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1.
JAMA Netw Open ; 4(1): e2032095, 2021 01 04.
Artigo em Inglês | MEDLINE | ID: mdl-33394003

RESUMO

Importance: There is little evidence to support patient-centered outcomes in patients with cardiovascular disease. Objective: To derive patient-defined adverse cardiovascular and noncardiovascular events (PACE) through a consensus-based process. Design, Setting, and Participants: This pan-Canadian, consensus-based, qualitative study used an iterative Delphi method to achieve consensus within a 35-member panel consisting of patients with cardiovascular diseases and their caregivers and clinicians. The process included 4 rounds of online questionnaires, followed by an in-person final consensus meeting. Data analysis was performed in September 2019. Main Outcomes and Measures: Defining PACE as a 5-item composite outcome. Results: Thirty-five potential panelists consented to participate, including 11 clinicians (8 men [73%]) and 24 patients and caregivers (13 men [54%]). Twenty-nine (83%), 28 (80%), 26 (74%), and 23 (66%) of the panelists participated in each of respective the online rounds. A shortlist of 11 patient-defined items was further refined at the in-person meeting, which 20 of the panelists attended. The PACE definition that was decided through the consensus process was a composite of severe stroke necessitating hospitalization for 14 days or longer or inpatient rehabilitation, ventilator dependence, new onset or worsening heart failure, nursing home admission, or new onset dialysis. Conclusions and Relevance: This study defined PACE as a versatile, patient-centered outcome through a consensus process with input from patients, caregivers, and clinicians. Given the paucity of patient-centered outcomes in cardiovascular research, PACE may be considered as a potential outcome after methodological evaluation of its reliability.


Assuntos
Doenças Cardiovasculares/terapia , Medidas de Resultados Relatados pelo Paciente , Adulto , Canadá/epidemiologia , Doenças Cardiovasculares/epidemiologia , Cuidadores , Consenso , Técnica Delfos , Feminino , Insuficiência Cardíaca/epidemiologia , Insuficiência Cardíaca/terapia , Hospitalização/estatística & dados numéricos , Humanos , Masculino , Casas de Saúde/estatística & dados numéricos , Médicos , Pesquisa Qualitativa , Diálise Renal/estatística & dados numéricos , Respiração Artificial/estatística & dados numéricos , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/terapia
2.
Artigo em Inglês | MEDLINE | ID: mdl-33237532

RESUMO

Coronary artery calcification (CAC) on body CT imaging is considered a coincidental finding in cancer patients. In order to determine the significance of CAC in cancer patients we evaluated the prognostic utility of CAC detected on oncology FDG-PET/CT studies. A retrospective study was performed of consecutive FDG-PET/CT studies from January to March 2011. CAC was identified on the CT portion of FDG/PET-CT studies. Chart review documented statin use, the Framingham risk score (FRS) (includes age, diabetes, hypertension, dyslipidemia and smoking), the primary malignancy and metastases. The primary end point was a composite of death and cardiovascular (CV) events (non-fatal myocardial infarction (MI), PCI or coronary artery bypass surgery (CABG)). 266 patients had a median follow up of 41 months (95% CI 31-56 months). CAC was noted in 140 patients. Based on CAC, potentially 84 patients would have had a change in statin prescribing (p < 0.01). CAC was associated with the primary end point on univariable and multivariable analysis (OR 2.6 (95% CI 1.42-4.77) (p < 0.01). On univariable Kaplan-Meier survival analysis, CAC was associated with decreased survival only in the absence of metastases (p < 0.01). Cox proportional hazard modelling demonstrated CAC was associated with mortality and cardiac events in patients without metastases, whereas FRS was not (For CAC: HR 1.69 (95% CI 1.22-2.35), p = 0.002). CAC is commonly detected with oncology FDG-PET/CT. In cancer patients CAC was associated with an increased risk of clinical events. CAC reduced survival free time in patients without metastases. CAC might therefore be considered more than a coincidentaloma in patients without metastases.

