Myocardial fibrosis in asymptomatic patients undergoing surgery for mitral and aortic valve regurgitation

BACKGROUND

Chronic heart valve regurgitation induces left ventricular (LV) volume overload, leading to the development of hypertrophy and progressive dilatation of the ventricle to maintain physiological cardiac output. In order to prevent potential irreversible LV structural changes, the identification of the best timing for treatment is pivotal.

OBJECTIVE

To assess the presence and extent of fibrosis in myocardial tissue in asymptomatic patients with valvular heart disease (VHD) and preserved LV dimensions and function undergoing cardiac surgery.

METHODS

Thirty-nine patients were enrolled. Sixteen patients were affected by aortic or mitral regurgitation: they were all asymptomatic, undergoing valve surgery according to VHD European Society of Cardiology guidelines. Twenty-three patients with end-stage nonischemic dilated cardiomyopathy (DCM) and severe LV dysfunction undergoing cardiac surgery for implantation of a durable left ventricular assist device (LVAD) served as controls. During surgery, VHD patients underwent three myocardial biopsies at the level of the septum, the lateral wall and LV apex, while in LVAD patients the coring of the apex of the LV was used. For both groups, the tissue samples were analyzed on one section corresponding to the apical area. All slides were stained with hematoxylin and eosin and Masson's trichrome staining and further digitalized. The degree of fibrosis was then calculated as a percentage of the total area.

RESULTS

Of 39 patients, 23 met the inclusion criteria: 12 had mitral or aortic insufficiency with a preserved ejection fraction and 11 had idiopathic dilated cardiomyopathy. Quantitative analysis of apical sections revealed a myocardial fibrosis amount of 10 ± 6% in VHD patients, while in LVAD patients the mean apical myocardial fibrosis rate was 38 ± 9%. In VHD patients, fibrosis was also present in the lateral wall (9 ± 4%) and in the septum (9 ± 6%).

CONCLUSION

Our case series study highlights the presence of tissue remodeling with fibrosis in asymptomatic patients with VHD and preserved LV function. According to our results, myocardial fibrosis is present at an early stage of the disease, well before developing detectable LV dysfunction and symptoms. Since the relationship between the progressive magnitude of myocardial fibrosis and potential prognostic implications are not yet defined, further studies on this topic are warranted.

Ventricular Arrhythmias and Sudden Death in Nonischemic Dilated Cardiomyopathy: Matter of Sex or Scar?

BACKGROUND

To evaluate the association between sex and ventricular arrhythmias (VA) or sudden death (SD) in nonischemic dilated cardiomyopathy, including analysis of potential confounders.

METHODS AND RESULTS

Retrospective cohort study of consecutive patients with DCM referred for cardiac magnetic resonance at 2 tertiary hospitals. The primary combined end point encompassed sustained VA, appropriate implantable cardioverter defibrillator therapies, resuscitated cardiac arrest, and SD. We included 1165 patients with median follow-up of 36 months (interquartile range 20-58 months). The majority of patients (66%) were males. Males and females had similar left ventricular ejection fraction, but the prevalence of late gadolinium enhancement (LGE) at cardiac magnetic resonance was significantly higher among males (48% vs 30%, P < .001). Males had higher cumulative incidence of the primary end point (8% vs 4%, P = .02), and male sex was a significant predictor of the primary end point at univariate analysis (hazard ratio 1.93, P = .02). However, LGE had a major confounding effect in the association between sex and the primary outcome: the hazard ratio of male sex adjusted for LGE was 1.29 (P = .37). LGE+ females had significantly higher cumulative incidence of the primary end point than LGE- males (13% vs 1.8%, P < .001).

CONCLUSIONS

In patients with DCM, the prevalence of LGE is significantly higher among males, implying a major confounding effect in the association between male sex and VA or SD. LGE+ females have significantly higher risk than LGE- males. These data do not support the inclusion of sex into risk stratification algorithms for VA or SD in DCM.

Left ventricular shape predicts arrhythmic risk in fibrotic dilated cardiomyopathy

AIMS

Remodelling of the left ventricular (LV) shape is one of the hallmarks of non-ischaemic dilated cardiomyopathy (DCM) and may contribute to ventricular arrhythmias and sudden cardiac death. We sought to investigate a novel three dimensional (3D) shape analysis approach to quantify LV remodelling for arrhythmia prediction in DCM.

