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Ford VJ, Applefeld WN, Wang J, Sun J, Solomon SB, Sidenko S, Feng J, Sheffield C, Klein HG, Yu ZX, Torabi-Parizi P, Danner RL, Sachdev V, Solomon MA, Chen MY, Natanson C. Cardiac Magnetic Resonance Studies in a Large Animal Model That Simulates the Cardiac Abnormalities of Human Septic Shock. J Am Heart Assoc 2024; 13:e034026. [PMID: 39101510 DOI: 10.1161/jaha.123.034026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Accepted: 04/30/2024] [Indexed: 08/06/2024]
Abstract
BACKGROUND Septic shock is associated with increases in end-diastolic volume (EDV) and decreases in ejection fraction that reverse within 10 days. Nonsurvivors do not develop EDV increases. The mechanism is unknown. METHODS AND RESULTS Purpose-bred beagles (n=33) were randomized to receive intrabronchial Staphylococcus aureus or saline. Over 96 hours, cardiac magnetic resonance imaging and echocardiograms were performed. Tissue was obtained at 66 hours. From 0 to 96 hours after bacterial challenge, septic animals versus controls had significantly increased left ventricular wall edema (6%) and wall thinning with loss of mass (15%). On histology, the major finding was nonocclusive microvascular injury with edema in myocytes, the interstitium, and endothelial cells. Edema was associated with significant worsening of biventricular ejection fractions, ventricular-arterial coupling, and circumferential strain. Early during sepsis, (0-24 hours), the EDV decreased; significantly more in nonsurvivors (ie, greater diastolic dysfunction). From 24 to 48 hours, septic animals' biventricular chamber sizes increased; in survivors significantly greater than baseline and nonsurvivors, whose EDVs were not different from baseline. Preload, afterload, or heart rate differences did not explain these differential changes. CONCLUSIONS The cardiac dysfunction of sepsis is associated with wall edema. In nonsurvivors, at 0 to 24 hours, sepsis induces a more severe diastolic dysfunction, further decreasing chamber size. The loss of left ventricular mass with wall thinning in septic survivors may, in part, explain the EDV increases from 24 to 48 hours because of a potentially reparative process removing damaged wall tissue. Septic cardiomyopathy is most consistent with a nonocclusive microvascular injury resulting in edema causing reversible systolic and diastolic dysfunction with more severe diastolic dysfunction being associated with a decreased EDV and death.
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MESH Headings
- Animals
- Dogs
- Disease Models, Animal
- Shock, Septic/physiopathology
- Shock, Septic/complications
- Stroke Volume
- Magnetic Resonance Imaging
- Edema, Cardiac/physiopathology
- Edema, Cardiac/pathology
- Edema, Cardiac/diagnostic imaging
- Ventricular Function, Left
- Time Factors
- Humans
- Staphylococcal Infections/complications
- Staphylococcal Infections/physiopathology
- Echocardiography
- Ventricular Dysfunction, Left/physiopathology
- Ventricular Dysfunction, Left/diagnostic imaging
- Ventricular Dysfunction, Left/etiology
- Male
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Affiliation(s)
- Verity J Ford
- Critical Care Medicine Department, Clinical Center National Institutes of Health, (NIH, CC) Bethesda MD USA
| | - Willard N Applefeld
- Critical Care Medicine Department, Clinical Center National Institutes of Health, (NIH, CC) Bethesda MD USA
- Division of Cardiology Duke University Medical Center Durham NC USA
| | - Jeffrey Wang
- Critical Care Medicine Department, Clinical Center National Institutes of Health, (NIH, CC) Bethesda MD USA
- Emory University Atlanta GA USA
| | - Junfeng Sun
- Critical Care Medicine Department, Clinical Center National Institutes of Health, (NIH, CC) Bethesda MD USA
| | - Steven B Solomon
- Critical Care Medicine Department, Clinical Center National Institutes of Health, (NIH, CC) Bethesda MD USA
| | - Stanislav Sidenko
- National Heart Lung and Blood Institute National Institutes of Health Bethesda MD USA
| | - Jing Feng
- Critical Care Medicine Department, Clinical Center National Institutes of Health, (NIH, CC) Bethesda MD USA
| | | | - Harvey G Klein
- Department of Transfusion Medicine, Clinical Center National Institutes of Health, (NIH, CC) Bethesda MD USA
| | - Zu-Xi Yu
- National Heart Lung and Blood Institute National Institutes of Health Bethesda MD USA
| | - Parizad Torabi-Parizi
- National Heart Lung and Blood Institute National Institutes of Health Bethesda MD USA
| | - Robert L Danner
- Critical Care Medicine Department, Clinical Center National Institutes of Health, (NIH, CC) Bethesda MD USA
- National Heart Lung and Blood Institute National Institutes of Health Bethesda MD USA
| | - Vandana Sachdev
- National Heart Lung and Blood Institute National Institutes of Health Bethesda MD USA
| | - Michael A Solomon
- Critical Care Medicine Department, Clinical Center National Institutes of Health, (NIH, CC) Bethesda MD USA
- National Heart Lung and Blood Institute National Institutes of Health Bethesda MD USA
| | - Marcus Y Chen
- National Heart Lung and Blood Institute National Institutes of Health Bethesda MD USA
| | - Charles Natanson
- Critical Care Medicine Department, Clinical Center National Institutes of Health, (NIH, CC) Bethesda MD USA
- National Heart Lung and Blood Institute National Institutes of Health Bethesda MD USA
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Kalekar T, Gupta A, Kumar M. 3-Tesla cardiac magnetic resonance imaging in primary dilated cardiomyopathy. Afr J Thorac Crit Care Med 2024; 30:e844. [PMID: 38756390 PMCID: PMC11094701 DOI: 10.7196/ajtccm.2024.v30i1.844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 01/08/2024] [Indexed: 05/18/2024] Open
Abstract
Background Cardiac magnetic resonance imaging (CMR) is an excellent non-invasive imaging tool in the assessment of patients with dilated cardiomyopathy (DCM). Few studies have analysed the findings in primary (idiopathic) DCM. Objectives To study the CMR features in primary DCM. Methods We conducted a descriptive observational study on 20 adult patients with suspected or confirmed primary DCM. Each patient underwent a dedicated 3-Tesla CMR scan, and the findings were evaluated. Results Seventeen patients had systolic dysfunction with a reduced ejection fraction and elevated end-diastolic volume, 19 patients had contractile dysfunction in the form of global left ventricular hypokinesia, 13 patients showed no abnormal delayed contrast enhancement with gadolinium administration, and 7 patients showed abnormal late gadolinium enhancement patterns. Conclusion In patients with primary DCM, CMR is a powerful diagnostic tool that can definitively establish the diagnosis, assess the severity of the disease, predict the risk of future adverse cardiovascular outcomes, check for complications, and assist in future follow-ups. Study synopsis What the study adds. Cardiac magnetic resonance imaging (CMR) is an excellent non-invasive imaging tool in the assessment of patients with primary dilated cardiomyopathy (DCM). Findings include global ventricular enlargement, systolic dysfunction (ejection fraction <40%), and elevated end-diastolic (≥140 mL) and end-systolic volumes. Global abnormal wall contractility is often seen. In DCM there is either no abnormal gadolinium enhancement or curvilinear mid-myocardial or subepicardial late gadolinium enhancement, unrelated to a coronary artery distribution.Implications of the findings. In patients with primary DCM, CMR provides powerful diagnostic and prognostic information. Enhanced awareness and understanding of this relatively uncommon condition among clinicians and radiologists would be of benefit in patient management and treatment.
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Affiliation(s)
- T Kalekar
- Department of Radiodiagnosis, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Pune, Maharashtra, India
| | - A Gupta
- Department of Radiodiagnosis, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Pune, Maharashtra, India
| | - M Kumar
- Department of Radiodiagnosis, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Pune, Maharashtra, India
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Ford VJ, Applefeld WN, Wang J, Sun J, Solomon SB, Sidenko S, Feng J, Sheffield C, Klein HG, Yu ZX, Torabi-Parizi P, Danner RL, Sachdev V, Solomon MA, Chen MY, Natanson C. Cardiac Magnetic Resonance Studies in a Large Animal Model that Simulates the Cardiac Abnormalities of Human Septic Shock. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.02.05.578971. [PMID: 38903100 PMCID: PMC11188083 DOI: 10.1101/2024.02.05.578971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/22/2024]
Abstract
Background Septic shock, in humans and in our well-established animal model, is associated with increases in biventricular end diastolic volume (EDV) and decreases in ejection fraction (EF). These abnormalities occur over 2 days and reverse within 10 days. Septic non-survivors do not develop an increase in EDV. The mechanism for this cardiac dysfunction and EDV differences is unknown. Methods Purpose-bred beagles randomized to receive intrabronchial Staphylococcus aureus (n=27) or saline (n=6) were provided standard ICU care including sedation, mechanical ventilation, and fluid resuscitation to a pulmonary arterial occlusion pressure of over 10mmHg. No catecholamines were administered. Over 96h, cardiac magnetic resonance imaging, echocardiograms, and invasive hemodynamics were serially performed, and laboratory data was collected. Tissue was obtained at 66h from six septic animals. Results From 0-96h after bacterial challenge, septic animals vs. controls had significantly increased left ventricular wall edema (6%) and wall thinning with loss of mass (15%) which was more pronounced at 48h in non-survivors than survivors. On histology, edema was located predominantly in myocytes, the interstitium, and endothelial cells. Edema was associated with significantly worse biventricular function (lower EFs), ventricular-arterial coupling, and circumferential strain. In septic animals, from 0-24h, the EDV decreased from baseline and, despite cardiac filling pressures being similar, decreased significantly more in non-survivors. From 24-48h, all septic animals had increases in biventricular chamber sizes. Survivors biventricular EDVs were significantly greater than baseline and in non-survivors, where biventricular EDVs were not different from baseline. Preload, afterload, or HR differences did not explain these differential serial changes in chamber size. Conclusion Systolic and diastolic cardiac dysfunction during sepsis is associated with ventricular wall edema. Rather than differences in preload, afterload, or heart rate, structural alterations to the ventricular wall best account for the volume changes associated with outcome during sepsis. In non-survivors, from 0-24h, sepsis induces a more severe diastolic dysfunction, further decreasing chamber size. The loss of left ventricular mass with wall thinning in septic survivors may, in part explain, the EDV increases from 24-48h. However, these changes continued and even accelerated into the recovery phase consistent with a reparative process rather than ongoing injury.
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Affiliation(s)
- Verity J. Ford
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, (NIH, CC) Bethesda, Maryland 20892 USA
| | - Willard N. Applefeld
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, (NIH, CC) Bethesda, Maryland 20892 USA
- Division of Cardiology, Duke University Medical Center, Durham, NC, USA
| | - Jeffrey Wang
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, (NIH, CC) Bethesda, Maryland 20892 USA
- Emory, 100 Woodruff Circle, Atlanta, GA 30322
| | - Junfeng Sun
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, (NIH, CC) Bethesda, Maryland 20892 USA
| | - Steven B. Solomon
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, (NIH, CC) Bethesda, Maryland 20892 USA
| | - Stanislav Sidenko
- National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland 20892 USA
| | - Jing Feng
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, (NIH, CC) Bethesda, Maryland 20892 USA
| | | | - Harvey G. Klein
- Department of Transfusion Medicine, Clinical Center, National Institutes of Health, (NIH, CC) Bethesda, Maryland 20892 USA
| | - Zu-Xi Yu
- National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland 20892 USA
| | - Parizad Torabi-Parizi
- National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland 20892 USA
| | - Robert L. Danner
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, (NIH, CC) Bethesda, Maryland 20892 USA
| | - Vandana Sachdev
- National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland 20892 USA
| | - Michael A. Solomon
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, (NIH, CC) Bethesda, Maryland 20892 USA
- National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland 20892 USA
| | - Marcus Y. Chen
- National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland 20892 USA
| | - Charles Natanson
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, (NIH, CC) Bethesda, Maryland 20892 USA
- National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland 20892 USA
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Chand Negi P, Gupta A, Rana M, Asotra S, Ganju N, Merwah R, Sharma R, Kandoria A. Clinical characteristics, etiological profile, treatment and long term outcomes in patients with non ischemic systolic heart failure; Himachal Pradesh Heart failure registry (HP-HF registry). Indian Heart J 2023:S0019-4832(23)00047-0. [PMID: 37003535 DOI: 10.1016/j.ihj.2023.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 11/05/2022] [Accepted: 03/28/2023] [Indexed: 04/03/2023] Open
Abstract
BACKGROUND The data on clinical characteristics, treatment practices and out comes in patients with Non- ischemic Systolic Heart Failure (NISHF) is limited. We report clinical characteristics, treatment and outcomes in patients with NISHF. METHODS 1004 patients with NISHF were prospectively enrolled and their demographics, clinical characteristics, and treatment were recorded systematically. Patients were followed annually for a median of 3 years (1 year to 8 years) for allcause death, major adverse cardiovascular events (MACE); composite of all-cause death, hospitalization of heart failure, and or for stroke. RESULTS Patients of NISHF were middle-aged (58.8±16.2 years) population with severely depressed left ventricular ejection fraction (29.3±7.02%) and 31.1% had symptoms of advanced Heart failure. Hypertension (43.6%), obesity and or overweight (28.0%), Diabetes (15.0%), and valvular heart disease (11.8%) were the common risk factors. The guideline directed medical treatment was prescribed in more than 80% of the study cohort. Incidence of all cause death and MACE was 7 (6.8, 8.8) per 100 person years and 11(10, 13) per 100 person years respectively. The cumulative incidence of deaths and MACE was 35% (30%, 40%) and 49% (44%, 53%) at 8 years of follow-up. CONCLUSIONS Patients of NISHF were middle-aged population with severely depressed LV systolic function with significant incident morbidity and mortality. Early detection of risk factors and their risk management and enhancing the use of guideline directed treatment may improve the outcomes.
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Affiliation(s)
| | - Ashu Gupta
- Department of Cardiology, IGMC Shimla, 171001, H.P. India
| | - Meena Rana
- Department of Cardiology, IGMC Shimla, 171001, H.P. India
| | - Sanjeev Asotra
- Department of Cardiology, IGMC Shimla, 171001, H.P. India
| | - Neeraj Ganju
- Department of Cardiology, IGMC Shimla, 171001, H.P. India
| | - Rajeev Merwah
- Department of Cardiology, IGMC Shimla, 171001, H.P. India
| | - Rajesh Sharma
- Department of Cardiology, IGMC Shimla, 171001, H.P. India
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Das B, Deshpande S, Akam-Venkata J, Shakti D, Moskowitz W, Lipshultz SE. Heart Failure with Preserved Ejection Fraction in Children. Pediatr Cardiol 2023; 44:513-529. [PMID: 35978175 DOI: 10.1007/s00246-022-02960-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 06/22/2022] [Indexed: 11/27/2022]
Abstract
Diastolic dysfunction (DD) refers to abnormalities in the mechanical function of the left ventricle (LV) during diastole. Severe LVDD can cause symptoms and the signs of heart failure (HF) in the setting of normal or near normal LV systolic function and is referred to as diastolic HF or HF with preserved ejection fraction (HFpEF). Pediatric cardiologists have long speculated HFpEF in children with congenital heart disease and cardiomyopathy. However, understanding the risk factors, clinical course, and validated biomarkers predictive of the outcome of HFpEF in children is challenging due to heterogeneous etiologies and overlapping pathophysiological mechanisms. The natural history of HFpEF varies depending upon the patient's age, sex, race, geographic location, nutritional status, biochemical risk factors, underlying heart disease, and genetic-environmental interaction, among other factors. Pediatric onset HFpEF is often not the same disease as in adults. Advances in the noninvasive evaluation of the LV diastolic function by strain, and strain rate analysis with speckle-tracking echocardiography, tissue Doppler imaging, and cardiac magnetic resonance imaging have increased our understanding of the HFpEF in children. This review addresses HFpEF in children and identifies knowledge gaps in the underlying etiologies, pathogenesis, diagnosis, and management, especially compared to adults with HFpEF.