4.
Artigo em Inglês | MEDLINE | ID: mdl-33111135

RESUMO

AIMS : This large prospective cohort study sought to confirm the incremental prognostic value of coronary computed tomographic angiography (CCTA) measured over a prolonged follow-up duration. CCTA has diagnostic and prognostic value but data supporting its long-term prognostic value in a large prospectively recruited cohort with suspected coronary artery disease (CAD) has been limited. METHODS AND RESULTS : Consecutive patients (without history of myocardial infarction, revascularization, cardiac transplantation, and congenital heart disease) were prospectively enrolled. CCTA was evaluated for CAD severity, total plaque score (TPS), and left ventricular ejection fraction. Patients were followed for major adverse events (MAE) and major adverse cardiac events (MACE).Over a total of 99 months, 8667 consecutive CCTA patients (mean age = 57.1 ± 11.1 years, 52.9% men) were prospectively enrolled and followed for a mean duration of 7.0 ± 2.6 years. At follow-up, there were a total of 723 MAE, 278 MACE, 547 all-cause deaths, 110 cardiac deaths, and 104 non-fatal myocardial infarction. Patients without coronary atherosclerosis at the time of CCTA had a very low annual event rate for both MAE and MACE (0.45%/year and 0.19%/year, respectively). Both MAE and MACE increased with increasing TPS and severity of CAD. In patients with non-obstructive CAD and who were statin-naive, TPS ≥5 had MACE rates >0.75%/year. Patients with high-risk CAD had an annual MAE and MACE rates of 3.52%/year and 2.58%/year, respectively. Adjusted hazard ratio of the severity of CAD based on multivariable analyses indicated that the prognostic values were incremental. CONCLUSION : CCTA has independent and incremental prognostic value that is durable over time. The absence of coronary atherosclerosis portends an excellent prognosis. Patients with increasing non-obstructive plaque burden have worse prognosis and a TPS threshold ≥5 may identify a population that may benefit from statin therapy.

5.
Artigo em Inglês | MEDLINE | ID: mdl-32981882

RESUMO

OBJECTIVE: We sought to determine the prognostic value of coronary computed tomography angiography (CCTA) in patients with a history of percutaneous coronary intervention (PCI). BACKGROUND: Although the prognostic value of CCTA has been well studied, its incremental value in patients with previous PCI has not been robustly investigated. METHODS: Consecutive patients with previous PCI were prospectively enrolled and CCTA images were evaluated for coronary artery disease (CAD) severity. Patients were followed for major adverse cardiovascular events (MACE) which was a composite of cardiac death and non-fatal myocardial infarction. All-cause death was assessed as a secondary endpoint. RESULTS: A total of 501 patients were analyzed with a mean follow-up time of 59.5 ± 32.0 months and 52 patients (10.4%) experienced MACE. Multivariable Cox regression analysis showed that CAD severity was a predictor of MACE with 0, 1, 2, and 3 vessel disease having annual rates of 1.3%, 2.2%, 2.2%, and 5.3%, respectively. All-cause death was similar in all categories of CAD. CONCLUSIONS: In patients with previous PCI, CAD severity as measured with CCTA has independent and incremental prognostic value.

7.
J Thorac Imaging ; 2020 Apr 03.
Artigo em Inglês | MEDLINE | ID: mdl-32251235

RESUMO

BACKGROUND: Left ventricular mass (LVM) is a predictor for adverse cardiovascular outcomes. Coronary atherosclerosis (coronary artery disease [CAD]) and concentric left ventricular (LV) remodeling are linked pathophysiologically by endothelial dysfunction. AIM: This study sought to determine the potential association between coronary atherosclerosis and LVM. METHODS: A total of 2384 consecutive patients, without structural heart disease or a medical history of CAD, undergoing prospective mid-diastolic electrocardiogram-gated computed tomography coronary angiography were enrolled in the study. LVM and LV mid-diastolic volume were measured using semiautomated software and indexed to body surface area. The average LV mid-diastolic wall thickness and concentricity index (LVM/LV mid-diastolic volume) were calculated. According to the Agatston Score, the patients were divided into 3 groups (Agatston=0, 0.1 to 399.9, ≥400). Similarly, patients were also divided into 4 groups on the basis of the Total Plaque Score (TPS) (0, 1 to 4, 5 to 8, and ≥9). In addition, patients were categorized according to CAD (normal coronaries, nonobstructive CAD, and obstructive stenosis [obstruction >50%]). The association between the different categories of CAD and LV measures was assessed. RESULTS: Both left ventricular mass index (LVMi) and the LV concentricity index increased with TPS categories from 55.3±12.1, 57.4±11.7, 60.9±13.6, and 63.7±15.3 g/m (P<0.05), and 0.935±0.424, 0.975±0.3273, 1.046±0.431, and 1.138±0.443 mL/g (P<0.01), respectively. A similar trend of increasing LVMi was observed with increasing Agatston Score (P<0.001) and CAD category (P<0.05). CONCLUSION: In patients without known structural heart disease, LVMi is independently associated with measures of CAD.

