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      Postnatal Cardiac Autonomic Nervous Control in Pediatric Congenital Heart Disease

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          Abstract

          Congenital heart disease is the most common congenital defect. During childhood, survival is generally good but, in adulthood, late complications are not uncommon. Abnormal autonomic control in children with congenital heart disease may contribute considerably to the pathophysiology of these long term sequelae. This narrative review of 34 studies aims to summarize current knowledge on function of the autonomic nervous system in children with a congenital heart defect. Large scale studies that measure both branches of the nervous system for prolonged periods of time in well-defined patient cohorts in various phases of childhood and adolescence are currently lacking. Pending such studies, there is not yet a good grasp on the extent and direction of sympathetic and parasympathetic autonomic function in pediatric congenital heart disease. Longitudinal studies in homogenous patient groups linking autonomic nervous system function and clinical outcome are warranted.

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          Most cited references76

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          Heart rate variability and first cardiovascular event in populations without known cardiovascular disease: meta-analysis and dose-response meta-regression.

          Heart rate variability (HRV) is associated with cardiovascular disease (CVD) in individuals with known CVD. It is less clear whether HRV is associated with a first cardiovascular event. Therefore, we performed a meta-analysis to study the association between HRV and incident cardiovascular events in populations without known CVD. We performed a meta-analysis and dose-response meta-regression of studies assessing the association between HRV and CVD. We searched Pubmed, Embase, Web of Science, Cochrane library, ScienceDirect, and CINAHL up to December 2011 for eligible studies. We selected studies that used the standard deviation of the normalized N-N interval (SDNN), low-frequency (LF) or high-frequency (HF) spectral component as a measure of HRV. Primary outcomes were (non)fatal cardiovascular events. Eight studies with a total number of 21 988 participants were included. The pooled relative risk (RR) comparing the lowest level to the highest level of SDNN was 1.35 (95% CI 1.10, 1.67). The pooled RRs for LF and HF were 1.45 (95% CI 1.12, 1.87) and 1.32 (95% CI 0.96, 1.81), respectively. In a meta-regression, the predicted RR of incident CVD of the 10th and 90th HRV (SDNN) percentiles compared with the 50th percentile were 1.50 (95% CI 1.22, 1.83) and 0.67 (95% CI 0.41, 1.09). In conclusion, low HRV is associated with a 32-45% increased risk of a first cardiovascular event in populations without known CVD. An increase in SDNN of 1% results in an ∼1% lower risk of fatal or non-fatal CVD.
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            Temporal trends in survival to adulthood among patients born with congenital heart disease from 1970 to 1992 in Belgium.

            Over the past decades, the life expectancy of individuals with congenital heart disease (CHD) has increased significantly. However, precise estimates for survival to adulthood are scarce for patients with CHD. We investigated the proportion of CHD patients born between 1990 and 1992 who survived into adulthood. We also compared their survival with that of CHD patients born in earlier eras and evaluated survival as a function of the type of heart defect. We reviewed the CHD program administrative and clinical database at the University Hospitals Leuven (Leuven, Belgium) and analyzed the records of 7497 CHD patients born from 1970 to 1992. Survival to 18 years of age in patients born between 1990 and 1992 was 88.6% (95% confidence interval [CI], 86.3% to 90.5%), which was significantly greater than that of patients born in previous decades (P<0.0001). For patients born between 1990 and 1992, survival into adulthood for those with mild heart defects was 98.0% (95% CI, 95.8% to 99.1%), whereas survival for those with moderate- and severe-complexity heart defects was 90.0% (95% CI, 86.8% to 92.5%) and 56.4% (95% CI, 47.4% to 64.5%), respectively. Analysis per heart defect confirmed these findings, demonstrating that patients with univentricular heart (49.1% [95% CI, 30.8% to 65.1%]) and hypoplastic left heart syndrome (7.5% [95% CI, 0.6% to 26.6%]) had the poorest survival rate. This study demonstrates that almost 90% of children with CHD have the prospect of surviving into adulthood.
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              The neurohormonal hypothesis: a theory to explain the mechanism of disease progression in heart failure.

              Because physicians have traditionally considered heart failure to be a hemodynamic disorder, they have described the syndrome of heart failure using hemodynamic concepts and have designed treatment strategies to correct the hemodynamic derangements of the disease. However, although hemodynamic abnormalities may explain the symptoms of heart failure, they are not sufficient to explain the progression of heart failure and, ultimately, the death of the patient. Therapeutic interventions may improve the hemodynamic status of patients but adversely affect their long-term outcome. These findings have raised questions about the validity of the hemodynamic hypothesis and suggest that alternative mechanisms must play a primary role in advancing the disease process. Several lines of evidence suggest that neurohormonal mechanisms play a central role in the progression of heart failure. Activation of the sympathetic nervous system and renin-angiotensin system exerts a direct deleterious effect on the heart that is independent of the hemodynamic actions of these endogenous mechanisms. Therapeutic interventions that block the effects of these neurohormonal systems favorably alter the natural history of heart failure, and such benefits cannot be explained by the effect of these treatments on cardiac contractility and ejection fraction. Conversely, pharmacologic agents that adversely influence neurohormonal systems in heart failure may increase cardiovascular morbidity and mortality, even though they exert favorable hemodynamic effects. These observations support the formulation of a neurohormonal hypothesis of heart failure and provide the basis for the development of novel therapeutic strategies in the next decade.
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                Author and article information

                Contributors
                Role: Academic Editor
                Journal
                J Cardiovasc Dev Dis
                J Cardiovasc Dev Dis
                jcdd
                Journal of Cardiovascular Development and Disease
                MDPI
                2308-3425
                15 April 2016
                June 2016
                : 3
                : 2
                : 16
                Affiliations
                [1 ]Department of Biological Psychology, Faculty of Behavioral and Movement sciences, VU Amsterdam, Van der Boechorststraat 1, 1081 BT Amsterdam, The Netherlands; eco.de.geus@ 123456vu.nl
                [2 ]EMGO+ Institute for Health and Care Research, VU Medical Center Amsterdam, Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands
                [3 ]Department of Pediatric Cardiology, LUMC University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands; N.A.Blom@ 123456lumc.nl (N.A.B.); A.D.J.ten_Harkel@ 123456lumc.nl (A.D.J.H.)
                [4 ]Department of Cardiology and Anatomy & Embryology, LUMC University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands; M.R.M.Jongbloed@ 123456lumc.nl
                Author notes
                [* ]Correspondence: i.nederend@ 123456vu.nl ; Tel.: +31-20-598-25-76; Fax: +31-20-598-88-32
                Article
                jcdd-03-00016
                10.3390/jcdd3020016
                5715679
                e9674b3e-72da-4227-95a7-66e52ebb81d3
                © 2016 by the authors.

                Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC-BY) license ( http://creativecommons.org/licenses/by/4.0/).

                History
                : 08 December 2015
                : 09 April 2016
                Categories
                Review

                autonomic nervous system,congenital heart disease,children,heart rate variability

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