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BACKGROUND: There is little information of progestogen-only contraceptives in patients with congenital heart disease (CHD) on the long-term. OBJECTIVE: To evaluate the use of contraception in patients with CHD. We studied both short-acting reversible contraceptives (SARCs), oral progestin-only pills (POPs) and long-acting reversible contraceptives (LARCs): intrauterine devices (IUD-IPs) and subdermal implants both impregnated with progestogens (SI-IPs). STUDY DESIGN: Retrospective study of all women attending the preconception clinic. Contraceptive methods were classified in three TIERs of effectiveness before and after consultation. ESC classification regarding pregnancy risk, WHOMEC classification for combined oral contraceptive safety was collected. RESULTS: Six hundred and fifty-three patients. A significant proportion of them switched from TIER 3 to TIER 2 or 1 (p < .001) after consultation. One hundred and ninety-nine patients used POPs, 53 underwent IUD-IPs implantation and 36 SI-IPs, mean duration was 58 ± 8, 59 ± 8 and 53 ± 38 months, respectively. CONCLUSIONS: Because of their safety and efficacy, IUD-IPs and SI-IPs should be considered as first-line contraception in patients with CHD.
We looked at the use of progestogen-only contraceptives in women with congenital heart disease (CHD) over a long period and determine how safe and effective these contraceptives are for such patients. We considered two types of contraceptives: short-acting ones like progestin-only pills (POPs) and long-acting ones like intrauterine devices and subdermal implants that release progestogens.We gathered information from 653 women and assessed how women's contraceptive choices changed before and after they had a consultation with us.After consulting with our clinic, a significant number of women switched from less effective contraceptives to more effective ones. Among the women who used POPs, most of them followed the prescribed regimen quite well. Additionally, 89 women used long-acting contraceptives, without failure of method.In conclusion, our findings suggest that long-acting progestogen-only contraceptives are safe and effective choices for contraception in women with CHD. Therefore, these options should be considered as the first choice.
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Cardiopatías Congénitas , Progestinas , Embarazo , Humanos , Femenino , Estudios Retrospectivos , Anticoncepción , Anticonceptivos Orales CombinadosRESUMEN
Right ventricular (RV) resynchronization therapy (CRT) with stimulation electrode implantation in the latest activation area guided by a high-density electroanatomic activation map was successfully performed in a patient with repaired tetralogy of Fallot (rToF), severe pulmonary regurgitation (PR), and severe dysfunction and dilatation of the right ventricle. An improvement in his clinical condition and intraventricular synchrony was achieved. There is a mechanical-electrical interaction in the right ventricle of patients with rToF; therefore, RV CRT in selected cases may be beneficial. Electroanatomic activation mapping can help achieve maximum clinical benefit by identifying the optimal stimulation site.
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Desfibriladores Implantables , Tetralogía de Fallot/cirugía , Disfunción Ventricular Derecha/fisiopatología , Disfunción Ventricular Derecha/terapia , Mapeo Epicárdico , Humanos , Masculino , Persona de Mediana EdadRESUMEN
Aim: Intra-atrial re-entrant tachycardia (IART) is a common complication in patients with congenital heart disease (CHD) and is related to increased morbidity and mortality. Few reports have been published about factors associated to IART severity. The aim of this study is to analyse factors associated to severe clinical presentation of IART. Methods and Results: Observational study of all consecutive CHD patients who underwent a first IART ablation from January 2009 to December 2015 (94 patients, 39.4% female, and age: 36.55 ± 14.9 years). Severe clinical presentation was defined as heart failure, syncope, shock, electromechanical dissociation (EMD), or aborted sudden death. The majority of patients had moderately or highly complex cardiac defect (90.4%). Types of IART included cavotricuspid isthmus(CTI) dependent in 51% (48), non-CTI-related in 22.3% (20), and both types in 27.7% (26). In 38 patients (40.4%), a severe event occurred and in 16 (17%), the symptoms included shock, syncope, sudden death, or EMD. In 21 (22.3%), severe symptoms were the first manifestation of IART. In multivariate analysis, transposition of the great arteries (TGA) with right systemic ventricle (OR 5.32, 95% C.I. 1.6-7.02, P = 0.0005) and severe dilation of the venous atrium (VsA) (OR 4.17; 95% CI 1.4-8.12, P = 0.0009) were factors independently associated with severity. Conclusion: In our series of 94 CHD patients with a high proportion of moderately to highly complex cardiac defects, severe consequences of IART were frequent. Transposition of the great arteries with systemic right ventricle and severe dilation of VsA were independently associated to severity. Early invasive procedures should be considered for these high-risk patients.
