Pieter De Meester

Objectives: To assess tricuspid regurgitation evolution after pulmonary endarterectomy and to identify predictive factors for residual postoperative tricuspid regurgitation. Methods: Perioperative and 6-month follow-up echocardiography and right heart catheterization data were retrospectively retrieved from all chronic thromboembolic pulmonary hypertension patients who underwent pulmonary endarterectomy between January 2009 and December 2023 in University Hospitals Leuven, Leuven and St. Antonius Hospital, Nieuwegein. Patients with vs without decreased tricuspid regurgitation and with vs without moderate/severe residual postoperative tricuspid regurgitation were compared. Results: Moderate/severe preoperative tricuspid regurgitation was present in 150/162 (93%) patients. It decreased with at least 1 degree 6 months postoperatively in 70/150 (47%) patients. In these patients, reductions in mean pulmonary artery pressure (−23 [−26; −21] vs −13 [−16; −11] mm Hg, P < .001), pulmonary vascular resistance (−6.73 [−7.61; −5.85] vs −3.28 [−4.05; −2.52] Wood units, P < .001), and N-terminal pro brain natriuretic peptide (ratio post-/preoperative measurement: 0.227 [0.168; 0.307] vs 0.968 [0.741; 1.265], P < .001) were larger than in patients without this decrease. Moderate/severe residual tricuspid regurgitation was seen in 26/162 (16%) patients. Postoperative mean pulmonary artery pressure (34 [30; 37] vs 24 [22; 25] mm Hg, P < .001) and pulmonary vascular resistance (5.54 [4.77; 6.31] vs 2.99 [2.65; 3.33] Wood units, P < .001) were higher in these patients vs those without moderate/severe residual tricuspid regurgitation. Arterial hypertension, older age, atrial fibrillation, shorter 6-min walking distance, and higher tricuspid regurgitation degree were potential preoperative risk factors for residual tricuspid regurgitation. Conclusions: In our study population, tricuspid regurgitation improvement after pulmonary endarterectomy was associated with improved pulmonary haemodynamics. Concomitant tricuspid valve annuloplasty might be considered in patients with atrial fibrillation and a dilated tricuspid valve annulus, but in the absence of risk factors for persistent pulmonary hypertension.

Background and Aims: Maternal infections have been proposed to play a role in the development of congenital heart defects (CHD). This study aims to synthesize contemporary evidence on the association between first-trimester maternal infection and risk of offspring CHD. Methods: This systematic review and meta-analysis (PROSPERO number: CRD42024523638) used Embase, PubMed, Web of Science, Scopus, and the Cochrane Library to identify studies investigating first-trimester maternal infection and offspring CHD, published up until 30 September 2024. Human studies with a minimum of 50 cases were eligible. Inverse variance weighted random-effects models were conducted to pool estimates and stratify associations by infection type and heart defect type. Results: A total of 30 studies (24 case-control, 3 cohort, and 3 cross-sectional studies) with 1 732 295 pregnancies were identified. Studies assessed maternal infectious status through self-reported questionnaires (n = 20, 66.7%), laboratory testing (n = 7, 23.3%) or medical records (n = 3, 10.0%). Overall, any first-trimester maternal infection was associated with higher risk of CHD in offspring, with a pooled odds ratio (OR) and 95% confidence interval (CI) of 1.63 (1.41, 1.88). Among specific types of infection, rubella virus, coxsackievirus, respiratory infections, and influenza presented higher risks of offspring CHD, with ORs (95% CI) of 2.78 (2.08, 3.72), 1.57 (1.12, 2.19), 1.57 (1.25, 1.96), and 1.50 (1.20, 1.87), respectively. Studies that reported associations by individual subtype of CHD relied on a comparatively modest number of cases. Pooled ORs for exposure to any first-trimester infection were 1.59 (1.16, 2.20) for ventricular septal defects, 1.55 (1.21, 1.99) for atrioventricular septal defects, and not statistically significant for other subtypes. Conclusions: First-trimester maternal infections are associated with increased risk of offspring CHD and appear to extend beyond infections commonly tested for during routine pregnancy screening. Larger-scale studies are warranted to confirm these findings using laboratory antibody testing and explore underlying mechanisms.

