Career perspectives for young cardiologists in the Netherlands: a steady increase in temporary positions.

In the Netherlands, concerns have been raised regarding the high unemployment rates and the lack of permanent positions for young medical specialists. In the current study, we present data on contemporary early career perspectives in the field of cardiology. We conducted a survey among 304 young cardiologists who completed their training between 2015 and 2020; the response rate was 91%. Our analysis revealed a low unemployment rate (0.3%). One, 3 and 5 years after registration, 81%, 41% and 18% of the respondents, respectively, had not gained a permanent position. Having conducted a fellowship significantly delayed the time to permanent position (hazard ratio (HR): 0.48; 95% confidence interval (CI): 0.34-0.67). For those who had conducted a fellowship, holding a PhD degree (HR: 1.95; 95% CI: 1.10-3.44), age (per year increase, HR: 0.90; 95% CI: 0.82-0.99) and training in an academic hospital (HR: 1.97; 95% CI: 1.10-3.52) were of significant influence on the likelihood of having a permanent position at 3 years of follow-up. These results showed a disturbing increase in time to permanent position compared with an earlier analysis. This trend justifies close monitoring of the labour market in the coming years. Solutions for this multifactorial problem in the field of cardiology and across the entire medical specialty spectrum should be explored.

Career perspectives for young cardiologists in the Netherlands: a steady increase in temporary positions.

In the Netherlands, concerns have been raised regarding the high unemployment rates and the lack of permanent positions for young medical specialists. In the current study, we present data on contemporary early career perspectives in the field of cardiology. We conducted a survey among 304 young cardiologists who completed their training between 2015 and 2020; the response rate was 91%. Our analysis revealed a low unemployment rate (0.3%). One, 3 and 5 years after registration, 81%, 41% and 18% of the respondents, respectively, had not gained a permanent position. Having conducted a fellowship significantly delayed the time to permanent position (hazard ratio (HR): 0.48; 95% confidence interval (CI): 0.34-0.67). For those who had conducted a fellowship, holding a PhD degree (HR: 1.95; 95% CI: 1.10-3.44), age (per year increase, HR: 0.90; 95% CI: 0.82-0.99) and training in an academic hospital (HR: 1.97; 95% CI: 1.10-3.52) were of significant influence on the likelihood of having a permanent position at 3 years of follow-up. These results showed a disturbing increase in time to permanent position compared with an earlier analysis. This trend justifies close monitoring of the labour market in the coming years. Solutions for this multifactorial problem in the field of cardiology and across the entire medical specialty spectrum should be explored. Supplementary Information: The online version of this article (10.1007/s12471-022-01736-1) contains supplementary material, which is available to authorized users.

Early career perspectives of young Dutch cardiologists.

BACKGROUND: There are nationwide concerns about the unemployment rate among young Dutch cardiologists and the increase in temporary positions. Therefore, the aim of this study was to investigate the unemployment rate in this subgroup as well as the length of time between the end of their training and the acquisition of a permanent position. METHODS: All cardiologists who completed their training between January 2015 and December 2018 were invited to fill in an online questionnaire about their demographic characteristics, professional profile and employment status. The unemployment rate was calculated and Kaplan-Meier curves were used to determine the time between the end of training and the first permanent contract. RESULTS: In total, 174 participants were included (mean age 35 ± 3 years, 64% male, median follow-up 2.3 years (interquartile range 1.4-3.2 years)). The unemployment rate was 0.6% (n = 1). Only 12 participants (7%) started their career with a permanent position. The percentage of cardiologists with a temporary position was 82%, 61% and 33% at 1, 2 and 3 years, respectively. The percentage of cardiologists with a temporary position did not differ with regard to age, gender, holding a PhD degree or type of teaching institution attended (academic vs non-academic). Forty-four per cent of participants perceived the current job market to be problematic. CONCLUSIONS: The unemployment rate among young cardiologists in the Netherlands was low between 2015 and 2018. The vast majority of cardiologists start their career on a temporary contract. Three years later, 33% still hold temporary positions. Due to the resultant job insecurity, many young cardiologists describe the job market as problematic.

