Left Heart Dilatation Research Articles

Long-term outcomes and immune profiling in children with multisystem inflammatory syndrome (MIS-C).

Existing follow-up data after MIS-C is limited. to investigate the long-term consequences in children who have undergone MIS-C. The retrospective study included 93 children. The identified changes were divided into the following periods: occurred within first 6 months, 1 year, 2 years, and more than 2 years after MIS-C. Besides, 31 children underwent prospective immunophenotyping of peripheral blood and the determination of cytokines during the acute period of the disease and after discharge. Outpatient monitoring events included pneumonia (9.6%), somatic disorder syndrome (11.8%), visual impairment (7.5%), joint damage (6.6%), weight changes (2.2%), and MIS-C recurrence (2.2%). A study of the cardiovascular system showed a statistically significant decrease in the frequency of the right and left heart dilatation, left ventricular dysfunction, pericarditis, pulmonary arterial hypertension, coronaritis, mitral regurgitation. But at the same time an increase in pulmonary and tricuspid valve regurgitation and arrhythmias compared with the acute period was detected. Most of the changes took place within first year of observation. Immune profiling showed reconstitution of CD3, CD4 T-lymphocytes, NK-cells, maintenance of a high relative value of CD8, reduction of CD19+ B-cells, expression of CD3-HLA-DR+, CD25, CD279, CD95. After the history of MIS-C, children in the long-term follow-up had various somatic disorders and disease recurrence. Most patients (64.1%) showed subclinical signs of myocardial involvement within first year of observation. Low expression of CD95 may justify an certain role in the pathogenesis of the disease.

Abstract 15296: Incidence and Predictive Factors for Left Ventricular Dysfunction After Transcatheter Device Closure of Patent Ductus Arteriosus in Extremely Low Birth Weight Infants

Background: Left ventricular (LV) dysfunction is a known complication after ligation or device closure of patent ductus arteriosus (PDA). Recently, an increasing number of premature and extremely low birth weight (ELBW) infants undergo transcatheter device closure of PDAs. Afterload sensitivity of the immature myocardium may be expected to result in important changes in LV ejection fraction (EF) post-procedure. Aim: To evaluate incidence and magnitude of LV dysfunction after device closure of PDA in ELBW infants. Methods: Subjects undergoing PDA device closure from 2020-2022 who were ELBW (<1 kg) and extremely premature (gestational age <29 weeks) at birth were included. A single cardiologist reviewed each pre- and post-intervention echocardiogram and calculated LVEF. Mildly depressed function was defined as an LVEF <53%, moderately depressed as LVEF <40% and severely depressed as LVEF <30%. Results: There were 62 subjects who met inclusion criteria. Mean gestational age and birth weight were 24.8 weeks and 646 g, respectively. Mean age and weight at intervention were 7.9 weeks and 1718 g, respectively. All patients had normal LVEF pre-procedure (mean LVEF 68%) with a significant decline post-procedure to 60% (p<0.001) (Figure). Post-procedure, 80.6% of subjects maintained normal LVEF. Of 12 subjects who developed depressed function, 83% (n=10) had mildly depressed function and 17% (n=2) had moderately depressed function. There was no significant difference in post-procedure LV dysfunction in relation to pre-procedural PDA size, left atrial dilation, or LV dilation on univariate analysis. All subjects recovered function without additional inotropic support with a median time to observed normal LVEF of 5 days. Conclusions: LV dysfunction develops in 19% of ELBW infants undergoing PDA device occlusion, is usually mild in severity, and normalizes in all subjects. The size of PDA or degree of left heart dilation does not predict LV dysfunction in this population.

Sacubitril/valsartan mitigates cardiac remodeling, systolic dysfunction, and preserves mitochondrial quality in a rat model of mitral regurgitation

Sacubitril/valsartan (SAC/VAL), an angiotensin receptor blocker-neprilysin inhibitor, has been widely used to treat several types of heart failure. Nevertheless, the effects of drugs in mitral regurgitation patients, from the molecular level to therapeutic effects, remain unclear. This study investigates the roles of SAC/VAL on cardiac function, mitochondrial quality, autophagy, mitophagy, and natriuretic peptides in a rat model of chronic mitral regurgitation. Male Sprague–Dawley rats underwent MR induction (n = 16) and sham surgeries (n = 8). Four weeks post-surgery confirmed MR rats were randomly divided into MR (n = 8) and SAC/VAL (n = 8) groups. The SAC/VAL group was administered SAC/VAL, whereas the MR and the sham rats received vehicle via oral gavage daily for 8 weeks. Cardiac geometry, function, and myocardial fibrosis were assessed by echocardiography and histopathology. Spectrophotometry and real-time PCR were performed to assess the pharmacological effects on mitochondrial quality, autophagy, mitophagy, and natriuretic peptides. MR rats demonstrated significant left heart dilation and left ventricular systolic dysfunction compared with the sham group, which could be significantly improved by SAC/VAL. In addition, SAC/VAL significantly reduced myocardial cardiac remodeling and fibrosis in MR rats. SAC/VAL improved the mitochondrial quality by attenuating mitochondrial reactive oxygen species production and mitochondrial depolarization compared with the MR group. Also, the upregulation of autophagy-related, mitophagy-related, and natriuretic peptide system gene expression in MR rats was attenuated by SAC/VAL treatment. In conclusion, this study demonstrated that SAC/VAL treatment could provide numerous beneficial effects in MR conditions, suggesting that this drug may be an effective treatment for MR.

