Cardiac Follow-up Research Articles

Invasive electrophysiology study guided loop recorder implantation in myotonic dystrophy type 1: a prospective single-center study

Abstract Funding Acknowledgements Type of funding sources: None. Introduction In one third of the patients with myotonic dystrophy type 1 (DMT1) the cause of death is of cardiac origin. The most common cardiac manifestations are arrhythmias and conduction disturbances. Purpose Due to its extreme long monitoring properties, implantable loop recorders (ILRs) are highly suitable to detect rare cardiac arrhythmias. To date, there are only limited data using ILRs in DMT1. We aimed to evaluate the role of the invasive electrophysiology study (EPS)-guided loop recorder implantation in patients with DMT. Methods In our prospective study 18 genetically confirmed DMT1 patients underwent non-invasive cardiac examination including transthoracic echocardiography, 24-hour Holter monitoring and surface ECG. In addition, EPS was performed in all cases to evaluate the risk of sudden cardiac death and infra-Hisian conduction properties. Based on the performed non-invasive diagnostic evaluation and EPS findings, patients were divided into low, intermediate and high-risk groups. For patients with normal investigation results and normal HV interval (<55 ms) only annual cardiac follow-up visits were planned (low-risk group). Patients with increased PR interval (>240 ms), QRS duration (>120 ms), or slightly prolonged HV interval (55-70 ms) underwent implantable loop recorder (ILR) implantation (intermediate-risk group). Permanent pacemaker (PM) or implantable cardiac defibrillator (ICD) was implanted in patients with 2nd/3rd degree atrioventricular block (AVB), significantly prolonged HV interval (>100 ms) or if sustained ventricular tachyarrhythmia could be induced during EPS. All patients were followed for at least 3 years. Results According to our study criteria, 8 patients could be categorized as "intermediate risk", 7 of them received implantable loop recorder (ILR). 1 ILR had to be removed 3 weeks after implantation due to skin infarction. During three-years of follow-up, 2 patients had many asymptomatic atrial high-rate episodes, but no 2nd or 3rd degree AVB, significant asystole or malignant ventricular arrhythmia were detected. Conclusions Our single-center prospective study examined the EPS-guided ILR implantation for the risk stratification of DMT1 patients for the first time. A more extensive, multicenter study is warranted to define optimal management of DMT1 patients with slightly impaired infrahisian conduction.

The use of a new ECG patch for exercise and prolonged monitoring: usability, evaluation of signal quality and utility to detect arrhythmias

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – EU funding. Main funding source(s): ITEA. Background Accurate detection of myocardial ischemia and arrhythmia’s during free-living exercise could play a pivotal role in optimizing screening and monitoring of individuals with underlying cardiovascular disease. Although remote electrocardiogram (ECG) solutions are emerging rapidly, these applications are generally not designed nor validated for continuous use during vigorous exercise. Purpose In this proof-of-concept study, we evaluated the usability, signal quality and arrhythmia detection of a new self-adhesive dry electrode ECG patch, the Nighthawk Vital Signs patch, during exercise and prolonged continuous ECG monitoring in individuals with chronic coronary syndrome (CCS). Methods Six consecutive CCS patients scheduled for an exercise stress test as part of routine cardiac follow-up were recruited. The traditional 12-lead exercise ECG was combined with monitoring with the 1-lead patch. Following the exercise test, the subjects continuously wore the sensor for five days. Intraclass correlation coefficients (ICC) and Wilcoxon signed-rank tests were used to assess the utility to detect arrhythmias with the patch. Signal quality for ECG recording was evaluated by using a signal quality indicator (SQI) based on the average QRS complex. Connection time and signal-to-noise ratio (SNR) were additionally calculated for prolonged ECG monitoring. Comfort and usability of the patch were evaluated by an online questionnaire. Results Six male patients with CCS (mean age 69.8 ± 6.2 years) completed the protocol. The mean time the patch was worn, was 118.3 hours (SD 5.6). The level of agreement between the patch and the 12-lead ECG was excellent for amount of premature atrial contractions (PAC’s) and premature ventricular contractions (PVC’s) during exercise stage, recovery stage and total test duration (ICC = 0.998, 0.998, 1.000, 1.000, 0.998, 1.000). There were no significant differences in the total amount of PAC’s and PVC’s detected with both methods during the exercise test (p = 0.785 and 0.180, respectively). One episode of atrial fibrillation was detected identically on both recorded ECG’s. Signal quality based on average QRS SQI during exercise did decrease slightly during (sub)maximal effort. Total connection time during recording was above 88% in all subjects and the SNR was above the target limit of 18dB. There were no reports on skin irritation, erythema or pain. Conclusion The Nighthawk Vital Signs ECG patch based on self-adhesive dry electrodes technology can be used for accurate arrhythmia detection during vigorous exercise. The sensor is also usable for prolonged ECG monitoring in free-living conditions and can therefore be of potential use in cardiac rehabilitation and telemonitoring for prevention of exercise-related cardiovascular events. However, more research is needed in order to analyze the signal quality over time together with a larger-scale validation study focusing on both arrhythmia and ischemia detection.