BACKGROUND: Covered stent correction for a sinus venosus atrial septal defect (SVASD) was first performed in 2009. This innovative approach was initially viewed as experimental and was reserved for highly selected patients with unusual anatomic variants. In 2016, increasing numbers of procedures began to be performed, and in several centers, it is now offered as a standard of care option alongside surgical repair. However, covered stent correction for SVASD is not recognized by regulatory authorities, and in the minds of many pediatric and adult congenital cardiologists and surgeons, the condition is viewed as treatable only by cardiac surgery with cardiopulmonary bypass. METHODS: In April 2023, all centers identified from international conferences, publications, and colleague networks to be undertaking covered stent correction for SVASD were invited to participate in a retrospective audit of their procedures. RESULTS: Data were received on 381 patients from 54 units over a 12-year period with 90% of procedures being performed over the past 5 years. Balloon-expandable stents (8 types) were used in the majority; self-expanding stents (4 types) were used in 4.5%. The commonest stent was the 10-zig covered Cheatham Platinum stent in 62% of cases. In 10 procedures, the stent embolized requiring surgical retrieval and repair of the defect, resulting in technically successful implantation in 371 of 381 (97.4%). Major complications (surgical drainage of tamponade, pacemaker implantation, surgery for pulmonary vein occlusion, and late stent removal) occurred in 5 patients (1.3%). Repeat catheterization to correct residual leaks was required in 7 patients (1.8%). Thus, 359 of 381 patients (94.2%) had successful correction without major complications or additional catheter interventions. CONCLUSIONS: This article details the exponential uptake of covered stent correction for SVASD during the past 5 years. Cardiopulmonary bypass was avoided in the majority of patients, and major complications were infrequent. Prospective registries with standardized definitions, inclusion criteria, and follow-up and comparative studies with surgery are now required to help support the extension of covered stent correction as an alternative standard-of-care option for patients with an SVASD.

Background: Atrial switch repair was the first surgical intervention to result in long-term survival in patients with ventriculo-arterial discordance or transposition of the great arteries. However, the natural history after atrial switch is not uneventful with frequent atrial arrhythmia, development of baffle stenosis, and eventually heart failure. For this, new interventions might be necessary but are often associated with increased risk. Case summary: We present the case of a 49-year-old woman born with ventriculo-arterial discordance or dextro-transposition of the great arteries who underwent atrial switch repair according to Mustard at the age of 1 year. She presented with shortness of breath and reduced exercise capacity. The echocardiography revealed prominent turbulent flow at the level of the pulmonary venous baffle (PVB). This was confirmed on cardiac computed tomography. After multidisciplinary discussion, a hybrid approach was considered as the preferred strategy. In this, the cardiac surgeon provided apical access by left lateral thoracotomy. The PVB was accessed retrograde through right ventricular apical access, and stenting with a covered stent with subsequent balloon dilatation up to 13 mm was performed. This reduced the peak gradient on echocardiography from 18 to 11 mmHg. Clinical follow-up was uneventful with improved functional capacity 6 months after discharge. Discussion: This case provides an alternative access to the PVB by left lateral mini-thoracotomy and apical ventricular access. Furthermore, we highlight the challenges in decision-making and the importance of the multidisciplinary collaboration between adult congenital cardiologist, the echocardiographer, and cardiac surgeon as well as the flexibility in interventional techniques to individualize the management of such cases.

