ABSTRACTS

Abstracts of the Scientific Meeting of the Netherlands Society of Cardiology (NWC)

Sessions Sesion 1, Friday 28 October 2005

27-29 October 2005, De Heerlickheijd, Ermelo Interventional Cardiology Voonzitters: M.J. de Boer en F.W.A. Verheugt

11.00 - 11.15 uur

EARLY CHANGES IN NT PRO BNP LEVELS AFTER SYMPTOM

UNMIMD EXERCISE ARE DETERMINED BY BASELINE LEVELS BUT NOT MYOCARDIAL ISCHEMIA P.M. van der Zee MD; H.J. Verberne MD; R.C. van Spijker; J.P. van Straalen; i.C. Fischer, MD, PhD; A. Sturk, PhD; B.L.F. van Eck-Smit, MD, PhD; R.3. de Winter, MD, PhD. AMC Amsterdam.

Purpos: Circulating levels of B-type natriuretic peptide (BNP) and the amino-terminal portion of the preprohormone (NTproBNP) have been reported to Increase Immediately during myocardial Ischemia. We studied the association between the extent of exercise induced Ischemia and the time course of NTproBNP levels. Methods: A total of 101 patients underwent symptom limited exercise myocardial perfusion scintigraphy (SPECT). Images were scored using a 5-point semI-quantItative score for each of 17 myocardial segments. The summed difference score (SDS) was calculated as the difference between summed stress score and summed rest score. An SDS of >2 was considered to indicate Ischemia. Serum samples were taken before start of exercise (baseline), at maximal exercise and every hour up to 6 hours later. Results: Myocardial ischemia was present in 37 (37%) patients. NTproBNP levels rapidly Increased during exercise (to 113% (104144) and 118% (106-142) of baseline, respectively), with a second peak at 4 hours (141% (119-169)) and at 5 hours (136% (93-188)), respectively. The absolute changes between baseilne levels and levels at maximum exercise were similar between ischemia and nonischemia patients (30 (7-45) (medIan (interquartile range)) versus 15 (4-46) pg/mL, respectively, p-0.230), but absolute changes between baseline levels and secondary peak levels were higher in lschemia patients than In non-lschemia patients (64 (32-172) versus 34 (1985) pg/mL, In multivariate linear stepwise regression analysis of determinants of post exercise changes In NTproBNP levels, baseline NTproBNP levels were the only independent deteminant of the absolute changes at maximum exercise, and baseline NTproBNP levels, cystatin C levels and end systolic volume were Independent determinants of the absolute increase to secondary peak levels.

Condusdons: Exercise Induced immedlate and secondary Increases In NTproBNP. Levels reflect baseline levels but not myocardlal

ischemia.

Interventnonal Cardiology Voorziltters: M.J. de Boer en F.W.A. Verheugt

11.30 - 11.45 uur

FROM ANATOMY TO PHYSIOLOGY: FRACTIONAL FLOW RESERVE (FFR) BASED REFERRAL AND DEFERRAL FOR PCI OF CORONARY INTERMEDIATE LESONS IN A NONINTERVENTIONAL CARDIOLOGY CLINIC - 2,5 YEAR FOLLOW-UP L.B. Winter. A. Hassan, H. van Kesteren, 3. Romkes, B. Baars, K. Hamraoul, H-i Munitinga, J. Widdershoven.

Badcground: We previously reported the short-term results of the feasibility, safety and cost-effectiveness of FFR based referral and deferral for PCI of Intermediate coronary lesions In a noninterventional cardiology clinic. We investigated whether these results are sustalned after a 2,5 year period. Methods: From January 2003 till January 2005, 187 Intermediate lesions (LAD, n=89, LCX, n=57, RCA, n=41) were studied In 124 patients. Anglographic stenosis was determined by quantitative coronary anglography. Ail FFR measurements were performed by a single experienced operator (35W). Following the Induction of maximal hyperemia with Intravenous adenosine, the FFR was obtained (PressureWire, RADI, Sweden). Lesions with a FFR < 0,75 were referred for PCI; lesions with a FFR > 0,75 were deferred for PCI and treated medically. During a 2,5 year period we Investigated in both groups 1/ the Intervention and re-intervention rates In the target vessels and 2/ the use of anti-anginal medication. Resufta: Mean diameter stenosis of all vessels was 59,8 % (SD +/14,2 %). No complications occurred during intracoronary FFR measurements. Mean FFR was 0,81 (SD +/- 14). 78 out of 187 lesions showed a FFR < 0,74 (42 %). These lesions were referred for PCI. The remaining 109 lesions were treated medically. During a median follow-up of 18 months (range 6 to 30 months) In none of these deferred lesions a PCI had to be performed. In the PCI-group an 11 % in-stent restenosis rate was observed, requiring reintervention. In addition, we found no difference in the use of antianginal medication between the 2 groups.

Conduslon: During a 2,5 year study period, our Initial short-term results remain sustalned. Our long-term results. underscore the safety, the (cost)effectiveness and the benefit for the individual patient of deferring a PCI based on FFR measurements in a nonIntervention cinic performed by experienced operators. Both the Individual patient and health care costs are better of with this physiological approach

2

tnterventlonal CardIoloy Voorzitters: MJ. de Bor en F.W.A. Verheugt

11.15 - 11.30 uur

MISSIONI CROSSING SECTION: OPTINALIZATION OF ACUTE AND L INFARCION PATIENTS CHRONIC CAR FOR ACUTE OC S.S. Llam, M,D B.L. van der Hoeven, MD, H.F. Verwey, MD, P.V. Oemrawsingh, MD, D.E. Atsma, MD, E.T. vd Velde, PhD, 3.W. Jukemna, MD, 3J.Bax, MD, E.E. van der Wall, MD, M.]. Schallij, MD. Ledden University Medical Center, Leldin, The Nefhatlnds. Sedogroniad: Gukde5ne-implementatlon programs for patients wlth acute myocardial infarcton (AMI) enhano adhence to evidence-based medicine and Improve dinical outcorne. Although optinal AMI care should cover both the acute and the chronic phase, most programs mainly focus on acute care and secondary prevention strtgis during the index hosptlization. To maximize the use of evidence based medicine in daity practice and to have to be crossed. Therefore we further improve AMI care, secti developed an all-phases integrtd AMI care program (I.e. pre-hospital, inhospital and out-patients protocol): MISSIONI