METHODS AND RESULTS

We created 3D LV shape models from end-diastolic cardiac magnetic resonance images of 156 patients with DCM and late gadolinium enhancement (LGE). Using the shape models, principle component analysis, and Cox-Lasso regression, we derived a prognostic LV arrhythmic shape (LVAS) score which identified patients who reached a composite arrhythmic endpoint of sudden cardiac death, aborted sudden cardiac death, and sustained ventricular tachycardia. We also extracted geometrical metrics to look for potential prognostic markers. During a follow-up period of up to 16 years (median 7.7, interquartile range: 3.9), 25 patients met the arrhythmic endpoint. The optimally prognostic LV shape for predicting the time-to arrhythmic event was a paraboloidal longitudinal profile, with a relatively wide base. The corresponding LVAS was associated with arrhythmic events in univariate Cox regression (hazard ratio = 2.0 per quartile; 95% confidence interval: 1.3-2.9), in univariate Cox regression with propensity score adjustment, and in three multivariate models; with LV ejection fraction, New York Heart Association Class III/IV (Model 1), implantable cardioverter-defibrillator receipt (Model 2), and cardiac resynchronization therapy (Model 3).

CONCLUSION

Biomarkers of LV shape remodelling in DCM can help to identify the patients at greatest risk of lethal ventricular arrhythmias.

Interatrial Block Predicts Life-Threatening Arrhythmias in Dilated Cardiomyopathy

Background Interatrial block (IAB) has been associated with supraventricular arrhythmias and stroke, and even with sudden cardiac death in the general population. Whether IAB is associated with life-threatening arrhythmias (LTA) and sudden cardiac death in dilated cardiomyopathy (DCM) remains unknown. This study aimed to determine the association between IAB and LTA in ambulant patients with DCM. Methods and Results A derivation cohort (Maastricht Dilated Cardiomyopathy Registry; N=469) and an external validation cohort (Utrecht Cardiomyopathy Cohort; N=321) were used for this study. The presence of IAB (P-wave duration>120 milliseconds) or atrial fibrillation (AF) was determined using digital calipers by physicians blinded to the study data. In the derivation cohort, IAB and AF were present in 291 (62%) and 70 (15%) patients with DCM, respectively. LTA (defined as sudden cardiac death, justified shock from implantable cardioverter-defibrillator or anti-tachypacing, or hemodynamic unstable ventricular fibrillation/tachycardia) occurred in 49 patients (3 with no IAB, 35 with IAB, and 11 patients with AF, respectively; median follow-up, 4.4 years [2.1; 7.4]). The LTA-free survival distribution significantly differed between IAB or AF versus no IAB (both P<0.01), but not between IAB versus AF (P=0.999). This association remained statistically significant in the multivariable model (IAB: HR, 4.8 (1.4-16.1), P=0.013; AF: HR, 6.4 (1.7-24.0), P=0.007). In the external validation cohort, the survival distribution was also significantly worse for IAB or AF versus no IAB (P=0.037; P=0.005), but not for IAB versus AF (P=0.836). Conclusions IAB is an easy to assess, widely applicable marker associated with LTA in DCM. IAB and AF seem to confer similar risk of LTA. Further research on IAB in DCM, and on the management of IAB in DCM is warranted.

Recovery of complete left bundle branch block in a dilated cardiomyopathy patient after treatment with sacubitril/valsartan: A case report

RATIONALE

The treatment of dilated cardiomyopathy (DCM) has recently been greatly improved, especially with the widespread use of sacubitril/valsartan (ARNI) combination therapy. We know that ARNI-like drugs can significantly improve the symptoms of heart failure with reducing ejection fraction. However, clinical studies evaluating the safety and efficacy of ARNI in DCM-associated arrhythmia are limited, and whether individuals with arrhythmia would benefit from ARNI remains controversial. In this case, we report a patient with complete left bundle branch block (CLBBB) associated with DCM whose CLBBB returned to normal after treatment with ARNI.

PATIENT CONCERNS

A 38-year-old man was admitted to the hospital for 20 days for idiopathic paroxysmal dyspnea. He presented with exacerbated dyspnea symptoms at night, accompanied by cough and sputum.

DIAGNOSIS

Physical examination revealed a grade 4/6 systolic murmur could be heard in the apical area of the heart and mild edema was present in both lower limbs. Laboratory examination found that the B-type natriuretic peptide was significantly increased. Echocardiography indicated left atrial internal diameter, right ventricular internal diameter, and left ventricular diastolic diameter were enlarged and ejection fraction was significantly decreased. Besides, the pulsation of the wall was diffusely attenuated. Electrocardiogram was suggestive of tachycardia and CLBBB. A diagnosis of DCM with CLBBB was considered based on a comprehensive evaluation of the physical examination, laboratory examination, echocardiography and electrocardiogram.

INTERVENTIONS

The patient was treated with ARNI at a dose of 50 mg (twice a day) at first, gradually increasing to the target dose (200 mg, twice a day) in the following 9 months as shown in Table 1, along with metoprolol 25 mg (once a day [qd]), diuretics 20 mg (qd), and aldosterone 20 mg (qd).

OUTCOMES

After treatment with ARNI during the 9-month follow-up, the patient's symptoms improved, and CLBBB returned to normal.

LESSONS

Clinical studies evaluating the safety and efficacy of ARNI in DCM-associated arrhythmia are limited, and whether individuals with arrhythmia would benefit from ARNI remains controversial. This report will help to instruct the clinical treatment of DCM patients with CLBBB and the potential application of ARNI.