OBJECTIVES: The potential risk of autograft dilatation and homograft stenosis after the Ross procedure mandates lifelong follow-up. This retrospective cohort study aimed to determine long-term outcome of the Ross procedure, investigating autograft and homograft failure patterns leading to reintervention. METHODS: All adults who underwent the Ross procedure between 1991 and 2018 at the University Hospitals Leuven were included, with follow-up data collected retrospectively. Autograft implantation was performed using the full root replacement technique. The primary end-point was long-term survival. Secondary end-points were survival free from any reintervention, autograft or homograft reintervention-free survival, and evolution of autograft diameter, homograft gradient and aortic regurgitation grade over time. RESULTS: A total of 173 adult patients (66% male) with a median age of 32 years (range 18–58 years) were included. External support at both the annulus and sinotubular junction was used in 38.7% (67/173). Median follow-up duration was 11.1 years (IQR, 6.4–15.9; 2065 patient-years) with 95% follow-up completeness. There was one (0.6%) perioperative death. Kaplan–Meier estimate for 15-year survival was 91.1% and Ross-related reintervention-free survival was 75.7% (autograft: 83.5%, homograft: 85%). Regression analyses demonstrated progressive neoaortic root dilatation (0.56 mm/year) and increase in homograft gradient (0.72 mmHg/year). CONCLUSIONS: The Ross procedure has the potential to offer excellent long-term survival and reintervention-free survival. These long-term data further confirm that the Ross procedure is a suitable option in young adults with aortic valve disease which should be considered on an individual basis.

Background: Mitral valve prolapse (MVP) and mitral annular disjunction (MAD) are common valvular abnormalities that have been associated with ventricular arrhythmias (VA). Cardiac magnetic resonance imaging (CMR) has a key role in risk stratification of VA, including assessment of late gadolinium enhancement (LGE). Methods: Single-center retrospective analysis of patients with MVP or MAD who had >1 CMR and >1 24 h Holter registration available. Data are presented in detail, including evolution of VA and presence of LGE over time. Results: A total of twelve patients had repeated CMR and Holter registrations available, of which in four (33%) patients, it was conducted before and after minimal invasive mitral valve repair (MVR). After a median of 4.7 years, four out of eight (50%) patients without surgical intervention had new areas of LGE. New LGE was observed in the papillary muscles and the mid to basal inferolateral wall. In four patients, presenting with syncope or high-risk non-sustained ventricular tachycardia (VT), programmed ventricular stimulation was performed and in two (50%), sustained monomorphic VT was easily inducible. In two patients who underwent MVR, new LGE was observed in the basal inferolateral wall of which one presented with an increased burden of VA. Conclusions: In patients with MVP and MAD, repeat CMR may show new LGE in a small subset of patients, even shortly after MVR. A subgroup of patients who presented with an increase in VA burden showed new LGE upon repeat CMR. VA in patients with MVP and MAD are part of a heterogeneous spectrum that requires further investigation to establish risk stratification strategies.

OBJECTIVES: We sought to assess the evolution of secondary tricuspid regurgitation (TR) after isolated aortic valve replacement (AVR) and its impact on mortality and to identify possible clinical and echocardiographic predictors of persisting and new-onset TR (TR de novo) after isolated AVR. METHODS: Clinical and echocardiographic data of 441 patients, consecutively operated for isolated AVR between January 2017 and January 2020, were retrospectively collected. Four time points were included: preoperative, discharge, 3–6 months and last available follow-up. We followed patients with at least moderate TR (TR ≥2) over time and monitored the impact on survival. Logistic regression analysis was performed to identify possible predictors of persistent TR and TR de novo. RESULTS: Median follow-up was 33 months. Incidence of TR ≥2 changed over the time points. Twenty-three percent of patients with preoperative TR ≥2 had persistent TR at 3–6 months follow-up, and this phenomenon was predicted by age at regression analysis. Preoperative TR ≥2 was associated with a 3-fold higher risk to die. At 3- to 6-month follow-up, 12% of patients developed TR de novo. At least moderate preoperative mitral regurgitation (≥2) was predictive of TR de novo. CONCLUSIONS: Patients with TR ≥2 undergoing isolated AVR had worse long-term survival, and this was particularly evident in the elderly. Older patients were also more prone to have persistent TR after AVR. Some patients developed TR de novo after isolated AVR, but this did not affect survival.