Deeing, MISSION! Is based on the most recent European Society of Cardiology and American College of Cardiolgy/American Heart AssocIation guidelines for AMI care. MISSIONI concentrates on rapid AMI dignosis, eariy reperfuslon and active lifestyle improvement up Oo one year following the Index event. All regional health care providers were Involved In the design and Implementation of MISSIONI. Relts: From February 2004 to August 2005, 324 patients (79% male, 60 ± 12 yrs) have been induded In the dinical and post-cOnical MISSIONI protocol. The pre-hospital MISSIONI protocol resulted in a reduction of door-to-balloon time from 100 i 34 min to 51 ± 18 min (p 80 bpm was no independent predictor of the primary endpoint (adjusted hazard ratio 0.9 [0.4 to 1.71, p=0.7). End Point

< 80 bpm

Heart rates 2 80 bpm

Heart rates

Absolute difference (90% CI)

(n=75)

(n- 139)

End point

20% (n=15)

Cardiovascular death Heart failure Thromboembolic

7% (n=S)

17% (n=24) 6% (n-9) 2% (n=3) 5% (n=7)

2.7 (-7.6 to 13.0) 0.2 (-5.9 to 6.2) 3.2 (-1.7 to 8.0) -1.0(-6.0 to 3.9)

7% (n=5) 1% (n=l)

4% (n=6)

1% (nml)

2.4 (-3.3 to 8.0) 0.6 (-1.9 to 3.1)

-

2% (n=3)

-2.2 (-4.2 to -0.1)

5% (n=4) 4% (n=3)

complications

Bleeding

adverse Severe effects of AAD Pacemaker

imelantation

Conclusion: There were no differences between patients with a mean heart rate > 80 bpm compared to patients < 80 bpm during follow up in terms of cardiovascular morbidity and mortality.

Electrophysology/ Pacing Voorzltters: H.A. Bosker en R.N.W. Hauer

11.45 - 12.00 uur

EFFECTIVENESS OF PULMONARY VEIN ISOLATION IN THE TREATMENT OF PAROXYSMAL VERSUS PERSISTENT ATRIAL FIBRILLATION R.N.W. Hauer, L.H. Boldt. H. van Wessel, C A.E. Tuinenburg, F.H.M. Wittkampf, K.P. Loh. UMC Utrecht. Background: Triggering foci in pulmonary veins (PV) can precipitate both paroxysmal and persistent atrial fibrillation (AF). In addition, an atrial electrophyslologic substrate facilitating multiple wavelet reentry may contribute to the maintenance of persistent AF. PV isolation (PVI) by radiofrequency (RF) catheter ablation in the left atrium targeting Isolation of triggers may have a different outcome in paroxysmal versus persistent AF. Purpose: To evaluate the outcome of PVI In patients with paroxysmal versus persistent AF.

Method: Paroxysmal and persistent AF were defined as spontaneous termnination within 48 hours and termnination by intervention (i.v. drugs or electrocardioversion), respectively. Patients with drug refractory AF (n=88, 23 women, mean age 53.4*9.63 years) underwent PVI, targeting all PV, In the period between January 2003 and May 2005. Slxty-six/88 patients (75%) had paroxysmal and 22/88 patients (25%) had persistent AF. Follow-up was at 4 weeks, 3, 6, 12 and 24 months. Rhythm status was determined using history, ECG, and 48 hours Holter. Results: The mean follow-up was 8.2±5.9 months. Sixty-two/88 patients (71%) were free of AF either with or without anti-arrhythmic drugs. In the subgroups, 45/66 patients (68%) with paroxysmal AF and 17/22 patients (77%) with persistent AF were free of AF (NS). During follow-up, a total of 42/88 patients (48%) were off antiarrhythmic drugs. In the subgroups, 33/66 patients (50%) with paroxysmal AF versus 9/22 patients (41%) with persistent AF were off anti-arrhythmic drugs (NS). The mean number of PV isolated was 3.73*0.64; 3.7*0.68 in patients with paroxysmal and 3.8*0.5 with persistent AF (NS). Additional PVI procedures were performned in 26 patients (mean of 1.3*0.55 sessions), in 19/66 patients (29%) wlth paroxysmal and in 7/22 patients (32%) with persistent AF (NS).

Conclusion: Both patients with paroxysmal and persistent AF benefit considerably from PVI with an overall success rate of 71%/o. Fortyeight percent of all patients were free of AF while off anti-arrhythmic drugs.

Electrophysiology/ Pacing

12.15 - 12.30 uur

Voorzltters: H.A. Bosker en R.N.W. Hauer

FUSION OF MULTI-SLICE COMPUTED TOMOGRAPHY WITH ELECTROANATOMICAL MAPPING TO GUIDE RADIOFREQUENCY CATHETER ABLATION FOR ATRIAL FIBRILLATION LF..IQ5L J.J. Bax, K. Zeppenfeld, H.]. Lamb, E.E. van der Wall, M.J. Schalij. Lelden University Medical Center, The Netherlands. Background: Radlofrequency catheter ablation offers a possible curative treatment for atrial fibrillation (AF). Outcome of the procedure depends on ability to depict target sites for ablation. A realistic anatomical representation can be difficult to obtain with 3D electroanatomical mapping alone. Fusion of different imaging modalities may facilitate ablation procedures and Improve the outcome.