8.
Am J Hypertens ; 33(6): 496-504, 2020 05 21.
Artigo em Inglês | MEDLINE | ID: mdl-31903488

RESUMO

BACKGROUND: There is conflicting data on early left ventricle (LV) remodeling in diabetes mellitus (DM) and hypertension (HTN). This study examines the feasibility of cardiac computed tomography angiography (CCTA) to detect early LV geometric changes in patients with DM and HTN. METHODS: Consecutive patients (n = 5,992) who underwent prospective electrocardiography (ECG)-triggered (mid-diastolic) CCTA were screened. Patients with known structural heart disease or known LV dysfunction were excluded. Left ventricular mass (LVM), left ventricular mid-diastolic volume (LVMDV), and LV concentricity (LVM/LVMDV) were measured and indexed to body surface area. RESULTS: A total of 4,283 patients were analyzed (mean age 57 ± 10.69 years, female 46.7%). DM, HTN, and HTN + DM were present in 4.1%, 35.8% and 10.6% of patients, respectively. Compared to normal patients, HTN and HTN + DM patients had increased LVM indexed to body surface area (LVMi) (56.87 ± 17.24, 59.26 ± 13.62, and 58.56 ± 13.09, respectively; P < 0.05). There was no difference in LVMi between normal subjects and patients with DM (56.39 ± 11.50, P = 0.617).Concentricity indices were higher in patient with HTN (1.0456 ± 0.417; P < 0.001), DM (1.109 ± 0.638; P = 0.004), and HTN + DM (1.083 ± 0.311, P < 0.001) than normal individuals (0.9671 ± 0.361). There was no overlap of the 95% confidence intervals in the composite of concentricity indices and LVMi between the different groups. CONCLUSIONS: CCTA measures of LVM and concentricity index may discriminate patients with HTN and DM before overt structural heart disease.

9.
J Neuromuscul Dis ; 6(4): 389-399, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31561382

RESUMO

Muscular dystrophies (MD) represent a heterogeneous group of rare genetic diseases that often lead to significant weakness due to progressive muscle degeneration. In many forms of MD, cardiac manifestations including heart failure, atrial and ventricular arrhythmias and conduction abnormalities can occur and may be a predominant feature of the disease. Cardiac magnetic resonance (CMR) can assess cardiac anatomy, global and regional ventricular function, volumes and mass as well as presence of myocardial inflammation, infiltration or fibrosis. The role for cardiac MRI has been well-established in a wide range of muscular dystrophies related cardiomyopathies. CMR is a more sensitive technique than echocardiography for early diagnosis of cardiac involvement. It has also great potential to improve the prediction of long-term outcome, particularly the development of heart failure and arrhythmic events; however it still has to be validated by longitudinal studies including large populations. This review will outline the utility of CMR in patients with muscular dystrophies for assessment of myocardial involvement, risk stratification, and in guiding therapeutic management.


Assuntos
Arritmias Cardíacas/fisiopatologia , Cardiomiopatias/fisiopatologia , Distrofias Musculares/fisiopatologia , Miocárdio/patologia , Cardiomiopatias/genética , Morte Súbita Cardíaca , Humanos , Imagem por Ressonância Magnética/métodos , Distrofias Musculares/genética
10.
Obes Res Clin Pract ; 13(5): 478-485, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31416719

RESUMO

BACKGROUND: Obesity is an in independent risk factor for cardiovascular disease. GOAL: To describe the early LV remodelling pattern in patients with overweight and obesity and structurally normal hearts. METHODS: Consecutive patients (n = 2374), with structurally normal hearts and BMI ≥ 18.5 kg/m2, undergoing prospective mid-diastolic ECG gated CTCA were selected. Left ventricular mass (LVM) and Left ventricular mid-diastolic volume (LVMDV) were measured. The concentricity index (LVM/LVMDV) were calculated. According to the definitions of the World Health Organization (WHO), the patients were divided into weight categories. RESULTS: The mean LVM ±â€¯Std. deviation in the subgroups according to WHO classification was 101.68 ±â€¯28.99 g (normal weight), 115.79 ±â€¯29.14 g (overweight), 123.8 ±â€¯33.44 g (class I obesity), 125.85 ±â€¯32.89 g (class II obesity) and 132.45 ±â€¯37.85 g (class III obesity). (p < 0.001) The mean LVMDV progressed with increasing WHO weight category from 112.37 ±â€¯36.46 in patients with normal BMI to 140.26 ±â€¯43.78 in patients with class III obesity. (p < 0.001) The concentricity index was 0.935 ±â€¯0.216 g/ml in patients with normal BMI, 0.979 ±â€¯0.253 g/ml, 1.058 ±â€¯0.635 g/ml, 0.996 ±â€¯0.284 g/ml and 0.9768 ±â€¯0.244 g/ml in patients with BMI categories 25-29.99, 30-34.99, 35-39.99 and ≥40 kg/m2, respectively. CONCLUSIONS: Our study demonstrates a non-linear (inverse U-shape) relationship between increasing BMI class and concentricity index, reaching its maximum at a BMI of 30-34.99 kg/m2. Further increase in BMI results in LV dilation.