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Affiliation(s)
- Bibhuti Das
- Department of Pediatrics, Division of Cardiology, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS, 39216, USA.
| | - Shriprasad Deshpande
- Department of Pediatrics, Children's National Hospital, The George Washington University, Washington, DC, USA
| | - Jyothsna Akam-Venkata
- Department of Pediatrics, Division of Cardiology, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS, 39216, USA
| | - Divya Shakti
- Department of Pediatrics, Division of Cardiology, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS, 39216, USA
| | - William Moskowitz
- Department of Pediatrics, Division of Cardiology, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS, 39216, USA
| | - Steven E Lipshultz
- Department of Pediatrics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Oishei Children's Hospital, Buffalo, NY, 14203, USA
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Ohte N, Ishizu T, Izumi C, Itoh H, Iwanaga S, Okura H, Otsuji Y, Sakata Y, Shibata T, Shinke T, Seo Y, Daimon M, Takeuchi M, Tanabe K, Nakatani S, Nii M, Nishigami K, Hozumi T, Yasukochi S, Yamada H, Yamamoto K, Izumo M, Inoue K, Iwano H, Okada A, Kataoka A, Kaji S, Kusunose K, Goda A, Takeda Y, Tanaka H, Dohi K, Hamaguchi H, Fukuta H, Yamada S, Watanabe N, Akaishi M, Akasaka T, Kimura T, Kosuge M, Masuyama T. JCS 2021 Guideline on the Clinical Application of Echocardiography. Circ J 2022; 86:2045-2119. [DOI: 10.1253/circj.cj-22-0026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Nobuyuki Ohte
- Department of Cardiology, Nagoya City University Graduate School of Medical Sciences
| | | | - Chisato Izumi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Hiroshi Itoh
- Department of Cardiovascular Medicine, Okayama University Faculty of Medicine, Dentistry and Pharmaceutical Science
| | - Shiro Iwanaga
- Department of Cardiology, Saitama Medical University International Medical Center
| | - Hiroyuki Okura
- Department of Cardiology, Gifu University Graduate School of Medicine
| | | | - Yasushi Sakata
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine
| | - Toshihiko Shibata
- Department of Cardiovascular Surgery, Osaka City University Graduate School of Medicine
| | - Toshiro Shinke
- Division of Cardiology, Department of Medicine, Showa University School of Medicine
| | - Yoshihiro Seo
- Department of Cardiology, Nagoya City University Graduate School of Medical Sciences
| | - Masao Daimon
- The Department of Clinical Laboratory, The University of Tokyo Hospital
| | - Masaaki Takeuchi
- Department of Laboratory and Transfusion Medicine, Hospital of University of Occupational and Environmental Health
| | - Kazuaki Tanabe
- The Fourth Department of Internal Medicine, Shimane University Faculty of Medicine
| | | | - Masaki Nii
- Department of Cardiology, Shizuoka Children's Hospital
| | - Kazuhiro Nishigami
- Division of Cardiovascular Medicine, Miyuki Hospital LTAC Heart Failure Center
| | - Takeshi Hozumi
- Department of Cardiovascular Medicine, Wakayama Medical University
| | - Satoshi Yasukochi
- Department of Pediatric Cardiology, Heart Center, Nagano Children’s Hospital
| | - Hirotsugu Yamada
- Department of Community Medicine for Cardiology, Tokushima University Graduate School of Biomedical Sciences
| | - Kazuhiro Yamamoto
- Department of Cardiovascular Medicine and Endocrinology and Metabolism, Faculty of Medicine, Tottori University
| | - Masaki Izumo
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine
| | - Katsuji Inoue
- Department of Cardiology, Pulmonology, Hypertension & Nephrology, Ehime University Graduate School of Medicine
| | | | - Atsushi Okada
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | | | - Shuichiro Kaji
- Department of Cardiovascular Medicine, Kansai Electric Power Hospital
| | - Kenya Kusunose
- Department of Cardiovascular Medicine, Tokushima University Hospital
| | - Akiko Goda
- Department of Cardiovascular and Renal Medicine, Hyogo College of Medicine
| | - Yasuharu Takeda
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine
| | - Hidekazu Tanaka
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine
| | - Kaoru Dohi
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine
| | | | - Hidekatsu Fukuta
- Core Laboratory, Nagoya City University Graduate School of Medical Sciences
| | - Satoshi Yamada
- Department of Cardiology, Tokyo Medical University Hachioji Medical Center
| | - Nozomi Watanabe
- Department of Cardiology, Miyazaki Medical Association Hospital Cardiovascular Center
| | | | - Takashi Akasaka
- Department of Cardiovascular Medicine, Wakayama Medical University
| | - Takeshi Kimura
- Department of Cardiology, Kyoto University Graduate School of Medicine
| | - Masami Kosuge
- Division of Cardiology, Yokohama City University Medical Center
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Das BB. Therapeutic Approaches in Heart Failure with Preserved Ejection Fraction (HFpEF) in Children: Present and Future. Paediatr Drugs 2022; 24:235-246. [PMID: 35501560 DOI: 10.1007/s40272-022-00508-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/07/2022] [Indexed: 12/29/2022]
Abstract
For a long time, pediatric heart failure (HF) with preserved systolic function (HFpEF) has been noted in patients with cardiomyopathies and congenital heart disease. HFpEF is infrequently reported in children and instead of using the HFpEF terminology the HF symptoms are attributed to diastolic dysfunction. Identifying HFpEF in children is challenging because of heterogeneous etiologies and unknown pathophysiological mechanisms. Advances in echocardiography and cardiac magnetic resonance imaging techniques have further increased our understanding of HFpEF in children. However, the literature does not describe the incidence, etiology, clinical features, and treatment of HFpEF in children. At present, treatment of HFpEF in children is extrapolated from clinical trials in adults. There are significant differences between pediatric and adult HF with reduced ejection fraction, supported by a lack of adequate response to adult HF therapies. Evidence-based clinical trials in children are still not available because of the difficulty of conducting trials with a limited number of pediatric patients with HF. The treatment of HFpEF in children is based upon the clinician's experience, and the majority of children receive off-level medications. There are significant differences between pediatric and adult HFpEF pharmacotherapies in many areas, including side-effect profiles, underlying pathophysiologies, the β-receptor physiology, and pharmacokinetics and pharmacodynamics. This review describes the present and future treatments for children with HFpEF compared with adults. This review also highlights the need to urgently test new therapies in children with HFpEF to demonstrate the safety and efficacy of drugs and devices with proven benefits in adults.
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Affiliation(s)
- Bibhuti B Das
- Department of Pediatrics, Division of Cardiology, University of Mississippi Medical Center, 2500 N State St., Jackson, MS, 39216, USA.
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8
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Chen HY, Lin CS, Fang WH, Lee CC, Ho CL, Wang CH, Lin C. Artificial Intelligence-Enabled Electrocardiogram Predicted Left Ventricle Diameter as an Independent Risk Factor of Long-Term Cardiovascular Outcome in Patients With Normal Ejection Fraction. Front Med (Lausanne) 2022; 9:870523. [PMID: 35479951 PMCID: PMC9035739 DOI: 10.3389/fmed.2022.870523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 03/10/2022] [Indexed: 11/13/2022] Open
Abstract
Background Heart failure (HF) is a global disease with increasing prevalence in an aging society. However, the survival rate is poor despite the patient receiving standard treatment. Early identification of patients with a high risk of HF is important but challenging. Left ventricular end-diastolic diameter (LV-D) increase was an independent risk factor of HF and adverse cardiovascular (CV) outcomes. In this study, we aimed to develop an artificial intelligence (AI) enabled electrocardiogram (ECG) system to detect LV-D increase early. Objective We developed a deep learning model (DLM) to predict left ventricular end-diastolic and end-systolic diameter (LV-D and LV-S) with internal and external validations and investigated the relationship between ECG-LV-D and echocardiographic LV-D and explored the contributions of ECG-LV-D on future CV outcomes. Methods Electrocardiograms and corresponding echocardiography data within 7 days were collected and paired for DLM training with 99,692 ECGs in the development set and 20,197 ECGs in the tuning set. The other 7,551 and 11,644 ECGs were collected from two different hospitals to validate the DLM performance in internal and external validation sets. We analyzed the association and prediction ability of ECG-LVD for CV outcomes, including left ventricular (LV) dysfunction, CV mortality, acute myocardial infarction (AMI), and coronary artery disease (CAD). Results The mean absolute errors (MAE) of ECG-LV-D were 5.25/5.29, and the area under the receiver operating characteristic (ROC) curves (AUCs) were 0.8297/0.8072 and 0.9295/0.9148 for the detection of mild (56 ≦ LV-D < 65 mm) and severe (LV-D ≧ 65 mm) LV-D dilation in internal/external validation sets, respectively. Patients with normal ejection fraction (EF) who were identified as high ECHO-LV-D had the higher hazard ratios (HRs) of developing new onset LV dysfunction [HR: 2.34, 95% conference interval (CI): 1.78–3.08], CV mortality (HR 2.30, 95% CI 1.05–5.05), new-onset AMI (HR 2.12, 95% CI 1.36–3.29), and CAD (HR 1.59, 95% CI 1.26–2.00) in the internal validation set. In addition, the ECG-LV-D presents a 1.88-fold risk (95% CI 1.47–2.39) on new-onset LV dysfunction in the external validation set. Conclusion The ECG-LV-D not only identifies high-risk patients with normal EF but also serves as an independent risk factor of long-term CV outcomes.
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Affiliation(s)
- Hung-Yi Chen
- Department of Internal Medicine, National Defense Medical Center, Tri-Service General Hospital, Taipei, Taiwan
| | - Chin-Sheng Lin
- Division of Cardiology, Department of Internal Medicine, National Defense Medical Center, Tri-Service General Hospital, Taipei, Taiwan
| | - Wen-Hui Fang
- Department of Family and Community Medicine, National Defense Medical Center, Tri-Service General Hospital, Taipei, Taiwan
- Department of Internal Medicine, National Defense Medical Center, Tri-Service General Hospital, Taipei, Taiwan
- Artificial Intelligence of Things Center, National Defense Medical Center, Tri-Service General Hospital, Taipei, Taiwan
| | - Chia-Cheng Lee
- Medical Informatics Office, National Defense Medical Center, Tri-Service General Hospital, Taipei, Taiwan
- Division of Colorectal Surgery, Department of Surgery, National Defense Medical Center, Tri-Service General Hospital, Taipei, Taiwan
| | - Ching-Liang Ho
- Division of Hematology and Oncology, Department of Internal Medicine, National Defense Medical Center, Tri-Service General Hospital, Taipei, Taiwan
| | - Chih-Hung Wang
- Department of Otolaryngology-Head and Neck Surgery, National Defense Medical Center, Tri-Service General Hospital, Taipei, Taiwan
- National Defense Medical Center, Graduate Institute of Medical Sciences, Taipei, Taiwan
| | - Chin Lin
- Artificial Intelligence of Things Center, National Defense Medical Center, Tri-Service General Hospital, Taipei, Taiwan
- Medical Technology Education Center, National Defense Medical Center, School of Medicine, Taipei, Taiwan
- *Correspondence: Chin Lin,
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Asher C, Puyol-Antón E, Rizvi M, Ruijsink B, Chiribiri A, Razavi R, Carr-White G. The Role of AI in Characterizing the DCM Phenotype. Front Cardiovasc Med 2021; 8:787614. [PMID: 34993240 PMCID: PMC8724536 DOI: 10.3389/fcvm.2021.787614] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 12/02/2021] [Indexed: 12/13/2022] Open
Abstract
Dilated Cardiomyopathy is conventionally defined by left ventricular dilatation and dysfunction in the absence of coronary disease. Emerging evidence suggests many patients remain vulnerable to major adverse outcomes despite clear therapeutic success of modern evidence-based heart failure therapy. In this era of personalized medical care, the conventional assessment of left ventricular ejection fraction falls short in fully predicting evolution and risk of outcomes in this heterogenous group of heart muscle disease, as such, a more refined means of phenotyping this disease appears essential. Cardiac MRI (CMR) is well-placed in this respect, not only for its diagnostic utility, but the wealth of information captured in global and regional function assessment with the addition of unique tissue characterization across different disease states and patient cohorts. Advanced tools are needed to leverage these sensitive metrics and integrate with clinical, genetic and biochemical information for personalized, and more clinically useful characterization of the dilated cardiomyopathy phenotype. Recent advances in artificial intelligence offers the unique opportunity to impact clinical decision making through enhanced precision image-analysis tasks, multi-source extraction of relevant features and seamless integration to enhance understanding, improve diagnosis, and subsequently clinical outcomes. Focusing particularly on deep learning, a subfield of artificial intelligence, that has garnered significant interest in the imaging community, this paper reviews the main developments that could offer more robust disease characterization and risk stratification in the Dilated Cardiomyopathy phenotype. Given its promising utility in the non-invasive assessment of cardiac diseases, we firstly highlight the key applications in CMR, set to enable comprehensive quantitative measures of function beyond the standard of care assessment. Concurrently, we revisit the added value of tissue characterization techniques for risk stratification, showcasing the deep learning platforms that overcome limitations in current clinical workflows and discuss how they could be utilized to better differentiate at-risk subgroups of this phenotype. The final section of this paper is dedicated to the allied clinical applications to imaging, that incorporate artificial intelligence and have harnessed the comprehensive abundance of data from genetics and relevant clinical variables to facilitate better classification and enable enhanced risk prediction for relevant outcomes.
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Affiliation(s)
- Clint Asher
- Department of Cardiovascular Imaging, School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
- Department of Cardiology, Guys and St Thomas' NHS Trust, London, United Kingdom
| | - Esther Puyol-Antón
- Department of Cardiovascular Imaging, School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - Maleeha Rizvi
- Department of Cardiovascular Imaging, School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
- Department of Cardiology, Guys and St Thomas' NHS Trust, London, United Kingdom
| | - Bram Ruijsink
- Department of Cardiovascular Imaging, School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
- Department of Cardiology, Guys and St Thomas' NHS Trust, London, United Kingdom
- Division of Heart and Lungs, Department of Cardiology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Amedeo Chiribiri
- Department of Cardiovascular Imaging, School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
- Department of Cardiology, Guys and St Thomas' NHS Trust, London, United Kingdom
| | - Reza Razavi
- Department of Cardiovascular Imaging, School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
- Department of Cardiology, Guys and St Thomas' NHS Trust, London, United Kingdom
| | - Gerry Carr-White
- Department of Cardiovascular Imaging, School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
- Department of Cardiology, Guys and St Thomas' NHS Trust, London, United Kingdom
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Caiati C, Argentiero A, Forleo C, Favale S, Lepera ME. Predictors of Exercise Capacity in Dilated Cardiomyopathy with Focus on Pulmonary Venous Flow Recorded with Transesophageal Eco-Doppler. J Clin Med 2021; 10:5954. [PMID: 34945249 PMCID: PMC8706207 DOI: 10.3390/jcm10245954] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 10/18/2021] [Accepted: 12/14/2021] [Indexed: 12/29/2022] Open
Abstract
The aim of this study was to clarify the relative contribution of elevated left ventricle (LV) filling pressure (FP) estimated by pulmonary venous (PV) and mitral flow, transesophageal Doppler recording (TEE), and other extracardiac factors like obesity and renal insufficiency (KI) to exercise capacity (ExC) evaluated by cardiopulmonary exercise testing (CPX) in patients with dilated cardiomyopathy (DCM). During the CPX test, 119 patients (pts) with DCM underwent both peak VO2 consumption and then TEE with color-guided pulsed-wave Doppler recording of PVF and transmitral flow. In 78 patients (65%), peak VO2 was normal or mildly reduced (>14 mL/kg/min) (group 1) while it was markedly reduced (≤14 mL/kg/min) in 41 (group 2). In univariate analysis, systolic fraction (S Fract), a predictor of elevated pre-a LV diastolic FP, appeared to be the best diastolic parameter predicting a significantly reduced peak VO2. Logistic regression analysis identified five parameters yielding a unique, statistically significant contribution in predicting reduced ExC: creatinine clearance < 52 mL/min (odds ratio (OR) = 7.4, p = 0.007); female gender (OR = 7.1, p = 0.004); BMI > 28 (OR = 5.8, p = 0.029), age > 62 years (OR = 5.5, p = 0.03), S Fract < 59% (OR = 4.9, p = 0.02). Conclusion: KI was the strongest predictor of reduced ExC. The other modifiable factors were obesity and severe LV diastolic dysfunction expressed by blunted systolic venous flow. Contrarily, LV ejection fraction was not predictive, confirming other previous studies. This has important clinical implications.