Oral itraconazole for epistaxis in hereditary hemorrhagic telangiectasia: a proof of concept study.

The inhibiting effects of itraconazole, an antifungal drug on vascular endothelial growth factor (VEGF) have recently been discovered. By inhibiting VEGF, itraconazole has shown potential in clinical trials as anti-cancer treatment. In hereditary hemorrhagic telangiectasia (HHT) patients, VEGF levels are elevated and inhibition of VEGF can decrease bleeding. Itraconazole could potentially serve as anti-angiogenic therapy for HHT-related bleeding. We report a proof of concept study with HHT patients and severe epistaxis. Patients were treated with daily 200 mg orally administered itraconazole for sixteen weeks. Twenty-one HHT patients, 8 females (38%), 13 males (62%), median age of 59 years (interquartile range (IQR) 55-69) were enrolled. Of these patients, 13 (62%) were diagnosed with HHT type 1, seven (33%) with HHT type 2 and in one patient (5%), no pathognomonic HHT mutation was found. Four patients (19%) prematurely terminated the study (3 due to mild or moderate side-effects) resulting in 17 patients included in the analyses. The median epistaxis severity score significantly decreased during treatment from 6.0 (IQR 5.1-7.2) to 3.8 (IQR 3.1-5.2) (p = 0.006). The monthly epistaxis frequency decreased from 56 to 38 epistaxis episodes (p = 0.004) and the monthly duration from 407 to 278 minutes (p = 0.005). Hemoglobin levels did not significantly change. The quality of life showed a small but significant improvement. In conclusion, oral itraconazole significantly improved epistaxis in HHT patients. The potential benefit of itraconazole in HHT should be further investigated.

Dutch cardiology residents and the COVID-19 pandemic: Every little thing counts in a crisis.

The COVID-19 pandemic has overwhelmed healthcare systems worldwide, and a large part of regular cardiology care came to a quick halt. A Dutch nationwide survey showed that 41% of cardiology residents suspended their training and worked at COVID-19 cohort units for up to 3 months. With tremendous flexibility, on-call schedules were altered and additional training was provided in order for residents to be directly available where needed most. These unprecedented times have taught them important lessons on crisis management. The momentum is used to incorporate novel tools for patient care. Moreover, their experience of pandemic and crisis management has provided future cardiologists with unique skills. This crisis will not be wasted; however, several challenges have to be overcome in the near future including, but not limited to, a second pandemic wave, a difficult labour market due to an economic recession, and limitations in educational opportunities.

Left atrial appendage closure in atrial fibrillation patients with prior major bleeding or ineligible for oral anticoagulation.

AIMS: Oral anticoagulation (OAC) reduces the ischaemic stroke risk in patients with atrial fibrillation (AF), but in turn leads to an increased risk of adverse bleeding events. Alternatively, left atrial appendage closure (LAAC) using a mechanical device might overcome these bleeding complications. However, evidence regarding LAAC in patients at high bleeding risk is scarce. This study evaluates the clinical features of AF patients with previous bleeding that underwent LAAC. METHODS: In this retrospective cohort study patients with previous major bleeding or a bleeding predisposition scheduled for transcatheter LAAC were included. The frequency and type of previous bleeding events and prevalence of bleeding and ischaemic stroke during follow-up were evaluated. RESULTS: A total of 73 patients (58% male, age 72.1 ± 7.2 years; CHA2DS2-VASc 4.5 [3.0-5.0]; HAS-BLED 4.0 [3.0-4.0]; 46% paroxysmal AF) were included. Previous bleeding occurred from intracranial (n = 50, 69%), gastro-intestinal (n = 13, 18%) or multiple (n = 16, 22%) foci. After OAC discontinuation due to bleeding, 19% suffered subsequent stroke. LAAC was successful in 96% of patients. During a median of almost 3 years' follow-up recurrent major bleeding occurred in 4 patients (5.5%) despite OAC discontinuation in 93.2%. A total of 6 ischaemic strokes were observed, resulting in an annualised stroke rate of 2.9% compared to a calculated expected stroke rate of 6.7%. CONCLUSIONS: Percutaneous LAAC may provide an alternative strategy to long-term OAC therapy in AF patients with a high bleeding risk. During follow-up, both ischaemic stroke and recurrent bleeding rates were lower than expected based on the CHA2DS2-VASc and HAS-BLED scores respectively.