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Cardiopatías Congénitas/complicaciones , Taquicardia Supraventricular/etiología , Potenciales de Acción , Adulto , Ablación por Catéter , Ecocardiografía , Electrocardiografía , Técnicas Electrofisiológicas Cardíacas , Femenino , Cardiopatías Congénitas/diagnóstico , Frecuencia Cardíaca , Humanos , Masculino , Persona de Mediana Edad , Medición de Riesgo , Factores de Riesgo , Índice de Severidad de la Enfermedad , Taquicardia Supraventricular/diagnóstico , Taquicardia Supraventricular/fisiopatología , Taquicardia Supraventricular/cirugía , Factores de Tiempo , Resultado del Tratamiento , Adulto JovenRESUMEN
INTRODUCTION: A growing number of patients with congenital heart disease (CHD) will reach adulthood. Infective endocarditis (IE) is a major complication in this population. The aim of this study was to describe the features of IE in adults with CHD treated in a reference centre. METHODS: A retrospective review was performed on a cohort of patients over 16 years of age with CHD who presented with IE (defined by the modified Duke criteria) between 1996 and 2014. Only the first episode from each patient was considered for the descriptive analysis. RESULTS: IE was observed in 27 patients. The median age at diagnosis of IE was 27.7 years, and 63% were male. Comorbidity was low (median Charlson index was 0). IE was mostly community-acquired (78%). The most frequent CHD were ventricular septal defect (33%). A repair was performed in 48% of patients, and 19% received palliative treatment. Forty-one percent of patients had some type of prosthesis. A residual defect was observed in 81%. The IE was detected in the right side of 44% of the patients. The most frequent aetiological agents were viridans group streptococci (41%) and Staphylococcus epidermidis (30%). Surgery was required to treat IE in 37% of patients. There were five re-infections and three relapses. Two patients died, both as a result of recurrence. CONCLUSIONS: IE in adults with CHD occurred in young patients, and almost all of them carried some prosthetic material or a residual defect. The IE is frequently right-sided. Although surgical treatment was required in many cases, mortality was low, except in the case of relapses.
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Endocarditis Bacteriana/complicaciones , Cardiopatías Congénitas/complicaciones , Adolescente , Adulto , Endocarditis Bacteriana/microbiología , Femenino , Humanos , Masculino , Estudios Retrospectivos , Estreptococos ViridansRESUMEN
OBJECTIVES: To describe the aortic-related risks associated with pregnancy in women with bicuspid aortic valve (BAV) and to evaluate changes in aortic diameter in pregnancy. METHODS: Prospective observational study of patients with BAV from a single-site registry of pregnant women with structural heart disease between 2013 and 2020. Cardiac, obstetric and neonatal outcomes were studied. An assessment of aortic dimensions was performed during pregnancy by two-dimensional echocardiography. Aortic diameters were measured at the annulus, root, sinotubular junction and maximum ascending aorta diameter, and the largest diameter was used. Measurements of the aorta were made using the end-diastolic leading edge-to-leading edge convention. RESULTS: Forty-three women (32.9 years, IQR 29.6-35.3) with BAV were included: 9 (20.9%) had repaired aortic coarctation; 23 (53.5%) had moderate or severe aortic valve disease; 5 (11.6%) had a bioprosthetic aortic valve; and 2 (4.7%) had a mechanical prosthetic aortic valve. Twenty (47.0%) were nulliparous. The mean aortic diameter in the first trimester was 38.5 (SD 4.9) mm, and that in the third trimester was 38.4 (SD 4.8) mm. Forty (93.0%) women had an aortic diameter of <45 mm; 3 (7.0%) had 45-50 mm; and none had >50 mm. Three women (6.9%) with BAV presented cardiovascular complications during pregnancy or the postpartum period (two prosthetic thrombosis and one heart failure). No aortic complications were reported. There was a small but significant increase in aortic diameter during pregnancy (third trimester vs first trimester, 0.52 (SD 1.08) mm; p=0.03). Obstetric complications appeared in seven (16.3%) of pregnancies, and there were no maternal deaths. Vaginal non-instrumental delivery was performed in 21 (51.2%) out of 41 cases. There were no neonatal deaths, and the mean newborn weight was 3130 g (95% CI 2652 to 3380). CONCLUSIONS: Pregnancy in BAV women had a low rate of cardiac complications with no aortic complications observed in a small study group. Neither aortic dissection nor need for aortic surgery was reported. A low but significant aortic growth was observed during pregnancy. Although requiring follow-up, the risk of aortic complications in pregnant women with BAV and aortic diameters of <45 mm at baseline is low.