Transfemoral Perimembranous Ventricular Septal Defect Device Closure in Infants Weighing ≤ 10 kg

Transcatheter closure of Perimembranous VSDs (PMVSD) remains challenging particularly in infants. The aim of this study is to evaluate the efficacy and safety of transfemoral PMVSD device closure in infants weighing ≤ 10 kg in a single centre. Retrospective review of departmental databases and medical charts to define patient cohort and collect demographic, procedural and follow-up data. Between July 2014 and March 2021, 16 patients underwent attempted transfemoral PMVSD device closure (12 retrograde) at a median age of 11 months (interquartile range [IQR] 9–15.5) and a median weight of 8.3 kg (IQR 7.2–9.5). All patients were either symptomatic, had progressive left heart dilation or had VSD associated valve regurgitation. Median defect size on pre-procedural transoesophageal echocardiography was 6.8 mm (IQR 6–8.5). Median device waist size was 6 mm (IQR 4.5–8). Successful device placement was achieved in 14 patients (88%). One patient developed moderate aortic and tricuspid valve regurgitation upon retrograde and antegrade device deployment, respectively, and subsequently underwent surgical closure. The second patient developed progressive aortic regurgitation (AR) 2 days post procedure, and also underwent surgical removal with no residual AR. There was no cases of device embolization and no femoral arterial compromise. On median follow-up of 40.5 months (IQR 25–64), none of the patients developed complete heart block. Three patients (18.75%) had small residual shunts at latest follow-up which have not required any further intervention. Device closure of PMVSD’s in children weighing ≤ 10 kg is feasible and safe with good procedural success rates. Use of both the antegrade and retrograde approaches may be necessary depending on anatomical variances.

Twenty-year changes in the clinical and echocardiographic characteristics of patients with early postinfarction remodeling after primary ST-segment elevation myocardial infarction

Aim. To compare structural and functional left ventricular (LV) changes in the early period of myocardial infarction (MI) within 20 years on the basis of the Emergency Cardiology Department of the Cardiology Research Institute (Tomsk).Material and methods. The study included two groups of patients who were treated at different periods of time with an interval of 20 years. Group 1 included 83 patients who had ST-segment elevation MI (STEMI) in 1997-1999, while group 2 — 83 patients with STEMI from 2019-2020. Echocardiography was performed during the first 72 hours from hospitalization and on the 7-10th day. Depending on the increase in LV end-diastolic volume (EDV) by >15% by the 7-10th day, the patients were divided into 2 subgroups: with remodeling (LVR+) and without remodeling (LVR-).Results. Patients of the 2nd group were older, with a larger proportion of females and with a high incidence of risk factors for coronary artery disease compared with patients of the 1st group. In the early postinfarction period among patients of the 2nd group, acute LV aneurysm, early postinfarction angina and Dressler syndrome developed less frequently. The proportion of adverse LV remodeling in patients of the 1st group was higher (32,8% vs 17%), and while the percentage of reverse remodeling was lower (10% vs 24%), p<0,05. Comparison of the absolute values of LV EDV, end-systolic volume (ESV) and ejection fraction (EF) at baseline and after 7 days, as well as their increase showed higher intensity of post-infarction remodeling in group 1 patients. In patients of the 1st group, there was a progression of LV remodeling (Me ΔEDV — 12,2%) with a deterioration in LV contractility by the 7th day (Me ΔESV — 14%), while in patients of the 2nd group during the first 7 days of MI, there were more stable LV EDV and ESV (p>0,05) and an increase in LVEF (p=0,03) before discharge.Conclusion. In the present era of primary percutaneous coronary intervention and pharmacological treatment of MI, early adverse LV remodeling develops less frequently and is characterized by less pronounced left heart dilatation.

Radiation Dose Exposure to Patients During Transcatheter Patent Ductus Arteriosus Closure via the Arterial Route