Reproducibility of right-to-left shunt quantification using transthoracic contrast echocardiography in hereditary haemorrhagic telangiectasia.

AIM: Transthoracic contrast echocardiography (TTCE) is recommended for screening of pulmonary arteriovenous malformations (PAVMs) in hereditary haemorrhagic telangiectasia. Shunt quantification is used to find treatable PAVMs. So far, there has been no study investigating the reproducibility of this diagnostic test. Therefore, this study aimed to describe inter-observer and inter-injection variability of TTCE. METHODS: We conducted a prospective single centre study. We included all consecutive persons screened for presence of PAVMs in association with hereditary haemorrhagic telangiectasia in 2015. The videos of two contrast injections per patient were divided and reviewed by two cardiologists blinded for patient data. Pulmonary right-to-left shunts were graded using a three-grade scale. Inter-observer and inter-injection agreement was calculated with κ statistics for the presence and grade of pulmonary right-to-left shunts. RESULTS: We included 107 persons (accounting for 214 injections) (49.5% male, mean age 45.0 ± 16.6 years). A pulmonary right-to-left shunt was present in 136 (63.6%) and 131 (61.2%) injections for observer 1 and 2, respectively. Inter-injection agreement for the presence of pulmonary right-to-left shunts was 0.96 (95% confidence interval (CI) 0.9-1.0) and 0.98 (95% CI 0.94-1.00) for observer 1 and 2, respectively. Inter-injection agreement for pulmonary right-to-left shunt grade was 0.96 (95% CI 0.93-0.99) and 0.95 (95% CI 0.92-0.98) respectively. There was disagreement in right-to-left shunt grade between the contrast injections in 11 patients (10.3%). Inter-observer variability for presence and grade of the pulmonary right-to-left shunt was 0.95 (95% CI 0.91-0.99) and 0.97 (95% CI 0.95-0.99) respectively. CONCLUSION: TTCE has an excellent inter-injection and inter-observer agreement for both the presence and grade of pulmonary right-to-left shunts.

SMAD4 gene mutation increases the risk of aortic dilation in patients with hereditary haemorrhagic telangiectasia.

BACKGROUND: Mutations in the genes ENG, ACVRL1 and SMAD4 that are part of the transforming growth factor-beta signalling pathway cause hereditary haemorrhagic telangiectasia (HHT). Mutations in non-HHT genes within this same pathway have been found to associate with aortic dilation. Therefore, we investigated the presence of aortic dilation in a large cohort of HHT patients as compared to non-HHT controls. METHODS: Chest computed tomography of consecutive HHT patients (ENG, ACVRL1 and SMAD4 mutation carriers) and non-HHT controls were reviewed. Aortic root dilation was defined as a z-score>1.96. Ascending and descending aorta dimensions were corrected for age, gender and body surface area. RESULTS: In total 178 subjects (57.3% female, mean age 43.9±14.9years) were included (32 SMAD4, 47 ENG, 50 ACVRL1 mutation carriers and 49 non-HHT controls). Aortopathy was present in a total of 42 subjects (24% of total). Aortic root dilatation was found in 31% of SMAD4, 2% of ENG, 6% of ACVRL1 mutation carriers, and 4% in non-HHT controls (p<0.001). The aortic root diameter was 36.3±5.2mm in SMAD4 versus 32.7±3.9mm in the non-SMAD4 group (p=0.001). SMAD4 was an independent predictor for increased aortic root (ß-coefficient 3.5, p<0.001) and ascending aorta diameter (ß-coefficient 1.6, p=0.04). CONCLUSIONS: SMAD4 gene mutation in HHT patients is independently associated with a higher risk of aortic root and ascending aortic dilation as compared to other HHT patients and non-HHT controls.