Assuntos
Ventrículos do Coração/diagnóstico por imagem , Obesidade/fisiopatologia , Sobrepeso/fisiopatologia , Tomografia Computadorizada por Raios X/métodos , Remodelação Ventricular/fisiologia , Adulto , Idoso , Índice de Massa Corporal , Estudos de Viabilidade , Feminino , Ventrículos do Coração/patologia , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos
11.
J Comput Assist Tomogr ; 43(3): 410-415, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31082946

RESUMO

OBJECTIVE: Marfan syndrome is an autosomal-dominant genetic disorder caused by mutations in the fibrillin-1 gene. The condition is a connective tissue disease that frequently involves the cardiovascular system. The existence of a primary cardiomyopathy in Marfan syndrome, however, is controversial. The aims of this study were to investigate the prevalence of left ventricular dysfunction with both transthoracic echocardiography and cardiovascular magnetic resonance (CMR) in a cohort of Marfan syndrome patients and to investigate patterns of myocardial strain across the cohort. METHODS: We used an institutional database to identify all patients with a firm diagnosis of Marfan syndrome based on Ghent criteria. Inclusion required left ventricular ejection fraction (LVEF) to have been measured by both CMR and transthoracic echocardiography within 12 months of each other. Normal LVEF was defined as a value of >55% when measured by CMR. Velocity vector imaging was used to measure left ventricular longitudinal strain patterns by application of feature tracking to cine magnetic resonance images. Results were compared with data from 20 age-matched control subjects. RESULTS: Sixty-nine Marfan syndrome patients met the inclusion criteria. The mean age was 35.4 ± 15.0 years, and 56.5% were male. The mean LVEF was 59.0% ± 7.0% by CMR and 59.1% ± 5.8% by echo. One-fifth of Marfan syndrome patients (15/69; 21.7%) had reduced function with LVEF ≤55% by CMR, but only 5 of these were identified by echo. Furthermore, echo identified 5 Marfan syndrome patients as having reduced LVEF in the presence of a normal LVEF by CMR. Some Marfan syndrome patients had abnormal longitudinal strain patterns even with LVEF within the reference range. CONCLUSIONS: These data provide support for a primary cardiomyopathy in some Marfan syndrome patients. Cardiovascular magnetic resonance is more sensitive than echo for identifying cases with mild systolic dysfunction. Strain analysis may be more sensitive than simple LVEF assessment for identifying at-risk individuals.


Assuntos
Cardiomiopatias/diagnóstico por imagem , Imagem Cinética por Ressonância Magnética/métodos , Síndrome de Marfan/complicações , Disfunção Ventricular Esquerda/diagnóstico por imagem , Adulto , Cardiomiopatias/etiologia , Estudos de Coortes , Ecocardiografia , Feminino , Humanos , Masculino , Síndrome de Marfan/diagnóstico por imagem , Síndrome de Marfan/fisiopatologia , Pessoa de Meia-Idade , Adulto Jovem
13.
Magn Reson Imaging ; 52: 69-74, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-29859946

RESUMO

OBJECTIVE: Current guidelines provide left ventricular ejection fraction (LVEF) criterion for use of implantable cardioverter defibrillators (ICD) but do not specify which modality to use for measurement. We compared LVEF measurements by radionuclide ventriculography (RNV) vs cardiac MRI (CMR) in ICD candidates to assess impact on clinical decision making. METHODS: This single-centre study included 124 consecutive patients referred for assessment of ICD implantation who underwent RNV and CMR within 30 days for LVEF measurement. RNV and CMR were interpreted independently by experienced readers. RESULTS: Among 124 patients (age 64 ±â€¯11 years, 77% male), median interval between CMR and RNV was 1 day; mean LVEF was 32 ±â€¯12% by CMR and 33 ±â€¯11% by RNV (p = 0.60). LVEF by CMR and RNV showed good correlation, but Bland-Altman analysis showed relatively wide limits of agreement (-12.1 to 11.4). CMR LVEF reclassified 26 (21%) patients compared to RNV LVEF (kappa = 0.58). LVEF by both modalities showed good interobserver reproducibility (ICC 0.96 and 0.94, respectively) (limits of agreement -7.27 to 5.75 and -8.63 to 6.34, respectively). CONCLUSION: Although LVEF measurements by CMR and RNV show moderate agreement, there is frequent reclassification of patients for ICD placement based on LVEF between these modalities. Future studies should determine if a particular imaging modality for LVEF measurement may enhance ICD decision making and treatment benefit.


