Physiological and clinical consequences of relief of right ventricular outflow tract obstruction late after repair of congenital heart defects.

BACKGROUND: Right ventricular outflow tract obstruction (RVOTO) is a common problem after repair of congenital heart disease. Percutaneous pulmonary valve implantation (PPVI) can treat this condition without consequent pulmonary regurgitation or cardiopulmonary bypass. Our aim was to investigate the clinical and physiological response to relieving RVOTO. METHODS AND RESULTS: We studied 18 patients who underwent PPVI for RVOTO (72% male, median age 20 years) from a total of 93 who had this procedure for various indications. All had a right ventricular outflow tract (RVOT) gradient >50 mm Hg on echocardiography without important pulmonary regurgitation (less than mild or regurgitant fraction <10% on magnetic resonance imaging [MRI]). Cardiopulmonary exercise testing, tissue Doppler echocardiography, and MRI were performed before and within 50 days of PPVI. PPVI reduced RVOT gradient (51.4 to 21.7 mm Hg, P<0.001) and right ventricular systolic pressure (72.8 to 47.3 mm Hg, P<0.001) at catheterization. Symptoms and aerobic (25.7 to 28.9 mL.kg(-1).min(-1), P=0.002) and anaerobic (14.4 to 16.2 mL.kg(-1).min(-1), P=0.002) exercise capacity improved. Myocardial systolic velocity improved acutely (tricuspid 4.8 to 5.3 cm/s, P=0.05; mitral 4.7 to 5.5 cm/s, P=0.01), whereas isovolumic acceleration was unchanged. The tricuspid annular velocity was not maintained on intermediate follow-up. Right ventricular end-diastolic volume (99.9 to 89.7 mL/m2, P<0.001) fell, whereas effective stroke volume (43.7 to 48.3 mL/m2, P=0.06) and ejection fraction (48.0% to 56.8%, P=0.01) increased. Left ventricular end-diastolic volume (72.5 to 77.4 mL/m2, P=0.145), stroke volume (45.3 to 50.6 mL/m2, P=0.02), and ejection fraction (62.6% to 65.8%, P=0.03) increased. CONCLUSIONS: PPVI relieves RVOTO, which leads to an early improvement in biventricular performance. Furthermore, it reduces symptoms and improves exercise tolerance. These findings have important implications for the management of this increasingly common condition

'In the wake of a pandemic': dietary patterns and impact on child health after COVID-19

INTRODUCTION Our companion Report: ‘Emerging Dietary Patterns: Impact on Child Health’ discussed ways in which traditional dietary patterns in both the UK and internationally were changing. In concluding we argued that: ‘The interconnected nature of food, climate and health is the biggest challenge we face, but therein also lies its strength and boundless potential should we act with the necessary urgency, creativity and commitment. It is at the local level – supported by national policy – that the largest returns from such pro-activity will accrue.’ We continued: ‘The food that we eat here and now can change the world.’ adding: ‘If we are serious about protecting and restoring natural environments, safeguarding the health and wellbeing of our children today and restoring and protecting that of future generations, then there is only one solution. We must change it.’ Then came Covid-19 and change was imposed – with the arrival and experience of a pandemic. The full outcome of Covid-19; its effects and repercussions not just for the present generations but for the many that will succeed it cannot be estimated now. In the 102 years since Spanish ‘flu devastated an older world order, we are still learning its lessons today. But what has become immediately apparent is that what we eat and how we eat has undergone a revolution in four short months. 6 ‘Coronavirus pandemic will change the food industry and eating habits forever, says CEO of Food and Drink Federation, Ian Wright.’ ([email protected] 7 April 2020) ‘To prevent the next pandemic we must take on factory farming.’ (Jonathan Safran Foer and Aaron Gross, The Guardian, 21 April 2020.) ‘Covid-19 will definitely be an accelerator on the conscious consumer patterns that we see unfolding. As the consumer gets more conscious, we also see more interest in sustainable, locally produced food systems solutions.’ (David Brandes, Food Navigator, 17 April 2020.) ‘The virus is a warning that Britain’s food system must change,’ (‘The Guardian,’ 18th April 2020). It would also be unjust to address the Covid-19 pandemic in isolation without highlighting its interactions with another global force to become manifest in the same era in response to an incident in the US; namely, the police killing of George Floyd and the Black Lives Matter Movement. Pandemics, poor health, systemic inequalities and a lack of environmental protections harm black, ethnic minority and disadvantaged communities in all countries more than any other groups, and the two events have shed a harsh light on those realities and their frightening interconnections – such as the higher death rate in BAME communities including healthcare workers on the frontline (Public Health England, June 2020, ‘Beyond the data: Understanding the impact of COVID-19 on BAME groups’): https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/892376/COVID_stakeholder_engagement_synthesis_beyond_the_data.pdf Therefore, to address fall-out from the pandemic without considering these marginalised groups would be inappropriate; to address the environmental crisis without considering its impact on such groups would be pointless and the separation of civil rights from health and environmental policy is delusional. The silos in which policy-making still exists in these fields are stubborn obstacles to change. Both within and without the UK’s boundaries, the diverse spectrum of peoples requires a similar diversity and inclusion in the systems that sustain life – and the production of the food that is eaten in order to live. Sometimes change is immediate and imposed rather than incremental and the pandemic has seen an abrupt conclusion to familiar and traditional ways of living. As we offer our thoughts about the many ways in which Covid-19 has changed our dietary patterns, we must remember that the ‘brave new world’ of our future ambition ‘has such people in it’, (‘The Tempest’, William Shakespeare). Those who would construct better dietary patterns in the wake of this pandemic must ensure that people rather than systems prevail…