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Estenosis de la Válvula Aórtica , Enfermedad de la Válvula Aórtica Bicúspide , Enfermedades de las Válvulas Cardíacas , Embarazo , Recién Nacido , Humanos , Femenino , Masculino , Enfermedades de las Válvulas Cardíacas/diagnóstico , Enfermedades de las Válvulas Cardíacas/diagnóstico por imagen , Aorta/diagnóstico por imagen , Válvula Aórtica/diagnóstico por imagen , Válvula Aórtica/cirugía , Estenosis de la Válvula Aórtica/cirugía , Estudios RetrospectivosRESUMEN
INTRODUCTION AND OBJECTIVES: Risk stratification of ventricular arrhythmias in patients with repaired tetralogy of Fallot (rTOF) remains unresolved. We aimed to identify right ventricular (RV) electrophysiological parameters potentially associated with a higher risk of ventricular arrhythmias in patients with rTOF. METHODS: We included all consecutive patients with rTOF who underwent RV electroanatomical mapping at a single tertiary center. We used logistic regression modeling to identify those variables associated with an increased risk of clinical or induced ventricular tachycardia (VT), or clinical VT exclusively. RESULTS: Twenty-one of the 56 patients included had clinical or induced VT. A high-frequency of premature ventricular contractions/nonsustained VT (OR, 11.34; 95%CI, 1.50-85.97; P=.019), an HV interval > 55 ms (OR, 21.20; 95%CI, 3.12-144.14; P=.002), and RV activation time (ms) (OR [per 10ms intervals], 1.34; 95%CI, 1.02-1.75; P=.035) proved to be associated with clinical or induced VT. The model including this information had good discrimination ability, with an area under the curve of 0.884 (95%CI, 0.79-0.97; P <.001). When considering only clinical VT as the outcome of interest, only an HV interval > 55ms (OR, 9.65; 95%CI, 1.41-66.14; P=.021) and high-frequency of premature ventricular contractions/nonsustained VT (OR, 13.14; 95%CI, 1.95-88.54; P=.008) were independently associated (area under the curve of 0.836 [95%CI, 0.663-1.000; P=.002]). CONCLUSIONS: High-frequency of premature ventricular contractions/nonsustained VT, an HV interval> 55ms and RV activation time are factors associated with an increased risk of ventricular arrhythmias in patients with rTOF.
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Taquicardia Ventricular , Tetralogía de Fallot , Complejos Prematuros Ventriculares , Ventrículos Cardíacos/diagnóstico por imagen , Humanos , Medición de Riesgo , Taquicardia Ventricular/diagnóstico , Taquicardia Ventricular/epidemiología , Taquicardia Ventricular/etiología , Tetralogía de Fallot/cirugía , Complejos Prematuros Ventriculares/diagnóstico , Complejos Prematuros Ventriculares/epidemiología , Complejos Prematuros Ventriculares/etiologíaRESUMEN
OBJECTIVES: To develop, calibrate, test and validate a logistic regression model for accurate risk prediction of sudden cardiac death (SCD) and non-fatal sudden cardiac arrest (SCA) in adults with congenital heart disease (ACHD), based on baseline lesion-specific risk stratification and individual's characteristics, to guide primary prevention strategies. METHODS: We combined data from a single-centre cohort of 3311 consecutive ACHD patients (50% male) at 25-year follow-up with 71 events (53 SCD and 18 non-fatal SCA) and a multicentre case-control group with 207 cases (110 SCD and 97 non-fatal SCA) and 2287 consecutive controls (50% males). Cumulative incidences of events up to 20 years for specific lesions were determined in the prospective cohort. Risk model and its 5-year risk predictions were derived by logistic regression modelling, using separate development (18 centres: 144 cases and 1501 controls) and validation (two centres: 63 cases and 786 controls) datasets. RESULTS: According to the combined SCD/SCA cumulative 20 years incidence, a lesion-specific stratification into four clusters-very-low (<1%), low (1%-4%), moderate (4%-12%) and high (>12%)-was built. Multivariable predictors were lesion-specific cluster, young age, male sex, unexplained syncope, ischaemic heart disease, non-life threatening ventricular arrhythmias, QRS duration and ventricular systolic dysfunction or hypertrophy. The model very accurately discriminated (C-index 0.91; 95% CI 0.88 to 0.94) and calibrated (p=0.3 for observed vs expected proportions) in the validation dataset. Compared with current guidelines approach, sensitivity increases 29% with less than 1% change in specificity. CONCLUSIONS: Predicting the risk of SCD/SCA in ACHD can be significantly improved using a baseline lesion-specific stratification and simple clinical variables.
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Muerte Súbita Cardíaca/epidemiología , Muerte Súbita Cardíaca/etiología , Cardiopatías Congénitas/complicaciones , Adulto , Estudios de Casos y Controles , Femenino , Humanos , Incidencia , Modelos Logísticos , Masculino , Persona de Mediana Edad , Pronóstico , Estudios Prospectivos , Medición de RiesgoRESUMEN
BACKGROUND: Three-dimensional (3D) substrate characterization by high-resolution late gadolinium enhancement cardiac magnetic resonance (LE-CMR) is useful for guiding ventricular tachycardia ablation of the left ventricle in ischemic heart disease. OBJECTIVE: The purpose of this study was to validate the substrate characterization and 3D reconstruction of LE-CMR images of the right ventricle (RV) in patients with repaired tetralogy of Fallot (rTOF) and to identify the algorithm that best fits with electroanatomic mapping (EAM). METHODS: RV LE-CMR images were compared with RV EAM in 10 patients with rTOF. RV LE-CMR images were postprocessed and analyzed to identify fibrotic tissue on 3D color maps. The 3D RV substrate reconstructions were created using an adjustable percentage of the maximum voxel signal intensity (MSI) of the scar region to define the threshold between core, transitional zone (TZ), and healthy tissue. Extensions of the core and TZ areas were compared with the scar (<0.5 mV) and low-voltage (0.5-1.5 mV) areas obtained by RV EAM. Agreement on anatomic isthmi identification was quantified. RESULTS: The best match between core and scar was obtained at 65% MSI cutoff (mean areas 17.4 ± 9.9 cm2 vs 16.9 ± 10.0 cm2, respectively; r = 0.954; P <.001). Agreement on anatomic isthmi identification was best at 60% MSI cutoff, which identified 95% of isthmi and achieved a total fit in 90% of patients. CONCLUSION: This study demonstrates that characterization of the RV substrate by postprocessing LE-CMR images in rTOF patients is feasible and validates the technique against RV EAM, which could help in planning target ablation.