Methods: Twenty-seven consecutive patients (23 men, age 54 * 8 years) with drug-refractory AF were scanned with a 64-slice CT scanner 2 days before the ablation procedure. AF was present for 6 i 5 years, and was paroxysmal In 14, persistent in 11 and permanent In 2. Raw CT data were loaded in the CARTOTh electroanatomical mapping system. Using the newly developed CartoMergetm Image Integration Module, a segmentation process was performed to depict the structures of interest (left atrium and pulmonary veins) out of the raw CT data. After mapping of the left atrium a registration process was performed to align the CT image and the electroanatomical map. First, landmarks were placed on a certain location on the electroanatomical map based on fluoroscopy, and on the same position on the CT Image. An algorithm then fused the map and CT image based on minimizing the distance between the two landmarks and the distance between the electroanatomical map and the CT image. A statistical algorithm provides information about the accuracy of the fusion process. Results: Segmentation of the CT images could be performed within 10 minutes In all patients. Mean mapping time was 42 i 18 minutes and a mean of 236 i 50 mapping points was used to create an electroanatomical map. In all patients an accurate fit between CT image and electroanatomical map was achieved. Mean distance between the CT Image and the electroanatomical map ranged from 1.6 i 1.2 mm to 2.8 i: 1.8 mm. This resulted in an average of 2.1 i 0.2 mm for the patient group as a whole.

Conclusion: Fusion of CT Images and 3D electroanatomical mapping can be performed with an acceptable degree of accuracy. Anatomical based catheter ablation procedures for AF can be facilitated by fusion of different imaging modalities.

Abstracts

Sessions Session 1, Friday 28 October 2005 Adult Congenital Heart DLsease I VoorzItters: Mw. B.J.M. Mulder en F.].

11.00 - 11.15 uur

Meijboom

PERCUTANEOUS CLOSURE OF ATRIAL SHUNTS FOR SECONDARY PREVENTION OF PARADOXaC EMBOLIZATION Brelier MC, Witsenburg M, De Jaegere PPT, Roos-Hesselink 3W, Koudstaal P, Dalinghaus M, Meijboom F]. Depts of Cardiology, Neurology and PediatrIc Cardiology ErasmusMC, Rotterdam, The

Netherlands.

Adult Congenital Heart Disease Voonrzltters: Mw. B.I.M. Mulder en F.J. Meiljboom

11.15 - 11.30 uur

COMPARISON OF OUTCOME AND COMPLICATIONS USING DIFFERENT TYPES OF DEVICES FOR PERCUTANEOUS CLOSURE OF A SECUNDUM ATRIAL SEPTAL DEFECT IN ADULTS. A SINGLE CENTRE EXPERIENCE M.C.Post M.J.Suttorp, W. Jaarsma, H.W.M. Plokker. Department of

Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands.

Purpose: Assessment of the efficacy and safety of transcatheter closure of intra-atrial shunts for prevention of recurrent cerebrovascular accidents.

Methods: Data of all pts that underwent device closure of atrial shunts for secondary prevention of cryptogenic stroke or systemic embolization were retrospectively collected from patient charts and cathlab reports. Results: Between 2000 and March 2005 42 pts (male 15/42; age 44*12 yrs; weight 74*13 kg) underwent transcatheter closure for an Intra-atrial shunt (ASD=5, PFO=37) after one or more lschaemic incidents. Mean nr of embolic events before treatment was 1.3*0.6 The transcatheter closure procedure was either guided by transesophageal echo (TEE; n-7) or intracardiac echo (ICE; n-33), or both (n-2). The stretched diameter of the PFO or ASD was assessed using a sizing balloon. The mean diameter was 9*4 mm. Defects were dosed with Cardloseal/starflex (NMT) in 30 patients, with an Amplatzer PFO occluder (AGA) In 9 patients and an Amplatzer ASD occluder In 4 patients. Successful release was achieved In all pts. One groin bleeding was the only procedural complication. After implantation pts were treated with aspirin or aspirin/dopidogrel for 6 months. Follow up TEE after 3 months revealed one patient with residual shunting and one patient with signs of thrombus formation on the right atrial side of the device. This thrombus dissolved after heparinization within one week. Mean duratlon of follow up was 0.6*0.7 yrs. Surgery was performed in 2 pts: 1 for residual shunting and 1 for thrombus formation on the device with a repeat stroke. This was one patient with a repeat stroke during follow up. No other complicatlons were seen during follow up.

Purpose: Percutaneous closure of a secundum type ASD is increasingly performed in adult patients. We evaluate the outcome and complications using three different types of devices for percutaneous atrial septal defect (ASD) closure in adults. Methods: All adult patients who underwent a percutaneous closure of a secundum type ASD in our centre between November 1996 and November 2004, were included. Failure was defined as dIslocation or embolizatlon of the device, which required surgical intervention. Periprocedural and mid-term complications were registered.

Results: Sixty-flve patients, mean age 45.7*18.1 years (18 men/47 women;,, underwent a percutaneous closure of an ASD with an ASDOS In 3, an AmplatzerO in 36, and a Cardioseal/Starflexs closure device in 26 patients. During an overall median follow up of 1.2 years, range 6.6 years, the failure occurred In four patients, all Cardioseal/Starflex (p-0.04). Within the CardloseaV/Starflexs subgroup the ASD and device diameters were significantly higher In those patients In whom the primary endpoint occurred compared to the other, 18.8*3.8 mm versus 13.0*3.8 mm for ASD diameter (p-0.01) and 40 mm (range 40-43 mm) versus 33 mm (range 2040 mm) for device diameter (p-0.008). Overall complications were transient arrhythmias In 15.4%, pericardial effusion In 1.5%, and TIA in 1.5%. Complete closure, six months after the procedure, occurred In 79.6%, without difference between the devices.