Heterogeneity of echocardiographic variables in systemic lupus erythematosus among clinical subgroups according to non-cardiac organ involvement

Systemic lupus erythematosus (SLE) is a heterogeneous autoimmune disease. Cardiac involvement is rare but plays an important prognostic role. The degree of cardiac involvement according to SLE subsets defined by non-cardiac manifestations is unknown. The objective of this study was to identify differences in TTE parameters associated with different SLE subgroups. One hundred and eighty-one patients fulfilling the ACR/EULAR 2019 classification criteria for SLE and had a TTE were included in this cross-sectional study. We defined four subsets of SLE based on the predominant clinical manifestations. A multivariate multinomial regression analysis was performed to determine whether TTE parameters differ between the subsets. The first subset (n = 37) of patients showed features of mixed connective tissue disease (MCTD); the second subset (n = 76) had primarily cutaneous involvement; the third subset (n = 18) exhibited serositis and the last subset (n = 50) had severe disease with significant organ involvement, including renal involvement. Forty TTE parameters were assessed in each patient. Using a multivariate multinomial regression analysis, 3 parameters differed between groups: early diastolic tricuspid annular velocity (RV-E′, P < 0.0001), RV-S′ (RV-pulse DTI systolic peak wave, P = 0.0031), and RV end-diastole diameter (P = 0.0419). The degree of RV dysfunction was lowest in patients with primarily cutaneous involvement. Four distinct clinical subsets based on clinical manifestations differed in terms of TTE parameters of right heart function and diastolic dysfunction. This could help to tailor the cardiac follow-up required by the different clinical subsets of SLE.

Cardiology Care and Loss to Follow-Up Among Adults With Congenital Heart Defects in CH STRONG

Many of the estimated 1.4 million adults with congenital heart defects (CHDs) in the United States are lost to follow-up (LTF) despite recommendations for ongoing cardiology care. Using 2016 to 2019 CH STRONG (Congenital Heart Survey To Recognize Outcomes, Needs, and well-beinG) data, we describe cardiac care among community-based adults with CHD, born in 1980 to 1997, identified through state birth defects registries. Our estimates of LTF were standardized to the CH STRONG eligible population and likely more generalizable to adults with CHD than clinic-based data. Half of our sample were LTF and more than 45% had not received cardiology care in over 5years. Of those who received care, only 1 in 3 saw an adult CHD physician at their last encounter. Not knowing they needed to see a cardiologist, being told they no longer needed cardiology care, and feeling "well" were the top reasons for LTF, and only half of respondents report doctors discussing the need for cardiac follow-up.

PO-01-050 STRUCTURAL CARDIAC CHANGES DETECTED BY MRI AFTER STEREOTACTIC BODY RADIOTHERAPY FOR TARGETS IN CLOSE PROXIMITY TO THE HEART

Stereotactic body radiation therapy (SBRT) has become a standard of care for inoperable early-stage non-small cell lung cancer and in case of pulmonary oligometastases. Recent studies indicate that incidental irradiation of the heart may be associated with an increased risk of non-cancer-related deaths. This study aims to assess and examine structural cardiac changes following peri- and myocardial SBRT using a systematic cardiac follow-up protocol including cardiac magnetic resonance (CMR) imaging. For 1485 patients treated with local-ablative SBRT from January 2014 to February 2022 at our institution, the distance between the planning target volume (PTV) and the heart was measured. Forty-eight out of 134 patients treated in close proximity (<2cm) to the heart were alive at follow-up. Of those, 20 were randomly invited to undergo a structured cardiac follow-up protocol including CMR. Ten patients consented to participate and underwent a structural follow-up protocol. Registration of CMR image data and the SBRT treatment plan was performed to examine a possible correlation between the dose delivered to the myocardium and structural cardiac changes assessed by CMR. Among the 10 participating patients, the most common primary tumors were non-small cell lung cancer (n=3) and small-cell lung cancer (n=2) (Table 1). Five patients presented with pre-SBRT cardiovascular comorbidities. Seven patients received SBRT for pulmonary or vertebral metastases and three patients for primary lung cancer with a median dose of 42.5 Gy (30.0-48.0 Gy) in 3-10 fractions. The mean heart dose (Dmean) and maximum heart dose (Dmax) were 4.9 Gy (0.7-8.4 Gy) and 36.2 Gy (8.3 – 64.1 Gy), respectively. On CMR, five patients showed myocardial alterations, such as late gadolinium enhancement and edema after a median follow-up time of 5.6 years (0.1-6.3 years) as shown in Figure 1. In patients with structural changes of the myocardium the median distance between the treated lesion and myocardium with 0.0 (0.0-1.08) cm vs. 1.4 (0.41-2.0) cm was significantly lower (p=0.015). Additionally, patients with structural changes on CMR showed significantly higher Dmax (135.4 Gy vs. 25.4 Gy, p=0.009), Dmean (4.4 Gy vs. 3.4 Gy, p=0.05). In this pilot study, patients treated with SBRT for pulmonary targets with PTV overlapping the heart showed structural changes of the myocardium in CMR. The presence of structural changes correlates with higher heart doses.