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Imagen por Resonancia Cinemagnética/métodos , Tetralogía de Fallot/diagnóstico por imagen , Tetralogía de Fallot/cirugía , Disfunción Ventricular Derecha/diagnóstico por imagen , Adulto , Algoritmos , Medios de Contraste , Mapeo Epicárdico , Femenino , Humanos , Interpretación de Imagen Asistida por Computador , Imagenología Tridimensional , Masculino , Persona de Mediana Edad , Compuestos OrganometálicosRESUMEN
INTRODUCTION AND OBJECTIVES: Although pulmonary valve stenosis (PVS) is considered a low risk congenital heart disease, there have been reports of complications and the need for reintervention throughout follow-up. The aims of this study were to evaluate the long-term outcome of repaired PVS and to identify predictors of cardiovascular complications and reintervention. METHODS: We studied 158 adult patients with repaired PVS (repair procedures performed from 1957 to 2010) receiving active follow-up in a tertiary referral center. RESULTS: A total of 95 patients (60%) received surgical treatment, and 63 patients (40%) received percutaneous pulmonary balloon valvuloplasty. At the end of follow-up (27 years, IQR, 20-33 years), most patients (n=134, 84.8%) were in New York Heart Association functional class I, but 61 patients (38.6%) required a reintervention, mainly pulmonary valve replacement (17.7%, n=28), and 19 patients (12%) had at least one cardiovascular complication: 13 (8.2%) supraventricular arrhythmias, 6 (3.8%) heart failure, 5 (3.2%) stroke, 1 (0.6%) death, 1 (0.6%) thromboembolism, and 1 (0.6%) ventricular arrhythmia. Multivariate analysis showed that age at PVS repair (HR, 1.08; 95%CI, 1.04-1.12; P <.001) and the presence of cyanosis before PVS repair (HR, 5.23; 95%CI, 1.99-13.78; P=.001) were independent predictors for cardiovascular complications. CONCLUSIONS: Good long-term outcome can be expected after PVS repair, but complications and the need for reintervention may appear. Older age and the presence of cyanosis at PVS repair emerged as predictors of cardiovascular complications and identified a population that may merit stricter control.
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Procedimientos Quirúrgicos Cardíacos/métodos , Estenosis de la Válvula Pulmonar/cirugía , Válvula Pulmonar/diagnóstico por imagen , Adulto , Ecocardiografía , Femenino , Estudios de Seguimiento , Humanos , Masculino , Estenosis de la Válvula Pulmonar/diagnóstico , Estudios Retrospectivos , Factores de Tiempo , Resultado del Tratamiento , Adulto JovenRESUMEN
BACKGROUND: Renal insufficiency in patients with ischemic heart disease and acquired heart failure is associated with higher mortality and morbidity. We studied the prevalence of renal dysfunction in adult patients with congenital heart disease (ACHD) and its relation to outcome. METHODS AND RESULTS: A total of 1102 adult patients with congenital heart disease (age 36.0+/-14.2 years) attending our institution between 1999 and 2006 had creatinine concentration measured. Glomerular filtration rate (GFR) was calculated with the Modification of Diet in Renal Disease equation. Patients were divided into groups of normal GFR (> or =90 mL . min(-1) . 1.73 m(-2)), mildly impaired GFR (60 to 89 mL . min(-1) . 1.73 m(-2)), and moderately/severely impaired GFR (<60 mL . min(-1) . 1.73 m(-2)). Survival was compared between GFR groups by Cox regression. Median follow-up was 4.1 years, during which 103 patients died. Renal dysfunction was mild in 41% of patients and moderate or severe in 9%. A decrease in GFR was more common among patients with Eisenmenger physiology, of whom 72% had reduced GFR (<90 mL . min(-1) . 1.73 m(-2), P<0.0001 compared with the remainder), and in 18%, this was moderate or severe (P=0.007). Renal dysfunction had a substantial impact on mortality (propensity score-weighted hazard ratio 3.25, 95% CI 1.54 to 6.86, P=0.002 for moderately or severely impaired versus normal GFR). CONCLUSIONS: Deranged physiology in adult patients with congenital heart disease is not limited to the heart but also affects the kidney. Mortality is 3-fold higher than normal in the 1 in 11 patients who have moderate or severe GFR reduction.