Changes in clinical and imaging variables during withdrawal of heart failure therapy in recovered dilated cardiomyopathy

AIMS

This study aimed to profile the changes in non-invasive clinical, biochemical, and imaging markers during withdrawal of therapy in patients with recovered dilated cardiomyopathy, providing insights into the pathophysiology of relapse.

METHODS AND RESULTS

Clinical, biochemical, and imaging data from patients during phased withdrawal of therapy in the randomized or single-arm cross-over phases of TRED-HF were profiled. Clinical variables were measured at each study visit and imaging variables were measured at baseline, 16 weeks, and 6 months. Amongst the 49 patients [35% women, mean age 53.6 years (standard deviation 11.6)] who withdrew therapy, 20 relapsed. Increases in mean heart rate [7.6 beats per minute (95% confidence interval, CI, 4.5, 10.7)], systolic blood pressure [6.6 mmHg (95% CI 2.7, 10.5)], and diastolic blood pressure [5.8 mmHg (95% CI 3.1, 8.5)] were observed within 4-8 weeks of starting to withdraw therapy. A rise in mean left ventricular (LV) mass [5.1 g/m2 (95% CI 2.8, 7.3)] and LV end-diastolic volume [3.9 mL/m2 (95% CI 1.1, 6.7)] and a reduction in mean LV ejection fraction [-4.2 (95% CI -6.6, -1.8)] were seen by 16 weeks, the earliest imaging follow-up. Plasma N-terminal pro-brain natriuretic peptide (NT-proBNP) fell immediately after withdrawing beta-blockers and only tended to increase 6 months after beginning therapy withdrawal [mean change in log NT-proBNP at 6 months: 0.2 (95% CI -0.1, 0.4)].

CONCLUSIONS

Changes in plasma NT-proBNP are a late feature of relapse, often months after a reduction in LV function. A rise in heart rate and blood pressure is observed soon after withdrawing therapy in recovered dilated cardiomyopathy, typically accompanied or closely followed by early changes in LV structure and function.

[Development and implementation of a heart failure telemonitoring system: the single centre experience]

Aim      To evaluate the efficacy of remote monitoring by the compliance with body weight control and drug therapy in patients with CHF, using a specially developed software module for chronic heart failure (CHF) monitoring.Material and methods  During 2018-2020, 79 patients with dilated cardiomyopathy (mean age, 36.1 [34.2; 38.4] years) and NYHA II-IV functional class CHF were included in the outpatient telemonitoring (TM) program.Results The duration of monitoring was 965 [768; 1065] days. During the monitoring time, the compliance with outpatient body weight control significantly improved: 73.3 [70; 80] % at baseline vs. 86.7 [76.7; 86.7] % at the end of the 31st month (p&lt;0.001). The proportion of patients measuring their body weight at least 6 times a week significantly increased: 8.9 % at baseline vs. 58.1 % by the end of the monitoring (p&lt;0.001). There was no significant association between the time-related changes in the compliance with body weight control and drug therapy and the patient's gender. In addition, during long-term TM, a small but statistically significant increase in left ventricular ejection fraction was noted (36.3 [35.5; 37.2] % at baseline vs. 37.2 [35.8; 38.3] % at the end of monitoring; p=0.0008). The involvement of staff physicians in the remote correction of therapy for CHF decreased during the study: the number of system notifications that required a physician's response reduced over two years from 26.6 to 13 % (p=0.011).Conclusion      Participation of patients with dilated cardiomyopathy and CHF in the structured TM program was associated with a significant increase in the compliance with regular self-control of body weight and drug therapy for heart failure.

Moderate excess alcohol consumption and adverse cardiac remodelling in dilated cardiomyopathy

OBJECTIVE

The effect of moderate excess alcohol consumption is widely debated and has not been well defined in dilated cardiomyopathy (DCM). There is need for a greater evidence base to help advise patients. We sought to evaluate the effect of moderate excess alcohol consumption on cardiovascular structure, function and outcomes in DCM.

METHODS

Prospective longitudinal observational cohort study. Patients with DCM (n=604) were evaluated for a history of moderate excess alcohol consumption (UK government guidelines; >14 units/week for women, >21 units/week for men) at cohort enrolment, had cardiovascular magnetic resonance and were followed up for the composite endpoint of cardiovascular death, heart failure and arrhythmic events. Patients meeting criteria for alcoholic cardiomyopathy were not recruited.

RESULTS

DCM patients with a history of moderate excess alcohol consumption (n=98, 16%) had lower biventricular function and increased chamber dilatation of the left ventricle, right ventricle and left atrium, as well as increased left ventricular hypertrophy compared with patients without moderate alcohol consumption. They were more likely to be male (alcohol excess group: n=92, 94% vs n=306, 61%, p=<0.001). After adjustment for biological sex, moderate excess alcohol was not associated with adverse cardiac structure. There was no difference in midwall myocardial fibrosis between groups. Prior moderate excess alcohol consumption did not affect prognosis (HR 1.29, 95% CI 0.73 to 2.26, p=0.38) during median follow-up of 3.9 years.

