Congenital aortic stenosis in adults: rate of progression and predictors of clinical outcome: Reply

Dear Editor,We thank Dr. Ramaraj for his interest in our analysis on the progression of congenital aortic stenosis. Age should be regarded as an important risk factor for faster stenosis progression. The mechanism for faster progression is probably valve calcification occurring at an earlier age, promoted by the abnormal mechanical and shear stresses associated with a bicuspid aortic valve. Recent insights into the pathogenesis of calcification of the aortic valve suggest that this is an active, rather than a passive process, with features reminiscent of atherosclerosis. Inflammation, lipid infiltration, dystrophic calcification, ossification, and endothelial dysfunction have been observed in both diseases. [...

Pregnancy in women with congenital heart disease

Due to the enormous improvements in the treatment of children with congenital heart disease, an increasing number of patients reach adulthood nowadays. To achieve the aim of excellent care concerning pregnancy in this patient population, a pro-active discussion of pregnancy with all women inthis patient population is essential. Several risk stratifi cation models have been developed in order to identify high risk pregnancies and better inform patients about these risks. Counselling and dedicated care are needed to optimise both maternal and fetal outcomes. Better access to health caresystems contributes to further improvements in mortality and morbidity. Furthermore a well-developed, multidisciplinary plan for each individual patient concerning pregnancy, delivery and follow-up is essential

Peripartum cardiomyopathy: Disease or syndrome?

Peripartum cardiomyopathy (PPCM) is a rare form of pregnancy-associated heart failure and is considered to be a diagnosis of exclusion. There are many hypotheses on the aetiology of PPCM; however, the exact pathophysiological mechanism remains unknown. It shows many resemblances to other conditions, such as familial dilated cardiomyopathy or myocarditis, and therefore it can be hard to make a definite diagnosis. We describe four cases of peripartum-onset heart failure in women who were suspected of having PPCM. We discuss the differential diagnosis, pathophysiological mechanisms and various diagnostic modalities

Heart failure in congenital heart disease: management options and clinical challenges

Introduction: The population of adults with congenital heart disease (ACHD) is rapidly expanding and one of the major complications is heart failure. Timely diagnosis and treatment are crucial, but strong evidence for effectiveness of heart failure treatment in ACHD is currently lacking. Components of the medical history, physical examination and further diagnostic tests including ECG, echocardiography, cardiac magnetic resonance imaging, exercise testing, and biomarkers can identify patients at risk for early mortality or heart failure. Areas covered: Although the number of studies guiding evidence-based treatment are expanding, many clinical questions have not been completely answered yet. Therefore, in this review we provide an overview of current available insights in epidemiology, diagnosis, risk stratification and treatment options in ACHD patients, including non-medical therapies and advanced care planning. Expert Opinion: We strongly advocate expanding current use of biomarkers in the diagnostic process and timely initiation of discussing advanced treatment options and advanced care planning with patients and their loved ones. More research in multi-center collaborations is needed to study all aspects of care of adult congenital heart disease patients

Effects of antiplatelet therapy on menstrual blood loss in reproductive-aged women:a systematic review

Background: The effects of antiplatelet therapy on menstrual bleeding have not been well characterized. Objectives: To systematically review the effects of antiplatelet therapy on menstrual bleeding. Methods: A literature search was performed for studies of reproductive-aged women who received antiplatelet therapy. Characteristics of menstrual bleeding both before and after initiation of antiplatelet therapy and from comparison groups were collected. Two reviewers independently assessed the risk of bias in individual studies. Results: Thirteen studies with a total of 611 women who received antiplatelet therapy were included. Types of antiplatelet drugs used were aspirin (n = 8), aspirin and/or clopidogrel (n = 2), prasugrel (n = 1), and not specified (n = 2). Risk of bias was assessed at moderate (n = 1), serious (n = 8), critical (n = 2), and no information (n = 2). Three studies reported changes in menstrual blood loss volume. One of these showed no increase during antiplatelet therapy; the other 2 studies suggested that aspirin may increase menstrual blood loss volume. In 3 studies that assessed the duration of menstrual bleeding, up to 13% of women reported an increased duration of menstruation. In 5 studies that reported the intensity of menstrual flow, 13% to 38% of women experienced an increase in the intensity of flow. Five studies reported the prevalence of heavy menstrual bleeding in women who received antiplatelet therapy, with estimates ranging from 7% to 38%. Conclusion: There is lack of high-quality data on the effects of antiplatelet therapy on menstrual bleeding. Aspirin may increase menstrual blood loss, at least in a minority of women, whereas the effects of P2Y12 inhibitors are unknown.</p