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Cardiopatías Congénitas/diagnóstico , Cardiopatías Congénitas/epidemiología , Insuficiencia Renal/diagnóstico , Insuficiencia Renal/epidemiología , Adulto , Femenino , Estudios de Seguimiento , Tasa de Filtración Glomerular/fisiología , Cardiopatías Congénitas/fisiopatología , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Prevalencia , Pronóstico , Insuficiencia Renal/fisiopatologíaRESUMEN
BACKGROUND: Intra-atrial re-entrant tachycardia (IART) in patients with congenital heart disease (CHD) increases morbidity and mortality. Radiofrequency catheter ablation has evolved as the first-line treatment. The aim of this study was to analyze the acute success and to identify predictors of failed IART radiofrequency catheter ablation in CHD. METHODS AND RESULTS: The observational study included all consecutive patients with CHD who underwent a first ablation procedure for IART at a single center from January 2009 to December 2015 (94 patients, 39.4% female, age: 36.55±14.9 years). In the first procedure, 114 IART were ablated (acute success: 74.6%; 1.21±0.41 IART per patient) with an acute success of 74.5%. Cavotricuspid isthmus-related IART was the only arrhythmia in 51%; non-cavotricuspid isthmus-related IART was the only mechanism in 27.7% and 21.3% of the patients had both types of IART. Predictors of acute radiofrequency catheter ablation failure were as follows: nonrelated cavotricuspid isthmus IART (odds ratio 7.3; confidence interval [CI], 1.9-17.9; P=0.04), previous atrial fibrillation (odds ratio 6.1; CI, 1.3-18.4; P=0.02), transposition of great arteries (odds ratio, 4.9; CI, 1.4-17.2; P=0.01) and systemic ventricle dilation (odds ratio 4.8; CI, 1.1-21.7; P=0.04) with an area under the receiver operating characteristic curve of 0.83±0.056 (CI, 0.74-0.93, P=0.001). After a mean follow-up longer than 3.5 years, 78.3% of the patients were in sinus rhythm (33.1% of the patients required more than 1 radiofrequency catheter ablation procedure). CONCLUSIONS: Although ablation in CHD is a challenging procedure, acute success of 75% can be achieved in moderate-highly complex CHD patients in a referral center. Predictors of failed ablation are IART different from cavotricuspid isthmus, previous atrial fibrillation, and markers of complex CHD (transposition of great arteries, systemic ventricle dilation).
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Fibrilación Atrial/complicaciones , Aleteo Atrial/complicaciones , Cardiopatías Congénitas/complicaciones , Ablación por Radiofrecuencia/efectos adversos , Taquicardia Supraventricular/cirugía , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/fisiopatología , Aleteo Atrial/diagnóstico , Aleteo Atrial/fisiopatología , Niño , Preescolar , Ecocardiografía , Electrocardiografía , Técnicas Electrofisiológicas Cardíacas , Femenino , Cardiopatías Congénitas/diagnóstico , Cardiopatías Congénitas/fisiopatología , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Estudios Retrospectivos , Factores de Riesgo , Taquicardia Supraventricular/diagnóstico , Taquicardia Supraventricular/etiología , Taquicardia Supraventricular/fisiopatología , Factores de Tiempo , Insuficiencia del Tratamiento , Adulto JovenRESUMEN
Intra-atrial re-entrant tachycardia (IART) is a severe complication in patients with congenital heart disease (CHD). Cavotricuspid isthmus (CTI)-related IART is the most frequent mechanism. However, due to fibrosis and surgical scars, non-CTI-related IART is frequent. The main objective of this study was to describe the types of IART, circuit locations, and to analyze predictors of CTI versus non-CTI-related IART. This is an observational study that includes all consecutive patients with CHD who underwent a first IART ablation in a single referral tertiary hospital from January 2009 to December 2015 (94 patients; 39.4% women; age: 36.55 ± 14.9 years, 40.4% with highly complex cardiac disease). During the study, 114 IARTs were ablated (1.21 ± 0.41 IARTs per patient). CTI-related IART was the only arrhythmia in 51% (nâ¯=â¯48) of patients; non-CTI-related IART was the only mechanism in 27.7% (nâ¯=â¯26), and 21.3% of patients (nâ¯=â¯20) presented the two types of IART. Severe dilation of the systemic ventricle, absence of severe dilation of the venous atrium, highly complex cardiac defects, and nontypical electrocardiography (ECG) were related to non-CTI-related IART in univariate analysis. In multivariate analysis, nontypical ECG (odds ratio 3.64; 1.01 to 4.9; pâ¯=â¯0.049) and grade III CHD complexity (odds ratio 9.43; 1.44 to 11.7; pâ¯=â¯0.001) were predictors of non-CTI-related IART. In conclusion, in our population with a high proportion of complex CHD, CTI-related IART was the most frequent mechanism, although non-CTI-related IART was present in 49% (alone or with concomitant CTI-related IART). High-grade CHD complexity and nontypical ECG were strongly related to non-CTI IART.