CONCLUSION

DCM patients with moderate excess alcohol consumption have adverse cardiac structure and function at presentation, but this is largely due to biological sex. Alcohol may contribute to sex-specific phenotypic differences in DCM. These findings help to inform lifestyle discussions for patients with DCM.

Prosthetic walking after bilateral transfemoral amputation in a patient with dilated cardiomyopathy: a case report

In this study, we present a case of a 14-year-old adolescent boy who developed rhabdomyolysis and underwent bilateral transfemoral amputation after cardiopulmonary resuscitation for cardiac arrest because of dilated cardiomyopathy (DCM). Patients with bilateral transfemoral amputation have slower walking velocity and greater oxygen consumption during walking. Rehabilitation of such patients may be demanding especially if they have DCM, one of the major causes of advanced heart failure. The patient was admitted to our hospital on postoperative day (POD) 206. At first, we started with residuum compression. Simultaneously, resistance training and range-of-motion exercise were performed. He started the walking training with short stubbies prostheses on POD 262. Then, we used two types of knee joint prostheses, microprocessor-controlled prosthetic knee (MPK) and non-MPK. We chose MPK for his bilateral knee joints because it was easier for him to walk with MPK than with non-MPK. MPK also has the advantage of high stability and less burden on the heart. He achieved to walk with the prosthesis using T-canes with both hands on POD 374. Furthermore, he was able to return to school after discharge. In patients with transfemoral amputations and DCM with exercise restrictions, MPK is preferred because it reduces cardiac load during physical activity.

Comparative efficacy of five Chinese medicine injections for treating dilated cardiomyopathy with heart failure: A Bayesian network meta-analysis

ETHNOPHARMACOLOGICAL RELEVANCE

Chinese medicine injections (CMIs) are widely used by clinicians in China as an adjuvant treatment in dilated cardiomyopathy with heart failure (DCM-HF). However, comprehensive and systematic evidence supporting the beneficial effects of CMIs combined with Western medicine (WM) against DCM-HF was lacking.

OBJECTIVE

This network meta-analysis aimed to assess the effectiveness of five different CMIs in the treatment of DCM-HF.

METHODS

The Cochrane Library, Embase, PubMed, China National Knowledge Infrastructure (CNKI), Allied and Alternative Medieine Database (AMED), Chinese Biological Medicine Database (CBM), Wanfang Database, and Chinese Scientific Journal Database (VIP) were comprehensively searched from their inception to March 10, 2020, for randomized controlled trials (RCTs) focusing on the use of CMIs combined with WM to treat DCM-HF. The quality of the included RCTs was assessed using the Cochrane Handbook 5.1.0. Bayesian network meta-analysis were designed to access the effectiveness of different CMIs.

RESULTS

A total of 38 eligible RCTs involving 3247 patients were enrolled. The study showed that Huangqi injection, Shengmai injection, Shenfu injection, Shenmai injection, and Xinmailong injection combined with WM significantly improved performance compared with WM alone in treating DCM-HF. Xinmailong injection + WM had the highest likelihood of being the best treatment in terms of the improvement in the clinical effectiveness rate, left ventricular end-diastolic dimension, and 6-min walking distance. Huangqi injection + WM had the highest probability of being the best treatment on account of the enhancement of left ventricular ejection fraction. Shenmai injection + WM had the highest likelihood of being the best treatment considering the improvement in cardiac output and the reduction in brain natriuretic peptide.

CONCLUSIONS

The combination between CMIs and WM exerted a more positive effect in DCM-HF treatment. Xinmailong injection + WM had the best performance in treating DCM-HF, followed by Shenmai injection and Huangqi injection. However, due to the low qualities of the original studies, more high-quality studies are needed to support the findings.

Left Heart Decompression on Veno-Arterial Extracorporeal Membrane Oxygenation in Children With Dilated Cardiomyopathy and Myocarditis: An Extracorporeal Life Support Organization Registry Review

OBJECTIVES

To describe the association between left heart decompression on veno-arterial extracorporeal membrane oxygenation and survival in patients with myocarditis and dilated cardiomyopathy. The secondary outcome is to study association of left heart decompression with survival in children with myocarditis compared with those with dilated cardiomyopathy.

DESIGN

Retrospective study of a multicenter registry database.

SETTING

Data reported to Extracorporeal Life Support Organization from international extracorporeal membrane oxygenation centers.