Assuntos
Desfibriladores Implantáveis , Imagem por Ressonância Magnética/métodos , Ventriculografia com Radionuclídeos/métodos , Disfunção Ventricular Esquerda/diagnóstico por imagem , Disfunção Ventricular Esquerda/fisiopatologia , Ecocardiografia , Feminino , Ventrículos do Coração/diagnóstico por imagem , Ventrículos do Coração/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Reprodutibilidade dos Testes , Estudos Retrospectivos , Volume Sistólico
14.
Radiology ; 288(2): 398-406, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-29688154

RESUMO

Purpose To compare left ventricular (LV) and right ventricular (RV) 3.0-T cardiac magnetic resonance (MR) imaging T1 values in Anderson-Fabry disease (AFD) and hypertrophic cardiomyopathy (HCM) and evaluate the diagnostic value of native T1 values beyond age, sex, and conventional imaging features. Materials and Methods For this prospective study, 30 patients with gene-positive AFD (37% male; mean age ± standard deviation, 45.0 years ± 14.1) and 30 patients with HCM (57% male; mean age, 49.3 years ± 13.5) were prospectively recruited between June 2016 and September 2017 to undergo cardiac MR imaging T1 mapping with a modified Look-Locker inversion recovery (MOLLI) acquisition scheme at 3.0 T (repetition time msec/echo time msec, 280/1.12; section thickness, 8 mm). LV and RV T1 values were evaluated. Statistical analysis included independent samples t test, receiver operating characteristic curve analysis, multivariable logistic regression, and likelihood ratio test. Results Septal LV, global LV, and RV native T1 values were significantly lower in AFD compared with those in HCM (1161 msec ± 47 vs 1296 msec ± 55, respectively [P < .001]; 1192 msec ± 52 vs 1268 msec ± 55 [P < .001]; and 1221 msec ± 54 vs 1271 msec ± 37 [P = .001], respectively). A septal LV native T1 cutoff point of 1220 msec or lower distinguished AFD from HCM with sensitivity of 97%, specificity of 93%, and accuracy of 95%. Septal LV native T1 values differentiated AFD from HCM after adjustment for age, sex, and conventional imaging features (odds ratio, 0.94; 95% confidence interval: 0.91, 0.98; P = < .001). In a nested logistic regression model with age, sex, and conventional imaging features, model fit was significantly improved by the addition of septal LV native T1 values (χ2 [df = 1] = 33.4; P < .001). Conclusion Cardiac MR imaging native T1 values at 3.0 T are significantly lower in patients with AFD compared with those with HCM and provide independent and incremental diagnostic value beyond age, sex, and conventional imaging features. © RSNA, 2018.


Assuntos
Cardiomiopatia Hipertrófica/diagnóstico por imagem , Doença de Fabry/diagnóstico por imagem , Ventrículos do Coração/diagnóstico por imagem , Imagem por Ressonância Magnética/métodos , Adulto , Cardiomiopatia Hipertrófica/fisiopatologia , Diagnóstico Diferencial , Doença de Fabry/fisiopatologia , Feminino , Ventrículos do Coração/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Miocárdio , Estudos Prospectivos
15.
J Cardiovasc Magn Reson ; 20(1): 19, 2018 03 15.
Artigo em Inglês | MEDLINE | ID: mdl-29544519

RESUMO

BACKGROUND: Calculation of cardiovascular magnetic resonance (CMR) extracellular volume (ECV) requires input of hematocrit, which may not be readily available. The purpose of this study was to evaluate the diagnostic accuracy of ECV calculated using various noninvasive measures of hematocrit compared to ECV calculated with input of laboratory hematocrit as the reference standard. METHODS: One hundred twenty three subjects (47.7 ± 14.1 years; 42% male) were prospectively recruited for CMR T1 mapping between August 2016 and April 2017. Laboratory hematocrit was assessed by venipuncture. Noninvasive hematocrit was assessed with a point-of-care (POC) device (Pronto-7® Pulse CO-Oximeter®, Masimo Personal Health, Irvine, California, USA) and by synthetic derivation based on the relationship with blood pool T1 values. Left ventricular ECV was calculated with input of laboratory hematocrit (Lab-ECV), POC hematocrit (POC-ECV), and synthetic hematocrit (synthetic-ECV), respectively. Statistical analysis included Wilcoxon signed-rank test, Bland-Altman analysis, receiver-operating curve analysis and intra-class correlation (ICC). RESULTS: There was no significant difference between Lab-ECV and POC-ECV (27.1 ± 4.7% vs. 27.3 ± 4.8%, p = 0.106), with minimal bias and modest precision (bias - 0.18%, 95%CI [- 2.85, 2.49]). There was no significant difference between Lab-ECV and synthetic-ECV (26.7 ± 4.4% vs. 26.5 ± 4.3%, p = 0.084) in subjects imaged at 1.5 T, although bias was slightly higher and limits of agreement were wider (bias 0.23%, 95%CI [- 2.82, 3.27]). For discrimination of abnormal Lab-ECV ≥30%, POC-ECV had good diagnostic performance (sensitivity 85%, specificity 96%, accuracy 94%, and AUC 0.902) and synthetic-ECV had moderate diagnostic performance (sensitivity 71%, specificity 98%, accuracy 93%, and AUC 0.849). POC-ECV had excellent test-retest (ICC 0.994, 95%CI[0.987, 0.997]) and inter-observer agreement (ICC 0.974, 95%CI[0.929, 0.991]). CONCLUSIONS: Myocardial ECV can be accurately and reproducibly calculated with input of hematocrit measured using a noninvasive POC device, potentially overcoming an important barrier to implementation of ECV. Further evaluation of synthetic ECV is required prior to clinical implementation.


