Progressive dilation of the diameter of the aortic root in adults with a bicuspid aortic valve

BACKGROUND: To determine the rate of progression of dilation of the aortic root in adults with a bicuspid aortic valve. METHODS: We reviewed retrospectively the transthoracic echocardiograms of 50 adults with a bicuspid aortic valve. Each patient had had at least two examinations made 12 months apart. Measurements were taken at four levels: at the basal attachment of the leaflets of the valve within the left ventricular outflow tract, at the widest point of the sinuses of Valsalva, at the sinutubular junction, and in the ascending aorta 1 cm beyond the sinutubular junction. RESULTS: Progressive dilation occurred at all levels, ranging from 0.3 mm/yr at the basal attachment within the left ventricular outflow tract to 1.0 mm/yr, 1 cm beyond sinutubular junction. These rates of dilation were greater than the reported rate of 0.8 mm per decade in the normal population. The rate of dilation found in the ascending aorta 1 cm beyond the sinutubular junction was significantly greater than at the other sites (p = 0.005). The 21 patients with baseline measurements greater than 34 mm had a significantly higher rate of progression (p = 0.007). Sex, age, and the degree of valvar obstruction or regurgitation did not significantly influence the rate of progression of dilation. CONCLUSION: There is a significantly higher rate of dilation of the aortic root in adults with a bicuspid aortic valve when compared to the normal population. Periodic evaluation of the ascending aorta is essential in these patients, even after replacement of the aortic valve. Other imaging modalities should be considered if the region beyond the sinutubular junction is not well visualized by transthoracic echocardiography.     

Laser lead extraction in adult congenital heart disease

Background: In adults with congenital heart disease (ACHD), lead extraction procedures are expected to parallel increasing transvenous pacemaker and defibrillator implantations. We sought to assess the safety and feasibility of laser lead extraction in ACHD.
Methods and Results: All laser lead extractions (Spectranectics, Colorado Springs, CO, USA) performed at the Montreal Heart Institute between September 2000 and August 2005 were prospectively registered. Efficacy and complications in patients with ACHD were compared to the larger cohort. Laser lead extraction was attempted on 270 leads in 175 patients. In ACHD, 23 (five atrial, 15 ventricular pacing, and three defibrillator) leads were targeted in 16 patients. Indications were: infection 44%, dysfunction 25%, upgrade 25%, and pain 6%. Patients with ACHD were younger (43.0 ± 13.5 vs 63.7 ± 14.7 years, P < 0.0001) and had a higher proportion of active fixation leads (74% vs 37%, P = 0.0013). Lead age in patients with and without ACHD was 9.0 ± 5.2 vs 7.7 ± 5.2 years (P = 0.2713). Overall, 21 of 23 leads (91%) were successfully extracted in ACHD compared with 220 of 247 leads (89%) (P = 0.7405). One major complication (6.3%) occurred in ACHD (tricuspid valve laceration) compared with five major (3.0%) and eight minor (5.0%) complications in patients without ACHD. Presence of ACHD did not modulate procedural success (OR 1.3, 95% CI [0.3, 5.8]) or complications (OR 1.0, 95% CI [0.2, 4.4]). Median procedural time was 27 minutes longer in ACHD (127 vs 100 minutes, P = 0.0595).
Conclusion: In selected patients with ACHD, laser lead extraction may be performed with a safety and efficacy profile comparable to patients without ACHD.     

Effect of inhibition of the Na+/H+ exchanger with cariporide on left ventricular function in acute coronary syndromes: results from the echocardiographic substudy of the GUARDIAN trial