PATIENTS

Patients less than or equal to 18 years old with a diagnosis of myocarditis or dilated cardiomyopathy receiving extracorporeal membrane oxygenation.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A total of 1,438 pediatric extracorporeal membrane oxygenation runs were identified. Thirty-seven percent of the patients had myocarditis (n = 532), whereas the rest had dilated cardiomyopathy. Survival to hospital discharge was 63%. Median extracorporeal membrane oxygenation duration was 148 hours with interquartile range (84-248 hr). Nineteen percent of patients (n = 274) had left heart decompression. Multivariable analysis revealed using left heart decompression (adjusted odds ratio, 1.42; 95% CI, 1.06-1.89; p = 0.02), e-cardiopulmonary resuscitation (adjusted odds ratio, 0.63; 95% CI, 0.51-0.79; p < 0.001), higher pH (adjusted odds ratio, 3.69; 95% CI, 1.80-7.53; p < 0.001), and diagnosis of myocarditis (adjusted odds ratio, 1.69; 95% CI, 1.35-2.08; p < 0.001) were associated with greater odds of survival. In the multivariable analysis for patients with dilated cardiomyopathy, left heart decompression failed to reveal a significant association with survival (20% among survivors vs 17% among nonsurvivors, 95% CI, -2.2% to 8.0%). Meanwhile in patients with myocarditis, the multivariable analysis failed to exclude the possibility that left heart decompression was associated with up to a three-fold greater odds of survival (adjusted odds ratio, 1.77; 95% CI, 0.99-.15).

CONCLUSIONS

Retrospective review of the Extracorporeal Life Support Organization registry revealed an association between left heart decompression and greater odds of survival in children with myocarditis and dilated cardiomyopathy on extracorporeal membrane oxygenation. When comparing patients with dilated cardiomyopathy against those with myocarditis, we could not exclude a three-fold greater odds of survival associated with the use of left heart decompression. This finding warrants further prospective evaluation.

Overexpression of Heat Shock Protein 70 Improves Cardiac Remodeling and Survival in Protein Phosphatase 2A-Expressing Transgenic Mice with Chronic Heart Failure

Heat shock protein (HSP) 70 is a molecular chaperone that regulates protein structure in response to thermal stress. In addition, HSP70 is involved in post-translational modification and is related to the severity of some diseases. Here, we tested the functional relevance of long-lasting HSP70 expression in a model of nonischemic heart failure using protein phosphatase 2 catalytic subunit A (PP2CA)-expressing transgenic mice. These transgenic mice, with cardiac-specific overexpression of PP2CA, abruptly died after 12 weeks of postnatal life. Serial echocardiograms to assess cardiac function revealed that the ejection fraction (EF) was gradually decreased in transgenic PP2CA (TgPP2CA) mice. In addition, PP2CA expression exacerbated systolic dysfunction and LV dilatation, with free wall thinning, which are indicators of fatal dilated cardiomyopathy. Interestingly, simultaneous expression of HSP70 in double transgenic mice (dTg) significantly improved the dilated cardiomyopathy phenotype of TgPP2CA mice. We observed better survival, preserved EF, reduced chamber enlargement, and suppression of free wall thinning. In the proposed molecular mechanism, HSP70 preferentially regulates the phosphorylation of AKT. Phosphorylation of AKT was significantly reduced in TgPP2CA mice but was not significantly lower in dTg mice. Signal crosstalk between AKT and its substrates, in association with HSP70, might be a useful intervention for patients with nonischemic heart failure to suppress cardiac remodeling and improve survival.

Electrical Ventricular Remodeling in Dilated Cardiomyopathy

Ventricular arrhythmias contribute significantly to morbidity and mortality in patients with heart failure (HF). Pathomechanisms underlying arrhythmogenicity in patients with structural heart disease and impaired cardiac function include myocardial fibrosis and the remodeling of ion channels, affecting electrophysiologic properties of ventricular cardiomyocytes. The dysregulation of ion channel expression has been associated with cardiomyopathy and with the development of arrhythmias. However, the underlying molecular signaling pathways are increasingly recognized. This review summarizes clinical and cellular electrophysiologic characteristics observed in dilated cardiomyopathy (DCM) with ionic and structural alterations at the ventricular level. Furthermore, potential translational strategies and therapeutic options are highlighted.

[Less Invasive Surgical Closure of the Left Atrial Appendage for Cardiogenic Cerebral Embolism in a Patient with Dilated Cardiomyopathy]

Less invasive surgical closure of the left atrial appendage is recommended to prevent cardiogenic thromboembolism in patients with chronic non-valvular atrial fibrillation( Af) and other high-risk cardiac diseases such as dilated cardiomyopathy (DCM). We report a case of a 57-year-old man with Af and DCM. Catheter ablation for Af was contraindicated in this patient with a history of cardiogenic thromboembolism, and anticoagulation therapy was initiated. Despite anticoagulation therapy, the patient developed another ischemic stroke and we administered aggressive anticoagulation therapy resulting in successful resolution of the left atrial appendage thrombus. Less invasive surgical closure of the left atrial appendage was successfully performed, and thromboembolism has not recurred for one year postoperatively.