Assuntos
Cardiopatias/diagnóstico por imagem , Hematócrito/instrumentação , Imagem Cinética por Ressonância Magnética , Oximetria/instrumentação , Sistemas Automatizados de Assistência Junto ao Leito , Testes Imediatos , Adulto , Estudos de Casos e Controles , Desenho de Equipamento , Feminino , Cardiopatias/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Variações Dependentes do Observador , Valor Preditivo dos Testes , Estudos Prospectivos , Reprodutibilidade dos Testes
16.
Int J Cardiol ; 252: 80-87, 2018 Feb 01.
Artigo em Inglês | MEDLINE | ID: mdl-29103857

RESUMO

OBJECTIVE: Although heart failure (HF) is the leading cause of premature death in adult congenital heart disease (ACHD), little population-specific data exist. This study reports early experience from a dedicated, sub-specialty adult congenital heart disease-heart failure (ACHD-HF) clinic, aiming to identify risk factors for adverse outcome. METHODS: Between 2012 and 2015, 126 patients (57% male) attended the ACHD-HF clinic. Baseline and follow-up data were analysed and compared across 4 anatomical/physiological subgroups: cyanotic ACHD, Fontan circulation (1V), biventricular circulation with a subaortic right ventricle (2V-RV) and biventricular circulation with a subaortic left ventricle (2V-LV). Predictors of the composite primary outcome: death, transplant or ventricular assist device (VAD) were identified using multivariable Cox proportional hazard models. RESULTS: Mean age at first visit was 38±13years. Patients were grouped as follows: cyanotic ACHD 10%, 1V 24%, 2V-RV 29% and 2V-LV 37%. During a median follow-up of 1.7 (IQR 0.8-2.9) years, 38 patients (30%) reached the primary outcome. Event-free survival was 89%, 78% and 63% at 1, 2 and 3years. Forty (31.7%) patients experienced 69 HF hospitalisations. Between-group differences were noted for systolic function, valvular regurgitation, pacing prevalence and invasive hemodynamics. Multivariable analysis revealed 2V-RV subgroup (p=0.001), NYHA class (p=0.002) B-type natriuretic peptide >164pg/ml (p=0.003) and sodium <136mmol/L (p=0.036) as independently associated with death, transplant or VAD. CONCLUSIONS: Our young ACHD-HF patients experienced high adverse event rates during a short period of follow-up. The prognostic markers identified will aid clinicians to stratify short-term risk and thereby guide advanced HF management decisions in ACHD.


Assuntos
Gerenciamento Clínico , Cardiopatias Congênitas/diagnóstico , Cardiopatias Congênitas/terapia , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/terapia , Fenótipo , Adulto , Estudos de Coortes , Eletrocardiografia/tendências , Feminino , Seguimentos , Cardiopatias Congênitas/fisiopatologia , Insuficiência Cardíaca/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Retrospectivos , Resultado do Tratamento
17.
Eur Heart J Cardiovasc Imaging ; 19(7): 777-784, 2018 07 01.
Artigo em Inglês | MEDLINE | ID: mdl-29045596