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Affiliation(s)
- Carlo Caiati
- Unit of Cardiovascular Diseases, Department of Emergency and Organ Transplantation, University of Bari, 70121 Bari, Italy; (A.A.); (C.F.); (S.F.); (M.E.L.)
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11
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Miller R, Kerfoot E, Mauger C, Ismail TF, Young AA, Nordsletten DA. An Implementation of Patient-Specific Biventricular Mechanics Simulations With a Deep Learning and Computational Pipeline. Front Physiol 2021; 12:716597. [PMID: 34603077 PMCID: PMC8481785 DOI: 10.3389/fphys.2021.716597] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 08/06/2021] [Indexed: 02/04/2023] Open
Abstract
Parameterised patient-specific models of the heart enable quantitative analysis of cardiac function as well as estimation of regional stress and intrinsic tissue stiffness. However, the development of personalised models and subsequent simulations have often required lengthy manual setup, from image labelling through to generating the finite element model and assigning boundary conditions. Recently, rapid patient-specific finite element modelling has been made possible through the use of machine learning techniques. In this paper, utilising multiple neural networks for image labelling and detection of valve landmarks, together with streamlined data integration, a pipeline for generating patient-specific biventricular models is applied to clinically-acquired data from a diverse cohort of individuals, including hypertrophic and dilated cardiomyopathy patients and healthy volunteers. Valve motion from tracked landmarks as well as cavity volumes measured from labelled images are used to drive realistic motion and estimate passive tissue stiffness values. The neural networks are shown to accurately label cardiac regions and features for these diverse morphologies. Furthermore, differences in global intrinsic parameters, such as tissue anisotropy and normalised active tension, between groups illustrate respective underlying changes in tissue composition and/or structure as a result of pathology. This study shows the successful application of a generic pipeline for biventricular modelling, incorporating artificial intelligence solutions, within a diverse cohort.
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Affiliation(s)
- Renee Miller
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - Eric Kerfoot
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - Charlène Mauger
- Auckland MR Research Group, University of Auckland, Auckland, New Zealand
| | - Tevfik F. Ismail
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - Alistair A. Young
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
- Auckland MR Research Group, University of Auckland, Auckland, New Zealand
| | - David A. Nordsletten
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
- Department of Biomedical Engineering and Cardiac Surgery, University of Michigan, Ann Arbor, MI, United States
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12
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Beneficial Effects of Ivabradine on Post-Resuscitation Myocardial Dysfunction in a Porcine Model of Cardiac Arrest. Shock 2021; 53:630-636. [PMID: 31274829 PMCID: PMC7161719 DOI: 10.1097/shk.0000000000001403] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Background: Ivabradine selectively inhibits the If current, reducing the heart rate and protecting against myocardial ischemia/reperfusion injury. We investigated the effects of ivabradine on post-resuscitation myocardial function in a porcine model of cardiopulmonary resuscitation. Methods and Results: Ventricular fibrillation was induced and untreated for 8 min while defibrillation was attempted after 6 min of cardiopulmonary resuscitation in anesthetized domestic swine. Then the animals were randomized into ivabradine and placebo groups (n = 5 each). Ivabradine and saline were administered at the same volume 5 min after Return of Spontaneous Circulation, followed by continuous intravenous infusion at 0.5 mg/kg for 480 min. Hemodynamic parameters were continuously recorded. Myocardial function was assessed by echocardiography at baseline and at 60, 120, 240, 480 min and 24 h after resuscitation. The serum levels of N-terminal pro-brain natriuretic peptide (NT-proBNP) and cardiac troponin I (cTnI) were measured by commercial enzyme-linked immunosorbent assay kits. Animals were killed 24 h after resuscitation, and all myocardial tissue was removed for histopathological analysis. The heart rate was significantly reduced from 1 h after resuscitation in the ivabradine group (all P < 0.05). The post-resuscitation mitral E/A and E/e′ velocity ratios and left ventricular ejection fraction were significantly better in the ivabradine than placebo group (P < 0.05). The serum levels of myocardial injury biomarkers (NT-proBNP, cTnI) and the myocardial biopsy scores were significantly lower in the ivabradine than placebo group (P < 0.05). Neurological deficit scores were lower in the IVA group at PR 24 h (P < 0.05). Conclusions: Ivabradine improved post-resuscitation myocardial dysfunction, myocardial injury, and post-resuscitation cerebral function, and also slowed the heart rate in this porcine model.
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Zairi I, Bejar MA, Ben Mrad I, Mzoughi K, Kraiem S. Prognostic value of atrial strain in non-ischemic dilated cardiomyopathy. LA TUNISIE MEDICALE 2021; 99:644-651. [PMID: 35244917 PMCID: PMC8796001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Left atrial function in non-ischemic dilated cardiomyopathy (DCM) has long been underestimated when studying the ultrasound parameters of DCM. Currently, several ultrasound parameters of left atrial function have been proposed as markers to detect patients at risk. AIM To evaluate the left atriumfunctionwith 2D speckle tracking echocardiography and itsprognostic value in the dilatedcardiomyopathy. METHODS The study prospectively recruited 40 patients with dilated cardiomyopathy, between January and June 2014, followed up at the cardiology department of Habib Thameur Hospital of Tunis. An echocardiogram was performed for all patients at the beginning of the study. After a 6-month follow-up, the primary endpoint was the occurrence of a major cardiovascular event. The patients were divided into a first group without cardiovascular events (group 1) and a second group with a cardiovascular event (group 2). RESULTS During the follow-up, 25 patients presented a major cardiovascular event (8 ventricular arrhythmias and 17 hospitalizations for acute decompensated heart failure). There were no significant differences between the two groups regarding cardiovascular risk factors, symptoms and blood testing values.In addition, regarding results obtained from speckle tracking echocardiography, atrial peak-systolic longitudinal strain (PALS) and time to peak atrial longitudinal strain (TPALS) values were observed to be significantly lower in group 2 ( 34.6% in group 1 vs 28.4% in group 2, p=0.000; and 344.6ms in group 1 vs 349.8 ms in group 2, p=0.016 respectively). CONCLUSION The analysis of the LA speckle tracking in the dilatedcardiomyopathymay help cardiologistto identify patients at high cardiovascular risk and thus improve their management and follow-up.
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Affiliation(s)
- Ihsen Zairi
- 1. Service de cardiologie Hôpital Habib Thameur, Faculté de médecine de Tunis
| | - Mohamed Amine Bejar
- 1. Service de cardiologie Hôpital Habib Thameur, Faculté de médecine de Tunis
| | - Imtinene Ben Mrad
- 1. Service de cardiologie Hôpital Habib Thameur, Faculté de médecine de Tunis
| | - Khadija Mzoughi
- 1. Service de cardiologie Hôpital Habib Thameur, Faculté de médecine de Tunis
| | - Sondos Kraiem
- 1. Service de cardiologie Hôpital Habib Thameur, Faculté de médecine de Tunis
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14
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Nguyen TV, Tran Vu MT, Do TNP, Tran THN, Do TH, Nguyen TMH, Tran Huynh BN, Le LA, Nguyen Pham NT, Nguyen TDA, Nguyen TMN, Le NHP, Pham Nguyen V, Ho Huynh TD. Genetic Determinants and Genotype-Phenotype Correlations in Vietnamese Patients With Dilated Cardiomyopathy. Circ J 2021; 85:1469-1478. [PMID: 34011823 DOI: 10.1253/circj.cj-21-0077] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Dilated cardiomyopathy (DCM) is an important cause of heart failure and cardiac transplantation. This study determined the prevalence of DCM-associated genes and evaluated the genotype-phenotype correlation in Vietnamese patients.Methods and Results:This study analyzed 58 genes from 230 patients. The study cohort consisted of 64.3% men; age at diagnosis 47.9±13.7 years; familial (10.9%) and sporadic DCM (82.2%). The diagnostic yield was 23.5%, 44.0% in familial and 19.6% in sporadic DCM.TTNtruncating variants (TTNtv) were predominant (46.4%), followed byTPM1,DSP,LMNA,MYBPC3,MYH6,MYH7,DES,TNNT2,ACTC1,ACTN2,BAG3,DMD,FKTN,PLN,TBX5,RBM20,TCAP(2-6%). Familial DCM, genotype-positive andTTNtv-positive patients were younger than those with genotype-negative and sporadic DCM. Genotype-positive patients displayed a decreased systolic blood pressure and left ventricular wall thickness compared to genotype-negative patients. Genotype-positive patients, particularly those withTTNtv, had a family history of DCM, higher left atrial volume index and body mass index, and lower right ventricle-fractional area change than genotype-negative patients. Genotype-positive patients reached the combined outcomes more frequently and at a younger age than genotype-negative patients. Major cardiac events occurred more frequently in patients positive with genes other thanTTNtv. CONCLUSIONS The study findings provided an overview of Vietnamese DCM patients' genetic profile and suggested that management of environmental factors may be beneficial for DCM patients.
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Affiliation(s)
- Thuy Vy Nguyen
- Department of Genetics, Faculty of Biology and Biotechnology, University of Science, VNUHCM [Vietnam National University, Ho Chi Minh City]
| | | | | | | | | | | | | | | | | | | | - Thi My Nuong Nguyen
- Department of Genetics, Faculty of Biology and Biotechnology, University of Science, VNUHCM [Vietnam National University, Ho Chi Minh City]
| | - Ngoc Hong Phuong Le
- Research Center for Genetics and Reproductive Health, School of Medicine, VNUHCM [Vietnam National University, Ho Chi Minh City]
| | | | - Thuy Duong Ho Huynh
- Department of Genetics, Faculty of Biology and Biotechnology, University of Science, VNUHCM [Vietnam National University, Ho Chi Minh City].,Research Center for Genetics and Reproductive Health, School of Medicine, VNUHCM [Vietnam National University, Ho Chi Minh City].,KTEST Science Company
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15
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Houard L, Militaru S, Tanaka K, Pasquet A, Vancraeynest D, Vanoverschelde JL, Pouleur AC, Gerber BL. Test–retest reliability of left and right ventricular systolic function by new and conventional echocardiographic and cardiac magnetic resonance parameters. Eur Heart J Cardiovasc Imaging 2020; 22:1157-1167. [DOI: 10.1093/ehjci/jeaa206] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 07/01/2020] [Indexed: 02/05/2023] Open
Abstract
Abstract
Aims
Reproducible evaluation of left (LV) and right ventricular (RV) function is crucial for clinical decision-making and risk stratification. We evaluated whether speckle-tracking echocardiography (STE) and cardiac magnetic resonance feature-tracking (cMR-FT) global longitudinal (GLS) and circumferential strains allow better test–retest reproducibility of LV and RV systolic function than conventional cMR and echocardiographic parameters.
Methods and results
Thirty healthy volunteers and 20 chronic heart failure patients underwent cMR and STE twice on separate days to evaluate test–retest coefficient of variation (CV), intraclass correlation coefficient (ICC) and estimated sample sizes for significant changes in LV and RV function. Among LV parameters, cMR-left ventricular ejection fraction (LVEF) had the highest reproducibility (CV = 6.7%, ICC = 0.98), significantly better than cMR-FT-GLS (CV = 15.1%, ICC = 0.84), global circumferential strains (CV = 11.5%, ICC = 0.94) and echocardiographic LVEF (CV = 11.3%, ICC = 0.93). STE-LV-GLS (CV = 8.9%, ICC = 0.94) had significantly better reproducibility than cMR-FT-LV-GLS. Among RV parameters, STE-RV-GLS (CV = 7.3%, ICC = 0.93) had significantly better CV than cMR-right ventricular ejection fraction (RVEF) (CV = 13%, ICC = 0.82). cMR-FT-RV-GLS (CV = 43%, ICC = 0.39) performed poorly with significantly lower reproducibility than all other RV parameters. Owing to their superior interstudy reproducibility, cMR-LVEF (n = 12), cMR-RVEF (n = 41), STE-LV-GLS and STE-RV-GLS (both n = 14) were the parameters allowing the lowest calculated sample sizes to detect 10% change in LV or RV systolic function.
Conclusion
STE-LV-GLS and STE-RV-GLS showed higher test–retest reliability than other echocardiographic measurements of LV and RV function. They also allowed smaller calculated sample sizes, supporting the use of STE-LV and RV-GLS for longitudinal follow-up of LV and RV function.