Myocardial dissection complicating left sinus of Valsalva aneurysm in silent takayasu arteritis

BACKGROUND

Myocardial dissection (MD) in a left sinus of Valsalva aneurysm (LSVA) is a rare condition that may lead to a fatal complication. Determining the MD etiology is challenging because of various possibilities ranging from congenital to acquired diseases. Here, we discuss an approach for determining the etiology of MD complicating LSVA in Takayasu arteritis (TA) and its treatment.

CASE PRESENTATION

A 41-year-old man presented with dyspnea on heavy activities and a history of consciousness loss at the age of 24 years. He was diagnosed with dilated cardiomyopathy and MD complicating LSVA in TA based on combined clinical and pathognomonic diagnostic criteria of TA evaluated using vascular Doppler and computed tomography angiography of the aorta. The patient refused to undergo surgery and received an optimal dose of chronic heart failure therapy, a high-dose steroid, and azathioprine. The patient experienced some improvements in clinical condition, functional outcome, and inflammatory markers at 1-year follow-up.

CONCLUSIONS

Clinical criteria and various imaging modalities may be used to determine the etiology of MD complicating LSVA in silent TA. As an alternative to surgery, the optimal medical treatment might result in a satisfactory outcome.

Advanced Heart Failure in Special Population: Cardiomyopathies and Myocarditis

Cardiomyopathies are a heterogeneous group of heart muscle diseases and an important cause of heart failure (HF) in young populations. The variety of causes, multiple underlying pathophysiological mechanisms, and different phenotypic expressions influence their presentation and response to treatment. Dilated cardiomyopathy is the most prevalent cause of HF. Advanced HF in hypertrophic, restrictive, and arrhythmogenic cardiomyopathies is rare, but its development portends a poor prognosis. The active phase of fulminant myocarditis may result in acute HF requiring advanced strategies to support the systemic circulation or may determine an irreversible persisting left ventricular failure with end-stage HF.

Comparison of the Limb-lead Electrocardiogram to the 12-Lead Electrocardiogram for Identifying Conditions Associated with Sudden Cardiac Death in Youth Athletes

The optimal screening strategy to prevent sudden cardiac death (SCD) in athletes remains unknown. Pre-participation screening with electrocardiogram (ECG) remains controversial. The utility and accuracy of limb-lead (LL) ECG alone in identifying cardiac abnormalities associated with SCD has not been studied. This study was a comparative secondary data analysis, comparing the interpretation accuracy of 4 physicians evaluating publicly available ECGs of the most common cardiac conditions associated with SCD in athletes. Each physician interpreted a total of 100 ECGs: 50 normal ECGs (25 LL and 25 standard 12L) and 50 abnormal ECGs (25 LL and 25 standard 12L). The agreement between LL ECGs and 12L ECGs was assessed by Cohen's kappa coefficient and the accuracy of identifying an abnormal ECG was compared across LL and 12L ECGs using a chi-squared test. Inter-rater reliability was assessed by estimating the Fleiss's kappa coefficient. The sensitivity of LL ECG and 12L ECG was identical at 86%. The specificity of LL ECG was 75% (95% CI = 65% to 83%) and 12L ECG was 82% (95% CI = 73% to 89%). Substantial agreement was seen between LL ECG and 12L ECG interpretation across all readers (k = 0.63; 95% CI = 0.49 to 0.77). Interpretation accuracy was 81% (95% CI = 74% to 86%) and 84% (95% CI 78% to 89%) using LL ECG and 12L ECG, respectively (p = 0.43). In conclusion, the accuracy, sensitivity, and specificity were high and comparable for both LL ECG and 12L ECG in identifying cardiovascular conditions associated with SCD. Agreement between LL ECG and 12L ECG was substantial.

Correlation of plasma TSG-6 with cardiac function, myocardial fibrosis, and prognosis in dilated cardiomyopathy patients with heart failure

OBJECTIVES

Tumor necrosis factor α stimulated gene 6 (TSG-6) protein is an inflammation-inducing protein. In recent years, TSG-6 protein has been found to play an anti-inflammatory and anti-fibrosis role in a variety of disease models. The level of TSG-6 protein in circulating blood is considered to be a biological indicator for the evaluation of acute coronary syndrome, severe infection, and other diseases, and it is closely related to the prognosis. The clinical correlation between TSG-6 protein and dilated cardiomyopathy (DCM) patients with heart failure has not been reported. This study aims to investigate the changes of plasma TSG-6 protein levels in cardiomyopathy patients with heart failure and its correlation with cardiac function, myocardial fibrosis, and prognosis.