Isolated Subclinical Right Ventricle Systolic Dysfunction in Patients after Liver Transplantation.

Although hemodynamic alterations in end-stage liver disease (ESLD) and its association with porto-pulmonary hypertension have been well-established, the long-term effects of ESLD on RV systolic function in patients without porto-pulmonary hypertension remain disregarded. Here we aimed to assess the long-term effect of ESLD on RV function and its relationship with the use of NSBBs and clinical, laboratory and imaging parameters in end-stage liver disease. The use of NSBBs is still controversial due to concerns about reduced cardiac contractility and the possibility of increased mortality. Thirty-four liver transplant recipients were included. Demographic characteristics, laboratory and baseline echocardiography measures were obtained. Patients were recalled for transthoracic echocardiographic evaluation after transplantation. Right ventricle dysfunction was identified by having at least one value below the reference levels of RV S', or TAPSE. Isolated subclinical RV dysfunction was observed at 20.6% of the sample population. The present study demonstrates hemodynamic circulation in cirrhosis and increased preload and afterload might have long-term effects on RV function, even the lack of porto-pulmonary hypertension. These findings underline the significance of cardiac function follow-up in cirrhotic patients after transplantation. In this study, patients treated with propranolol seemed to have better RV function and less gastrointestinal bleeding. We speculated that preoperative propranolol treatment might help preserve RV function by providing RAS suppression, improving endothelial function and hyperdynamic circulation seen in ESLD. This potential protective relationship between the use of propranolol and RV function might improve mortality or graft-failure during OLT and after liver transplantation in patients with cirrhosis.

Strategies to Aid Successful Transition of Adolescents with Congenital Heart Disease: A Systematic Review

The majority of patients born with congenital heart disease (CHD) need lifelong surveillance with serial clinical attendance and examinations. However, loss of follow-up (namely no documented follow-up for 3 years or more) is a recognised common problem since it is often related to remarkable worsening in the health of CHD patients with increased morbidity and mortality. Transitioning from paediatric to adult care has proven to be the most vulnerable point in the care of these subjects. As such, a systematic review was carried out to ask the following questions: What is the percentage of loss of follow-up worldwide? Are there regional fluctuations in the percentage? Is there a link between loss of follow-up and the complexity of CHD? What strategies should be employed to lower the risk of discontinuity in care? The most recent worldwide averaged loss of follow-up is 26.1%, with significant fluctuations across continents and countries. This percentage is even higher (31.9%) when one includes all untraceable patients, presuming that they are not having any cardiac follow-up. The highest discontinuity of care was reported in the USA and in patients with simple CHD. Planning the rules of transition seems to be one of the most reliable tools to minimise the number of CHD patients who are lost in transition. Recalling patients, with general practitioners who are crucial in readdressing half of the lost to follow-up CHD patients to adult CHD specialists, and a good relationship between paediatric cardiologists and the adult CHD team are two other valuable strategies in aiding successful transition.

Select Congenital Heart Disease: Important Echocardiographic Features and Changes during Pregnancy.

Congenital heart disease (CHD), which affects 1% to 2% of all births, is the most common abnormality in women contemplating pregnancy in western countries. With diagnostic and interventional advances, most patients with CHD survive into adulthood and require lifelong cardiac follow-up with cardiac imaging, particularly echocardiography and cardiac computed tomography. Multiple hemodynamic and physiologic changes of pregnancy may predispose patients with CHD to clinical decompensation and an inability to tolerate pregnancy. This manuscript reviews common CHD lesions, their repair or palliative interventions, long-term sequelae, important features to assess on cardiac imaging, and the impact of pregnancy on these types of lesions. Moreover, the review bridges the fields of CHD, cardiac imaging, and maternal cardiology, which will aid clinicians in counseling patients and managing pregnancies.