Condusdon: Percutaneous ASD closure seems to be a relatively safe the effective procedure. larger However, using and Cardhoseal/Starfiexn devices for dosure seems to be related to a higher rate of device dislocation and embolization.

Conclusions: Percutaneous closure of atrial shunts Is a safe procedure with a high percentage of complete closure within 3 months. Repeat cryptogenic events are rare at short term-follow-up.

Adult Congenital Heart Disease I Voorzitters: Mw. B.).M. Mulder en F.]. Meiljboom

11.30 - 11.45 uur

Adult Congenital Heart Disease 1 Voorzitters: Mw. B1..M. Mulder en F.].

11.45 - 12.00 uur

Meijboom

REAL-TIME 3D ECHOCARDIOGRAPHY CAN REPLACE 2D IN THE ECHOCARDIOGRAPHY TRANSESOPHAGEAL CHARACTERISATION OF ATRIAL SEPTAL DEFECT yAEvan denBoJ b, 3A Ten Harkel, 'JS McGhle, 13W Roos-Hesselink, 1ML Simoons, AJJC Bogers and 'FJ Meljboom. 'Departments of Cardiology, 2 Cardiothoradc surgery, 3 PedIatric Cardiology, Erasmus MC Hospital, Rotterdam, The Netherlands.

FEASIBILITY OF BOSENTAN IN EISENMENGER PATIENTS: PRELIMINARY RESULTS MG] Duffelsz. RMF Berger2, P.Bresser', BJM Mulderl.'Acedem/c Medical Center, Amsterdam; 2University Medical Center Groningen.

Background: The aim of the present study was (1) to describe a quantitative evaluation by real-time 3-D echocardiography (RT-3DE) of ASD characteristics that are Important for patient selection for transcatheter closure, and (2) to assess the reliability of this method by comparing the RT-3DE data with 2D transesophageal

Purpose: We present the preliminary results of our recently started study on the tolerability and effect of bosentan on the clinical status of patients with Elsenmenger syndrome.

echocardiography and/or surgical flndings. Methods: 45 consecutive patients (43% male) scheduled for either surgical or transcatheter closure of an ASD were included in this study. There were 24 children (mean age 2.9 * 4.3 yrs) and 21 adults (mean age 47 * 15 yrs). Two-dimensional transthoradc (2D TTE) and transesophageal echocardlographic (2D TEE) study, RT-3DE were performed with Philips Sonos 7500 echo-system and off-line analysis with TomTec Echoviewe software. The exact localisation of the ASD, its maximal diameter, area changes during the cardiac cycle and the surrounding rims were assessed by RT-3DE. The 3D data were compared with measurements and descriptions by the surgeon and/or with 2-D echo data and balloon sizing (BZS). Results: Three-dimensional echocardlographic reconstructions allowed adequate imaging of the ASD In 43 (96%) of the 45 patients. Thirty-five patients had surgical closure and 10 patients transcatheter dosure of the ASD. The correlation and agreement of ASD maximal diameter by all methods are shown In table 1.

Introduction: In patients with a congenital heart defect, the Elsenmenger syndrome carries a high risk of morbidity.

Methods: At the end of August 8 adult patients with Elsenmenger syndrome and NYHA cass III were enrolled In this study. Underlying diag-noses are AVSD (3 Down patients), VSD, ASD, ASD and VSD, VSD and PDA and, DILV and PDA. Patient clinical status and liver enzymes were closely monitored throughout. Baseline and 3-month assessment Included resting oxygen saturations and 6-min walking test.

Results: All 8 patients (median age 41, range 30-53 years; 4 female) with a mean follow up of 2.5 months tolerated bosentan well. No major adverse events were observed. Mean res-ting oxygen saturatlons (87±4 versus 89±1%; P-0.77) and mean 6 min walking distance (358± 84 versus 392±78m; P= 0.2) tended to increase.

Conclusion: Bosentan is well tolerated in adults with Eisenmenger syndrome during the first months of oral therapy. Clinical status of patients appeared to Improve. This first results need to be confirmed with a larger number of patients, Included in our study.

Conclusion: Real-time 3D echocardiography allows accurate determination of ASD size, location and surrounding rims. It has potential to replace 2D TEE in the patient selection for transcatheter device closure. Table 1. 2D TTE vs RT-3DE 2D TTE vs Surgery RT-3DE vs Surgery RT-3DE vs BZS

4JC

Mean duff. -7.4 + 12 -8.4 A 12 -0.9 * 4.9 0.4 A 2.2

Line of identity 5.1; 5.7; 1.3; 0.8;

y = O.Slx + y = 0.46x + y = 0.91x + y = 1.05x +

r = 0.77 r = 0.75 r - 0.95 r = 0.97

Ncdtlnds Heart Journal, Volume 13, Supplement 3, Decmber 2005

5

Adult Congenital Heart Disease I Voorzitters: Mw. B.J.M. Mulder en F.J. Meijboom

11.00 - 11.15 uur

PERCUTANEOUS CLOSURE OF ATRIAL SHUNTS FOR SECONDARY PREVENTION OF PARADOXIC EMBOLIZATION Witsenburg M, De Jaegere PPT, Roos-Hesselink JW, B±i,j Koudstaal P, Dalinghaus M, Meijboom FJ. Depts of Cardiology, Neurology and Pediatric Cardiology ErasmusMC, Rotterdam, The Netherlands. Purpose: Assessment of the efficacy and safety of transcatheter closure of intra-atrial shunts for prevention of recurrent cerebro-