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Affiliation(s)
- Laura Houard
- Division of Cardiology, Department of Cardiovascular Diseases, Cliniques Universitaires St. LucPôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain (UCLouvain), Av Hippocrate 10/2806, B-1200 Woluwe St. Lambert, Brussels, Belgium
| | - Sebastian Militaru
- Division of Cardiology, Department of Cardiovascular Diseases, Cliniques Universitaires St. LucPôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain (UCLouvain), Av Hippocrate 10/2806, B-1200 Woluwe St. Lambert, Brussels, Belgium
| | - Kaoru Tanaka
- Afdeling Hart en Vaatziekten, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel (VUB), Avenue du Laerbeek 101, B-1090 Brussels, Belgium
| | - Agnès Pasquet
- Division of Cardiology, Department of Cardiovascular Diseases, Cliniques Universitaires St. LucPôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain (UCLouvain), Av Hippocrate 10/2806, B-1200 Woluwe St. Lambert, Brussels, Belgium
| | - David Vancraeynest
- Division of Cardiology, Department of Cardiovascular Diseases, Cliniques Universitaires St. LucPôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain (UCLouvain), Av Hippocrate 10/2806, B-1200 Woluwe St. Lambert, Brussels, Belgium
| | - Jean-Louis Vanoverschelde
- Division of Cardiology, Department of Cardiovascular Diseases, Cliniques Universitaires St. LucPôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain (UCLouvain), Av Hippocrate 10/2806, B-1200 Woluwe St. Lambert, Brussels, Belgium
| | - Anne-Catherine Pouleur
- Division of Cardiology, Department of Cardiovascular Diseases, Cliniques Universitaires St. LucPôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain (UCLouvain), Av Hippocrate 10/2806, B-1200 Woluwe St. Lambert, Brussels, Belgium
| | - Bernhard L Gerber
- Division of Cardiology, Department of Cardiovascular Diseases, Cliniques Universitaires St. LucPôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain (UCLouvain), Av Hippocrate 10/2806, B-1200 Woluwe St. Lambert, Brussels, Belgium
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Multiparametric Differentiation of Idiopathic Dilated Cardiomyopathy With and Without Congestive Heart Failure by Means of Cardiac and Hepatic T1-Weighted MRI Mapping. AJR Am J Roentgenol 2020; 215:79-86. [DOI: 10.2214/ajr.19.22009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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17
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Relationships between Pulmonary Hypertension Risk, Clinical Profiles, and Outcomes in Dilated Cardiomyopathy. J Clin Med 2020; 9:jcm9061660. [PMID: 32492830 PMCID: PMC7355437 DOI: 10.3390/jcm9061660] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 05/28/2020] [Accepted: 05/28/2020] [Indexed: 12/28/2022] Open
Abstract
Pulmonary hypertension (PH) in patients with heart failure (HF) contributes to a poorer prognosis. However, in those with dilated cardiomyopathy (DCM), the true prevalence and role of PH is unclear. Therefore, this study aimed to analyze the profile of DCM patients at various levels of PH risk, determined via echocardiography, and its impact on outcomes. The 502 DCM in- and out-patient records were retrospectively analyzed. Information on patient status was gathered after 45.9 ± 31.3 months. Patients were divided into 3 PH-risk groups based on results from echocardiography measurements: low (L, n = 239, 47.6%), intermediate (I, n = 153, 30.5%), and high (H, n = 110, 21.9%). Symptom duration, atrial fibrillation, ventricular tachyarrhythmia, ejection fraction, right atrial area, and moderate or severe mitral regurgitation were found to be independently associated with PH risk. During the follow-up period, 83 (16.5%) DCM patients died: 29 (12.1%) in L, 31 (20.3%) in I, and 23 (20.9%) in H. L-patients had a significantly lower risk of all-cause death (L to H: HR 0.55 (95%CI 0.32–0.98), p = 0.01), while no differences in prognosis were found between I and H. In conclusion, over one in five DCM patients had a high PH risk, and low PH risk was associated with better prognoses.
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Abstract
Dilated cardiomyopathy (DCM) is the most common form of cardiomyopathy and one of the most common causes of heart failure. It is characterized by left or biventricular dilation and a reduced systolic function. The causes are manifold and range from myocarditis to alcohol and other toxins, to rheumatological, endocrinological, and metabolic diseases. Peripartum cardiomyopathy is a special form that occurs at the end of or shortly after pregnancy. Genetic mutations can be detected in approximately 30-50% of DCM patients. Owing to the growing possibilities of genetic diagnostics, increasingly more triggering variants and hereditary mechanisms emerge. This is particularly important with regard to risk stratification for patients with variants with an increased risk of arrhythmias. Patient prognosis is determined by the occurrence of heart failure and arrhythmias. In addition to the treatment of the underlying disease or the elimination of triggering harmful toxins, therapy consists in guideline-directed heart failure treatment including drug and device therapy.
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Affiliation(s)
- A Hänselmann
- Dept. of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - C Veltmann
- Dept. of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - J Bauersachs
- Dept. of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - D Berliner
- Dept. of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
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Kim H, Kim IC, Choi SW, Chung JW, Kim JY. Clinical significance of early-diastolic tissue velocity imaging of lateral mitral annulus for prognosis of nonischemic left ventricular dysfunction. JOURNAL OF CLINICAL ULTRASOUND : JCU 2020; 48:160-167. [PMID: 31675137 DOI: 10.1002/jcu.22787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 10/08/2019] [Accepted: 10/13/2019] [Indexed: 06/10/2023]
Abstract
PURPOSE We explored the potential of tissue velocity imaging (TVI) for prognosis of nonischemic left ventricular (LV) dysfunction (LVD). METHODS We reviewed 138 nonischemic LVD patients (58 ± 14 years) who underwent both cardiac magnetic resonance (CMR) and echocardiography. Septal and lateral mitral annular TVI data were compared with late gadolinium enhancement (LGE) on CMR. During a mean follow-up of 24 months, recovery (>15%) of LV ejection fraction and clinical outcomes (cardiovascular death and heart failure hospitalization) were assessed. RESULTS LGE was commonly observed in the basal anteroseptal, inferoseptal, and inferior segments, but infrequently observed in the anterolateral segment. LGE was associated with lower early diastolic, septal (Sep-e' = 5.2 ± 2.0 vs 6.9 ± 2.0 cm/s, P = .031) and lateral (Lat-e' = 7.3 ± 3.0 vs 9.5 ± 2.0 cm/s, P < .001) TVI. The relationship between Lat-e' and anterolateral LGE (area under the curve, AUC 0.834) was much better than that between Sep-e' and inferoseptal LGE (AUC 0.699). The 60 patients with LVD reversibility revealed higher Lat-e' (9.8 ± 2.0 vs 6.7 ± 2.2 cm/s, P < .001) and lower LGE burden (7.3 ± 9.0 vs 22 ± 10%, P < .001), while Lat-e' ≤ 7.8 cm/s appeared unfavorable for 31 events patients. On multivariate analyses, Lat-e' (HR 0.79, 95% CI 0.63-0.99, P = .044) and LVD reversibility (HR 0.53, 95% CI 0.16-0.90, P = .018) were still meaningful together with LGE segments and burden. CONCLUSION Lat-e' was related with LVD reversibility and a significant predictor of clinical outcomes.
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Affiliation(s)
- Hyungseop Kim
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Medical Center, Daegu, Republic of Korea
| | - In-Cheol Kim
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Medical Center, Daegu, Republic of Korea
| | - Sang-Woong Choi
- Division of Cardiology, Department of Internal Medicine, Daegu Dongsan Hospital, Daegu, Republic of Korea
| | - Jin-Wook Chung
- Division of Cardiology, Department of Internal Medicine, Daegu Dongsan Hospital, Daegu, Republic of Korea
| | - Jin Young Kim
- Department of Radiology, Keimyung University Dongsan Medical Center, Daegu, Republic of Korea
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20
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Calò L, Capucci A, Santini L, Pecora D, Favale S, Petracci B, Molon G, Bianchi V, Cipolletta L, De Ruvo E, Ammirati F, La Greca C, Campari M, Valsecchi S, D’Onofrio A. ICD-measured heart sounds and their correlation with echocardiographic indexes of systolic and diastolic function. J Interv Card Electrophysiol 2020; 58:95-101. [DOI: 10.1007/s10840-019-00668-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 11/11/2019] [Indexed: 10/25/2022]
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Abstract
Heart failure (HF) with either reduced or preserved ejection fraction is an increasingly prevalent condition. Cardiac imaging plays a central role in trying to identify the underlying cause of the underlying systolic and diastolic dysfunction, as the imaging findings have implications for patient's management and individualised treatment. The imaging modalities used more frequently in patients with heart failure in clinical routine are echocardiography and cardiac magnetic resonance. Both techniques keep some strengths and weakness due to their spatial and temporal resolution. Notably, several features in the diagnostic algorithm of heart failure with preserved systolic function (HFpEF) may be improved by an integrated approach. This review focuses on the role of each modality in characterising cardiac anatomy, systolic and diastolic function as well as myocardial tissue characterisation in the most common phenotypes of dilated and hypertrophied hearts.
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Reichart D, Magnussen C, Zeller T, Blankenberg S. Dilated cardiomyopathy: from epidemiologic to genetic phenotypes: A translational review of current literature. J Intern Med 2019; 286:362-372. [PMID: 31132311 DOI: 10.1111/joim.12944] [Citation(s) in RCA: 93] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Dilated cardiomyopathy (DCM) is characterized by left ventricular dilatation and, consecutively, contractile dysfunction. The causes of DCM are heterogeneous. DCM often results from myocarditis, exposure to alcohol, drugs or other toxins and metabolic or endocrine disturbances. In about 35% of patients, genetic mutations can be identified that usually involve genes responsible for cytoskeletal, sarcomere and nuclear envelope proteins. Due to its heterogeneity, a detailed diagnostic work-up is necessary to identify the specific underlying cause and exclude other conditions with phenotype overlap. Patients with DCM show typical systolic heart failure symptoms, but, with progress of the disease, diastolic dysfunction is present as well. Depending on the underlying pathology, DCM patients also become apparent through arrhythmias, thromboembolic events or cardiogenic shock. Disease progression and prognosis are mostly driven by disease severity and reverse remodelling within the heart. The worst prognosis is seen in patients with lowest ejection fractions or severe diastolic dysfunction, leading to terminal heart failure with subsequent need for left ventricular assist device implantation or heart transplantation. Guideline-based heart failure medication and device therapy reduces the frequency of heart failure hospitalizations and improves survival.
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Affiliation(s)
- D Reichart
- From the, University Heart Center Hamburg, Hamburg, Germany
| | - C Magnussen
- From the, University Heart Center Hamburg, Hamburg, Germany
| | - T Zeller
- From the, University Heart Center Hamburg, Hamburg, Germany
| | - S Blankenberg
- From the, University Heart Center Hamburg, Hamburg, Germany
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23
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Benfari G, Miller WL, Antoine C, Rossi A, Lin G, Oh JK, Roger VL, Thapa P, Enriquez-Sarano M. Diastolic Determinants of Excess Mortality in Heart Failure With Reduced Ejection Fraction. JACC-HEART FAILURE 2019; 7:808-817. [DOI: 10.1016/j.jchf.2019.04.024] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Accepted: 04/29/2019] [Indexed: 01/09/2023]
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Sannino A, Smith RL, Schiattarella GG, Trimarco B, Esposito G, Grayburn PA. Survival and Cardiovascular Outcomes of Patients With Secondary Mitral Regurgitation: A Systematic Review and Meta-analysis. JAMA Cardiol 2019; 2:1130-1139. [PMID: 28877291 DOI: 10.1001/jamacardio.2017.2976] [Citation(s) in RCA: 153] [Impact Index Per Article: 30.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Importance The outcomes of patients with left ventricular (LV) dysfunction and secondary mitral regurgitation (SMR) are still controversial. Objective To clarify the role of SMR in the outcomes of patients with ischemic or idiopathic cardiomyopathies. Data Sources MEDLINE, ISI Web of Science, and Scopus databases were searched for studies published up to March 2017. Study Selection Studies reporting data on outcomes in patients with SMR were included. Duplicate publication data, studies lacking data on SMR grade and its correlation with outcomes, mixed data on SMR and primary mitral regurgitation, studies not clearly reporting the outcome of interest, and studies with fewer than 100 patients were excluded. Of the initial 3820 articles identified, 1.4% were finally included. Data Extraction and Synthesis The study met PRISMA requirements. Two of us independently screened articles for fulfillment of inclusion criteria. Main Outcomes and Measures The primary outcome, set after data collection, was the incidence of all-cause mortality in patients with and without SMR. Secondary outcomes included hospitalization for heart failure (HF), cardiac mortality, and a composite end point of death, HF hospitalization, and cardiac transplant. Results Fifty-three studies and 45 900 patients were included in the meta-analysis. The mean (SD) length of follow-up was 40.8 (22.2) months. In 26 of 36 studies reporting LV function by SMR grade, increasing SMR severity was associated with worse LV function. When SMR was categorized as present or absent, all-cause mortality was significantly higher in the patients with SMR (17 studies, 26 359 patients; risk ratio [RR],1.79; 95% CI, 1.47-2.18; P < .001, I2 = 85%); when SMR was qualitatively graded, the incidence of all-cause mortality was significantly increased in patients having any degree of SMR compared with patients not having SMR (21 studies, 21 081 patients; RR, 1.96; 95% CI, 1.67-2.31; P < .001, I2 = 74%). Finally, when SMR was quantitatively graded, it remained associated with an increased all-cause mortality rate (9 studies, 3649 patients; RR, 1.97; 95% CI, 1.71-2.27; P < .001, I2 = 0%). Moreover, SMR was associated with an increased risk of hospitalization for HF (16 studies, 10 171 patients; RR, 2.26; 95% CI, 1.92-2.67; P < .001, I2 = 41%), cardiac mortality (12 studies, 11 896 patients; RR, 2.62; 95% CI, 1.87-3.69; P < .001, I2 = 74%), and death, HF, and transplant (11 studies, 8256 patients; RR, 1.63; 95% CI, 1.33-1.99; P < .001, I2 = 78%). Conclusions and Relevance To our knowledge, this study is the first meta-analysis to date to demonstrate that SMR, even when mild, correlates with adverse outcomes in patients with ischemic or idiopathic cardiomyopathies. Because SMR is an intrinsic consequence of LV dysfunction, causality between SMR and mortality should not be implied.
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Affiliation(s)
- Anna Sannino
- Division of Cardiology, Department of Medicine, Baylor University Medical Center, Baylor Heart and Vascular Hospital, Dallas, Texas.,Currently with Division of Cardiology, Department of Medicine, Università Degli Studi di Napoli Federico II, Naples, Italy
| | - Robert L Smith
- Department of Cardiothoracic Surgery, The Heart Hospital Baylor Plano, Plano, Texas
| | - Gabriele G Schiattarella
- Currently with Division of Cardiology, Department of Medicine, Università Degli Studi di Napoli Federico II, Naples, Italy.,Division of Cardiology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Bruno Trimarco
- Division of Cardiology, Department of Medicine, Università Degli Studi di Napoli Federico II, Naples, Italy
| | - Giovanni Esposito
- Division of Cardiology, Department of Medicine, Università Degli Studi di Napoli Federico II, Naples, Italy
| | - Paul A Grayburn
- Division of Cardiology, Department of Medicine, Baylor University Medical Center, Baylor Heart and Vascular Hospital, Dallas, Texas
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25
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Abstract
Diastolic filling of the heart is a complex sequence of multiple inter-related events consisting of processes such as ventricular relaxation, erectile coronary effect, visco-elastic forces of the myocardium, ventricular interaction, myocardial stress strain relationships, pericardial restraint, passive filling, and atrial contraction. However, in order to understand diastolic filling from a clinical aspect, a simplified foundation can be used which divides the cardiac cycle into contraction, relaxation, passive filling, and filling at atrial contraction. The mitral flow velocity curves are representative of the relative driving pressure between left atrium and left ventricle and allow one to grade the progression of diastolic dysfunction which occurs in disease states. Doppler tissue imaging is necessary as a surrogate of ventricular relaxation to further determine the stages of diastolic dysfunction in patients with preserved ejection fraction. These Doppler flow velocity curves can be applied to understanding diastolic filling of the heart in patients with both reduced ejection fraction and preserved ejection fraction.
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26
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Paterick ZR, Paterick TE. Preparticipation Cardiovascular Screening of Student-Athletes with Echocardiography: Ethical, Clinical, Economic, and Legal Considerations. Curr Cardiol Rep 2019; 21:16. [PMID: 30820677 DOI: 10.1007/s11886-019-1101-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
PURPOSE OF REVIEW To identify whether the use of echocardiography is a viable approach for the screening of athletes for the prevention of sudden cardiac death when considering ethical, clinical, economic, and legal issues. RECENT FINDINGS Ethical musings, echocardiographic findings, economic calculations, and legal analysis suggest that echocardiographic screening may reduce sudden cardiac death on the athletic field. Ethical, clinical, economic, and legal considerations suggest echocardiographic screening is a viable option to meet the societal goal to prevent athletic field sudden death.