Objective This study aims to evaluate the radiation dose for transcatheter patent ductus arteriosus (PDA) viathe arterial route and compare it with previously published benchmarks. Background Exposure to radiation in the catheterization lab can cause skin injury and cancer in the long run, especially in pediatric patients with complex heart conditions, which necessitate serial catheterizations. Therefore, measuring the patient radiation dose and establishing a benchmark for each cardiac interventional procedure is essential. Material and methods In this prospective study, 34 patients with transcatheter patent ductus arteriosus closure via an arterial route were included. Patients who had silent PDAs, no left heart dilatation and PDA size of less than 2mm had PDA closed via an arterial route. All the study group patients received an Amplatzer duct occluder II-additional size device (St. Jude Medical Corp, St. Paul, MN) using biplane flat-panel fluoroscopy equipment adjusted in accordance with the pediatric parameters. Patients' dose area product, air kerma and fluoroscopytime were recorded in the catheterization lab and finally compared with internationally published reference data. Results Of 73 patients who had transcatheter patent ductus arteriosus closure between April 2021 to December 2021, 34patients who had a PDA closure via an arterial route were enrolled. The median age and weight were 11.5 (4-168) months and 10.5 (6-31) kg. Twenty-one (61.8%) were males, and 13 (38.2%) were males. The median radiation dose parameters were as follows: air kerma 11 (3-42) milliGray, dose area product 131 (33-443) microGray per m2, median dose area product indexed to weight 12 (1-48) microGray m2 per kg, fluoroscopy time 2 (2-4) min and frame rate 15 (7.5-15) frames per second. Due to many factors, our radiation dose parameters were less than internationally published reference values for transcatheter PDA closure. Conclusion Patient selection, detailed pre-catheterization echocardiography and procedure planning are essential for accomplishing device closure of PDA with a significant reduction in radiation dose. Hemodynamic assessment in the catheterization lab is unnecessary for most PDA patients. Additionally, a next-generation imaging platform equipped with flat-panel detectors and adjusted for pediatric settings and a fluoro recording option can be used to reduce radiation exposure.

Characteristics of the acute myocardial infarction course in patients with type 2 diabetes mellitus before and after reperfusion therapy

Introduction. Scientific research is currently being done to diagnose and manage comorbid conditions in patients. The importance of studying the pathophysiological mechanisms of acute myocardial infarction (AMI) in patients with type 2 diabetes mellitus (DM) has been proven. The purpose of the study: to conduct a retrospective analysis before and after reperfusion therapy by evaluating the features of the AMI course in patients with type 2 DM. Material and methods. The study was conducted from January 10, 2020 to January 12, 2021. In total, 74 STEMI patients with or without type 2 DM, aged 59.42±7.66 years were examined at the Intensive Care Unit of the Government Institution “L. T. Malaya National Therapy Institute of the National Academy of Medical Sciences of Ukraine” and the Kharkiv Railway Clinical Hospital No. 1 of the branch “Center of Healthcare” of Public Joint Stock Company “Ukrainian Railway”. Serum levels of insulin, adropin, irisin, fatty acid binding protein 4 (FABP4) and C1q/TNF-related protein (CTRP3) were detected by enzyme-linked immunosorbent assay. Analysis and processing of the findings obtained after examinations were carried out using the computer program IBM SPPS software, version 27.0 (IBM Inc., USA, 2020). Results and discussion. Before the treatment, patients with AMI and type 2 DM had significantly higher values of end-systolic size (ESS) by 5.56%, left atrium (LA) by 10.53%, left ventricular myocardial mass index (LVMMI) by 6.87% and lower values of systolic blood pressure (SBP) by 11.76%, atherogenic index (AI) by 5.80%, glucose by 25.71%, insulin by 39.92%, irisin by 15.34%, FABP4 by 19.76% compared to the values of these indicators 14 days after medicamentous therapy (p<0.05). Patients with AMI and type 2 DM had significantly higher values of adropin by 46.10%, irisin by 20.11%, CTRP3 by 28.78% and lower values of SBP by 17.65%, diastolic blood pressure by 12.38%, heart rate (HR) by 13.73%, pulse by 10.87%, body mass index by 5.57%, weight by 9.52%, glucose by 26.67%, insulin by 40, 75%, total cholesterol by 10.04%, very low-density lipoproteins by 24.75%, low-density lipoproteins by 8.52%, triglycerides by 27.06%, AI by 10.55%, FABP4 by 37.04% before treatment as compared to the values of these indicators 14 days after percutaneous coronary intervention (PCI) (p<0.05). Comparing the studied indicators between subgroups after medicamentous treatment and PCI, a significant decrease in HR by 8.33%, ESS by 4.11%, LA by 9.52%, LVMMI by 5.53%, FABP4 by 21.53% and an increase in the levels of adropin by 36.99%, irisin by 41.88%, CTRP3 by 30.25%, high-density lipoproteins (HDL) by 10.28% were identified (p<0.05). Conclusions. When compared PCI advantages due to the absence of a tendency to the left heart dilatation over the medicamentous therapy, improvements of energy and adipokine metabolism have been observed amid increased levels of adropin, irisin and CTRP3 and decreased levels of FABP4 in patients with AMI and type 2 DM. It should be noted that there has been a significant improvement in the state of energy and adipokine profiles under the conditions of performing PCI.

Catheter Closure of Clinically Silent Patent Ductus Arteriosus Using the Amplatzer Duct Occluder II-Additional Size: A Single-Center Experience.