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Electrocardiografía/métodos , Atrios Cardíacos/fisiopatología , Sistema de Conducción Cardíaco/fisiopatología , Cardiopatías Congénitas/complicaciones , Frecuencia Cardíaca/fisiología , Taquicardia por Reentrada en el Nodo Sinoatrial/etiología , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Ablación por Catéter/métodos , Niño , Preescolar , Femenino , Estudios de Seguimiento , Atrios Cardíacos/diagnóstico por imagen , Cardiopatías Congénitas/diagnóstico , Humanos , Masculino , Persona de Mediana Edad , Pronóstico , Estudios Retrospectivos , Taquicardia por Reentrada en el Nodo Sinoatrial/diagnóstico , Taquicardia por Reentrada en el Nodo Sinoatrial/cirugía , Adulto JovenRESUMEN
OBJECTIVES: The aim of this study was to analyze the long-term outcomes after intra-atrial re-entrant tachycardia (IART) ablation in congenital heart disease (CHD). BACKGROUND: IART increases morbidity and mortality in CHD patients. Radiofrequency catheter ablation has evolved into the first-line treatment of this complication. METHODS: This was a prospective, single-center study of all consecutive CHD patients who underwent first ablation for IART from January 2009 to December 2015 (n = 94, 39.4% female, age 36.55 ± 14.9 years, follow-up 44.45 ± 22.7 months). RESULTS: During the study period, 130 procedures were performed (n = 94, 1.21 ± 0.41 IART/patient). In the first procedure, 114 IART were ablated (short-term success 74.66%). Forty-nine percent of the patients whose IART was ablated had non-cavotricuspid isthmus (CTI)-related IART (alone or with concomitant CTI IART). After the first ablation, 54.3% maintained sinus rhythm (SR), 23.9% presented with recurrence of the ablated IART, 14.2% developed new IART, and 7.6% presented with atrial fibrillation (AF). After the second radiofrequency catheter ablation, 78.3% were in SR, 8.7% presented with AF, and 23.0% presented with IART (50% new IART). Multivariate predictors of recurrences were non-CTI IART (hazard ratio [HR]: 5.06; 95% confidence interval [CI]: 1.6 to 15.9; p = 0.006), PR interval >200 ms (HR: 4.02; 95% CI: 1.9 to 11.3; p = 0.009), AF induction (HR: 3.11; 95% CI: 1.1 to 9.1; p = 0.04). and previous AF (HR: 3.08; 95% CI: 1.1 to 9.3; p = 0.04). A risk score according multivariate model identified 3 levels of recurrence risk: 5.8%, 20%, and 58.5% (area under the receiver-operating characteristic curve 0.8 ± 0.03; p < 0.0001). CONCLUSIONS: Ablation of IART in CHD is a challenging procedure, but after ablation in experienced centers, SR can be maintained in 78.3%. Predictors of recurrences are non-CTI-related IART, long PR interval, and previous or induced AF. A risk score based on these factors can be useful for recurrence prediction.
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Aleteo Atrial , Ablación por Catéter , Cardiopatías Congénitas , Adulto , Aleteo Atrial/epidemiología , Aleteo Atrial/cirugía , Ablación por Catéter/efectos adversos , Ablación por Catéter/estadística & datos numéricos , Femenino , Cardiopatías Congénitas/complicaciones , Cardiopatías Congénitas/epidemiología , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Recurrencia , Adulto JovenRESUMEN
OBJECTIVES: Infective endocarditis (IE) and cardiac device infection (CDI) are a major complication in the growing number of patients with congenital heart disease (CHD) reaching adulthood. We aimed to evaluate the added value of 18F-FDG-PET/CT angiography (PET/CTA) in the diagnosis of IE-CDI in adults with CHD and intravascular or intracardiac prosthetic material, in whom echocardiography (ECHO) and modified Duke Criteria (DC) have limitations because of the patients' complex anatomy. METHODS: A prospective study was conducted in a referral center with multidisciplinary IE and CHD Units. PET/CTA and ECHO findings were compared in consecutive adult (≥18years) patients with CHD who have prosthetic material and suspected IE-CDI. The initial diagnosis using the DC and the diagnosis with the additional PET/CTA data (DC+PET/CTA) were compared with the final diagnostic consensus established by an expert team at three months. RESULTS: Between November-2012 and April-2017, 25 patients (15 men; median age 40years) were included. Cases were initially classified as definite in 8 (32%), possible in 14 (56%) and rejected in 3 (12%). DC+PET/CTA allowed reclassification of 12/14 (86%) cases initially identified as possible IE. The sensitivity, specificity, PPV, NPV, and accuracy of DC at IE suspicion were 39.1%/83.3%/90.4%/25.5%/61.2%, respectively. The diagnostic performance increased significantly with addition of PET/CTA data: 87%/83.3%/95.4%/61.5%/85.1%, respectively. PET/CTA also provided an alternative diagnosis in 3 patients with rejected IE, and detected pulmonary embolisms in 3 patients. CONCLUSIONS: PET/CTA was a useful diagnostic tool in the complex group of adult patients with CHD who have cardiac or intravascular prosthetic material and suspected IE or CDI, providing added diagnostic value to the modified DC (increased sensitivity) and improving case classification.