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27
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Agiba N, Mohammed L, Aly A. Effect of left atrial functions upon the functional capacity in patients with systolic heart failure. AL-AZHAR ASSIUT MEDICAL JOURNAL 2019. [DOI: 10.4103/azmj.azmj_81_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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28
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Arenja N, Fritz T, Andre F, Riffel JH, Aus dem Siepen F, Ochs M, Paffhausen J, Hegenbart U, Schönland S, Müller-Hennessen M, Giannitsis E, Kristen AV, Katus HA, Friedrich MG, Buss SJ. Myocardial contraction fraction derived from cardiovascular magnetic resonance cine images-reference values and performance in patients with heart failure and left ventricular hypertrophy. Eur Heart J Cardiovasc Imaging 2018; 18:1414-1422. [PMID: 28165128 DOI: 10.1093/ehjci/jew324] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2016] [Accepted: 12/19/2016] [Indexed: 11/13/2022] Open
Abstract
Aims Left ventricular hypertrophy (LVH) has strong prognostic implications and is associated with heart failure. Recently, myocardial contraction fraction (MCF) was identified as a useful marker for specifically identifying cardiac amyloidosis (CA). The purpose of this study was to evaluate the diagnostic accuracy of MCF for the discrimination of different forms of LVH. Methods and results We analysed cardiovascular magnetic resonance (CMR) scans of patients with CA (n = 132), hypertrophic cardiomyopathy (HCM, n = 60), hypertensive heart disease (HHD, n = 38) and in 100 age- and gender-matched healthy controls. MCF was calculated by dividing left ventricular (LV) stroke volume by LV myocardial volume. The diagnostic accuracy of MCF was compared to that of LV ejection fraction (EF) and the mass index (MI). Compared with controls (136.3 ± 24.4%, P < 0.05), mean values for MCF were significantly reduced in LVH (HHD:92.6 ± 20%, HCM:80 ± 20.3%, transthyretin CA:74.9 ± 32.2% and light-chain (AL) CA:50.5 ± 21.4%). MCF performed better than LVEF (AUC = 0.96 vs. AUC = 0.6, P < 0.001) and was comparable to LVMI (AUC = 0.95, P = 0.4) in discriminating LVH from controls. There was a significant yet weak correlation between MCF and LVEF (r = 0.43, P < 0.0001). MCF outperformed LVEF and LVMI in discriminating between different etiologies of LVH and between AL and other forms of LVH (AUC = 0.84, P < 0.0001). Moreover, cut-off values for MCF <50% and LVEF <60% allowed to identify patients with high probability for CA. Conclusion In patients with heart failure MCF discriminates CA from other forms of LVH. As it can easily be derived from standard, non-contrast cine images, it may be a very useful marker in the diagnostic workup of patients with LVH.
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Affiliation(s)
- Nisha Arenja
- Department of Cardiology, Angiology and Pneumology, University of Heidelberg, Im Neuenheimer Feld 410, Heidelberg 69120, Germany.,Department of Cardiology, Solothurner Spitäler AG, Kantonsspital Olten, Switzerland
| | - Thomas Fritz
- Department of Cardiology, Angiology and Pneumology, University of Heidelberg, Im Neuenheimer Feld 410, Heidelberg 69120, Germany
| | - Florian Andre
- Department of Cardiology, Angiology and Pneumology, University of Heidelberg, Im Neuenheimer Feld 410, Heidelberg 69120, Germany
| | - Johannes H Riffel
- Department of Cardiology, Angiology and Pneumology, University of Heidelberg, Im Neuenheimer Feld 410, Heidelberg 69120, Germany
| | - Fabian Aus dem Siepen
- Department of Cardiology, Angiology and Pneumology, University of Heidelberg, Im Neuenheimer Feld 410, Heidelberg 69120, Germany
| | - Marco Ochs
- Department of Cardiology, Angiology and Pneumology, University of Heidelberg, Im Neuenheimer Feld 410, Heidelberg 69120, Germany
| | - Judith Paffhausen
- Department of Cardiology, Angiology and Pneumology, University of Heidelberg, Im Neuenheimer Feld 410, Heidelberg 69120, Germany
| | - Ute Hegenbart
- Department of Hematology, University of Heidelberg, Im Neuenheimer Feld 410, Heidelberg 69120, Germany
| | - Stefan Schönland
- Department of Hematology, University of Heidelberg, Im Neuenheimer Feld 410, Heidelberg 69120, Germany
| | - Matthias Müller-Hennessen
- Department of Cardiology, Angiology and Pneumology, University of Heidelberg, Im Neuenheimer Feld 410, Heidelberg 69120, Germany
| | - Evangelos Giannitsis
- Department of Cardiology, Angiology and Pneumology, University of Heidelberg, Im Neuenheimer Feld 410, Heidelberg 69120, Germany
| | - Arnt V Kristen
- Department of Cardiology, Angiology and Pneumology, University of Heidelberg, Im Neuenheimer Feld 410, Heidelberg 69120, Germany
| | - Hugo A Katus
- Department of Cardiology, Angiology and Pneumology, University of Heidelberg, Im Neuenheimer Feld 410, Heidelberg 69120, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Heidelberg, Germany
| | - Matthias G Friedrich
- Department of Cardiology, Angiology and Pneumology, University of Heidelberg, Im Neuenheimer Feld 410, Heidelberg 69120, Germany
| | - Sebastian J Buss
- Department of Cardiology, Angiology and Pneumology, University of Heidelberg, Im Neuenheimer Feld 410, Heidelberg 69120, Germany.,Das Radiologische Zentrum - Radiology Center Sinsheim-Eberbach-Erbach-Walldorf-Heidelberg, Germany
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Matsuura H, Yamada A, Sugimoto K, Sugimoto K, Iwase M, Ishikawa T, Ishii J, Ozaki Y. Clinical implication of LAVI over A' ratio in patients with acute coronary syndrome. HEART ASIA 2018; 10:e011038. [PMID: 30018662 DOI: 10.1136/heartasia-2018-011038] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 06/14/2018] [Indexed: 11/04/2022]
Abstract
Purpose The ratio of the left atrial volume index (LAVI) and late diastolic mitral annular velocity (A') is a useful echocardiographic index for identifying advanced left ventricular (LV) diastolic dysfunction in patients with dyspnoea. We investigated the clinical implications and prognostic value of the aforementioned ratio (LAVI/A') in patients with ST elevation (STE) or non-STE (NSTE) acute coronary syndrome (ACS). Methods We studied 212 patients with ACS. All patients underwent electrocardiography, echocardiography and measurement of plasma B-type natriuretic peptide (BNP) level on admission. The study endpoints were hospitalisation and mortality because of heart failure (HF). Results There was a significant, moderate positive correlation between LAVI/A' and natural logarithm (Ln) BNP level among the participants (r=0.48, p<0.0001). During a mean follow-up of 17 months, eight patients died and nine patients were hospitalised because of HF. The receiver operating characteristics curve indicated that LAVI/A'≥3.0 predicted these events (log-rank, p=0.0021). A significant and moderate positive correlation existed between LAVI/A' and Ln BNP level in the NSTE-ACS group (n=128; r=0.58, p<0.0001). However, the correlation between LAVI/A' and Ln BNP level was weaker in the STE-ACS group (n=84; r=0.33, p=0.0017). Conclusion LAVI/A' was related to plasma BNP levels in patients with ACS, particularly in those with NSTE-ACS. This index was useful for predicting cardiac events in patients with ACS.
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Affiliation(s)
- Hideaki Matsuura
- Clinical Laboratory, Fujita Health University Hospital, Toyoake, Japan
| | - Akira Yamada
- Department of Cardiology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Kunihiko Sugimoto
- Clinical Laboratory, Fujita Health University Hospital, Toyoake, Japan
| | - Keiko Sugimoto
- Department of Clinical Physiology, Fujita Health University School of Health Sciences, Toyoake, Japan
| | - Masatsugu Iwase
- Department of Cardiology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Takashi Ishikawa
- Clinical Laboratory, Fujita Health University Hospital, Toyoake, Japan
| | - Junichi Ishii
- Clinical Laboratory, Fujita Health University Hospital, Toyoake, Japan
| | - Yukio Ozaki
- Department of Cardiology, Fujita Health University School of Medicine, Toyoake, Japan
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30
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Determinants of Normal Left Atrial Volume in Heart Failure with Moderate-to-Severely Reduced Ejection Fraction. Cardiol Res Pract 2018; 2018:7512758. [PMID: 29850229 PMCID: PMC5937574 DOI: 10.1155/2018/7512758] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Revised: 02/16/2018] [Accepted: 03/04/2018] [Indexed: 01/08/2023] Open
Abstract
Background Indexed left atrial volume (LAVi) is a robust predictor of adverse cardiovascular events. A minority of patients with moderate-to-severe left ventricular (LV) systolic dysfunction maintain normal LAVi. We followed clinical and echocardiographic parameters for at least 6 months to understand how this population is different from patients with similar systolic dysfunction and dilated left atria. Methods and Results We searched our electronic medical records for "normal" (n=817) and "severely dilated" (n=1094) LA size and LV ejection fraction (EF) ≤ 35% on echocardiogram reports from 2009 to 2015. We analyzed 115 subjects for LAVi, biplane EF, and diastolic parameters over 2 echocardiograms at least 6 months apart. Younger age, white race, being on an angiotensin-converting enzyme inhibitor, smaller end-diastolic LV volume (LVEDV), and longer deceleration time (DT) were associated with having a normal LAVi. The receiver-operating characteristic curve has an area under the curve of 0.95 (p < 0.0001) for this model. An increase in LVESVi and early mitral flow velocity and a decrease in DT explain 32% of the variance seen in LAVi increase over time. Conclusion In patients with moderate-to-severely reduced EF, younger age, being on heart failure therapies, and better diastolic dysfunction were independently associated with a normal LAVi. Improvement in systolic and diastolic performances was associated with decreasing LAVi with 6-month to 1-year follow-up.
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31
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Mowakeaa S, Dwivedi A, Grossman JR, Parikh G, Curillova Z, Aragam KG, Elmariah S, Kinlay S, Aragam J. Prognosis of patients with secondary mitral regurgitation and reduced ejection fraction. Open Heart 2018; 5:e000745. [PMID: 29344383 PMCID: PMC5761303 DOI: 10.1136/openhrt-2017-000745] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 11/17/2017] [Accepted: 11/18/2017] [Indexed: 12/21/2022] Open
Abstract
Objective The impact of the severity of secondary mitral regurgitation (MR) on the risk of death and heart failure (HF) hospitalisations in patients with reduced left ventricular (LV) systolic function is poorly defined. The study sought to identify the incremental risk of secondary MR in patients with reduced LV systolic function. Methods We studied 615 consecutive patients with LV ejection fraction ≤35% by transthoracic echocardiography at a single medical centre. Patients were divided into three groups of no MR, mild, or moderate to severe MR. The median follow-up was 2.9 years. The primary endpoint was a composite of death or HF hospitalisations. Results Compared with patients with no MR, the risk of death or HF hospitalisations was higher for mild MR (HR 1.7, P=0.003) and moderate to severe MR (HR 2.7, P<0.001). The risk was also higher for the component endpoints of HF hospitalisations (mild MR: HR 2.3, P=0.001; moderate to severe MR: HR 3.5, P<0.001) and death (mild MR: HR 1.6, P=0.033; moderate to severe MR: HR 2.6, P<0.001). After adjustment for other covariates, MR was no longer significantly associated with death or HF hospitalisations, or death alone, but remained significantly associated with HF hospitalisations (mild MR: HR 1.7, P=0.028; moderate to severe MR: HR 2.2, P=0.002). Conclusions In patients with reduced LV systolic function, secondary MR is associated with an increased risk of HF hospitalisations but not death.
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Affiliation(s)
- Samer Mowakeaa
- Cardiology, Loyola University Medical Center, Maywood, Illinois, USA
| | - Aeshita Dwivedi
- Cardiology, New York University Langone Medical Center, New York, New York, USA
| | - Jason R Grossman
- Cardiology, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
| | - Gaurav Parikh
- Cardiology, Pomona Valley Hospital Medical Center, Pomona, California, USA
| | | | - Krishna G Aragam
- Cardiology, Harvard Medical School, Boston, Massachusetts, USA.,Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sammy Elmariah
- Cardiology, Harvard Medical School, Boston, Massachusetts, USA.,Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Scott Kinlay
- Cardiology, Harvard Medical School, Boston, Massachusetts, USA.,Cardiology, VA Boston Healthcare System, West Roxbury, Massachusetts, USA.,Cardiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jayashri Aragam
- Cardiology, Harvard Medical School, Boston, Massachusetts, USA.,Cardiology, VA Boston Healthcare System, West Roxbury, Massachusetts, USA
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James R, Guillot E, Garelli-Paar C, Huxley J, Grassi V, Cobb M. The SEISICAT study: a pilot study assessing efficacy and safety of spironolactone in cats with congestive heart failure secondary to cardiomyopathy. J Vet Cardiol 2017; 20:1-12. [PMID: 29277469 DOI: 10.1016/j.jvc.2017.11.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Revised: 11/07/2017] [Accepted: 11/09/2017] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The pathophysiology of heart failure involves activation of several neurohormonal systems including the renin-angiotensin-aldosterone system. The mineralocorticoid receptor antagonist spironolactone has been shown to be beneficial in humans and dogs with heart failure. The objective of this pilot study was to investigate the efficacy and safety of spironolactone in cats with heart failure secondary to cardiomyopathy already treated with furosemide and an angiotensin-converting enzyme inhibitor. ANIMALS Twenty cats with heart failure due to cardiomyopathy. METHODS The study was a double-blind, randomised, placebo-controlled, multicentre clinical study assessing the effect of spironolactone on survival and clinical parameters in cats with heart failure due to cardiomyopathy. The primary end point was mortality, defined as death (spontaneous or by euthanasia) due to cardiac causes. RESULTS Twenty cats were enrolled: 9 in the spironolactone group and 11 in the placebo group of which 56% (5/9) and 0% (0/11) completed the 15-month period respectively. At inclusion, differences in systemic blood pressure, body condition score, electrocardiographic abnormalities and LA/Ao ratio suggested that disease may be less severe in the spironolactone group. Twenty-two percent (2/9) of cats in the spironolactone group and 82% (9/11) in the control group reached the primary end point (Fisher's exact test, p = 0.0216). No safety issues were identified in either group. CONCLUSIONS This study suggests that spironolactone is well tolerated, and preliminary results support further investigation to evaluate the efficacy of spironolactone in the treatment of cats with cardiac failure due to cardiomyopathy.
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Affiliation(s)
- Rachel James
- School of Veterinary Medicine and Science, University of Nottingham, Sutton Bonington Campus, Sutton Bonington, Loughborough, Leicestershire, LE12 5RD, United Kingdom
| | - Emilie Guillot
- Ceva Santé Animale, 10 av. de la Ballastière, 33500 Libourne, France
| | | | - Jacqueline Huxley
- School of Veterinary Medicine and Science, University of Nottingham, Sutton Bonington Campus, Sutton Bonington, Loughborough, Leicestershire, LE12 5RD, United Kingdom
| | - Vanessa Grassi
- Ceva Santé Animale, 10 av. de la Ballastière, 33500 Libourne, France
| | - Malcolm Cobb
- School of Veterinary Medicine and Science, University of Nottingham, Sutton Bonington Campus, Sutton Bonington, Loughborough, Leicestershire, LE12 5RD, United Kingdom.