ObjectivesTranscatheter closure is the treatment of choice for most patent ductus arteriosus (PDA) in infants, children, and adults. However, there is a controversy regarding transcatheter closure of clinically silent PDAs. Some authors favor device closure to eliminate the lifelong risk of infective endarteritis while others recommend avoiding PDA closure in such patients. The study describes our experience of closing the silent PDAs using the Amplatzer duct occluder II-additional size (ADO II-AS) (St. Jude Medical Corp, St. Paul, MN).Materials and methodsFrom April 2018 through March 2021, 52 consecutive pediatric patients aged 18 years and less with clinically silent PDA who had transcatheter closure at our center were enrolled. Patients were excluded if they had clinically detected PDAs; had surgical ligation of PDA with no residual shunt; had left heart dilatation on echocardiography; or moderate-sized PDAs closed with ADO II-AS. In addition, patients with an innocent murmur or murmur due to an associated lesion were included. This study was retrospective, and all of the 52 patients underwent PDA device closure using ADO II-AS.ResultsFifty-two consecutive patients were enrolled with a median age of 17 months, range (97-2.5) 94.5 months. Mean weight was 11.29 kilogram, range (24.8-3.5) 21.3 kilogram, and mean follow-up was 13.5 months, range (29-0) 29 months. Thirty-one (59.6%) were females, and 21 (40.4%) were males. The mean procedure time was 30.6 min, range (60-10) 50 min, and mean fluoroscopic time was 5.5 min, range (28-1.7) 26.3 min. The mean volume of contrast given was 9.1 milliliter, range (30-4) 26 milliliter. Forty-five (45; 88.2%) patients had immediate closure of PDA. No patients had anesthetic or vascular complications; however, two patients had procedural complications. Device placement was unsuccessful in one patient with Downs syndrome. The mean follow-up for our patients was 13.5 months, range (29-0) 29 months; the patients were asymptomatic at the follow-up, and none of the patients had any residual leak. None of the patients showed coarctation or left pulmonary artery stenosis at the latest follow-up.ConclusionThe usefulness of catheter-based therapy for silent PDA is less well-established by current evidence. Further studies are needed to justify the intervention solely based on the premise that the silent duct is a substrate for infective endarteritis; however, our reason to close silent PDA was to do so primarily because of social reasons. This study found that device closure of silent PDA is safe and effective using an ADO II-AS device with minimal risk of embolization and a low residual shunt rate. Coils have been used to close small PDAs, however, with higher rates of embolization and device malpositioning. We believe ADO-II AS offers an advantage of safety and efficacy over coils. In addition, the study highlights the advantage of using an ADO II-AS device, which can be delivered via a four French delivery system with no arterial complications.

Dapagliflozin Improves Cardiac Hemodynamics and Mitigates Arrhythmogenesis in Mitral Regurgitation-Induced Myocardial Dysfunction.

BackgroundMitral regurgitation (MR) is a major contributor for heart failure (HF) and atrial fibrillation. Despite the advancement of MR surgeries, an effective medical therapy to mitigate MR progression is lacking. Sodium glucose cotransporter 2 inhibitors, a new class of antidiabetic drugs, has shown measurable benefits in reduction of HF hospitalization and cardiovascular mortality but the mechanism is unclear. We hypothesized that dapagliflozin (DAPA), a sodium glucose cotransporter 2 inhibitor, can improve cardiac hemodynamics in MR‐induced HF.Methods and ResultsUsing a novel, mini‐invasive technique, we established a MR model in rats, in which MR induced left heart dilatation and functional decline. Half of the rats were randomized to be administered with DAPA at 10 mg/kg per day for 6 weeks. After evaluation of electrocardiography and echocardiography, hemodynamic studies were performed, followed by postmortem tissue analyses. Results showed that DAPA partially rescued MR‐induced impairment including partial restoration of left ventricular ejection fraction and end‐systolic pressure volume relationship. Despite no significant changes in electrocardiography at rest, rats treated with DAPA exhibited lower inducibility and decreased duration of pacing‐induced atrial fibrillation. DAPA also significantly attenuated cardiac fibrosis, cardiac expression of apoptosis, and endoplasmic reticulum stress‐associated proteins.ConclusionsDAPA was able to suppress cardiac fibrosis and endoplasmic reticulum stress and improve hemodynamics in an MR‐induced HF rat model. The demonstrated DAPA effect on the heart and its association with key molecular contributors in eliciting its cardio‐protective function, provides a plausible point of DAPA as a potential strategy for MR‐induced HF.

Combination of chronic myocarditis and progressive coronary artery disease: differential diagnosis and stepwise treatment