OBJECTIVE: To evaluate the effects of inhibition of the Na+/H+ exchanger (NHE) on regional left ventricular dysfunction in patients with a non-ST elevation acute coronary syndrome (ACS) BACKGROUND: NHE inhibition protects against myocardial necrosis and stunning in ischemia-reperfusion models. METHODS AND RESULTS: In a substudy of the GUARd During Ischemia Against Necrosis (GUARDIAN) trial, 141 patients with an ACS and wall motion abnormalities on a baseline echocardiogram underwent repeated studies after 48 h and 36 days to determine the extent of early and late recovery of ventricular function. Patients were randomized to cariporide 20 mg, 80 mg or 120 mg intravenously three times per day or placebo for two to seven days. The wall motion score index improved from baseline to day 36 by 0.13+/-0.21, 0.16+/-0.34 and 0.15+/-0.28, respectively, in the cariporide groups, and by 0.10+/-0.16 with placebo (P=0.57). From baseline to 48 h, the wall motion score index decreased by 0.04+/-0.16, 0.08+/-0.20 and 0.03+/-0.22, respectively, for the cariporide groups and by 0.03+/-0.11 with placebo (P=0.09); the number of abnormal chords (centreline method) decreased by 11.2+/-24.0, 9.5+/-24.3 and 8.1+/-27.9, respectively, in the cariporide groups compared with an increase of 0.6+/-20.0 with placebo (P=NS). CONCLUSION: No significant benefit of NHE inhibition could be detected in ACS patients in the GUARDIAN trial.     

Pregnancy in women with Fontan physiology

Advances in the care of patients with a univentricular heart have enabled the majority to survive well into adulthood. Consequently, an increasing number of women with Fontan palliation are contemplating pregnancy. This review summarizes physiologic modifications related to pregnancy in the setting of single-ventricle physiology, discusses potential maternal cardiovascular concerns and describes commonly encountered obstetrical and neonatal complications. Management issues are addressed, including counseling, anesthetic considerations and the need for multidisciplinary specialized care.     

Variability in the Echocardiographic Evaluation of the Systemic Right Ventricle

Background

Echocardiographic evaluation of the systemic right ventricle (sRV) remains challenging in patients with transposition of the great arteries (TGA) corrected by an atrial switch (AS) and with congenitally corrected TGA (ccTGA). The aim of this study was to determine the interobserver and intraobserver variability of echocardiographic parameters for sRV size and systolic function.

Embolic myocardial infarction in a pregnant woman with a mechanical heart valve on low molecular weight heparin

Even with continuing technical improvements in prosthesis design and the development of less thrombogenic materials, mechanical valve prostheses still carry a thromboembolic risk significant enough to warrant long-term anticoagulation therapy. Optimal anticoagulation is especially crucial during pregnancy due to the hypercoagulable state that rapidly develops after conception. Conventional anticoagulation therapy with coumarin derivatives is associated with risks of teratogenicity and hemorrhage for the fetus, and thromboembolic and hemorrhagic complications for the mother. As a result, other forms of anticoagulation, such as unfractionated or low molecular weight heparin, have been advocated as an alternative in selected cases. The present report describes a case of embolic myocardial infarction occurring in a pregnant woman with an aortic bileaflet mechanical valve prosthesis while on therapeutic low molecular weight heparin after only one dose was withheld before amniocentesis.     

Cloth tears in asymptomatic survivors of aortic valve replacement with Starr-Edwards prostheses: detection by transesophageal echocardiography.

Cloth-covered Starr-Edwards valves were withdrawn in the 1970s because of complications of cloth tear. Nevertheless, many patients are still alive with their prosthesis in place. We evaluated the ability of transesophageal echocardiography (TEE) to detect cloth tear in 9 asymptomatic patients operated on with a cloth-covered Starr-Edwards aortic valve at our institution.An echogenic mobile structure attached to the prosthesis, suggestive of a tear, was detected in 5 patients (55%). A tear was diagnosed in a sixth patient when TEE was repeated during follow-up because of neurologic symptoms. In all cases, transthoracic echocardiography failed to detect any abnormality. Two patients had symptoms develop and underwent reoperation; cloth tear was more extensive than suspected by TEE.Cloth tear is a frequent finding that can be detected by TEE in asymptomatic patients with cloth-covered Starr-Edwards aortic prosthesis. TEE is recommended in these patients and reoperation should be considered as soon as symptoms appear.     

Recent advances in adult congenital heart disease

As a result of major achievements in pediatric cardiac care, a growing number of patients with congenital heart disease (CHD) are flourishing well into adulthood. This heterogeneous and aging population of patients, many of whom represent the first generation of middle-age survivors, faces unique issues and challenges. As a field, adult CHD has evolved markedly during the past decade on several fronts, including imaging, arrhythmia management, percutaneous interventions, surgical techniques, research, and multidisciplinary care that extends beyond the cardiac realm. This review highlights recent advances across the wide spectrum of key issues encountered by adults with CHD.