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Kowalczys A, Bohdan M, Gruchała M. Prognostic value of daytime heart rate, blood pressure, their products and quotients in chronic heart failure. Cardiol J 2017; 26:20-28. [PMID: 29131282 DOI: 10.5603/cj.a2017.0130] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 09/05/2017] [Accepted: 09/07/2017] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Chronic heart failure (CHF) is an important epidemiological and therapeuthic issue with poor prognosis. The aim of the study was to estimate the prognostic value of daytime heart rate (HR), blood pressure (BP), their products and quotients in patients with CHF. METHODS The study included 80 stable patients with CHF and reduced left ventricular ejection frac- tion (LVEF ≤ 35%). Physical examination, laboratory blood tests, electrocardiogram, chest X-ray, echocardiography, 6-minute walk test, telemetry monitoring and BP measurements were performed in all participants. We estimated mean daytime: BP, HR, their products and quotients. The follow-up period was 6 months. Major adverse cardiac events (MACE) included: death, cardiovascular death, hospitalization due to CHF exacerbation. RESULTS The analysis involved all recruited patients with CHF (91% men) aged 59 ± 12 years, in New York Heart Association class 2.15 ± 0.57 and reduced LVEF (mean LVEF: 23 ± 6%). The 3-month and 6-month mortality rates were 4% and 6%, respectively. There was a significant correlation between diastolic blood pressure (DBP), all-cause mortality (p = 0.048) and CHF decompensation (p = 0.0004) after 3-month observation period. No relationship was found between HR or systolic blood pressure (SBP) and MACE. Both higher SBP × HR and DBP × HR products were related to lower risk of heart failure exacerbations during 6-month follow-up. None of the analyzed products or ratios had an impact on mortality in this study group. CONCLUSIONS Diastolic blood pressure, SBP × HR and DBP × HR products may be useful in sub- sequent heart failure exacerbation risk stratification. Moreover, DBP value may predict short-term mortality in patients with CHF.
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Affiliation(s)
- Anna Kowalczys
- First Department of Cardiology, Medical University of Gdansk, Poland.
| | - Michał Bohdan
- First Department of Cardiology, Medical University of Gdansk, Poland
| | - Marcin Gruchała
- First Department of Cardiology, Medical University of Gdansk, Poland
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Kajimoto K, Minami Y, Otsubo S, Sato N, Sato N, Asai K, Munakata R, Aokage T, Yoshida A, Minami Y, Yumino D, Mizuno M, Kawada E, Yoshida K, Ozaki Y, Kogure T, Haruki S, Mizuno M, Kajimoto K, Nakao K, Sawamura T, Nuki T, Ishiki R, Yokota S, Fujinaga H, Yamamoto T, Harada K, Saito A, Kageyama N, Okumura T, Hata N, Murai K, Nozaki A, Kawanaka H, Tanabe J, Sato Y, Ishii K, Oiwa H, Matsumoto T, Yoshida D, Kato N, Suzuki H, Shimizu N, Keida T, Fujita M, Nakamura K, Chinen T, Meguro K, Kikuchi T, Nishikido T, Nakata M, Yamashita T, Nakata M, Hirono A, Mitsudo K, Kadota K, Makita N, Watanabe N, Kawabata M, Fujii K, Okuda S, Kobayashi S, Moriuchi I, Mizuno KO, Osato K, Murakami T, Shimada Y, Misawa K, Kokado H, Fujita T, Fukuoka Y, Takabatake S, Takata Y, Miyagi M, Tanaka N, Yamashina A, Sudo S, Shimamura K, Nagashima M, Kaneda T, Ueda K, Kato H, Higashikata T, Fujimori K, Kobayashi H, Fujii S, Yagi M, Ozaki Y, Takaki J, Yamashita E, Toyama T, Hirata T, Kamisihima K, Oka T, Komatsu R, Itoh A, Naruko T, Abe Y, Nakagawa E, Furukawa A, Kinou N, Uematsu S, Tabuchi I, Imai T, Sakamoto T, Todaka K, Koide Y, Maemura K, Yoshioka K, Yoshihisa A, Sato T, Takeishi Y, Ebina T, Kimura K, Konishi M, Kato M, Kinugasa Y, Ishida K, Sugihara S, Yanagihara K, Takeuchi T, Okada M, Hasebe N, Sakai T, Asano T, Minoura Y, Toshida T, Sato T, Yokota Y, Kondo S, Sakata Y, Komuro I, Otsu K, Yamashita S, Asano Y, Yoshida A, Kajimoto K, Kashiwase K, Ueda Y, Kondo T, Kawaguchi K, Sawamura A, Saito T, Higa T, Noguchi H, Yanagita Y, Nakamura K, Komaki T, Muramatsu T, Koizumi T, Nakajima Y, Kikutani T, Ikeda Y, Tamaki T, Funada S, Ogawa H, Sakuragawa K, Kohsaka S, Ando SI, Kadokami T, Ishida E, Ide K, Sotomi Y, Higuchi Y, Uehara M, Goto T, Ohte N, Miura M, Shiba N, Nochioka K, Shimokawa H, Ishihara S, Koga T, Fujishima S, Kaseda S, Haga Y, Kida K, Kamisihima K, Nakamura M, Sunagawa O, Miyara T, Taba Y, Touma T, Shinjo O, Nishimura Y, Kario K, Shimizu H, Uchida T, Amitani KI, Sato N, Shimada K. Ischemic or Nonischemic Functional Mitral Regurgitation and Outcomes in Patients With Acute Decompensated Heart Failure With Preserved or Reduced Ejection Fraction. Am J Cardiol 2017; 120:809-816. [PMID: 28705383 DOI: 10.1016/j.amjcard.2017.05.051] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Revised: 05/11/2017] [Accepted: 05/23/2017] [Indexed: 10/19/2022]
Abstract
The aim of this study was to evaluate the association of functional mitral regurgitation (FMR), preserved or reduced ejection fraction (EF), and ischemic or nonischemic origin with outcomes in patients discharged alive after hospitalization for acute decompensated heart failure (HF). Of the 4,842 patients enrolled in the Acute Decompensated Heart Failure Syndromes (ATTEND) registry, 3,357 patients were evaluated to assess the association of FMR, preserved or reduced EF, and ischemic or nonischemic origin with the primary end point (all-cause death and readmission for HF after discharge). At the time of discharge, FMR was assessed semiquantitatively (classified as none, mild, or moderate to severe) by color Doppler analysis of the regurgitant jet area. According to multivariable analysis, in the ischemic group, either mild or moderate to severe FMR in patients with a preserved EF had a significantly higher risk of the primary end point than patients without FMR (hazard ratio [HR] 1.60; 95% confidence interval [CI] 1.12 to 2.29; p = 0.010 and HR 1.98; 95% CI 1.30 to 3.01; p = 0.001, respectively). In patients with reduced EF with an ischemic origin, only moderate to severe FMR was associated with a significantly higher risk of the primary end point (HR 1.67; 95% CI 1.11 to 2.50; p = 0.014). In the nonischemic group, there was no significant association between FMR and the primary end point in patients with either a preserved or reduced EF. In conclusion, among patients with acute decompensated HF with a preserved or reduced EF, the association of FMR with adverse outcomes may differ between patients who had an ischemic or nonischemic origin of HF.
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Weintraub RG, Semsarian C, Macdonald P. Dilated cardiomyopathy. Lancet 2017; 390:400-414. [PMID: 28190577 DOI: 10.1016/s0140-6736(16)31713-5] [Citation(s) in RCA: 385] [Impact Index Per Article: 55.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 09/09/2016] [Accepted: 09/14/2016] [Indexed: 12/18/2022]
Abstract
Dilated cardiomyopathy is defined by the presence of left ventricular dilatation and contractile dysfunction. Genetic mutations involving genes that encode cytoskeletal, sarcomere, and nuclear envelope proteins, among others, account for up to 35% of cases. Acquired causes include myocarditis and exposure to alcohol, drugs and toxins, and metabolic and endocrine disturbances. The most common presenting symptoms relate to congestive heart failure, but can also include circulatory collapse, arrhythmias, and thromboembolic events. Secondary neurohormonal changes contribute to reverse remodelling and ongoing myocyte damage. The prognosis is worst for individuals with the lowest ejection fractions or severe diastolic dysfunction. Treatment of chronic heart failure comprises medications that improve survival and reduce hospital admission-namely, angiotensin converting enzyme inhibitors and β blockers. Other interventions include enrolment in a multidisciplinary heart failure service, and device therapy for arrhythmia management and sudden death prevention. Patients who are refractory to medical therapy might benefit from mechanical circulatory support and heart transplantation. Treatment of preclinical disease and the potential role of stem-cell therapy are being investigated.
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Affiliation(s)
- Robert G Weintraub
- Department of Cardiology, Royal Children's Hospital, Melbourne, VIC, Australia; Murdoch Children's Research Institute, Melbourne, VIC, Australia; Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia.
| | - Christopher Semsarian
- Agnes Ginges Centre for Molecular Cardiology, Centenary Institute and Sydney Medical School, University of Sydney, Sydney, NSW, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Peter Macdonald
- St Vincent's Hospital, Sydney, NSW, Australia; Victor Chang Cardiac Research Institute, Sydney, NSW, Australia
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Shaffer R, Sinno Z, Tyler M, Ghosh J. The obesity paradox in ICU patients. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2017; 2017:3360-3364. [PMID: 29060617 DOI: 10.1109/embc.2017.8037576] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Excessive weight is connected with an increased risk of certain life-threatening diseases. However, some evidence shows that among patients with chronic diseases such as heart failure (HF) chronic kidney disease (CKD) and COPD, increased weight is paradoxically associated with a decreased risk of mortality. This counterintuitive phenomenon is referred to as the obesity paradox. The obesity paradox has been mostly observed among certain cohorts of patients with HF, but not specific to patients in the Intensive Care Unit (ICU) setting. This paper studies the relationship between obesity and mortality of ICU patients with and without HF and presents evidence supporting the existence of this paradox. The results provide helpful insights for developing more patient-centric care in ICUs. Additionally, we use both the MIMIC-II and (recently available) MIMIC-III databases, for which few comparative studies exist to date. We demonstrate an aspect of consistency between the databases, providing a significant step towards validating the use of the newly announced MIMIC-III in broader studies.
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Diastolic dysfunction revisited: A new, feasible, and unambiguous echocardiographic classification predicts major cardiovascular events. Am Heart J 2017; 188:136-146. [PMID: 28577669 DOI: 10.1016/j.ahj.2017.03.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Accepted: 03/20/2017] [Indexed: 01/20/2023]
Abstract
BACKGROUND Echocardiographic classification of DDF has been widely discussed. The aim of this study was to investigate the independent prognostic value of established echocardiographic measures in a community-based population and create a new classification of DDF. METHODS Within the Copenhagen City Heart Study, a prospective, community-based study, 1851 participants were examined by echocardiography including Tissue Doppler Imaging (TDI) in 2001 to 2003 and followed with regard to MACE (median, 10.9 years). RESULTS We found that persons with impaired myocardial relaxation as defined by low peak early diastolic mitral annular velocity e' by TDI had higher incidence of clinical and echocardiographic markers of cardiac dysfunction and increased risk of MACE. Among persons with impaired relaxation, only echocardiographic indices of increased filling pressures such as LAVi≥34 mL/m2 (HR 1.97 (1.13-3.45, P=.017), E/e' ≥ 17 (HR 1.89 (1.34-2.65), P<.001), and E/A>2 (HR 5.24 (1.91-14.42), P=.001) provided additional and independent prognostic information on MACE. Based on these findings, we created a new classification of DDF where all grades were significant predictors of MACE independently of age, sex, and cardiac clinical risk markers (Mild DDF: HR 1.99 (1.23-3.21), P=.005; Moderate DDF: HR 3.11 (1.81-5.34), P<.001; Severe DDF: HR 4.20 (1.81-9.73), P<.001). Increasing severity of DDF was linearly associated with increasing plasma proBNP concentrations. CONCLUSIONS In the general population, the presence of echocardiographic markers of elevated filling pressures in persons with impaired relaxation increased the risk of MACE significantly. Based on this, we present a new, feasible, and unambiguous classification of DDF capable of accurate risk prediction in the community.
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Zambon E, Iorio A, Di Nora C, Carriere C, Abate E, Merlo M, Barbati G, Di Lenarda A, Pinamonti B, Agostoni P, Sinagra G. Left ventricular function and exercise performance in idiopathic dilated cardiomyopathy. J Cardiovasc Med (Hagerstown) 2017; 18:230-236. [DOI: 10.2459/jcm.0000000000000411] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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den Boer SL, Flipse DHK, van der Meulen MH, Backx APCM, du Marchie Sarvaas GJ, Ten Harkel ADJ, van Iperen GG, Rammeloo LAJ, Tanke RB, Helbing WA, Takken T, Dalinghaus M. Six-Minute Walk Test as a Predictor for Outcome in Children with Dilated Cardiomyopathy and Chronic Stable Heart Failure. Pediatr Cardiol 2017; 38:465-471. [PMID: 27909753 PMCID: PMC5355503 DOI: 10.1007/s00246-016-1536-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Accepted: 11/12/2016] [Indexed: 11/24/2022]
Abstract
Cardiopulmonary exercise testing is an important tool to predict prognosis in children and adults with heart failure. A much less sophisticated exercise test is the 6 min walk test, which has been shown an independent predictor for morbidity and mortality in adults with heart failure. Therefore, we hypothesized that the 6 min walk test could be predictive for outcome in children with dilated cardiomyopathy. We prospectively included 49 children with dilated cardiomyopathy ≥6 years who performed a 6 min walk test. Median age was 11.9 years (interquartile range [IQR] 7.4-15.1), median time after diagnosis was 3.6 years (IQR 0.6-7.4). The 6 min walk distance was transformed to a percentage of predicted, using age- and gender-specific norm values (6MWD%). For all patients, mean 6MWD% was 70 ± 21%. Median follow-up was 33 months (IQR 14-50). Ten patients reached the combined endpoint of death or heart transplantation. Using univariable Cox regression, a higher 6MWD% resulted in a lower risk of death or transplantation (hazard ratio 0.95 per percentage increase, p = 0.006). A receiver operating characteristic curve was generated to define the optimal threshold to identify patients at highest risk for an endpoint. Patients with a 6MWD% < 63% had a 2 year transplant-free survival of 73%, in contrast to a transplant-free survival of 92% in patients with a 6MWD% ≥ 63% (p = 0.003). In children with dilated cardiomyopathy, the 6 min walk test is a simple and feasible tool to identify children with a higher risk of death or heart transplantation.