Aim. To assess the differential diagnosis in a patient with a combination of coronary artery disease and myocarditis and the results of stepwise treatment (including immunosuppressive therapy (IST), and coronary stenting).Material and methods. A 56-year-old female patient with hypertension, obesity (body mass index, 31,6 kg/m2), diabetes and psoriasis developed shortness of breath after a respiratory viral infection. Primary echocardiography revealed left heart dilatation, ejection fraction (EF) of 21%. Coronary angiography revealed anterior descending artery stenosis of 75%, circumflex artery — 80%, right coronary artery (RCA) — 70%. RCA stenting was performed and cardiovascular and diuretic therapy was started. However, shortness of breath and low exercise tolerance persisted.Results. In the blood test, anti-endothelial cell antibodies were 1:320, anticardiomyocyte and anti-smooth muscle antibodies — 1:80, anti-cardiac conduction system fibers — 1:320 (N≤1:40). During myocardial perfusion scintigraphy with computed tomography, an uneven distribution of the indicator was noted. Signs of myocardial scarring and indications for further revascularization were not revealed. Cardiac magnetic resonance imaging confirmed a decrease in left ventricular (LV) contractility (LVEF 37%) and moderate dilatation. Biopsy was not performed due to dual antiplatelet therapy. The condition is regarded as infectious-immune myocarditis. IST was started with azathioprine 150 mg/day. We noted dyspnea relief and a stable increase in LVEF to 50-52%. The clinical course was complicated by sick sinus syndrome with pauses up to 6 seconds and presyncope; a pacemaker was implanted. After 5 years from the onset of IST, dyspnea episodes reappeared without exacerbation of myocarditis. As their cause, ischemia was diagnosed due to the progression of coronary atherosclerosis. Symptoms regressed after repeated coronary stenting.Conclusion. The presence of moderate coronary atherosclerosis without signs of ischemia and myocardial infarction should not be considered as the only cause of severe systolic myocardial dysfunction. Diagnosis and treatment of myocarditis in combination with coronary artery disease is carried out according to the standard principles and can improve LV systolic function and control the heart failure symptoms.

Dynamics of quality of life parameters and echocardiography depending on adherence to treatment in patients with chronic rheumatic heart disease at 5-year follow-up

Aim. To assess the dynamics of quality of life indicators and echocardiography parameters depending on adherence to treatment in patients with chronic rheumatic heart disease at 5-year follow-up. Material and methods . A total of 180 patients with RHD were examined. According to the Moriski-Green test 60% were not adherent to treatment; 28,9% are not sufficiently adherent; 11,1% — adherent to treatment. Echocardiography was performed on a Philips Affinity 50 machine, the quality of life was assessed using SF-36, KCCQ, MHFLQ. Results. Both at baseline and after 5 years of observation, the maximum linear dimensions of left atrium — 4,90 [4,62;5,22] cm, left ventricle end-diastolic dimension — 5,55 [4,39;6,69] cm and left ventricle end-systolic dimension 3,70 [4,63;5,23] cm were in a group of adherent to treatment patients. The maximum dimensions of the right atrium (4,80 [4,55;5,15] cm) and of the right ventricle (2,70 [2,40;2,94]) cm at baseline and, after 5 years, were observed in group not adherent to treatment. Differences in the area of mitral valve between groups are not received. On the scales of quality of life, initially, the best value was in group of not sufficiently adherent: MHFLQ — 34,29 [26,97;40,3]; KCCQ functional status — 25,20 [19,28;31,18], KCCQ clinical summary score — 55,00 [47Д67.0]; SF-36 physical health — 34,26 [26,05;45,36], SF-36 mental health — 43,36 [37,49;48,60]. In the group of treatment adherents, the worst values of physical health SF-36 were 33,62 [32,5;36,92] and KCCQ clinical summary score was 37,50 [21,5;56,5]. After 5 years, in group of not sufficiently adherent patients maintained the best quality of life values: MHFLQ - 30,5 [11,5;48,5]; SF-36 physical health is 37,81 [31,51;45,91 ], KCCQ overall summary score — 24,85 [18,55;33,95]. Group of adherents to treatment had the best indicators of quality of life only for SF-36 mental health — 44,29 [30,47;58,33] and KCCQ clinical summary score — 67,50 [48,8;87,5]. Conclusion. In the study with RHD, there was no unambiguous effect of adherence to drug therapy on indicators of heart remodeling and quality of life. The data obtained on the greater severity of dilatation of left heart in adherents to treatment and dilatation of right in non-adherents require a comparison with patients who did not receive drug therapy and, possibly, a longer follow-up period.

The role of ADRB1 genes polymorphism in examined patients with chronic rheumatic heart disease

The study purpose is to evaluate effect of ADRB1 gene polymorphism on echocardiography indices and endothelial function in patients with chronic rheumatic heart disease. The sampling consisted of 128 patients with chronic rheumatic heart disease. The echocardiography was performed on Philips Affinity 50 device and evaluation of endothelial function was implemented on "AngioScan01" device. The genetic typing was carried out according polymorphic markers Gly49Ser and Gly389Arg. The nucleotide replacement of glycine with serine resulted in increasing of left sections of heart both at Ser49Ser (left atrium 5.65±0.09 cm; LVED 5.61±0.27 cm; LVES 3.76±0.16 cm), and Gly49Ser (left atrium 5.65±0.09 cm; LVED 5.61±0.27 cm; LVES 3.76±0.16 cm), The similar situation occurred when glycine was replaced with arginine: for Arg389Arg homozygotes (left atrium 5.63±0.12 cm; LVED 5.97±0.20 cm; LVES 3.97±0.16 cm); and heterozygotes Gly389Arg (LVED 5.60±0.08 cm; LVES 3.78±0.07 cm). Homozygosity of Ser49Ser in endothelial function led to low values of index augmentation (5.83±0.80%) and indicators reflecting function of small resistive arteries were the worst (1.30±0.07). Arg389Arg homozygotes had the worst endothelial function in system of large arteries (-20.40±0.68 ms). highest severity of arterial stiffness (23.00±0.68%) as compared with Gly389Gly homozygotes (8.92±0.99% and 62.67±1.41 years). ADRB1 gene polymorphism in subjects with HRBS leads to dilatation of left heart. The effect on endothelial dysfunction is multidirectional: Ser49Ser homozygosity leads to minimal arterial stiffness and changes in small resistive arteries; homozygosity of Arg389Arg leads to maximum changes in large conducting arteries and the highest rates of vascular stiffness.