Cardiac MRI with late gadolinium enhancement shows cardiac involvement 3-6 months after severe acute COVID-19 similar to or worse than PIMS.

Coronavirus disease 2019 (COVID-19) in children is rarely severe. However, severe courses occur, especially in the presence of risk factors. A minority of children develop pediatric inflammatory multisystem syndrome (PIMS) with substantial morbidity. While the importance of cardiac involvement after PIMS is well established, its role after severe acute COVID-19 remains unclear. We aim to compare cardiac sequelae of children after severe acute COVID-19 using cardiac MRI and compare them with patients after PIMS. For this prospective cohort study, we recruited patients with acute COVID or PIMS in a single center. Clinical follow-up, lab work, ECG, and echocardiography were done within 2 days after disease onset and 3-6 months after discharge. At the last visit 3-6 months later, cardiac MRI (CMR) with late gadolinium enhancement (LGE) was performed to evaluate cardiac sequelae and compare both groups. Data were obtained from n = 14 patients with PIMS and n = 7 patients with severe acute COVID-19. At the start of the respective disease, left ventricular (LV) ejection fraction was reduced in seven patients with PIMS but none in the acute COVID-19 group. Transient mitral valve insufficiency was present in 38% of patients, of whom PIMS accounted for 7/8 cases. Eight patients (38%) with PIMS presented coronary artery abnormalities, with normalization in 7/8 patients. A significant decrease in LV mass index 3-6 months after disease onset was observed in both groups. MRI follow-up revealed non-ischemic myocardial pattern of LGE in 12/21 patients- in all (6/6) after severe acute COVID-19 and in less than half (6/14) after PIMS. Normal body weight-adjusted stroke volumes and end-diastolic volumes were found in 20/21 patients. We show that children suffering from severe acute COVID-19 have a similar, or worse, cardiac risk profile as patients with PIMS. Both patient groups should therefore receive close pediatric cardiac follow-up examinations. Cardiac MRI is the technique of choice, as most patients presented with delayed LGE as a sign of persistent cardiac injury despite normalization of laboratory and echocardiographic findings.

Cardiac Magnetic Resonance Imaging and Clinical Follow-up in Antimalarial-induced Cardiomyopathy in Patients With Systemic Lupus Erythematosus.

Antimalarial-induced cardiomyopathy is under-recognized in clinical practice and there is limited data on the evolution of cardiac imaging abnormalities after cessation of anti-malarial therapy. In this case series of 9 patients with antimalarial-induced cardiomyopathy, follow-up cardiac magnetic resonance imaging demonstrated interval increase in late gadolinium enhancement extent in 89% of patients and interval decrease in left ventricular ejection fraction in all, despite cessation of anti-malarial therapy. Progression of cardiac abnormalities despite cessation of therapy underscores the important role of imaging in the early recognition of antimalarial-related treatment changes.

The role of parenting stress in anxiety and sleep outcomes in toddlers with congenital heart disease.

This retrospective cohort study investigates how parenting stress, measured at 4 months of age by use of a classic three-dimensional parent-reported scale (Parenting Stress Index, 4th Ed. or PSI-4), can predict anxiety symptoms and quality of sleep at 24 months in toddlers with congenital heart disease (CHD). Sixty-six toddlers with CHD followed at our cardiac neurodevelopmental follow-up clinic were included in this study. As part of their systematic developmental assessment program, parents completed questionnaires on their stress level (PSI-4) when their child was 4 months old, and on their child's anxiety symptoms and quality of sleep at 24 months. Eight multiple linear regression models were built on the two measures collected at 24 months using the PSI-4 scores collected at 4 months. For each measure, four models were built from the PSI-4 total score and its three subscales (Parental Distress, Parent-Child Dysfunctional Interaction, Difficult Child), controlling for sex and socioeconomic status. The PSI-4 Difficult Child subscale, which focuses on parenting anxiety related to the child's behavioral problems and poor psychosocial adjustment, accounted for 17% of the child's anxiety symptoms at 24 months. The two other PSI-4 subscales (Parental Distress and Parent-Child Dysfunctional Interaction) and the PSI-4 total score did not contribute significantly to the models. None of the four regression models on perceived quality of sleep were significant. It is important to note that 33% of parents responded defensively to the PSI-4. Parenting stress related to the child's behavioral problems and poor psychosocial adjustment, measured when the child is 4 months old, is associated with the child's ulterior anxiety symptoms. As very few standardized tools are available to assess the behavioral and psychoaffective development of infants, this study highlights the importance of early psychosocial screening in parents of infants with CHD. The high rate of significant Defensive Responding Indices reminds us to not take parent reports at face value, as their actual stress levels might be higher.