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Affiliation(s)
- Susanna L. den Boer
- Division of Pediatric Cardiology, Sophia Children’s Hospital, Erasmus University Medical Center, Dr. Molewaterplein 60, P.O. Box 2060, 3000 CB Rotterdam, The Netherlands
| | - Daniël H. K. Flipse
- Division of Pediatric Cardiology, Sophia Children’s Hospital, Erasmus University Medical Center, Dr. Molewaterplein 60, P.O. Box 2060, 3000 CB Rotterdam, The Netherlands
| | - Marijke H. van der Meulen
- Division of Pediatric Cardiology, Sophia Children’s Hospital, Erasmus University Medical Center, Dr. Molewaterplein 60, P.O. Box 2060, 3000 CB Rotterdam, The Netherlands
| | - Ad P. C. M. Backx
- Division of Pediatric Cardiology, Emma Children’s Hospital, Academic Medical Center, Amsterdam, The Netherlands
| | - Gideon J. du Marchie Sarvaas
- Division of Pediatric Cardiology, Beatrix Children’s Hospital, University of Groningen, Groningen, The Netherlands
| | - Arend D. J. Ten Harkel
- Division of Pediatric Cardiology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Gabriëlle G. van Iperen
- Division of Pediatric Cardiology, Wilhelmina Children’s Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Lukas A. J. Rammeloo
- Division of Pediatric Cardiology, Department of Pediatrics, Free University Medical Center, Amsterdam, The Netherlands
| | - Ronald B. Tanke
- Division of Pediatric Cardiology, Department of Pediatrics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Willem A. Helbing
- Division of Pediatric Cardiology, Sophia Children’s Hospital, Erasmus University Medical Center, Dr. Molewaterplein 60, P.O. Box 2060, 3000 CB Rotterdam, The Netherlands
| | - Tim Takken
- Child Development and Exercise Center, Wilhelmina Children’s Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Michiel Dalinghaus
- Division of Pediatric Cardiology, Sophia Children’s Hospital, Erasmus University Medical Center, Dr. Molewaterplein 60, P.O. Box 2060, 3000 CB Rotterdam, The Netherlands
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Li SN, Zhang XL, Cai GL, Lin RW, Jiang H, Chen JZ, Xu B, Huang W. Prognostic Significance of Frontal QRS-T Angle in Patients with Idiopathic Dilated Cardiomyopathy. Chin Med J (Engl) 2017; 129:1904-11. [PMID: 27503013 PMCID: PMC4989419 DOI: 10.4103/0366-6999.187844] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Current risk stratification of idiopathic dilated cardiomyopathy (IDC) lacks sufficient sensitivity and specificity. The objective of this study was to investigate the predictive role of frontal QRS-T angles in IDC. METHODS A prospective study with 509 IDC patients was performed from February 2008 to December 2013 in the Affiliated Drum Tower Hospital, Nanjing University School of Medicine. Baseline values and changes in QRS-T angles were recorded. Follow-up was conducted every 6 months. Analyses by Cox Proportional Hazards model were performed to evaluate the association between QRS-T angle and outcomes. The primary outcome of interest was all-cause mortality. RESULTS During a median follow-up of 34 months, 90 of 316 patients with QRS-T angles >90° died compared to 31 of 193 patients with QRS-T angles ≤90° (hazard ratio [HR] =2.4, P < 0.001). Cardiac death was more prevalent in patients with a wide QRS-T angle (HR = 2.4, P < 0.001), similar to heart failure rehospitalization (HR = 2.5, P < 0.001). After adjustment for potential prognostic factors, the QRS-T angle was independently associated with all-cause mortality (HR = 2.5, P < 0.05), cardiac mortality (HR = 1.9, P < 0. 05), and heart failure rehospitalization (HR = 2.3, P < 0.01). Optimized therapy significantly narrowed the frontal QRS-T angle (100.9 ± 53.4° vs. 107.2 ± 54.4°, P < 0.001). The frontal QRS-T angle correlated well with established risk factors, such as left ventricular ejection fraction, brain natriuretic peptide, and New York Heart Association functional class. CONCLUSIONS The frontal QRS-T angle is a powerful predictor of all-cause mortality, cardiac mortality, and worsening heart failure in IDC patients, independent of well-established prognostic factors. Optimized therapy significantly narrows the QRS-T angle, which might be an indicator of medication compliance, but this requires further investigation.
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Affiliation(s)
- Sheng-Na Li
- Intensive Care Unit, Zhejiang Hospital, Hangzhou, Zhejiang 310031, China
| | - Xin-Lin Zhang
- Department of Cardiology, School of Medicine, Affiliated Drum Tower Hospital, Nanjing University, Nanjing, Jiangsu 210008, China
| | - Guo-Long Cai
- Department of Education and Science, Zhejiang Hospital, Hangzhou, Zhejiang 310031, China
| | - Ruo-Wei Lin
- Department of Cardiology, School of Medicine, Affiliated Drum Tower Hospital, Nanjing University, Nanjing, Jiangsu 210008, China
| | - He Jiang
- Department of Cardiology, School of Medicine, Affiliated Drum Tower Hospital, Nanjing University, Nanjing, Jiangsu 210008, China
| | - Jian-Zhou Chen
- Department of Cardiology, School of Medicine, Affiliated Drum Tower Hospital, Nanjing University, Nanjing, Jiangsu 210008, China
| | - Biao Xu
- Department of Cardiology, School of Medicine, Affiliated Drum Tower Hospital, Nanjing University, Nanjing, Jiangsu 210008, China
| | - Wei Huang
- Department of Cardiology, School of Medicine, Affiliated Drum Tower Hospital, Nanjing University, Nanjing, Jiangsu 210008, China
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Arenja N, Riffel JH, Fritz T, André F, Aus dem Siepen F, Mueller-Hennessen M, Giannitsis E, Katus HA, Friedrich MG, Buss SJ. Diagnostic and Prognostic Value of Long-Axis Strain and Myocardial Contraction Fraction Using Standard Cardiovascular MR Imaging in Patients with Nonischemic Dilated Cardiomyopathies. Radiology 2017; 283:681-691. [PMID: 28156200 DOI: 10.1148/radiol.2016161184] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Purpose To assess the utility of established functional markers versus two additional functional markers derived from standard cardiovascular magnetic resonance (MR) images for their incremental diagnostic and prognostic information in patients with nonischemic dilated cardiomyopathy (NIDCM). Materials and Methods Approval was obtained from the local ethics committee. MR images from 453 patients with NIDCM and 150 healthy control subjects were included between 2005 and 2013 and were analyzed retrospectively. Myocardial contraction fraction (MCF) was calculated by dividing left ventricular (LV) stroke volume by LV myocardial volume, and long-axis strain (LAS) was calculated from the distances between the epicardial border of the LV apex and the midpoint of a line connecting the origins of the mitral valve leaflets at end systole and end diastole. Receiver operating characteristic curve, Kaplan-Meier method, Cox regression, and classification and regression tree (CART) analyses were performed for diagnostic and prognostic performances. Results LAS (area under the receiver operating characteristic curve [AUC] = 0.93, P < .001) and MCF (AUC = 0.92, P < .001) can be used to discriminate patients with NIDCM from age- and sex-matched control subjects. A total of 97 patients reached the combined end point during a median follow-up of 4.8 years. In multivariate Cox regression analysis, only LV ejection fraction (EF) and LAS independently indicated the combined end point (hazard ratio = 2.8 and 1.9, respectively; P < .001 for both). In a risk stratification approach with classification and regression tree analysis, combined LV EF and LAS cutoff values were used to stratify patients into three risk groups (log-rank test, P < .001). Conclusion Cardiovascular MR-derived MCF and LAS serve as reliable diagnostic and prognostic markers in patients with NIDCM. LAS, as a marker for longitudinal contractile function, is an independent parameter for outcome and offers incremental information beyond LV EF and the presence of myocardial fibrosis. © RSNA, 2017 Online supplemental material is available for this article.
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Affiliation(s)
- Nisha Arenja
- From the Department of Cardiology, Angiology, and Pneumology (N.A., J.H.R., T.F., F.A., F.a.d.S., M.M.H., E.G., H.A.K., M.G.F., S.J.B.), University of Heidelberg, Im Neuenheimer Feld 410, Heidelberg 69120, Germany; Department of Cardiology, Solothurner Spitäler, Solothurn, Switzerland (N.A.); DZHK (German Centre for Cardiovascular Research), Heidelberg, Germany (H.A.K.); and Radiology Center, Sinsheim-Eberbach-Erbach-Walldorf-Heidelberg, Germany (S.J.B.)
| | - Johannes H Riffel
- From the Department of Cardiology, Angiology, and Pneumology (N.A., J.H.R., T.F., F.A., F.a.d.S., M.M.H., E.G., H.A.K., M.G.F., S.J.B.), University of Heidelberg, Im Neuenheimer Feld 410, Heidelberg 69120, Germany; Department of Cardiology, Solothurner Spitäler, Solothurn, Switzerland (N.A.); DZHK (German Centre for Cardiovascular Research), Heidelberg, Germany (H.A.K.); and Radiology Center, Sinsheim-Eberbach-Erbach-Walldorf-Heidelberg, Germany (S.J.B.)
| | - Thomas Fritz
- From the Department of Cardiology, Angiology, and Pneumology (N.A., J.H.R., T.F., F.A., F.a.d.S., M.M.H., E.G., H.A.K., M.G.F., S.J.B.), University of Heidelberg, Im Neuenheimer Feld 410, Heidelberg 69120, Germany; Department of Cardiology, Solothurner Spitäler, Solothurn, Switzerland (N.A.); DZHK (German Centre for Cardiovascular Research), Heidelberg, Germany (H.A.K.); and Radiology Center, Sinsheim-Eberbach-Erbach-Walldorf-Heidelberg, Germany (S.J.B.)
| | - Florian André
- From the Department of Cardiology, Angiology, and Pneumology (N.A., J.H.R., T.F., F.A., F.a.d.S., M.M.H., E.G., H.A.K., M.G.F., S.J.B.), University of Heidelberg, Im Neuenheimer Feld 410, Heidelberg 69120, Germany; Department of Cardiology, Solothurner Spitäler, Solothurn, Switzerland (N.A.); DZHK (German Centre for Cardiovascular Research), Heidelberg, Germany (H.A.K.); and Radiology Center, Sinsheim-Eberbach-Erbach-Walldorf-Heidelberg, Germany (S.J.B.)
| | - Fabian Aus dem Siepen
- From the Department of Cardiology, Angiology, and Pneumology (N.A., J.H.R., T.F., F.A., F.a.d.S., M.M.H., E.G., H.A.K., M.G.F., S.J.B.), University of Heidelberg, Im Neuenheimer Feld 410, Heidelberg 69120, Germany; Department of Cardiology, Solothurner Spitäler, Solothurn, Switzerland (N.A.); DZHK (German Centre for Cardiovascular Research), Heidelberg, Germany (H.A.K.); and Radiology Center, Sinsheim-Eberbach-Erbach-Walldorf-Heidelberg, Germany (S.J.B.)
| | - Matthias Mueller-Hennessen
- From the Department of Cardiology, Angiology, and Pneumology (N.A., J.H.R., T.F., F.A., F.a.d.S., M.M.H., E.G., H.A.K., M.G.F., S.J.B.), University of Heidelberg, Im Neuenheimer Feld 410, Heidelberg 69120, Germany; Department of Cardiology, Solothurner Spitäler, Solothurn, Switzerland (N.A.); DZHK (German Centre for Cardiovascular Research), Heidelberg, Germany (H.A.K.); and Radiology Center, Sinsheim-Eberbach-Erbach-Walldorf-Heidelberg, Germany (S.J.B.)
| | - Evangelos Giannitsis
- From the Department of Cardiology, Angiology, and Pneumology (N.A., J.H.R., T.F., F.A., F.a.d.S., M.M.H., E.G., H.A.K., M.G.F., S.J.B.), University of Heidelberg, Im Neuenheimer Feld 410, Heidelberg 69120, Germany; Department of Cardiology, Solothurner Spitäler, Solothurn, Switzerland (N.A.); DZHK (German Centre for Cardiovascular Research), Heidelberg, Germany (H.A.K.); and Radiology Center, Sinsheim-Eberbach-Erbach-Walldorf-Heidelberg, Germany (S.J.B.)
| | - Hugo A Katus
- From the Department of Cardiology, Angiology, and Pneumology (N.A., J.H.R., T.F., F.A., F.a.d.S., M.M.H., E.G., H.A.K., M.G.F., S.J.B.), University of Heidelberg, Im Neuenheimer Feld 410, Heidelberg 69120, Germany; Department of Cardiology, Solothurner Spitäler, Solothurn, Switzerland (N.A.); DZHK (German Centre for Cardiovascular Research), Heidelberg, Germany (H.A.K.); and Radiology Center, Sinsheim-Eberbach-Erbach-Walldorf-Heidelberg, Germany (S.J.B.)
| | - Matthias G Friedrich
- From the Department of Cardiology, Angiology, and Pneumology (N.A., J.H.R., T.F., F.A., F.a.d.S., M.M.H., E.G., H.A.K., M.G.F., S.J.B.), University of Heidelberg, Im Neuenheimer Feld 410, Heidelberg 69120, Germany; Department of Cardiology, Solothurner Spitäler, Solothurn, Switzerland (N.A.); DZHK (German Centre for Cardiovascular Research), Heidelberg, Germany (H.A.K.); and Radiology Center, Sinsheim-Eberbach-Erbach-Walldorf-Heidelberg, Germany (S.J.B.)
| | - Sebastian J Buss
- From the Department of Cardiology, Angiology, and Pneumology (N.A., J.H.R., T.F., F.A., F.a.d.S., M.M.H., E.G., H.A.K., M.G.F., S.J.B.), University of Heidelberg, Im Neuenheimer Feld 410, Heidelberg 69120, Germany; Department of Cardiology, Solothurner Spitäler, Solothurn, Switzerland (N.A.); DZHK (German Centre for Cardiovascular Research), Heidelberg, Germany (H.A.K.); and Radiology Center, Sinsheim-Eberbach-Erbach-Walldorf-Heidelberg, Germany (S.J.B.)
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Mikami Y, Cornhill A, Heydari B, Joncas SX, Almehmadi F, Zahrani M, Bokhari M, Stirrat J, Yee R, Merchant N, Lydell CP, Howarth AG, White JA. Objective criteria for septal fibrosis in non-ischemic dilated cardiomyopathy: validation for the prediction of future cardiovascular events. J Cardiovasc Magn Reson 2016; 18:82. [PMID: 27839514 PMCID: PMC5108079 DOI: 10.1186/s12968-016-0300-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 10/28/2016] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Expert subjective reporting of mid-wall septal fibrosis on late gadolinium enhancement (LGE) images has been shown to predict major cardiovascular outcomes in patients with non-ischemic dilated cardiomyopathy (NIDCM). This study aims to establish objective criteria for non-experts to report clinically relevant septal fibrosis and compare its performance by such readers versus experts for the prediction of cardiovascular events. METHODS LGE cardiovascular magnetic resonance (CMR) was performed in 118 consecutive patients with NIDCM (mean age 57 ± 14, 42 % female) and the presence of septal fibrosis scored by expert readers. CMR-naive readers performed signal threshold-based LGE quantification by referencing mean values of remote tissue and applying these to a pre-defined anatomic region to measure septal fibrosis. All patients were followed for the primary composite outcome of cardiac mortality or appropriate implantable cardioverter-defibrillator (ICD) therapy. RESULTS The mean LVEF was 32 ± 12 %. At a median follow-up of 1.9 years, 20 patients (17 %) experienced a primary composite outcome. Expert visual scoring identified 55 patients with septal fibrosis. Non-expert septal fibrosis quantification was highly reproducible and identified mean septal fibrosis burden for three measured thresholds as follows; 5SD: 2.9 ± 3.6 %, 3SD: 6.9 ± 6.3 %, and 2SD: 11.1 ± 7.5 % of the left ventricular (LV) mass, respectively. By ROC analysis, optimal thresholds for prediction of the primary outcome were; 5SD: 2.74 % (HR 8.7, p < 0.001), 3SD: 6.63 % (HR 5.7, p = 0.001) and 2SD: 10.15 % (HR 6.1, p = 0.001). By comparison, expert visual scoring provided a HR of 5.3 (p = 0.001). In adjusted analysis, objective quantification by a novice reader (>5SD threshold) was the strongest independent predictor of the primary outcome (HR 8.7) and provided improved risk reclassification beyond LVEF alone (NRI 0.54, 95 % CI 0.16-0.92, p = 0.005). CONCLUSIONS Novice readers were able to achieve superior risk prediction for future cardiovascular events versus experts using objective criteria for septal fibrosis in patients with NIDCM. Patients with a septal fibrosis burden >2.74 % of the LV mass (>5SD threshold) were at a 9-fold higher risk of cardiac death or appropriate ICD therapy versus those not meeting this criteria. As such, this study validates reproducible criteria applicable to all levels of expertise to identify NIDCM patients at high risk of future cardiovascular events.