Old Problem, New Solution

What procedure is being performed in Video 1? Select one of the following responses: Video 1. Click here to view the video. Patent ductus arteriosus (PDA) is a common complication of prematurity. Video 1 is from the cardiac catheterization of a 3-week-old female infant born at 28 weeks’ gestation with a birthweight of 960 g (27th percentile), length of 36 cm (39th percentile), and head circumference of 25.5 cm (42nd percentile). The infant had a hemodynamically significant PDA that did not respond to acetaminophen therapy. Echocardiography showed a moderate to large PDA with left heart dilation, and hence, at 23 days of age (weight 1,160 g), she met the indications for intervention. Hemodynamically significant PDAs that are unresponsive to medical treatment have, until recently, required surgical ligation via lateral thoracotomy. The associated morbidity for surgical ligation includes pneumothorax, bleeding, recurrent laryngeal nerve injury, and postoperative pain. (1) In an effort to minimize morbidity, Zahn et al reported a case series in 2015 of 6 extremely preterm infants undergoing catheter-based closure of the PDA at a median weight of 1,180 g. (2) Their novel technique minimized contrast dose and radiation exposure by using intraprocedural echocardiography as the primary imaging modality. Since their initial report in 2015, multiple centers across the United States have …

10-YEAR HEART TRANSPLANTATION EXPERIENCE IN NOVOSIBIRSK

Aim:to show the analysis of 10-year heart transplantation experience, the main complications and problems of the heart transplantation evaluation. Materials and methods.66 orthotopic heart transplantations were performed in patients with terminal chronic heart failure in our clinic since 2008. The heart failure causes were dilated cardiomyopathy in 46 cases (70%), postinfarction cardiosclerosis in 20 cases (30%). The recipients were 59 men (89%) and 7 women (11%), the average age was 46 ± 10 years. All patients had a severe left heart dilatation and critical left ventricular systolic dysfunction (left ventricular EDV 283 ± 58 ml, left ventricular ejection fraction 17 ± 5%, cardiac index 1.5 ± 0.3 l/min/m2). In some recipients, heart transplantation is performed in the second stage after preliminary implantation of mechanical circulatory support systems (LVAD, BVAD). The fi rst heart transplantations were performed using the biatrial technique (8 cases (12%)), the others were performed using the bicaval technique (58 cases (88%)). After the operation, patients received a three-component immunosuppressive therapy: the inhibitors of calcineurin, mycophenolate and corticosteroids.Results.54 patients (82%) were discharged from the clinic after heart transplantation. The hospital mortality was 12 recipients (18%). The mortality in the long-term period was 10 recipients (15%). The hospital mortality cases were acute graft dysfunction in 5 cases (42%), infectious-septic complications in 4 cases (33%), massive intraoperative bleeding in 2 cases (17%), and total thrombosis of pulmonary artery in 1 case (8%). The death causes in the long-term period were acute transplant rejection in 4 cases (40%), coronary artery disease of the transplanted heart in 3 cases (30%), Kaposi’s sarcoma in 1 case (10%), lung cancer in 1 case (10%), and viral pneumonia in 1 case (10%).Conclusion.Over a 10-year period, we have gained a lot of experience in heart transplantation; the procedures complications have been studied; the stages of preservation, harvesting and transportation of the donor heart, operative technique and postoperative treatment of patients have been improved to avoid complications in the early and long-term postoperative period.