Progressive left ventricular remodeling in patients with hypertrophic cardiomyopathy and severe left ventricular hypertrophy.

OBJECTIVES The aim of this study was to determine the natural history of patients with hypertrophic cardiomyopathy (HCM) and severe left ventricular hypertrophy (LVH) (i.e., maximal left ventricular wall thickness [MLVWT] >/= 30 mm) and whether changes in cardiac morphology influence the course of the disease. BACKGROUND Severe LVH is common in young and rare among elderly patients with HCM. This has been explained by a high incidence of sudden death. We hypothesized that this age-related difference might be explained by left ventricular wall thinning. METHODS A total of 106 (age 33 +/- 15 years; 71 males) consecutive patients with severe LVH underwent history taking, examination, electrocardiography, echocardiography, cardiopulmonary exercise testing, and Holter analysis. Survival data were collected at subsequent clinic visits or by communication with patients and their general practioners. In order to assess morphologic and functional changes, 71 (67.0%) patients (mean age 31 +/- 15 years; 47 males) followed at our institution underwent serial (>/= 1 year) assessment. RESULTS Of the 106 patients, the majority (78 [71.6%]) were < 40 years of age. During follow-up (92 +/- 50 months [range 1 to 169]), 18 (17.0%) patients died or underwent heart transplantation (13 sudden cardiac deaths, 2 heart failure deaths, 1 heart transplantation, 1 stroke, 1 postoperative death). Five-year survival from sudden death was 90.1% (95% confidence interval [CI] 84.0% to 96.3%), and that from heart failure death or transplantation was 97.7% (95% CI 94.5 to 100). In patients serially evaluated over 85 +/- 51 months, there was an overall reduction in MLVWT of 0.6 mm/year (95% CI 0.31 to 0.81, p = 0.00004). Wall thinning >/= 5 mm was observed in 41 patients (57.7%; age 35 +/- 13 years; 28 males). On multivariate analysis, the follow-up duration only predicted wall thinning (0.6 mm/year, 95% CI 0.38 to 0.85, p < 0.00001). CONCLUSIONS Left ventricular remodeling is common in patients with severe LVH and contributes to the low prevalence of severe LVH seen in middle age and beyond

Reversal of inappropriate peripheral vascular responses in hypertrophic cardiomyopathy

We assessed the frequency of abnormal forearm vasodilator responses during lower body negative pressure (LBNP) in 21 non-obstructive hypertrophic cardiomyopathy (HCM) patients (31 +/- 8 [20 to 43] years) with abnormal blood pressure response (ABPR) to exercise and the effects of three drugs used to treat vasovagal syncope (propranolol, clonidine, and paroxetine) in a double-blind crossover study

The potential role of chronic pain and the polytrauma clinical triad in predicting prodromal PD: A cross-sectional study of U.S. Veterans

Introduction: The research criteria for prodromal Parkinson disease (pPD) depends on prospectively validated clinical inputs with large effect sizes and/or high prevalence. Neither traumatic brain injury (TBI), post-traumatic stress disorder (PTSD), nor chronic pain are currently included in the calculator, despite recent evidence of association with pPD. These conditions are widely prevalent, co-occurring, and already known to confer risk of REM behavior disorder (RBD) and PD. Few studies have examined PD risk in the context of TBI and PTSD; none have examined chronic pain. This study aimed to measure the risk of pPD caused by TBI, PTSD, and chronic pain. Methods: 216 US Veterans were enrolled who had self-reported recurrent or persistent pain for at least three months. Of these, 44 met criteria for PTSD, 39 for TBI, and 41 for all three conditions. Several pain, sleep, affective, and trauma questionnaires were administered. Participants’ history of RBD was determined via self-report, with a subset undergoing confirmatory video polysomnography. Results: A greater proportion of Veterans with chronic pain met criteria for RBD (36 % vs. 10 %) and pPD (18.0 % vs. 8.3 %) compared to controls. Proportions were increased in RBD (70 %) and pPD (27 %) when chronic pain co-occurred with TBI and PTSD. Partial effects were seen with just TBI or PTSD alone. When analyzed as continuous variables, polytrauma symptom severity correlated with pPD probability (r = 0.28, P = 0.03). Conclusion: These data demonstrate the potential utility of chronic pain, TBI, and PTSD in the prediction of pPD, and the importance of trauma-related factors in the pathogenesis of PD