Long-term outcomes for females with early-onset dystrophinopathy.

To study long-term disease course for females with early-onset dystrophinopathy, including common (female) symptoms, challenges in social participation, the need for care, and current healthcare management to support guideline development. Twelve females with early-onset dystrophinopathy were followed for a median period of more than 17 years (range 1-36). One patient died owing to end-stage cardiac failure. Cardiac abnormalities were observed in three of the remaining 11 participants. Respiratory function was reduced in seven of 10 participants. Fatigue, myalgia, lower back pain, and arthralgia were reported in more than six of the participants. Functional status varied from exercise intolerance to wheelchair dependency. Most or all of the 10 participants reported restrictions in participation in work (n=10), household duties (n=10), sports (n=9), and education (n=8). Only a few participants received followed-up pulmonary (n=2) or rehabilitation (n=3) care. Females with early-onset dystrophinopathy experience a wide range of impairments, comorbidities, limitations in activities, and restrictions in social participation. The whole spectrum should be acknowledged in the healthcare setting. Neuromuscular and cardiac follow-up are indispensable. Additional respiratory assessment and rehabilitation care are expected to improve health status and support daily activities and participation. No standard diagnostic procedures seem to exist for female patients suspected for dystrophinopathy. Female participants with early-onset dystrophinopathy experienced a broad scope of burdening symptoms, such as fatigue, myalgia, lower back pain, and arthralgia. None of participants worked full time, all felt restricted in paid work, and most felt restricted in education. Most participants showed decreased lung function, while only one was symptomatic. Availability of rehabilitation care may improve support for daily activities and participation for females with early-onset dystrophinopathy.

Inflammatory responses in SARS-CoV-2 associated Multisystem Inflammatory Syndrome and Kawasaki Disease in children: An observational study.

Multisystem Inflammatory Syndrome in Children (MIS-C) is a severe inflammatory disease in children related to SARS-CoV-2 with multisystem involvement including marked cardiac dysfunction and clinical symptoms that can resemble Kawasaki Disease (KD). We hypothesized that MIS-C and KD might have commonalities as well as unique inflammatory responses and studied these responses in both diseases. In total, fourteen children with MIS-C (n=8) and KD (n=6) were included in the period of March-June 2020. Clinical and routine blood parameters, cardiac follow-up, SARS-CoV-2-specific antibodies and CD4+ T-cell responses, and cytokine-profiles were determined in both groups. In contrast to KD patients, all MIS-C patients had positive Spike protein-specific CD3+CD4+ T-cell responses. MIS-C and KD patients displayed marked hyper-inflammation with high expression of serum cytokines, including the drug-targetable interleukin (IL)-6 and IFN-γ associated chemokines CXCL9, 10 and 11, which decreased at follow-up. No statistical differences were observed between groups. Clinical outcomes were all favourable without cardiac sequelae at 6 months follow-up. In conclusion, MIS-C and KD-patients both displayed cytokine-associated hyper-inflammation with several high levels of drug-targetable cytokines.

Partial anomalous pulmonary venous return in adults: Insight into pulmonary hypertension

BackgroundPartial anomalous pulmonary venous return (PAPVR) is a rare condition that may lead to pulmonary arterial hypertension (PAH). We sought to determine the prevalence of PAPVR, the follow-up rate of incidentally discovered PAPVR, the repercussions of volume and pressure overload on the right ventricle (RV), and the prevalence and predictors of PAH. Methods and resultsFifty PAPVR patients aged ≥18 years were included. All underwent transthoracic echocardiography and multislice imaging. PAPVR prevalence was 0.2% (23/13,606 chest computed tomography reports). Of the 26 incidentally diagnosed patients, 14 (54%) did not have a cardiac follow-up. Seven (14%) patients had PAH, of whom one third (28%) had Eisenmenger syndrome. The left-to-right shunt ratio (Qp/Qs) was the only predictor of PAH. PAPVR-induced volume overload led to increased right chamber volumes (RV basal diameter 45±8 mm, RV mid-diameter 38±9 mm, RV/left ventricle ratio 1.2 ± 0.2, indexed RV end-diastolic area 14±4 cm2/m2, indexed RV end-systolic area 8.6 ± 3.2 cm2/m2) and increased RV functional parameters (tricuspid annular plane systolic excursion 27±5 mm, fractional area change [FAC] 42 ± 10%, global longitudinal strain [GLS] −22 ± 5). In contrast, PAH-induced pressure overload had no impact on right heart volumes, but on RV functional parameters, which were decreased compared to non-PAH patients (FAC 35 ± 13% vs. 43 ± 10%, p = 0.049; GLS -18 ± 5 vs. −23 ± 4%, p = 0.01). ConclusionsPAPVR prevalence was 0.2%. When incidentally diagnosed, its management was often neglected despite potentially serious consequences (14% PAH). Only the Qp/Qs ratio was predictive of PAH. PAPVR-induced volume overload was shown to increase right heart volumes, while PAH-induced pressure overload caused alterations of RV functional parameters.