METHODS

Based on the prospective studies, a number of 90 DCM patients with heart failure were selected as a DCM heart failure group from Dec.1, 2019 to Sept.1, 2020. Thirty-nine healthy people were served as a control group. Plasma TSG-6, Collagen Ⅰ, Collagen III, and α-smooth muscle actin (α-SMA) were measured with ELISA test. Echocardiography was used to evaluate the structure and function of the heart. DCM patients with heart failure were followed up for 3 months. The patients were assigned into 2 groups according to whether they had major adverse cardiovascular events (MACE). The general clinical data, plasma TSG-6, Collagen Ⅰ, Collagen III, and α-SMA protein levels were compared between the control group and the DCM heart failure group. At the same time, the correlation between plasma TSG-6 protein level and cardiac function grade, myocardial fibrosis or prognosis of patients in the DCM heart failure group was analyzed.

RESULTS

Compared with the control group, the heart rate, TSG-6, Collagen Ⅰ, Collage III, α-SMA, hemoglobin, atrial natriuretic peptide (NT-proBNP), hypersensitive C-reactive protein, aspartate aminotransferase, serum creatinine, lactate dehydrogenase, and left ventricular end diastolic diameter (LVEDD) increased significantly (all P<0.001). High-density lipoprotein, left ventricular short axis shortening rate (LVFS), and left ventricular ejection fraction (LVEF) decreased significantly in the DCM heart failure group (all P<0.001). Plasma levels of TSG-6 were positively correlated with NT-proBNP, Collagen Ⅰ, Collagen III, α-SMA, and LVEDD (all P<0.001), while they were negatively correlated with LVFS and LVEF (all P<0.001). With the increase of NYHA heart function classification, plasma levels of TSG-6, Collagen Ⅰ, Collagen III, and α-SMA increased significantly (all P<0.001). The increases in plasma levels of NT-proBNP and TSG-6 was associated with poor prognosis in DCM patients with heart failure (all P<0.05). The sensitivity and specificity of plasma NT-proBNP for evaluating the prognosis of DCM heart failure were 76.2% and 68.1%, respectively. The sensitivity and specificity of plasma TSG-6 for evaluating the prognosis of DCM heart failure were 95.2% and 66.7%, respectively. The sensitivity and specificity of plasma TSG-6 combined with NT-proBNP for prognostic evaluation of DCM heart failure were 85.7% and 81.2%, respectively. The specificity of plasma TSG-6 combined with NT-proBNP for the prognosis of heart failure was better than that of NT-proBNP or TSG-6 alone (P<0.001).

CONCLUSIONS

The plasma levels TSG-6 in DCM patients with heart failure increase significantly, and the plasma levels TSG-6 could be used as a new predictor for cardiac function, myocardial fibrosis, and prognosis.

Determinants of Exercise-Induced Mitral Regurgitation Using Three-Dimensional Transesophageal Echocardiography Combined With Isometric Handgrip Exercise

Using three-dimensional (3D) transesophageal echocardiography (TEE) and isometric handgrip exercise (IHE), we investigated the determinants of exercise-induced mitral regurgitation (MR) according to MR etiologies. Seventy-six patients with more than moderate MR, 40 patients with functional MR (FMR) and 36 patients with degenerative MR (DMR), underwent 3D TEE combined with IHE. Mitral valve (MV) geometry and 3D vena contracta area (3D VCA) were simultaneously evaluated at baseline and during IHE. With regard to exercise-induced MR, Δ3D VCA was calculated as the difference between 3D VCA at baseline and 3D VCA during IHE. IHE caused different changes in MV geometry between etiologies and led to exacerbation of 3D VCA at baseline. Larger Δ3D VCA was observed in the FMR group compared with the DMR group (15.9 ± 10.3 mm² versus 7.3 ± 4.2 mm²; p < 0.0001). In multivariate analyses, tenting height and 3D VCA were selected as independent factors associated with Δ3D VCA in the FMR group (p = 0.0135 and p = 0.0201, respectively), while flail width was selected as an independent factor associated with Δ3D VCA in the DMR group (p = 0.0066). In conclusion, IHE alters mitral valve geometry and causes exacerbation of MR regardless of MR etiology and the determinants of exercise-induced MR differed between MR etiologies.

DNA methylation analysis reveals epimutation hotspots in patients with dilated cardiomyopathy-associated laminopathies

BACKGROUND

Mutations in LMNA, encoding lamin A/C, lead to a variety of diseases known as laminopathies including dilated cardiomyopathy (DCM) and skeletal abnormalities. Though previous studies have investigated the dysregulation of gene expression in cells from patients with DCM, the role of epigenetic (gene regulatory) mechanisms, such as DNA methylation, has not been thoroughly investigated. Furthermore, the impact of family-specific LMNA mutations on DNA methylation is unknown. Here, we performed reduced representation bisulfite sequencing on ten pairs of fibroblasts and their induced pluripotent stem cell (iPSC) derivatives from two families with DCM due to distinct LMNA mutations, one of which also induces brachydactyly.