Invited Commentary

Mitral regurgitation (MR) accompanying ventricular septal defect (VSD) is uncommon and when present is often presumed to be a result of the physiologic mechanisms of VSD, with left ventricular dilatation that is a consequence of intracardiac shunting. The common expectation is for MR to regress as the ventricle remodels after VSD closure. Indeed, several studies have observed that ventricular volume load and associated MR regress with time after VSD closure alone [1Cho H.J. Ma J.S. Cho Y.K. Ahn B.H. Na K.J. Jeong I.S. Timing in resolution of left heart dilation according to the degree of mitral regurgitation in children with ventricular septal defect after surgical closure.J Pediatr (Rio J). 2014; 90: 71-77Crossref PubMed Scopus (7) Google Scholar, 2Mahadin D.R. Srivastava S. Parness I.A. et al.Outcomes of mitral regurgitation associated with large ventricular septal defect and a normal mitral valve apparatus: does intact atrial septum have an impact?.Pediatr Cardiol. 2011; 32: 1128-1131Crossref PubMed Scopus (9) Google Scholar], or even without VSD closure [3Kleinman C.S. Tabibian M. Starc T.J. Hsu D.T. Gersony W.M. Spontaneous regression of left ventricular dilation in children with restrictive ventricular septal defects.J Pediatr. 2007; 150: 583-586Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar]. Indications to intervene for specific types of MR in this setting may lack clear definition. Among 1,898 consecutive VSD closures, Jang and colleagues [4Jang W.S. Kim W.-H. Cho J.Y. et al.Surgical indications and results of mitral valve repair in pediatric patients with ventricular septal defects accompanied by mitral valve regurgitation.Ann Thorac Surg. 2015; 99: 891-898Scopus (6) Google Scholar] found MR in 5.6% of patients, and mitral repairs were judged necessary in half of those with MR. Of the patients who underwent concomitant mitral repair, 35 of 48 patients had prolapse of the anterior mitral valve leaflet, and the remaining patients had annular dilatation alone. At follow-up, all the patients who had VSD closure alone had regression or stability of the degree of MR. Of the patients who underwent repair, MR was also stable or improved, although 2 patients had mild to moderate mitral stenosis. Jang and colleagues demonstrate that, at least in short- to midterm follow-up, annular growth and sustained competence is achievable when posterior annuloplasty and commissuroplasty techniques are used to repair the mitral valve in infancy. Such repair in infancy is not without cost, however, as evidenced by the 2 patients who exhibited mitral stenosis after repair. The history of surgical and catheter-based interventions for cardiac defects is rife with junctures at which we are challenged to separate what we can do from what we should do. It is established that MR from annular dilatation regresses after closure of the VSD and generally does not require valvuloplasty. The fate of MR from structural valve abnormalities in addition to annular enlargement is less clearly defined. Jang and colleagues describe anterior leaflet prolapse as a common structural abnormality among those who underwent valvuloplasty in their series. The prognosis of untreated isolated mitral prolapse in children may be good [5Bisset G.S. Schwartz D.C. Meyer R.A. James F.W. Kaplan S. Clinical spectrum and long-term follow-up of isolated mitral valve prolapse in 119 children.Circulation. 1980; 62: 423-429Crossref PubMed Scopus (88) Google Scholar], but prolapse in the setting of VSD has not undergone specific scrutiny. It would be useful for the authors to leverage their large experience to specifically compare outcomes of treated versus untreated anterior mitral prolapse in the setting of VSD. Surgical Indications and Results of Mitral Valve Repair in Pediatric Patients With Ventricular Septal Defects Accompanied by Mitral Valve RegurgitationThe Annals of Thoracic SurgeryVol. 99Issue 3PreviewVentricular septal defects (VSDs) can be accompanied by mitral regurgitation (MR) owing to chronic volume overload or mitral valve (MV) abnormalities. This study investigates the surgical indications, results, and natural course of pediatric VSD patients with MR. Full-Text PDF

Timing in resolution of left heart dilation according to the degree of mitral regurgitation in children with ventricular septal defect after surgical closure

ObjectiveChildren with ventricular septal defects (VSD) can have chronic volume overload, which can result in changes of left heart echocardiographic parameters. To evaluate the changes before and after surgical closure, the children were divided into three groups according to the degree of mitral regurgitation (MR), and their echocardiographic characteristics were reviewed at serial follow-up after surgical closure. MethodsThe preoperative, and one-, three-, and 12-month postoperative echocardiographic data of 40 children who underwent surgical closure of VSD were retrospectively reviewed. Left ventricular end-diastolic volume (LVEDV), left ventricular end-diastolic dimension (LVEDD), left ventricular end-systolic dimension (LVESD), mitral valvular characteristics, including degree of MR and mitral valve annulus, and left atrial (LA) characteristics, including volume and dimensions, were observed. ResultsPreoperative LVEDV, LVEDD, LVESD, mitral valvular annulus, LA volume, and LA dimensions were significantly larger in children with MR. Additionally, there were significant decreases in LVEDV, LVEDD, LA volume, and LA dimensions at one, three, and 12 months postoperatively. The degree of MR also improved to a lower grade after surgical closure of the VSD without additional mitral valve repair. ConclusionThe echocardiographic parameters of left heart dilation and MR in children with VSD improved within the first year after surgical closure without additional mitral valve repair. Furthermore, in all of the patients with VSD, regardless of MR, LA dilation was reduced within three months after surgical closure of the VSD; however, LV and mitral valve annular dilatation decreased within 12 months.