RESUMO

Aims: Our aims were to explore cardiac magnetic resonance quantification of myocardial extracellular volume (ECV) in adults with repaired tetralogy of Fallot (rTOF) when compared with healthy controls and to investigate the association between ECV and major adverse cardiovascular outcomes. Methods and results: We prospectively recruited adults with rTOF (n = 44, 59% male, 32.9 ± 13.6 years) and evaluated right ventricular (RV) and left ventricular (LV) ECV by pre/post-gadolinium T1 measurements (modified Look-Locker inversion recovery technique) on a 1.5-T Siemens scanner compared with the healthy controls (n = 10, 50% male, 31.5 ± 4.4 years). The primary end point was a composite of death, out-of-hospital cardiac arrest, heart failure (HF) requiring admission for escalation of therapy, or haemodynamically significant ventricular tachycardia (VT) (lasting >30 s and/or resulting in invasive therapy). The association between ECV and adverse events was assessed using Cox proportional hazard models [median follow-up 236 days, interquartile range (IQR) 38-342]. RVECV was higher in patients compared with the controls (31.5 ± 5.4% vs. 26.3 ± 2.1%, P = 0.027). The following major adverse events occurred (n = 9, 21%): death (n = 1), out-of-hospital cardiac arrest (n = 1), HF (n = 1), and VT (n = 6). RVECV was higher among those with an adverse event compared to those without (35.0 ± 5.5% vs. 29.6 ± 4.5%, P = 0.014) and was associated with increased risk for adverse events [hazard ratio 1.13, 95% confidence interval (1.01-1.28); P = 0.037]. LVECV was not associated with adverse events (P = 0.667). Conclusion: Increased RVECV is associated with adverse cardiovascular events in adults with rTOF. These results may lead to further studies exploring the potential role for RVECV in risk stratification and targeted therapeutic interventions in this population.


Assuntos
Procedimentos Cirúrgicos Cardíacos/métodos , Imagem Cinética por Ressonância Magnética/métodos , Miocárdio/patologia , Taquicardia Ventricular/diagnóstico por imagem , Tetralogia de Fallot/cirurgia , Disfunção Ventricular Esquerda/diagnóstico por imagem , Adulto , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Estudos de Casos e Controles , Morte Súbita Cardíaca , Feminino , Gadolínio , Humanos , Masculino , Pessoa de Meia-Idade , Monitorização Fisiológica/métodos , Variações Dependentes do Observador , Prognóstico , Estudos Prospectivos , Valores de Referência , Volume Sistólico/fisiologia , Taxa de Sobrevida , Taquicardia Ventricular/patologia , Tetralogia de Fallot/diagnóstico por imagem , Tetralogia de Fallot/mortalidade , Disfunção Ventricular Esquerda/patologia , Adulto Jovem
18.
JACC Cardiovasc Interv ; 10(17): 1763-1773, 2017 09 11.
Artigo em Inglês | MEDLINE | ID: mdl-28882284

RESUMO

OBJECTIVES: This study sought to obtain in vivo data to confirm assumptions on device loading conditions and assess procedural feasibility, safety, and valve performance. BACKGROUND: The Harmony transcatheter pulmonary valve (Medtronic, Minneapolis, Minnesota) was designed for patients with severe pulmonary regurgitation who require pulmonary valve replacement. METHODS: Three sites participated in this first Food and Drug Administration-approved early feasibility study using an innovative device design to accommodate the complex anatomy of the right ventricular outflow tract. Potentially eligible patients underwent review by a screening committee to determine implant eligibility. Six-month outcomes are reported. RESULTS: Between May 2013 and May 2015, 66 subjects were enrolled, and 21 were approved for implant and underwent catheterization; 20 were implanted. Catheterized patients had a median age of 25 years, were predominantly diagnosed with tetralogy of Fallot (95%), had severe pulmonary regurgitation (95%), and had trivial or mild stenosis. The device was delivered in the desired location in 19 of 20 (95%) patients. Proximal migration occurred in 1 patient during delivery system removal. Two devices were surgically explanted. Premature ventricular contractions related to the procedure were reported in 3 patients; 2 were resolved without treatment. One patient had ventricular arrhythmias that required treatment and later were resolved. At 1 month, echocardiography revealed none or trivial pulmonary regurgitation in all and a mean right ventricular outflow tract gradient of 16 ± 8 mm Hg (range 6 to 31 mm Hg). CONCLUSIONS: In this feasibility study of the Harmony transcatheter pulmonary valve device, there was high procedural success and safety, and favorable acute device performance.


Assuntos
Cateterismo Cardíaco/instrumentação , Implante de Prótese de Valva Cardíaca/instrumentação , Próteses Valvulares Cardíacas , Insuficiência da Valva Pulmonar/cirurgia , Valva Pulmonar/cirurgia , Adolescente , Adulto , Boston , Cateterismo Cardíaco/efeitos adversos , Cateterismo Cardíaco/métodos , Criança , Estudos de Viabilidade , Feminino , Implante de Prótese de Valva Cardíaca/efeitos adversos , Implante de Prótese de Valva Cardíaca/métodos , Humanos , Masculino , Ohio , Ontário , Complicações Pós-Operatórias/etiologia , Estudos Prospectivos , Desenho de Prótese , Valva Pulmonar/diagnóstico por imagem , Valva Pulmonar/fisiopatologia , Insuficiência da Valva Pulmonar/diagnóstico por imagem , Insuficiência da Valva Pulmonar/fisiopatologia , Recuperação de Função Fisiológica , Índice de Gravidade de Doença , Fatores de Tempo , Resultado do Tratamento , Adulto Jovem
19.
Am J Cardiol ; 120(8): 1387-1392, 2017 Oct 15.
Artigo em Inglês | MEDLINE | ID: mdl-28823485

