUCTION AND OBJECTIVES: There is scarce information on patients with single ventricle physiology (SVP) and restricted pulmonary flow not undergoing Fontan circulation. This study aimed to compare survival and cardiovascular events in these patients according to the type of palliation. METHODS: SVP patient data were obtained from the databases of the adult congenital heart disease units of 7 centers. Patients completing Fontan circulation or developing Eisenmenger syndrome were excluded. Three groups were created according to the source of pulmonary flow: G1 (restrictive pulmonary forward flow), G2 (cavopulmonary shunt), and G3 (aortopulmonary shunts±cavopulmonary shunt). The primary endpoint was death. RESULTS: We identified 120 patients. Mean age at the first visit was 32.2 years. Mean follow-up was 7.1 years. Fifty-five patients (45.8%) were assigned to G1, 30 (25%) to G2, and 35 (29.2%) to G3. Patients in G3 had worse renal function, functional class, and ejection fraction at the first visit and a more marked ejection fraction decline during follow-up, especially when compared with G1. Twenty-four patients (20%) died, 38 (31.7%) were admitted for heart failure, and 21 (17.5%) had atrial flutter/fibrillation during follow-up. These events were more frequent in G3 and significant differences were found compared with G1 in terms of death (HR, 2.9; 95%CI, 1.14-7.37; P=.026) and atrial flutter/fibrillation (HR, 2.9; 95%CI, 1.11-7.68; P=.037). CONCLUSIONS: The type of palliation in patients with SVP and restricted pulmonary flow not undergoing Fontan palliation identifies distinct profiles. Patients palliated with aortopulmonary shunts have an overall worse prognosis with higher morbidity and mortality.

Long-term Outcomes of Adults With Single Ventricle Physiology Not Undergoing Fontan Repair: A Multicentre Experience.

BACKGROUND: To describe long-term survival and cardiovascular events in adult patients with single ventricle physiology (SVP) without Fontan palliation, focusing on predictors of mortality and comparing groups according to their cardiovascular physiology. METHODS: Multicentre observational and retrospective study including adult patients with SVP without Fontan palliation since their first adult clinic visit. The cohort was subdivided into 3 groups: Eisenmenger, restricted pulmonary flow, and aortopulmonary shunt. Death was considered as the main end point. Other clinical outcomes occurring during follow-up were considered as secondary end points. RESULTS: A total of 146 patients, mean age 32.5 ± 11.1 years, were analysed. Over a mean follow-up of 7.3 ± 4.1 years, 33 patients (22.6%) died. Survival was 86% and 74% at 5 and 10 years, respectively. Right ventricular morphology was not associated with higher mortality. Four variables at baseline were related to a higher mortality: at least moderate atrioventricular valve regurgitation, platelet count < 150 × 103/mm3, GFR < 60 mL/min/1.73 m2, and QRS > 120 ms). A total of 34.2% of patients were admitted to the hospital due to heart failure, and 7.5% received a heart transplant. Other cardiovascular outcomes were also frequent: atrial arrhythmias in 19.2%, stroke in 15.1%, and pacemaker/implantable cardioverter-defibrillator in 6.2%/2.7%. CONCLUSIONS: Adult patients with SVP who had not undergone Fontan exhibit a high mortality rate and frequent major cardiovascular events. At least moderate atrioventricular valve regurgitation, thrombocytopenia, renal dysfunction, and QRS duration > 120 ms at baseline visit allow identification of a cohort of patients at higher risk of mortality.

Patent foramen ovale not so patent.

Transesophageal echocardiography (TEE) with agitated saline contrast is the most sensitive tool for diagnosing patent foramen ovale (PFO), but false positives can result. We report a patient who underwent a TEE during the study of a cryptogenic stroke. Contrast appeared in the left atrium with the Valsalva maneuver. However, the contrast exit site was not identified, and contrast continued to appear with Valsalva once the saline microbubbles had disappeared. Combined with the contrast characteristics, this suggested a spontaneous contrast phenomenon rather than a PFO. This phenomenon must be kept in mind to avoid overdiagnosing PFO.

Echocardiographic parameters in adolescents with sleep-related breathing disorders.

Few data are known about the effects of sleep-related breathing disorders (SRBD) on the cardiovascular system in adolescents. Forty healthy adolescents (mean age, 13.7 +/- 1.6 years) answered a questionnaire regarding symptoms of sleep-related breathing disorders (SRBD) and underwent a cardiorespiratory polygraphy and echocardiography. Echocardiographic data in snorers with polygraphic abnormalities suggestive of SRBD (positive group, n = 29) were compared with the results in nonsnorers without polygraphic abnormalities (n = 11) who were included in the control group. Ventricular dimensions and indices of left ventricular systolic function were within normal limits and were not significantly different between the two groups. Indices of left ventricular diastolic function were also within normal limits, but isovolumetric relaxation time (IVRT) was significantly longer among the positive group (72.5 +/- 8.4 msec) than among the controls (65.1 +/- 7.9 msec) (P = 0.018). Multiple regression analysis showed that posterior wall thickness was predicted by a model that included cardiac events related with respiratory events and/or desaturations, and respiratory disturbance index (RDI) in supine position. Deceleration of early diastolic flow was predicted by RDI, percentage of total recording time with SaO(2) < 90% (CT(90)), and age; the variability of isovolumetric relaxation time was predicted by a model that included RDI in supine position. We found a significant relationship between polygraphic parameters suggestive of SRBD and echocardiographic measurements of ventricular dimensions and diastolic function. Also, echocardiographic parameters suggestive of some degree of left ventricular diastolic dysfunction were found in snoring adolescents with polygraphic abnormalities.

Value of NT-ProBNP level and echocardiographic parameters in ST-segment elevation myocardial infarction treated by primary angioplasty: relationships between these variables and their usefulness as predictors of ventricular remodeling.

INTRODUCTION AND OBJECTIVES: To assess the value of N-terminal fragment of brain natriuretic peptide (NT-proBNP) measurement and echocardiography for predicting ventricular remodeling after myocardial infarction and to investigate relationships between the NT-proBNP level and echocardiographic parameters at discharge and in the medium term. METHODS: The study involved 159 patients with myocardial infarction treated by primary coronary angioplasty. The NT-proBNP level was measured on admission, at discharge and after 6 months. Echocardiography was performed at discharge and after 6 months. RESULTS: Overall, 31 patients (19.5%) demonstrated remodeling. At discharge, the variables associated with remodeling were: mitral inflow E-wave-to-A-wave velocity ratio (E/A), systolic mitral annulus velocity (Sm), early diastolic mitral annulus velocity (Em), the mitral inflow E wave to early diastolic mitral annulus velocity ratio (E/ Em), left atrial volume (LAV), left ventricular end-systolic volume (LVESV), left ventricular end-diastolic volume (LVEDV), and discharge NT-proBNP level. Only E/Em was an independent predictor of ventricular remodeling (odds ratio [OR]=1.143; 95% confidence interval [CI], 1.039-1.258; P=.006). At discharge, correlations were observed between the NT-proBNP level and LVEDV, LVESV, ejection fraction (EF) and E/Em. At 6 months, correlations with ventricular volumes and EF were unchanged, the correlation with E/Em was better (r=0.47 vs. r=0.69), and a modest correlation with LAV developed (r=0.43; P=.001). CONCLUSIONS: The E/Em ratio was the best echocardiographic predictor of left ventricular remodeling after myocardial infarction. The NT-proBNP level had no additional predictive value over echocardiography. Correlations between the NT-proBNP level and ventricular volumes and EF at discharge and 6 months were similar, while correlations with E/Em and LAV were better at 6 months.