Timing in resolution of left heart dilation according to the degree of mitral regurgitation in children with ventricular septal defect after surgical closure

Objectivechildren with ventricular septal defects (VSD) can have chronic volume overload, which can result in changes of left heart echocardiographic parameters. To evaluate the changes before and after surgical closure, the children were divided into three groups according to the degree of mitral regurgitation (MR), and their echocardiographic characteristics were reviewed at serial follow-up after surgical closure. Methodsthe preoperative, and one-, three-, and 12-month postoperative echocardiographic data of 40 children who underwent surgical closure of VSD were retrospectively reviewed. Left ventricular end-diastolic volume (LVEDV), left ventricular end-diastolic dimension (LVEDD), left ventricular end-systolic dimension (LVESD), mitral valvular characteristics, including degree of MR and mitral valve annulus, and left atrial (LA) characteristics, including volume and dimensions, were observed. Resultspreoperative LVEDV, LVEDD, LVESD, mitral valvular annulus, LA volume, and LA dimensions were significantly larger in children with MR. Additionally, there were significant decreases in LVEDV, LVEDD, LA volume, and LA dimensions at one, three, and 12 months postoperatively. The degree of MR also improved to a lower grade after surgical closure of the VSD without additional mitral valve repair. Conclusionthe echocardiographic parameters of left heart dilation and MR in children with VSD improved within the first year after surgical closure without additional mitral valve repair. Furthermore, in all of the patients with VSD, regardless of MR, LA dilation was reduced within three months after surgical closure of the VSD; however, LV and mitral valve annular dilatation decreased within 12 months.

Changes in Left Ventricular Morphology and Function After Mitral Valve Surgery

Degenerative mitral valve disease is the leading cause of mitral regurgitation in North America. Surgical intervention has hinged on the symptoms and ventricular changes that develop as compensatory ventricular remodeling occurs. In the present study, we sought to characterize the temporal response of left ventricular (LV) morphology and function to mitral valve surgery for degenerative disease and to identify the preoperative factors that influence reverse remodeling. From 1986 to 2007, 2,778 patients with isolated degenerative mitral valve disease underwent valve repair (n = 2,607 [94%]) or replacement (n = 171 [6%]) and had ≥1 postoperative transthoracic echocardiogram; 5,336 transthoracic echocardiograms were available for analysis. Multivariate longitudinal repeated-measures analysis was performed to identify the factors associated with reverse remodeling. The LV dimensions decreased in the first year after surgery (end-diastolic from 5.7 ± 0.80 to 4.9 ± 1.4 cm; end-systolic from 3.4 ± 0.71 to 3.1 ± 1.4 cm). The LV mass index decreased from 139 ± 44 to 112 ± 73 g/m(2). The reduction in LV hypertrophy was less pronounced in patients with greater preoperative left heart enlargement (p <0.0001) and a greater preoperative LV mass (p <0.0001). The postoperative LV ejection fraction initially decreased from 58 ± 7.0% to 53 ± 20%, increased slightly during the first postoperative year, and was negatively influenced by preoperative heart failure symptoms (p <0.0001) and a lower preoperative LV ejection fraction (p <0.0001). The risk-adjusted response of LV morphology and function to valve repair and replacement was similar (p >0.2). In conclusion, a positive response toward normalization of LV morphology and function after mitral valve surgery is greatest in the first year. The best response occurs when surgery is performed before left heart dilation, LV hypertrophy, or LV dysfunction develop.

Mitral valve dysplasia syndrome: A unique form of left-sided heart disease

Mitral valve dysplasia syndrome is a unique form of left-sided heart disease characterized by aortic outflow hypoplasia, dilated left ventricle, dysplastic/incompetent mitral valve, and a restrictive/intact atrial septum. Patients with this constellation of abnormalities have been managed in a variety of ways with overall poor outcomes. We performed a retrospective review of all patients with mitral valve dysplasia syndrome to identify fetal echocardiographic markers predictive of outcomes. Mitral valve dysplasia syndrome was identified in 10 fetuses. Fetal left heart dilation and abnormal pulmonary venous flow were associated with increased mortality. Seven fetuses had abnormal pulmonary venous Doppler patterns; 3 had a unique "double-reversal" flow pattern. Severe fetal left heart dilation (left heart/right heart area ratio > 1.5) was present in 5. Prenatal intervention was performed on 3 fetuses: balloon aortic valvuloplasty (n=2) and balloon atrial septostomy (n=1). Of the 3, one died in utero and neither survivor underwent a 2-ventricle repair. Five patients required an immediate postnatal intervention to open the atrial septum. The overall mortality was 50%. Mitral valve dysplasia syndrome is a unique form of congenital heart disease with severe aortic stenosis but normal or enlarged left ventricle secondary to primary mitral valve disease. Increased left heart size and pulmonary vein Doppler patterns are predictive of postnatal outcome. Despite the presence of a dilated left ventricle, postnatal management with staged single ventricle palliation may be the most effective strategy.

SHA 050. Effect of age in patient with acute coronary syndrome in SPACE registry

the other presented at 5 months of age with profound cyanosis and left heart dilatation without congenital heart disease and without lung hypoplasia, both patients underwent successful occlusion of the fistula by amplatzer occluding devices with normalization of saturation without complications at five years of follow up. Conclusion: Diagnosis of large pulmonary fistula is feasible in the fetus and early infancy with excellent outcome by catheter intervention in absence of congenital heart disease or lung hypoplasia.