RESUMO

This early feasibility study was designed to obtain in vivo data to confirm assumptions on device loading conditions of the Medtronic Harmony transcatheter pulmonary valve (TPV). Secondary objectives included procedural feasibility, safety, and valve performance. The Harmony TPV was developed for nonsurgical pulmonary valve replacement in non-right ventricle-pulmonary artery conduit patients. The Native Outflow Tract TPV Research Clinical Study was the first study approved under the Food and Drug Administration Early Feasibility Study guidance. Enrollment required that patient anatomy be precisely matched to the single-size Harmony TPV implant, necessitating a rigorous selection process. The study was nonrandomized, prospective, and performed at 3 sites. All patients met standard indications for surgical pulmonary valve replacement. The goal of the screening committee was to match the candidate anatomy to predetermined engineering criteria thought to be predictive of secure Harmony TPV implantation for the single-size device under study. A majority of the screening committee was required to recommend a patient as eligible for implant. A total of 270 patients underwent prescreening cardiac magnetic resonance imaging, 66 were enrolled and received a computed tomography scan (24%), 21 met criteria for implant and were catheterized (8%), and 20 underwent implant. Nineteen of 20 met criteria for implant success. In conclusion, the Medtronic Harmony TPV represents an emerging therapeutic option for patients with complex postoperative right ventricular outflow tract failure. The initial clinical evaluation of this technology was unique, and the highly variable anatomy of this population required careful screening to ensure acceptable device fit.


Assuntos
Cateterismo Cardíaco/métodos , Implante de Prótese de Valva Cardíaca/métodos , Ventrículos do Coração/diagnóstico por imagem , Seleção de Pacientes , Insuficiência da Valva Pulmonar/cirurgia , Valva Pulmonar/cirurgia , Adulto , Estudos Clínicos como Assunto , Ecocardiografia , Estudos de Viabilidade , Feminino , Seguimentos , Ventrículos do Coração/fisiopatologia , Humanos , Imagem Cinética por Ressonância Magnética , Masculino , Estudos Prospectivos , Insuficiência da Valva Pulmonar/diagnóstico , Fatores de Tempo , Resultado do Tratamento
20.
Cardiol Young ; 27(8): 1529-1537, 2017 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-28412993

RESUMO

OBJECTIVES: Individuals with childhood-onset coronary artery anomalies are at increased risk of lifelong complications. Although pregnancy is thought to confer additional risk, a few data are available regarding outcomes in this group of women. We sought to define outcomes of pregnancy in this unique population. METHODS: We performed a retrospective survey of women with paediatric-onset coronary anomalies and pregnancy in our institution, combined with a systematic review of published cases. We defined paediatric-onset coronary artery anomalies as congenital coronary anomalies and inflammatory arteriopathies of childhood that cause coronary aneurysms. Major cardiovascular events were defined as pulmonary oedema, sustained arrhythmia requiring treatment, stroke, myocardial infarction, cardiac arrest, or death. RESULTS: A total of 25 surveys were mailed, and 20 were returned (80% response rate). We included 46 articles from the literature, which described cardiovascular outcomes in 82 women (138 pregnancies). These data were amalgamated for a total of 102 women and 194 pregnancies; 59% of women were known to have paediatric-onset coronary artery anomalies before pregnancy. In 23%, the anomaly was unmasked during or shortly after pregnancy. The remainder, 18%, was diagnosed later in life. Major cardiovascular events occurred in 14 women (14%) and included heart failure (n=5, 5%), myocardial infarction (n=7, 7%), maternal death (n=2, 2%), cardiac arrest secondary to ventricular fibrillation (n=1, 1%), and stroke (n=1, 1%). The majority of maternal events (13/14, 93%) occurred in women with no previous diagnosis of coronary disease. CONCLUSIONS: Women with paediatric-onset coronary artery anomalies have a 14% risk of adverse cardiovascular events in pregnancy, indicating the need for careful assessment and close follow-up. Prospective, multicentre studies are required to better define risk and predictors of complications during pregnancy.


Assuntos
Anomalias dos Vasos Coronários , Complicações Cardiovasculares na Gravidez , Diagnóstico Pré-Natal/métodos , Anomalias dos Vasos Coronários/diagnóstico , Anomalias dos Vasos Coronários/epidemiologia , Anomalias dos Vasos Coronários/etiologia , Feminino , Saúde Global , Humanos , Incidência , Recém-Nascido , Gravidez
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