vascular accidents. Methods: Data of all pts that underwent device closure of atrial shunts for secondary prevention of cryptogenic stroke or systemic embolization were retrospectively collected from patient charts and cathlab reports. Results: Between 2000 and March 2005 42 pts (male 15/42; age 44*12 yrs; weight 74*13 kg) underwent transcatheter closure for an intra-atrial shunt (ASD=5, PFO=37) after one or more ischaemic Incidents. Mean nr of embolic events before treatment was 1.3*0.6 The transcatheter closure procedure was either guided by transesophageal echo (TEE; n=7) or intracardiac echo (ICE; n-33), or both (n=2). The stretched diameter of the PFO or ASD was assessed using a sizing balloon. The mean diameter was 9*4 mm. Defects were closed with Cardloseal/starflex (NMT) in 30 patients, with an Amplatzer PFO occluder (AGA) in 9 patients and an Amplatzer ASD occluder in 4 patients. Successful release was achieved In all pts. One groin bleeding was the only procedural complication. After implantation pts were treated with aspirin or aspirln/clopidogrel for 6 months. Follow up TEE after 3 months revealed one patient with residual shunting and one patient with signs of thrombus formnation on the right atrial side of the device. This thrombus dissolved after heparinization within one week. Mean duration of follow up was 0.6*0.7 yrs. Surgery was performed in 2 pts: 1 for residual shunting and 1 for thrombus form,ation on the device with a repeat stroke. This was one patient with a repeat stroke during follow up. No other complications were seen during follow up.

Conclusions: Percutaneous closure of atrial shunts Is a safe procedure with a high percentage of complete closure within 3 months. Repeat cryptogenic events are rare at short term-follow-up.

11.30 - 11.45 uur

Adult Congenital Heart Disease I Voorzitters: Mw. B.J.M. Mulder en F.J. Meijboom

REAL-TIME 3D ECHOCARDIOGRAPHY CAN REPLACE 2D IN THE ECHOCARDIOGRAPHY TRANSESOPHAGEAL CHARACTERISATION OF ATRIAL SEPTAL DEFECT 'AE van den B?h 3A Ten Harkel, 'JS McGhie, 1JW Roos-Hesselink, 1ML Simoons, A3JC Bogers and 1FJ Meijboom. 'Departments of Cadiology, 2 Cardiothoracic surgery, Pediatric Cardiology, Erasmus MC Hospital, Rotterdam, The Netherlands. Background: The aim of the present study was (1) to describe a quantitative evaluation by real-time 3-D echocardiography (RT-3DE) of ASD characteristics that are important for patient selection for transcatheter closure, and (2) to assess the reliability of this method by comparing the RT-3DE data with 2D transesophageal echocardiography and/or surgical flndings.

Methods: 45 consecutive patients (43% male) scheduled for either surgical or transcatheter closure of an ASD were included In this study. There were 24 children (mean age 2.9 * 4.3 yrs) and 21 adults (mean age 47 * 15 yrs). Two-dimensional transthoracic (2D TTE) and transesophageal echocardiographic (2D TEE) study, RT-3DE were performed with Philips Sonos 7500 echo-system and off-line analysis with TomTec Echoview0 software. The exact localisation of the ASD, its maximal diameter, area changes during the cardiac cycle and the surrounding rims were assessed by RT-3DE. The 3D data were compared with measurements and descriptions by the surgeon and/or with 2-D echo data and balloon sizing (BZS). Reults: Three-dimensional echocardlographic reconstructions allowed adequate imaging of the ASD In 43 (96%) of the 45 patients. Thirty-five patients had surgical closure and 10 patients transcatheter closure of the ASD. The correlation and agreement of ASD maximal diameter by all methods are shown in table 1.

Real-time 3D echocardiography allows accurate determination of ASD size, location and surrounding rims. It has potential to replace 2D TEE in the patient selection for transcatheter device closure.

Conclusion:

Table 1. 2D TTE vs RT-3DE 2D TTE vs Surgery RT-3DE vs Surgery RT-3DE vs BZS

Mean diff. -7.4 t 12 -8.4 i 12 -0.9 * 4.9 0.4 * 2.2

Line of identity y - 0.51x + 5.1; y = 0.46x + 5.7; y = 0.91x + 1.3; y = 1.05x + 0.8;

r = 0.77 r = 0.75 r 0.95 r 0.97

Adult Congenital Heart Disease 1 Voorzitters: Mw. B.J.M. Mulder en F.J. Meijboom

11.15 - 11.30 uur

COMPARISON OF OUTCOME AND COMPLICATIONS USING DIFFERIENT TYPES OF DEVICES FOR PERCUTANEOUS CLOSURE OF A SECUNDUM ATRIAL SEPTAL DEFECT IN ADULTS. A SINGLE CENTRE EXPERIENCE M"1. sf M.J.Suttorp, W. Jaarsma, H.W.M. Plokker. Department of Cardiology, St. Antonius Hospital, Nleuwegein, The Netherlands.

Purpose: Percutaneous closure of a secundum type ASD Is Increasingly performed In adult patients. We evaluate the outcome and complications using three different types of devices for percutaneous atrial septal defect (ASD) closure in adults. Methods: All adult patients who underwent a percutaneous closure of a secundum type ASD in our centre between November 1996 and November 2004, were included. Failure was defined as dislocation or embolization of the device, which required surgical intervention. Periprocedural and mid-termn complications were registered.

Results: Sixty-flve patients, mean age 45.7i18.1 years (18 men/47 women) underwent a percutaneous closure of an ASD with an ASDOS in 3, an Amplatzer* in 36, and a Cardioseal/Starflex* closure device in 26 patients. During an overall median follow up of 1.2 years, range 6.6 years, the failure occurred in four patients, all Cardioseal/Startlexe (p=0.04). Within the Cardioseal/Starflexe subgroup the ASD and device diameters were significantly higher in those patients In whom the primary endpoint occurred compared to the others, 18.8*3.8 mm versus 13.0i3.8 mm for ASD diameter (p-O.01) and 40 mm (range 40-43 mm) versus 33 mm (range 2040 mm) for device diameter (p=0.008). Overall complications were transient arhythmias In 15.4%, pericardial effusion In 1.5%, and TIA In 1.5%. Complete closure, six months after the procedure, occurred In 79.6%, without difference between the devices.