Cardiac magnetic resonance follow-up of COVID-19 vaccine associated acute myocarditis

Mass COVID-19 vaccination campaigns have helped impede the COVID-19 pandemic. In rare cases, some vaccines have led to vaccine associated myocarditis in a specific subset of the population, usually young males. Cardiac magnetic resonance (CMR) can reliably diagnose vaccine associated myocarditis, but follow-up data of CMR proven acute myocarditis is scarce. Nine patients with acute vaccine associated myocarditis underwent baseline and follow-up CMR examinations and were compared to baseline parameters at initial presentation and to a group of 20 healthy controls. CMR protocol included functional assessment, T1 and T2 mapping, T2 signal intensity ratio, strain feature tracking, and late gadolinium enhancement (LGE). Myocarditis patients (n = 9, aged 24 ± 6 years, 8 males) underwent CMR follow-up after an average of 5.8 ± 4.3 months. All patients showed a complete resolution of visual myocardial edema while also demonstrating a reduction in overall LGE extent from baseline to follow-up (4.2 ± 2.1 vs. 0.9 ± 0.8%, p < 0.001), although visual LGE was still noted in all patients. Left ventricular ejection fraction was normal at baseline and at follow-up (58 ± 6 vs. 62 ± 4%, p = 0.10) as well as compared to a healthy control group (60 ± 4%, p = 0.24). T1 (1024 ± 77 vs. 971 ± 34 ms, p = 0.05) and T2 relaxations times (57 ± 6 vs. 51 ± 3 ms, p = 0.03) normalized at follow-up. Most patients reported a resolution of clinical symptoms, while two (22%) reported new onset of exertional dyspnea. Patients with COVID-19 vaccine associated acute myocarditis showed a complete, uncomplicated resolution of myocardial inflammation on follow-up CMR, which was associated with a near complete resolution of symptoms. Minor, residual myocardial scarring was present on follow-up LGE imaging. The long-term implications of the remaining myocardial scar-tissue after vaccine associated myocarditis remain unknown warranting further studies.

Enhanced Telehealth Home-Monitoring Intervention for Vulnerable and Frail Patients after Cardiac Surgery (THE-FACS Pilot Intervention Study)

BackgroundFrail cardiac surgery patients have an increased risk of worse postoperative outcomes. The purpose of this study was to evaluate the implementation of a novel Telehealth Home monitoring Enhanced-Frailty And Cardiac Surgery (THE-FACS) intervention and determine its impact on clinical outcomes in frail patients post-cardiac surgery.MethodsFrail/vulnerable patients defined by Edmonton Frailty Scale (EFS > 4) undergoing cardiac surgery were prospectively enrolled (November 2019 -March 2020) at the New Brunswick Heart Centre. Exclusion criteria included age < 55 years, emergent status, minimally invasive surgery, lack of home support, and > 10-days postoperative hospital stay. Following standard training on THE-FACS, participants were sent home with a tablet device to answer questions about their health/recovery and measure blood pressure for 30-consecutive days. Transmitted data were monitored by trained cardiac surgery follow-up nurses. Patients were contacted only if the algorithm based on the patient’s self-collected data triggered an alert. Patients who completed the study were compared to historical controls. The primary outcome of interest was to determine the number of patients that could complete THE-FACS; secondary outcomes included participant/caregiver satisfaction and impact on hospital readmission.ResultsWe identified 86 eligible (EFS > 4), out of 254 patients scheduled for elective cardiac surgery during the study period (vulnerable: 34%). The patients who consented to participate in THE-FACS (64/86, 74%) had a mean age of 69.1 ± 6.4 years, 25% were female, 79.7% underwent isolated Coronary Artery Bypass Graft (CABG) and median EFS was 6 (5–8). 29/64 (45%) were excluded post-enrollment due to prolonged hospitalization (15/64) or requirement for hospital-to-hospital transfer (12/64). Of the remaining 35 patients, 21 completed the 30-day follow-up (completion rate:60%). Reasons for withdrawal (14/35, 40%) were mostly due to technical difficulties with the tablet. Hospital readmission, although non-significant, was reduced in THE-FACS participants compared to controls (0% vs. 14.3%). A satisfaction survey revealed > 90% satisfaction and ~ 67% willingness to re-use a home monitoring device.ConclusionsTHE-FACS intervention can be used to successfully monitor vulnerable patients returning home post-cardiac surgery. However, a significant number of frail patients could not benefit from THE-FACS given prolonged hospitalization and technological challenges. Our findings suggest that despite overall excellent satisfaction in participants who completed THE-FACS, there remain major challenges for wide-scale implementation of technology-driven home monitoring programs as only 24% completed the study.