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Endocarditis Bacteriana/diagnóstico por imagen , Endocarditis Bacteriana/etiología , Contaminación de Equipos , Fluorodesoxiglucosa F18 , Prótesis Valvulares Cardíacas/microbiología , Tomografía Computarizada por Tomografía de Emisión de Positrones/métodos , Adulto , Endocarditis/diagnóstico por imagen , Endocarditis/etiología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios ProspectivosRESUMEN
Pregnancy and delivery are associated with substantial physiological changes that require adaptations in the cardiovascular system. These changes, well-tolerated in pregnant women without heart disease, expose woman with cardiovascular disease to serious risk. In fact, heart disease is the most frequent cause of maternal death, after psychiatric disorders, and the number of pregnant women with heart disease is expected to grow in the coming years. Preventing cardiovascular complications should be the main aim of every cardiologist involved in managing pregnant woman with congenital or acquired heart disease. Unfortunately, there is a lack of data which would help in the management of these patients during pregnancy and the clinical practice guidelines are often based on assumptions regarding how a specific substrate is going to respond to the physiological changes occurring due to pregnancy.
Asunto(s)
Cardiopatías/diagnóstico , Cardiopatías/terapia , Complicaciones Cardiovasculares del Embarazo/diagnóstico , Complicaciones Cardiovasculares del Embarazo/terapia , Fármacos Cardiovasculares/uso terapéutico , Femenino , Cardiopatías/fisiopatología , Pruebas de Función Cardíaca , Humanos , Embarazo , Complicaciones Cardiovasculares del Embarazo/fisiopatología , Resultado del Embarazo , Factores de RiesgoRESUMEN
OBJECTIVES: The objective of this study is to evaluate obstetric outcomes in women with heart disease and determine whether current multidisciplinary management approaches adversely affect the mother, the neonate, or both. Also to compare the accuracy of several risk scores (RS) including the modified World Health Organization classification (mWHO) and CARPREG to predict obstetric and neonatal complications and to study the addition value of Uteroplacental-Doppler flow (UDF) parameters to predict obstetric complications. METHODS: A prospective cohort study examined outcomes in women with heart disease (HD), the majority of whom had corrective surgery and delivered between January 2007 and March 2012. RESULTS: One hundred and seventy-four patients with 179 pregnancies were included in the study. Obstetric complications, including premature labor, arose in 87 patients (48.6%). Neonatal complications were observed in 11 cases (7%). On multivariate analysis, maternal heart disease was predictive of adverse perinatal events (46 cases, 25.7%) and mode of delivery (Thierry's spatula) of third- or fourth-degree perineal tears (six cases, 3.2%). mWHO classification predicted obstetric complications (p = 0.0001) better than the CARPREG study. Impaired UDF (uterine artery pulsatility index-20 weeks and umbilical artery pulsatility index-32 weeks in HD versus healthy women: 20w 1.12 versus 1.34, p = 0.005; 32w 0.87 versus 1.09, p = 0.008) was associated with adverse obstetric and offspring outcome in the group of HD pregnant women. CONCLUSIONS: Nearly 50% of pregnancies were associated with an adverse obstetric outcome, particularly IUGR. mWHO was better at predicting obstetric and neonatal complications that CARPREG in all categories. Furthermore, compromised UDF combined with mWHO improved the prediction of obstetric and offspring complications in this population.
Asunto(s)
Cardiopatías/epidemiología , Complicaciones Cardiovasculares del Embarazo/epidemiología , Adulto , Cesárea/estadística & datos numéricos , Bases de Datos Factuales , Parto Obstétrico/efectos adversos , Enterocolitis/epidemiología , Femenino , Retardo del Crecimiento Fetal/epidemiología , Cardiopatías/complicaciones , Humanos , Recién Nacido , Unidades de Cuidado Intensivo Neonatal/estadística & datos numéricos , Análisis Multivariante , Perineo/lesiones , Hemorragia Posparto/epidemiología , Embarazo , Nacimiento Prematuro/epidemiología , Estudios Prospectivos , Flujo Pulsátil/fisiología , Síndrome de Dificultad Respiratoria del Recién Nacido/epidemiología , España/epidemiología , Arterias Umbilicales/fisiopatología , Arteria Uterina/fisiopatología , Inercia Uterina/epidemiologíaRESUMEN
OBJECTIVES: In the general population, planned caesarean section is thought to be safer in high-risk situations as it avoids the greater risk of an emergency caesarean section. Only limited data exist on the optimal mode of delivery in women with structural heart disease. We investigated the relationship between mode of delivery and pregnancy outcome in women with pre-existing heart disease. METHODS: The Registry on Pregnancy and Cardiac Disease is an on-going, global, prospective observational registry of women with structural heart disease. We report on 1262 deliveries, between January 2007 and June 2011. RESULTS: The caesarean section was planned in 393 women (31%): 172 (44%) for cardiac and 221 (56%) for obstetric reasons of whom 53 delivered by emergency caesarean section. Vaginal delivery was planned in 869 (69%) women, of whom 726 (84%) actually delivered vaginally and 143 (16%) had an emergency caesarean section. Perinatal mortality(1.1 vs 2.7, p=0.14) and low apgar score (11.9 vs 10.1, p=0.45) were not significantly different in women who had a caesarean section or vaginal delivery; gestational age(37 vs 38â weeks p=0.003) and birth weight (3073 vs 2870â g p<0.001) were lower in women delivered by caesarean section compared with women delivered by vaginal delivery. In those delivered by elective or emergency caesarean section, there was no difference in maternal mortality (1.8% vs 1.5%, p=1.0), postpartum heart failure (8.8% vs 8.2% p=0.79) or haemorrhage (6.2% vs 5.1% p=0.61). CONCLUSIONS: These data suggest that planned caesarean section does not confer any advantage over planned vaginal delivery, in terms of maternal outcome, but is associated with an adverse fetal outcome.