Conclusion: Percutaneous ASD closure seems to be a relatively safe However, using the larger and effecive procedure. Cardloseal/Starflexe devices for dosure seems to be related to a higher rate of device dislocation and embolization.

Adult Congenital Heart Disease I Voorzltters: Mw. B.J.M. Mulder en F.J. Meijboom

11.45 - 12.00 uur

NTAN IN EISENMENGER PATIENT: FEASIBILTY OF PRELIMINARY RESULTS IVIt. uffgiil RMF Berger2, P.Bresserl, BJM Mulder1.*Academkc Medkal Center, Amsterdam; 2Unlversity Medical Center Groningen.

Introduction: In patients with a congenital heart defect, the Elsenmenger syndrome carries a high risk of morbidity. Purpos: We present the preliminary results of our recently started study on the tolerability and effect of bosentan on the clinical status of patients with Eisenmenger syndrome.

Methods: At the end of August 8 adult patients with Elsenmenger syndrome and NYHA class III were enrolled in this study. Underlying diag-noses are AVSD (3 Down patients), VSD, ASD, ASD and VSD, VSD and PDA and, DILV and PDA. Patient clinical status and liver enzymes were closely monitored throughout. Baseline and 3-month assessment Included resting oxygen saturations and 6-min walking test.

Results: All 8 patients (median age 41, range 30-53 years; 4 female) with a mean follow up of 2.5 months tolerated bosentan well. No major adverse events were observed. Mean res-ting oxygen saturations (87±4 versus 89±1%; P-0.77) and mean 6 min walking distance (358± 84 versus 392±78m; P= 0.2) tended to Increase.

ConcAluion: Bosentan is well tolerated in adults with Eisenmenger syndrome during the first months of oral therapy. Clinical status of patients appeared to improve. This first results need to be confirmed with a larger number of patients, Included In our study.

Abstracts

Sessions Sesslon 1, Friday 28 October 2005 12.00 - 12.15 uur

Adult Congenital Heart Disease 1 Voorzitters: Mw. B.J.M. Mulder en F.J. Meljiboom

Adult Congenital Heart Disease 1 Voorzntters: Mw. B.2.M. Muider en F.3.

12.15 - 12.30 uur

Melijboon

BOSENTAN TREATMiENT TO IM4PROVE EUGIBILITY FOR ASD CLOSURE IN A PATIENT WITH PULMONARY HYPERTENSION C.A.W. lanssensa H.W.M. Plokker2. 'Zh Zeeuws Viaanderen, lc. de Honte, Afd. Cardlologle, Terneuzen; 2Hart Long Centrum Utrecht, St. Antonius Zh., Afd. Cardhlogle, Nleuwegein.

BEYOND THE ROOT: DILATATION OF THE DISTAL AORTA IN THE MARFAN SYNDROME P. Engeifit H. Boersma, 3. Tljssen, 1, B. Mulder. Cardiology, Academic Medkal Center Amsterdam, 'Thorax center, ErasmusMC,

Bacground: Cardiac surgery for septal defects may be complicated

Purpose: Prolonged survival after aortic root replacement in the Marfan syndrome has led to an increased number of patients with aortic complications beyond the root. In this study, we Investigated pathology of the aorta distal from the root.

Case: A 43-yr-old woman with progressive dyspnoea and progressively reduced exercise tolerance during the past six months presented herself in our outpatient clinic. She was very insecure and believed her complaints were psychological.

Methods: Relevant data of the recent Euro Heart Survey on adult congenital heart disease was analysed. Data used for this study inducded baseline medical history, dlameter measurements at 4 levels of the aorta, and events during follow-up (dissection, death, repairs). Patients were divided into 3 groups, according to their history at baseline: 1) those with a previous dissection; 2) those with a previous elective aortic repair; and 3) those with none of these.

by an increased PVR. Here we present a patient with inoperable ASD in which treatment with bosentan resulted in eligibillty for corrective surgery.

of in Asthma childhood. Diagnosis History: Current Medication: Contraceptives, budesonide and terbutaline.

Findings: Phys. Ex.: dubbed flngers, BP: 130/60, Normal pulse. Auscultation: Gr. 2/6 syst. murmur with punct. max. at apex. Abdomen: normal. No oedema. ECG: VES, normal SR, left(L) ant. hemi block, right(R) BB, L axis. Lab: NT-pro-BNP tt, Blood gas: respiratory alkalosis; sO2 jump between Vena Cava Sup. (66%) and R Chest and CT: enlarged X-ray atrium (86%). R heart. Echo cor: Suspect of large ASD, no dear visible shunt. Chest MtU: large primum ASD. RH cath: ASD with significant PAH Treatment: Bosentan, oral 2dd. 125 mg during 6 months

Rasutas:

Paramneter

Basene

Normal rano

Wmisn4m PVRI(dsma/cms)

44 2.1 1372 4780 395

2.5 - 4 80 - 230 < 180

6 months 32 3.23 593 1184 NTPromNP(p/rml) 520 6 MWT (m) Patient is now referred for dosure of the ASD

mPAP (mm Ha) Cl )

12 - 15

>500

Rotterdam.

Rwsets: The cohort consisted of 270 aduft Marfan patients reropectively foilowed-up for a median of 5.3 years. Of those, 21 patients had a previous dissection, and 58 had previously undergone an elective aortic Intervention. Actuarial 5-year survival and dissection-free survival were not significantiy different between Martan patients with compared to those without previous elective aortic root replacement, but considerably worse In patients after aortic dissection. After aortlc root replacement diameters of the distal aorta were significantly Increased and aortic surgery was rather common. Regarding overall cinical practice, It was found that measurement of the entire aorta was done insufficiently. Condusiuon: Elective aortic root repair has greatly improved survival of patients with the Marfan syndrome. Yet, the distal aorta is dilated more in patients who have undergone an elective aortic root repair compared to patients without such an intervention, and should be monitored more carefully than is done presently.