Clinical outcomes and maternal associated conditions between antepartum and postpartum-onset of peripartum cardiomyopathy

ObjectivePeripartum cardiomyopathy (PPCM) developed from late pregnancy to five months after delivery. Women with PPCM have the risk of mortality or non-recovered cardiac function. We aimed to investigate women with PPCM in Taiwan. Materials and methodsThe retrospective study recruited patients with PPCM from January 2002 to October 2018 in a tertiary center. We evaluated the presentations, onset, associated conditions, maternal and fetal outcomes, follow-up cardiac function, and subsequent pregnancies. The clinical data were compared between antepartum and postpartum-onset of PPCM. ResultsThirty women were identified and seventeen (56.6%) patients were antepartum-onset. The delivery time, ranged from 26 to 40 weeks, was mostly at 35 weeks. Twenty-one patients had cardiac function follow-up and seven (33.3%) were non-recovered in six months. The associated conditions of PPCM included age >30, primiparity, preeclampsia or hypertension, obesity, twin pregnancy, and tocolysis. The maternal characteristics and associated conditions were not significant different, but early preterm (32.8 ± 3.6 vs. 35.5 ± 2.4 weeks, p = 0.042) and lower Apgar scores in one (7 vs. 9, p = 0.002) and 5 min (9 vs. 10, p = 0.005) were observed in the antepartum-onset group. ConclusionIn conclusion, PPCM commonly occurred around 35 weeks of gestation, ranged from 26 to 40 weeks. Additionally, there were risks of early preterm and low Apgar scores in women with antepartum-onset of PPCM.

Incremental prognostic value of myocardial strain over ventricular volume in patients with repaired tetralogy of Fallot.

The relative incremental predictive value of myocardial deformation over ventricular volume for future adverse events in patients with repaired tetralogy of Fallot (rTOF) remains unknown. We aimed to determine the incremental prognostic value of myocardial deformation over ventricular volume to predict adverse events in patients with rToF. We retrospectively included patients with rTOF who completed cardiac magnetic resonance (CMR) and follow-up in our hospital from January 2014 to October 2020, and stratified according to the presence or absence of adverse events during follow-up. The strain parameters of the right ventricular (RV) and left ventricular (LV) were obtained from CMR-derived feature tracking. Multivariable Cox proportional hazard models and net reclassification improvement analysis were used to analyze the prognostic information of biventricular strain and volume parameters in rTOF patients. Among 98 patients with rTOF, 54 (55.1%) experienced primary and/or secondary events during a median follow-up period of 27.0 months. Univariable analysis indicated that RV volume and strain were significantly associated with both primary events and all adverse events (all p < .01). Multivariable Cox regression and net reclassification improvement analyses achieved incremental global χ2 (all p < .001), C index (all p < .001), and overall correct reclassification by sequentially adding CMR-derived RV volume, RV strain and LV strain parameters to preexisting clinical factors in adverse events model analyses. RV and LV myocardial deformation provided incremental prognostic information and significant improvement for risk stratification over RV size and clinical variables and therefore can be combined to further enhance prognostication. • RV volume and strain were significantly associated with both primary events and all adverse events, whereas LV volume and strain were associated with primary events. • Ventricular myocardial deformation is a strong predictor of adverse outcomes of patients with repaired tetralogy of Fallot, providing increased prognostic information and significantly improved risk stratification over ventricular size.

Prevalence of Wolff-Parkinson-White syndrome, association with congenital heart disease, and natural history in newborns