Asunto(s)
Cesárea , Cardiopatías , Complicaciones Cardiovasculares del Embarazo , Adolescente , Adulto , Femenino , Humanos , Persona de Mediana Edad , Embarazo , Estudios Prospectivos , Adulto JovenRESUMEN
Pulmonary valve replacement (PVR) reduces right ventricular (RV) volumes in the setting of long-term pulmonary regurgitation after Tetralogy of Fallot (ToF) repair; however, little is known of its effect on RV diastolic function. Right atrial volumes may reflect the burden of RV diastolic dysfunction. The objective of this paper is to evaluate the clinical, echocardiographic, biochemical and cardiac magnetic resonance (CMR) variables, focusing particularly on right atrial response and right ventricular diastolic function prior to and after elective PVR in adult patients with ToF. This prospective study was conducted from January 2009 to April 2013 in consecutive patients > 18 years of age who had undergone ToF repair in childhood and were accepted for elective PVR. Twenty patients (mean age: 35 years; 70% men) agreed to enter the study. PVR was performed with a bioporcine prosthesis. Concomitant RV reduction was performed in all cases when technically possible. Pulmonary end-diastolic forward flow (EDFF) decreased significantly from 5.4 ml/m(2) to 0.3 ml/m(2) (p < 0.00001), and right atrial four-chamber echocardiographic measurements and volumes by 25% (p = 0.0024): mean indexed diastolic/systolic atrial volumes prior to surgery were 43 ml/m(2) (SD+/-4.6)/63 ml/m(2) (SD+/-5.5), and dropped to 33 ml/m(2) (SD+/-3)/46 ml/m(2) (SD+/-2.55) post-surgery. All patients presented right ventricular diastolic and systolic volume reductions, with a mean volume reduction of 35% (p < 0.00001). Right ventricular diastolic dysfunction was common in a population of severely dilated RV patients long term after ToF repair. Right ventricular diastolic parameters improved as did right atrial volumes in keeping with the known reduction in RV volumes, after PVR.
Asunto(s)
Volumen Cardíaco/fisiología , Atrios Cardíacos/fisiopatología , Implantación de Prótesis de Válvulas Cardíacas , Insuficiencia de la Válvula Pulmonar/cirugía , Válvula Pulmonar/cirugía , Tetralogía de Fallot/complicaciones , Función Ventricular Derecha/fisiología , Adulto , Ecocardiografía , Femenino , Estudios de Seguimiento , Atrios Cardíacos/diagnóstico por imagen , Humanos , Masculino , Estudios Prospectivos , Insuficiencia de la Válvula Pulmonar/etiología , Insuficiencia de la Válvula Pulmonar/fisiopatología , Volumen Sistólico , Tetralogía de Fallot/fisiopatología , Tetralogía de Fallot/cirugía , Resultado del TratamientoRESUMEN
The objective of the study is to report the contraceptive methods used by patients with congenital heart disease (CHD) before referral to a specific preconception clinic and evaluate safety and treatment adherence of the alternative contraception method, progesterone-only component (PC), offered. Contraceptive methods in the CHD population reported included estrogen-progesterone combined contraceptives (EPCC), despite the potential risk for thromboembolism. PC has been suggested as an alternative, but, no information on its use has been reported. Retrospective analysis was performed of all patients (n = 237) referred to the preconception clinic of an adult CHD center. Thirty-three percent of patients had used EPCC in the past; 3.8% had had thromboembolic events during its use. Current contraception consisted of barrier methods in 58% of patients, EPCC in 18%, and PC in 1.3%; 21.7% of patients were not using any contraception. PC was offered as an alternative in 146 patients; 73% of patients agreed to start the treatment. At a median follow-up of 1 year, 73% of patients who started PC maintained the treatment. Gynecologic side effects were reported in 25% of patients, with no cardiovascular effects. In conclusion, a significant proportion of patients with CHD were former users of EPCC, although some had formal contraindications, and the rate of PC use before referral to the preconception clinic was low. After being offered as an alternative treatment, the use of PC in its various forms was extensive, with no thrombogenic side effects and an acceptable rate of gynecologic side effects being reported.