Conciusion: 1) Clinically significant ASD may be missed until late age, resulting in PAH/Elsenmenger. 2) PAH-specific treatment may improve operability of septal defects, probably even in Elsenmenger patients.

Basic Sciance Voorzittars: C.J.A. van Echtadd en A. van dar Laame

11.00 - 11.15 uur

THE RIGHT VENTRICLE AS ARRHYTHMOGENIC SUBSTRATE IN THE SENESCENT MOUSE HEART Mtain Mi3 van Veen, MA Engelen, M Boulaksil, RNW Hauer, HVM van Rijen, JMT de Biakker. Heart Lung Center Utrecht, Utrecht, the

Netherlands.

Background: The aging heart is marked by cellular and structural changes which increase the propensity for ventricular arrhythmias. In this study assessed arrhythmogeneity, impulse conduction and tissue properties of young and old mice. Mttiods: 10 Old (94wk) and 7 young mice (12wk) were subjected to echocardlography. Hearts were Langendorff perfused and epicardial ventricular activation mapping performed. Effective refractory periods (ERP) were determined by the extrastimulus method and vulnerability to arrhythmias was tested by programmed stimulation. Subsequently, hearts were processed for Cx43 immunohistochemistry, Western blotting (WB) and Sirius Red staining (flbrosis). Rauis: Ventricular arrhythmias were Induced In 6 of 10 old mice (sustained n=2; short run n-4). Arrhythmias originated In the right ventricle (RV) and were due to anisotropic reentry. Arrhythmias were not Inducible In young mice. Old hearts revealed decreased ERP and conduction velocity and Increased anisotropic ratio (AR) only In the RV. Echocardlography showed no structural abnormalities in old mice. Low levels of Interstitial fibrosis were found In young mice. In old mice interstitial flbrosis was Increased with scattered patches of severe fibrosis. Cx43 expression and distribution was homogeneous and comparable between young and old mice, but was Irregular In areas of severe fibrosis In old mice. WB showed no difference In Cx43 protein levels between young and old mice.

Conclusions: Aging related increased fibrosis leads to slow conduction and enhanced AR, which in concert with the reduced ERP decreases wavelength In RV. As such, RV forns an arrhythmogenic substrate that Increases the vulnerability for arrhythmias in old mice.

Sasic Science Voorzters: C.J.A. van Echteld en A. van der Laarse

11.15 - 11.30 uur

ACTVATION OF FOCAL ADHEION KINASE AND NEURONAL NiTRIC OXaDE SYNTHASE IN NYOCARDIUM OF RATS WITH RIGHT-SIDED CONGESTVE HEART FAILURE S. Umar. M.H.M. Hessel, W.H. Bax, C. Schutte, P. Steendijk, A. van der Laarse. Department of Cardiblogy, Lelden University Medikal Center,

Albinusdreef 2, 2333 Z4 Lelden, the Netherlands.

Purpose: Focal adhesion kinase (FAK) Is an Important component of an Integrin-dependent signaling pathway, which functions to transmit signals from the extracellular matrix Into the cytoplasm. Muscle-specific 0lD-integrin and FAK are Involved In the hypertrophic response pathway of cardiomyocytes. Neuronal nitric oxide synthase (nNOS) Induced NO production modulates the myocardial inotropic state. We assessed the activation of FAK and nNOS In the myocardlum of rats with right-sided congestive heart failure.

Nehoda: Rats were treated without (CONT, n-4) or with monocrotaline (MCT) In low dose (30 mg/kg, n=5) to Induce compensated right ventricular hypertrophy (RVH) and in high dose (80 mgtkg, n=S) to Induce right ventricular failure (RVF). After 28-33 days RV function was determined from RV pressure-volume loops measured with a conductance catheter, and rats were subsequentiy sacriflced. Hearts were dissected; RV, LV and the interventricular septum were cut free, weighed, fixed and embedded. FAK, nNOS and their phosphorylated forms, FAK-P and nNOS-P, respectively, were quantified in RV and LV myocardlum by immunofluorescence using appropriate antibodies. Rults: Ratio of RV over ventricular weight (mean * SD) was 0.22 * 0.02 in CONT, 0.28 * 0.01 In RVH (p40 mmHg.

Results: Patients with RV volume overload had lower RV EF compared to patients with pressure overload (p = 0.02) and lower LV EF (p35 years (median = 18.0 weeks). MRI data were available In 20 patients. No significant correlation was found between baseline RVEDVI and functional recovery time. Ukewise, no significant correlation was found between cRVEF and recovery time. Of the other selected parameters only younger age at PVR, and younger age at total correction were significantly correlated with earlier return to work (n-22, r=0.81, pA. Patient 2 carried the matemally inherited frameshift mutation c.3288delA and the paternally Inherited non-sense mutation c.2827C>T (p.Arg943X). Conclusions: These findings indicate the need for mutation analysis of genes encoding sarcomeric proteins in childhood HCM and the possibility of compound heterozygosity.

Abstracts

Sessions Sesslon 11, Saturday 29 October 2005 Genomnks/Regeneration

10.00 - 10.15 uur

Voorzitters: Y.M. Pinto en P.A.F.M. Doevendans

PLAKOPHILIN 2 MUTATIONS OCCUR FREQUENTLY IN PATIENTS FULFILUNG ARVC CRITERIA .P. vap Tintelen', M. Entius2, Z. Bhuiyan3, A.C.P.Wiesfeld4, J. van der Smagt, M. M.A.M. Mannens3, R.M.W. Hofstral, L.Otterspoor2, P.A.F.M. Doevendans2, A.A.M. WildeO, I.C. Van Gelder4, R.N.W. Hauer2. Departnents of Clinical GenetlcsZ and Cardilgy4, University Medkal Center Groningen, Heart Lung Center Utreche2 and Department of Clinical Geneticss, University Medkal Center Utrecht Departments of Clinial Genetcs3 and Experimental Cardlolgy4 Academic Medical Center, Amsterdam.