RESULTS

Family-specific differentially methylated regions (DMRs) were identified by comparing the DNA methylation landscape of patient and control samples. Fibroblast DMRs were found to enrich for distal regulatory features and transcriptionally repressed chromatin and to associate with genes related to phenotypes found in tissues affected by laminopathies. These DMRs, in combination with transcriptome-wide expression data and lamina-associated domain (LAD) organization, revealed the presence of inter-family epimutation hotspots near differentially expressed genes, most of which were located outside LADs redistributed in LMNA-related DCM. Comparison of DMRs found in fibroblasts and iPSCs identified regions where epimutations were persistent across both cell types. Finally, a network of aberrantly methylated disease-associated genes revealed a potential molecular link between pathways involved in bone and heart development.

CONCLUSIONS

Our results identified both shared and mutation-specific laminopathy epimutation landscapes that were consistent with lamin A/C mutation-mediated epigenetic aberrancies that arose in somatic and early developmental cell stages.

[Left Ventricular Thrombectomy in Patients with Dilated Cardiomyopathy Accompanied by Cerebral Embolism:Report of Two Cases]

Left ventricular thrombus( LVT) formation is a known complication of ischemic heart diseases including acute myocardial infarction, dilated cardiomyopathy (DCM) and myocarditis. Among them, few cases involve DCM. Two DCM patients with LVT developed acute cerebral infarction and underwent thrombectomy. Both patients presented with sinus rhythm and neither had previous thromboembolic event. However, their transthoracic echocardiography (TTE) showed left ventricular ejection fractions<35% and left ventricular diastolic diameters≥60 mm, indicating high possibilities of LVT formation. The TTE findings suggest that DCM patients require anticoagulation therapy and frequent imaging examination, even with sinus rhythm and no history of thromboembolic events. Once a thromboembolic event occurs, thrombectomy is urgently needed.

Catheter ablation for atrial fibrillation in left ventricular assist device: A case report

INTRODUCTION

Mechanical circulatory support such as the left ventricular assist device (LVAD) has become widely implemented in the treatment of end-stage heart failure, whether as bridge-to-transplant or as destination therapy. The hemodynamic effects of arrhythmia on LVADs and its management are significant in determining the long-term outcome of these patients. Both atrial arrhythmia and ventricular arrhythmia are commonly seen after implantation of the device. There are no strict guidelines, however, on the need for intensive management of arrhythmias in LVAD. In this case report, we present a patient with new onset atrial fibrillation after LVAD implantation which leads to acute decompensating heart failure. The patient was treated with catheter ablation. The intervention demonstrated positive outcomes for this patient.

PATIENT CONCERNS

The patient was a Korean male, who presented with dyspnea, fatigue and generalized edema after persistent atrial fibrillation precipitated by implantation of the left ventricular assist device.

DIAGNOSIS

The patient was diagnosed with acute decompensating heart failure that was aggravated by recurrent atrial arrhythmia.

INTERVENTION

We attempted to relieve symptoms of right ventricular dysfunction by method of strict rhythm control in this patient. The patient underwent radiofrequency catheter ablation for recurrent atrial fibrillation.

OUTCOME

The patient showed improved clinical symptoms, BNP levels, and echocardiogram parameters immediately after the procedure as well as during long term outpatient follow up.

CONCLUSION

In this case report, we present the first successful case in Korea of atrial fibrillation in LVAD treated with catheter ablation. This case suggests setting catheter ablation as a routine first-line treatment for atrial arrhythmia in LVAD patients, especially when the arrhythmia predisposes the patient at risk for decompensating heart failure.

Prospective clinical trial evaluating spironolactone in Doberman pinschers with congestive heart failure due to dilated cardiomyopathy

INTRODUCTION/OBJECTIVES

Whether the aldosterone antagonist spironolactone has beneficial survival effects in dogs with dilated cardiomyopathy (DCM) is not known. The primary objective of the study was to evaluate the effect of spironolactone, when added to conventional therapy, on survival time in Doberman pinschers with congestive heart failure (CHF) due to DCM.

ANIMALS

Sixty-seven client-owned Doberman pinschers with CHF due to DCM.

MATERIALS AND METHODS

The trial design was prospective, randomized, blinded, and placebo controlled. Dogs were randomized to receive 50-75 mg of spironolactone twice daily (n = 34) or a placebo (n = 33), in addition to standard CHF therapy. Follow-up visits were targeted every 1-6 weeks until endpoint. Quality-of-life questionnaire and physical examination were performed at every visit, while renal biochemistry, ECG, echocardiography, and thoracic radiography were reassessed as needed. The primary endpoint was time to cardiac death, defined as death or euthanasia from CHF or sudden death.

RESULTS

Median time to primary endpoint in the spironolactone group (183 days) was not statistically significantly different than that for the placebo group (124 days) (p = 0.254). The development of atrial fibrillation (AF) was significantly less frequent in the spironolactone group (n = 7) than the placebo group (n = 15, p = 0.037).

CONCLUSIONS

While median time to cardiac death in the spironolactone group was not statistically significantly different than that in the placebo group, adding spironolactone to conventional therapy resulted in reduced occurrence of AF.