Abstract Background Wolff-Parkinson-White (WPW) syndrome is characterized by an accessory electrical pathway between the atria and ventricles. Clinically, the condition can lead to supraventricular tachycardia, and is associated with sudden cardiac death and congenital heart disease. Studies investigating the prevalence, associated structural cardiac abnormalities, and natural history in newborns are few. Purpose To determine the prevalence of WPW syndrome in newborns, describe electrocardiographic and echocardiographic characteristics, and the natural history in childhood. Methods Electrocardiograms (ECGs) and echocardiograms of newborns (aged 0–30 days) from a large, prospective, general population study were included. WPW cases were identified through manual evaluation of outliers in PR-interval, QRS-duration, and QRS axis. Newborns with suspected or confirmed pre-excitation on their initial ECG were offered a cardiac follow-up. Localization of the accessory pathway was assessed utilizing a QRS polarity algorithm. Cases were matched 1:4 to controls by age, sex, weight and gestational age. Results Among the 17,489 ECGs we identified 17 (76% boys) newborns with definite WPW syndrome consistent with a prevalence of 0.1%. At follow-up (available in 12/17 children) at a mean age of three years, the WPW pattern remained in three children while the ECG had normalized in the nine remaining children. The median values for the newborns' heart rate, PR-interval, QRS-duration, QTc(Bazett), the maximum amplitude in R-V1 and S-V6 in cases and controls were 131 vs. 142 beats per minute, 80 vs. 96 ms, 74 vs. 56 ms, 449 vs. 420 ms, 1,562 vs. 1,028 μV and 546 vs. 693 μV, respectively (all p&amp;lt;0.05, Figure 1). The newborns' QRS axis, max amplitude in S-V1 and R-V6 did not differ among cases and controls (all p&amp;gt;0.05). Echocardiographic measurements of the newborns' left ventricular diameter and function, wall thicknesses, and doppler measurements of trans-mitral- and main pulmonary artery blood flow did not differ significantly between cases and controls (all p&amp;gt;0.05). The accessory electrical pathway was left-sided in 14 (82%) of the newborns. One newborn had significant mitral regurgitation while all other newborns had structurally normal hearts; there were no cases of Ebstein's anomaly. Conclusion The prevalence of WPW syndrome in our cohort of asymptomatic newborns was 0.1%. The syndrome was more frequent in boys, the accessory pathway was mostly left-sided, and was associated with changes in several ECG parameters, but generally not associated with structural heart disease. A striking observation was, that the WPW pattern in the majority of children could not be reproduced on follow-up ECGs at a mean age of three years, suggesting either that the ECG pattern is intermittent, or normalization occurs. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): The Danish Heart Foundation

Editorial for "Cardiac Magnetic Resonance Imaging Findings in COVID-19 Vaccine-Related Myocarditis: A Pooled Analysis of 468 Patients".

Samimisedeh et al,1 have published a systematic review and metanalysis of 102 publications with 468 patients with suspected myocarditis following COVID-19 vaccination. An accompanying editorial by Hanneman et al,2 highlights how patients were predominately young, male, and affected after their second dose of vaccine. A total of 79% met the accepted Lake Louise criteria for myocarditis. The authors show that the overall rate of myocarditis is low, ~16 cases per million doses of vaccine, and comparable to other vaccines such as influenza and non-smallpox vaccines.3 The authors can be applauded for demonstrating in a large, pooled cohort that vaccine-related myocarditis is usually mild and self-limiting, with no deaths occurring within the time frame. This provides substantial evidence for clinicians in their counseling of patients with vaccine hesitancy, particularly a younger population who as less likely to develop severe disease. This is in stark contrast to myocarditis related to the COVID-19 virus itself, which portends a poor prognosis due to arrythmias, heart failure and death. One study has shown a 0.2% chance of arrythmias or death within 28 days of a COVID vaccine, compared with 10.3% after a positive COVID test. In another large registry study of COVID-19 positive patients, those with myocarditis compared with those without myocarditis had a mortality rate of 13.4% vs. 4.2%.4 There is evidence cardiac MRI follow-up has prognostic value after an acute diagnosis of myocarditis, with patients with late gadolinium enhancement having complete resolution on a 6-month convalescent scan.5, 6 Early signal in published reports of vaccine-related myocarditis first appeared in mid-2021.7 Therefore, it would have been interesting to review that papers that include 6 to 12 month follow up cardiac MRI studies of cases to see if the degree of late gadolinium enhancement improved or resolved, particularly as it is a self-limiting disease clinically. Cardiac magnetic resonance imaging is non-invasive and excellent investigative tool in diagnosis myocarditis.6 Though cardiac MRI can demonstrate the classic subepicardial basal to mid inferolateral wall late gadolinium enhancement pattern, it does not have enough precision to identify the underlying etiology. Moreover, despite extensive research into vaccine-related myocarditis, we are still unclear as to the exact mechanisms that cause it.8, 9 It would have been interesting to review the studies that included histopathological correlation with endomyocardial biopsy. Finally, there is an emerging signal that myocarditis may represent an early signal of a “hot phase” of inherited or inflammatory cardiomyopathies, and that patients may have a genetic disposition to develop myocarditis.10 This could have been an interesting additional question in this review and will be interesting to follow in the coming years as we learn about the long-term effects of COVID-19 and vaccines to mitigate the risks.