Objective: In at least 50% of cases Arrhythmogenic Right Ventricular Cardlomyopathy (ARVC) is a familial disease with an autosomal dominant mode of Inheritance. Diagnosis is based on dinical criteria proposed by a task force in 1994. The recent identification of mutations in the plakophilin 2 (PKP2) gene In 27% of patients has increased insight In this disorder. This will facilitate eariy identification of persons at risk. Our goal was to assess the prevalence of PKP2 mutations in patients with (supposedly) ARVC In three Dutch tertiary referral centers.

Methos: A total of 80 Index patients were analyzed; 46 patients fulfilled the criteria for ARVC whereas 34 did not meet the Task Force criteria. The PKP2 gene was screened for mutations using DGGE:/DHPLC and direct sequencing.

Results: In 19 out of 46 index patients (41%) fulfilling the criteria, mutations were identified. Three different mutations were recurrent: 2386T>C (5 index patients), 235C>T (4 index patients), 397C>T (2 index patients). Of the 11 difterent mutations, 4 were missense, 6 nonsense, and 1 frameshift. Eight of these were novel. In 2 out of 34 patients (6%) not fulfilling the Task Force criteria, mutations were

identified.

Conclusions: PKP2 mutations can be identified In up to 41% of Dutch patients fulfilling the task force criteria for ARVC. Recurrent mutations occur frequentiy. These results will fcilitte eariy recognition of persons at risk and future studies of potential genotype-phenotype relationships.

10.30 - 10.45 uur

Genomics/Regeneration Voorzittws: Y.M. Pinto en P.A.F.M. Doevendans

EFFECT

OF

AUTOLOGOUS

10.15 - 10.30 uur

FAMILIAL DISEASE WITH A RISK ON SUDDEN DEATH: A OF STUDY THE LONGITDINAL PSYCHOLOGICAL CONSEQUENCES OF PREDICTIVE TESTING FOR LONG QT SYNDROME Hendriks KSWH1, Van Jan9en IM2, Hendriks MMWB1, Bimle E2, Grosfeid F1M2, Wilde MM, Van den Bout j1, Van Tintelen iP3, Ten Kroode HFJ1, 1)Universltry Medical Centre Utrecht, 2)Academlc Medkal Centre Amsterdam, 3)Uiniversltary Medial Centre Groningen.

Purpoe: From 1996 electrocardiographic (ECG) and molecular screening in families with long QT syndrome (LQTS), a potentially life-threatening but treatable cardiac arrhythmia syndrome has been performed In the Netheriands. We examined the psychological influence of predictive ECG and molecular screening in these families.

Methods: In a prospective study the extent and course of anxiety and depression associated with two sequential screening tests: first ECG, second DNA, are described In applicants and their partners from the flrst consultation until 18 months after disclosure of the DNAresults.

Results: Seventy-seven applicants and 57 partners completed measures of distress at three time points. Both ECG findings and DNA results were associated with Increased depression, anxiety and disease related distress In short term. Highest scores of distress were found in those who rKcelved inconcdusive ECG results. The distress scores exceed those from presymptomatic testing In oncogenetics and neurogenetics. In the long-term the high leveis of distress were restored. In carriers, however, the scores of disease related anxiety remained Increased. Conduskone: In predictive two step testing in LQTS, applicants and their partners are responding to risk Information, whether from LCG or DNA. (Prospective) carniers and partners experience distress during and after the process of testing. This finding highlights the importance of proper Initial pre-test counselling before ECG testing and of psychosocial support during and after the procedure.

Genomks/Regeneratlon

10.45 - 11.00 uur

Voorzittem: Y.M. Pinto en P.A.F.M. Doevendans

BONE

MARROW-DIVED

MONONUCLEAR CELL INJECTION ON MYOCARDIAL FUNCTION AND PERFUSION IN PATIESm WITH REFRACTORY ANGINA PECTORIS AND CHRONIC ISCHEMA S.LM.A.iBeies, 3.3. Sax, K. Zeppenfeld, P. Dibbets, M.P. Stokkel, W.E. Fibbe, E.E. van der Wall, M.3. Schallij, D.E. Atsma. Dept. of Cardiology, Lelden University Medicl Center, Leiden. Purpose: Bone marrow cell transplantation has been proposed as a novel therapeutic option for patients with chronic Ischemic heart disease. We studied whether autologous bone marrow-derived mononudear cell (MNC) Injection into ischemic myocardium of patients with refractory angina pectoris reduces anginal symptoms, improves left ventricular (LV) function and Increases myocardial

perfusion (reduces Ischemia). Methds: In 21 patients (63*11 yrs, 17 men) with refractory angina pectoris (Canadian Cardiovascular Society (CCS) dass III-N) despite optimized medical therapy and withOUt options for conventional revascularization, bone marrow was aspirated from the Ililac crest. In myocardial segments with stress-induced lschemia on gated perfusion SPECT, 30-100x106 MNC were Injected (10±2 InjecUons of 0.2 ml) using the Myostar Injection catheter (NOGA, Blosense Webster). Anginal symptoms were assessed at 3 and 6 months folow-up. At baseline and 3 months folow-up, gated SPECr using technetium-99m tetrofosmin was performed to assess LV ejection fraction, LV volumes and the number of segments with stress-induced ischemia

Results: Mean CCS score Improved from 3.5±0.5 at baseline to 2.4±0.6 at 3 months (P

Abstracts of the Scientific Meeting of the Netherlands Society of Cardiology (NVVC): 27-29 October 2005, De Heerlickheijd, Ermelo.

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