Echocardiographic pulmonary hypertension probability is associated with clinical outcomes after transcatheter aortic valve implantation.

AIMS: Pulmonary hypertension (PH) is associated with mortality after transcatheter aortic valve implantation (TAVI). However, diagnosis based on tricuspid regurgitant velocity (TRV) is often inaccurate and unreliable. The updated PH guidelines introduced a PH probability grading implementing additional PH signs on transthoracic echocardiography (TTE), from which we aimed to analyse its effects on clinical outcomes in patients undergoing TAVI. METHODS AND RESULTS: We included 591 consecutive patients (mean age 80.2±8.4years, 58.0% female, mean STS risk score 6.2±3.8%) undergoing TAVI. Patients were divided into "low" (n=270; TRV ≤2.8m/s without additional PH signs), "intermediate" (n=131; TRV ≤2.8m/s with additional PH signs, or TRV 2.9-3.4m/s without additional PH signs), and "high" PH probability (n=190; TRV 2.9-3.4m/s with additional PH signs, or TRV >3.4m/s). The overall 30-day and 2-year mortality rates were 10.2% and 33.8%, respectively. "High" PH probability was an independent predictor of mortality at 30days (HR 3.68, 95% CI 2.03 to 6.67, p<0.01) and 2years (HR 2.19, 95% CI 1.57 to 3.04, p<0.01), compared to "low" PH probability. The "intermediate" group did not show an increased risk. The presence of additional PH signs resulted in a significantly higher mortality at 30days (19.6% vs. 5.1%, p<0.01) and two years (54.2% vs. 22.5%, p<0.01). CONCLUSIONS: The updated echocardiographic PH probability model incorporating additional PH signs independently predicts early and late mortality after TAVI. Additional PH signs are of great value in assessing one's risks since its presence is strongly associated with early and late mortality.

Direct haemodynamic effects of pulmonary arteriovenous malformation embolisation.

BACKGROUND: Transcatheter embolisation is widely used to close pulmonary arteriovenous malformations (PAVMs) in patients with hereditary haemorrhagic telangiectasia (HHT). Data on the direct cardiovascular haemodynamic changes induced by this treatment are scarce. OBJECTIVES: We investigated the direct haemodynamic effects of transcatheter embolisation of PAVMs, using non-invasive finger pressure measurements. METHODS: During the procedure, blood pressure, heart rate (HR), stroke volume (SV), cardiac output (CO), total peripheral resistance (TPR) and delta pressure/delta time (dP/dt) were continuously monitored using a Finometer®. Potential changes in these haemodynamic parameters were calculated from the pressure registrations using Modelflow® methodology. Absolute and relative changes were calculated and compared using the paired sample t-test. RESULTS: The present study includes 29 HHT patients (mean age 39 ± 15 years, 11 men) who underwent transcatheter embolotherapy of PAVMs. The total number of embolisations was 72 (mean per patient 2.5). Directly after PAVM closure, SV and CO decreased significantly by -11.9 % (p = 0.01) and -9.5 % (p = 0.01) respectively, without a significant change in HR (1.8 %). Mean arterial blood pressure increased by 4.1 % (p = 0.02), while the TPR and dP/dt did not increase significantly (5.8 % and 0.2 %, respectively). CONCLUSIONS: Significant haemodynamic changes occur directly after transcatheter embolisation of PAVMs, amongst which a decrease in stroke volume and cardiac output are most important.