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Affiliation(s)
- Yoko Mikami
- Stephenson Cardiac Imaging Centre, Libin Cardiovascular Institute of Alberta, University of Calgary, #0700, SSB, Foothills Medical Centre, 1403-29th St. NW, Calgary, AB T2N2T9 Canada
| | - Aidan Cornhill
- Stephenson Cardiac Imaging Centre, Libin Cardiovascular Institute of Alberta, University of Calgary, #0700, SSB, Foothills Medical Centre, 1403-29th St. NW, Calgary, AB T2N2T9 Canada
| | - Bobak Heydari
- Stephenson Cardiac Imaging Centre, Libin Cardiovascular Institute of Alberta, University of Calgary, #0700, SSB, Foothills Medical Centre, 1403-29th St. NW, Calgary, AB T2N2T9 Canada
- Department of Cardiac Sciences, Libin Cardiovascular Institute, University of Calgary, Calgary, Canada
- Department of Diagnostic Imaging, University of Calgary, Calgary, Canada
| | - Sebastien X. Joncas
- Stephenson Cardiac Imaging Centre, Libin Cardiovascular Institute of Alberta, University of Calgary, #0700, SSB, Foothills Medical Centre, 1403-29th St. NW, Calgary, AB T2N2T9 Canada
| | - Fahad Almehmadi
- Department of Medicine, Western University, London, ON Canada
| | | | - Mahmoud Bokhari
- Department of Medicine, Western University, London, ON Canada
| | - John Stirrat
- Robarts Research Institute, University of Western Ontario, London, ON Canada
| | - Raymond Yee
- Department of Medicine, Western University, London, ON Canada
| | - Naeem Merchant
- Stephenson Cardiac Imaging Centre, Libin Cardiovascular Institute of Alberta, University of Calgary, #0700, SSB, Foothills Medical Centre, 1403-29th St. NW, Calgary, AB T2N2T9 Canada
- Department of Cardiac Sciences, Libin Cardiovascular Institute, University of Calgary, Calgary, Canada
- Department of Diagnostic Imaging, University of Calgary, Calgary, Canada
| | - Carmen P. Lydell
- Stephenson Cardiac Imaging Centre, Libin Cardiovascular Institute of Alberta, University of Calgary, #0700, SSB, Foothills Medical Centre, 1403-29th St. NW, Calgary, AB T2N2T9 Canada
- Department of Cardiac Sciences, Libin Cardiovascular Institute, University of Calgary, Calgary, Canada
- Department of Diagnostic Imaging, University of Calgary, Calgary, Canada
| | - Andrew G. Howarth
- Stephenson Cardiac Imaging Centre, Libin Cardiovascular Institute of Alberta, University of Calgary, #0700, SSB, Foothills Medical Centre, 1403-29th St. NW, Calgary, AB T2N2T9 Canada
- Department of Cardiac Sciences, Libin Cardiovascular Institute, University of Calgary, Calgary, Canada
- Department of Diagnostic Imaging, University of Calgary, Calgary, Canada
| | - James A. White
- Stephenson Cardiac Imaging Centre, Libin Cardiovascular Institute of Alberta, University of Calgary, #0700, SSB, Foothills Medical Centre, 1403-29th St. NW, Calgary, AB T2N2T9 Canada
- Department of Cardiac Sciences, Libin Cardiovascular Institute, University of Calgary, Calgary, Canada
- Department of Diagnostic Imaging, University of Calgary, Calgary, Canada
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Benfari G, Dandale R, Rossi A, Onorati F, Mugnai G, Ribichini F, Temporelli PL, Vassanelli C. Functional mitral regurgitation. J Cardiovasc Med (Hagerstown) 2016; 17:767-73. [DOI: 10.2459/jcm.0000000000000429] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Liu T, Ma X, Liu W, Ling S, Zhao L, Xu L, Song D, Liu J, Sun Z, Fan Z, Luo T, Kang J, Liu X, Dong J. Late Gadolinium Enhancement Amount As an Independent Risk Factor for the Incidence of Adverse Cardiovascular Events in Patients with Stage C or D Heart Failure. Front Physiol 2016; 7:484. [PMID: 27840608 PMCID: PMC5083842 DOI: 10.3389/fphys.2016.00484] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Accepted: 10/10/2016] [Indexed: 01/06/2023] Open
Abstract
Background: Myocardial fibrosis (MF) is a risk factor for poor prognosis in dilated cardiomyopathy (DCM). Late gadolinium enhancement (LGE) of the myocardium on cardiac magnetic resonance (CMR) represents MF. We examined whether the LGE amount increases the incidence of adverse cardiovascular events in patients with stage C or D heart failure (HF). Methods: Eighty-four consecutive patients with stage C or D HF, either ischemic or non-ischemic, were enrolled. Comprehensive clinical and CMR evaluations were performed. All patients were followed up for a composite endpoint of cardiovascular death, heart transplantation, and cardiac resynchronization therapy with defibrillator (CRT-D). Results: LGE was present in 79.7% of the end-stage HF patients. LGE distribution patterns were mid-wall, epi-myocardial, endo-myocardial, and the morphological patterns were patchy, transmural, and diffuse. During the average follow-up of 544 days, 13 (15.5%) patients had endpoint events: 7 patients cardiac death, 2 patients heart transplantation, and 4 patients underwent CRT-D implantation. On univariate analysis, LGE quantification on cardiac magnetic resonance, blood urine nitrogen, QRS duration on electrocardiogram, left ventricular end-diastolic diameter (LVEDD), and left ventricular end-diastolic volume (LVEDV) on CMR had the strongest associations with the composite endpoint events. However, on multivariate analysis for both Model I (after adjusting for age, sex, and body mass index) and Model II (after adjusting for age, sex, BMI, renal function, QRS duration, and atrial fibrillation on electrocardiogram, the etiology of HF, LVEF, CMR-LVEDD, and CMR-LVEDV), LGE amount was a significant risk factor for composite endpoint events (Model I 6SD HR 1.037, 95%CI 1.005–1.071, p = 0.022; Model II 6SD HR 1.045, 95%CI 1.001–1.084, p = 0.022). Conclusion: LGE amount from high-scale threshold on CMR increased the incidence of adverse cardiovascular events for patients in either stage C or D HF.
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Affiliation(s)
- Tong Liu
- Department of Cardiology, Capital Medical University, Beijing Anzhen Hospital Beijing, China
| | - Xiaohai Ma
- Department of Radiology, Capital Medical University, Beijing Anzhen Hospital Beijing, China
| | - Wei Liu
- Department of Cardiology, Capital Medical University, Beijing Anzhen Hospital Beijing, China
| | - Shukuan Ling
- State Key Lab of Space Medicine Fundamentals and Application, China Astronaut Research and Training Center Beijing, China
| | - Lei Zhao
- Department of Radiology, Capital Medical University, Beijing Anzhen Hospital Beijing, China
| | - Lei Xu
- Department of Radiology, Capital Medical University, Beijing Anzhen Hospital Beijing, China
| | - Deli Song
- Department of Cardiology, Capital Medical University, Beijing Anzhen Hospital Beijing, China
| | - Jie Liu
- Department of Vascular Surgery, Chinese PLA General Hospital Beijing, China
| | - Zhonghua Sun
- Department of Medical Radiation Sciences, School of Science, Curtin University Perth, WA, Australia
| | - Zhanming Fan
- Department of Radiology, Capital Medical University, Beijing Anzhen Hospital Beijing, China
| | - Taiyang Luo
- Department of Cardiology, Capital Medical University, Beijing Anzhen Hospital Beijing, China
| | - Junping Kang
- Department of Cardiology, Capital Medical University, Beijing Anzhen Hospital Beijing, China
| | - Xiaohui Liu
- Department of Cardiology, Capital Medical University, Beijing Anzhen Hospital Beijing, China
| | - Jianzeng Dong
- Department of Cardiology, Capital Medical University, Beijing Anzhen Hospital Beijing, China
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Higher hemoglobin A1c levels are associated with impaired left ventricular diastolic function and higher incidence of adverse cardiac events in patients with nonischemic dilated cardiomyopathy. Heart Vessels 2016; 32:446-457. [PMID: 27672077 DOI: 10.1007/s00380-016-0895-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Accepted: 09/16/2016] [Indexed: 01/06/2023]
Abstract
We aimed to elucidate the relationship between glycated hemoglobin (HbA1c), cardiac systolic/diastolic function, and heart failure (HF) prognosis during guideline-directed medical therapy in patients with nonischemic dilated cardiomyopathy (NIDCM). We evaluated 283 hospitalized NIDCM patients, who were grouped according to baseline (BL) and 1-year (1Y) levels of HbA1c (<6.0, 6.0-6.9, and ≥7.0 %). The primary endpoint was defined as either readmission for HF worsening or cardiac death. Approximately half of the patients had BL- or 1Y-HbA1c ≥6.0 % (31 % at BL, 34 % at 1Y had 6.0-6.9 %; 12 % at BL, 12 % at 1Y had ≥7.0 %). The absolute value of left ventricular ejection fraction (LVEF) and its improvement during 1 year showed no significant difference among the 1Y-HbA1c groups (p = 0.273), whereas a lower absolute value and a more significant reduction in the early diastolic velocity of the mitral annulus (E a) were seen in the group with 1Y-HbA1c ≥7.0 % (both p < 0.001). In multiple regression analysis, higher 1Y-plasma B-type natriuretic peptide and lower 1Y-Ea were independently associated with higher 1Y-HbA1c (both adjusted p < 0.05). The cumulative incidence of the primary endpoint was highest in the group with 1Y-HbA1c ≥7.0 % (log-rank p = 0.001). Multivariate analysis demonstrated that higher 1Y-HbA1c was independently associated with a higher incidence of the primary endpoint (adjusted p = 0.005). In conclusion, hyperglycemia during clinical follow-up is a risk factor for progression of concomitant LV abnormal relaxation, leading to poor HF prognosis in patients with NIDCM.
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Oki T, Miyoshi H, Oishi Y, Mizuguchi Y, Iuchi A, Yamada H, Nakatani S. Challenges for 'diastology': contributions from Japanese researchers. J Echocardiogr 2016; 14:93-103. [PMID: 27539160 DOI: 10.1007/s12574-016-0307-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Accepted: 07/29/2016] [Indexed: 01/08/2023]
Abstract
Diastology is a study to treat diastole of the heart. Transmitral flow and pulmonary venous flow velocities recorded by pulsed Doppler echocardiography provide more important information about left ventricular (LV) diastolic dysfunction [left atrial (LA)-LV coupling] than cardiac catheterization in clinical practice; however, these waveforms are influenced by loading conditions, particularly preload. The early diastolic mitral annular and LV wall motion indices measured by tissue Doppler echocardiography can evaluate LV relaxation abnormality and filling pressure by being relatively preload independent. In addition, the role of concomitant systolic longitudinal dysfunction is well characterized in asymptomatic patients and in patients with heart failure and preserved ejection fraction. Two-dimensional speckle tracking echocardiography is an angle-independent method, and has the potential to evaluate the contraction and relaxation abnormalities in the longitudinal, circumferential, and radial directions of the LV myocardium as well as LV torsion/untwisting and, moreover, deformation of the LA myocardium and large arterial wall. As a result, this new technique can facilitate the early detection of impaired LA-LV-arterial coupling in patients before occurrence of overt heart failure symptoms.
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Affiliation(s)
- Takashi Oki
- Cardiovascular Section, Higashi Tokushima Medical Center, National Hospital Organization, Tokushima, Japan.
| | - Hirokazu Miyoshi
- Cardiovascular Section, Higashi Tokushima Medical Center, National Hospital Organization, Tokushima, Japan
| | - Yoshifumi Oishi
- Cardiovascular Section, Higashi Tokushima Medical Center, National Hospital Organization, Tokushima, Japan
| | - Yukio Mizuguchi
- Cardiovascular Section, Higashi Tokushima Medical Center, National Hospital Organization, Tokushima, Japan
| | - Arata Iuchi
- Cardiovascular Section, Higashi Tokushima Medical Center, National Hospital Organization, Tokushima, Japan
| | - Hirotsugu Yamada
- Department of Cardiovascular Medicine, Tokushima University Hospital, Tokushima, Japan
| | - Satoshi Nakatani
- Division of Functional Diagnostics, Department of Health Sciences, Osaka University Graduate School of Medicine, Osaka, Japan
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Zhu YS, Li YL, Ju JQ, Du F, Zang YP, Wang XB, Sheng J. Oral Chinese Herbal Medicine for Treatment of Dilated Cardiomyopathy: A Systematic Review and Meta-Analysis. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE : ECAM 2016; 2016:1819794. [PMID: 27630730 PMCID: PMC5007314 DOI: 10.1155/2016/1819794] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Revised: 06/29/2016] [Accepted: 07/06/2016] [Indexed: 11/18/2022]
Abstract
Dilated cardiomyopathy (DCM) is one of the main causes of heart failure and could increase death, hospitalization, and rehospitalization rate. The effect of conventional medicine treatment (CMT) is limited; meanwhile, the combination of CMT and Oral Chinese Herbal Medicine (OCHM) represents exciting adjunctive therapies. In this study, we ascertained the therapeutic effect of OCHM in combination with CMT for dilated cardiomyopathy by using meta-analysis methods for controlled clinical trials. We searched studies from five databases and extracted data from these studies. We also assessed the methodological quality of the included studies. We evaluated the following outcome measures to estimate the prognosis in patients with DCM: left ventricular ejection fraction (LVEF), left ventricular end-diastolic dimension (LVEDD), stroke volume (SV), brain natriuretic peptide (BNP), 6-minute walk test (6MWT), and overall efficacy. The result showed that OCHM combined with CMT for the improvement of therapeutic effect in DCM patients. However, the evidence remains weak due to the small sample size, high clinical heterogeneity, and poor methodological quality of the included trials. Further, large sample size and well-designed trials are needed.
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Affiliation(s)
- Yu-Shuo Zhu
- Traditional Chinese Medicine Clinical Research Base for Hypertension, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, No. 42, Wenhua Xi Road, Jinan, Shandong 250011, China
- Shandong University of Traditional Chinese Medicine, Jinan, Shandong 250355, China
| | - Yun-Lun Li
- Traditional Chinese Medicine Clinical Research Base for Hypertension, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, No. 42, Wenhua Xi Road, Jinan, Shandong 250011, China
- Shandong University of Traditional Chinese Medicine, Jinan, Shandong 250355, China
| | - Jian-Qing Ju
- Traditional Chinese Medicine Clinical Research Base for Hypertension, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, No. 42, Wenhua Xi Road, Jinan, Shandong 250011, China
- Shandong University of Traditional Chinese Medicine, Jinan, Shandong 250355, China
| | - Feng Du
- Shandong University of Traditional Chinese Medicine, Jinan, Shandong 250355, China
| | - Yan-Ping Zang
- Shandong University of Traditional Chinese Medicine, Jinan, Shandong 250355, China
| | - Xiao-Bing Wang
- Shandong University of Traditional Chinese Medicine, Jinan, Shandong 250355, China
| | - Jie Sheng
- Shandong University of Traditional Chinese Medicine, Jinan, Shandong 250355, China
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Gupta A, Sharma P, Bahl A. Left ventricular size as a predictor of outcome in patients of non-ischemic dilated cardiomyopathy with severe left ventricular systolic dysfunction. Int J Cardiol 2016; 221:310-3. [PMID: 27404697 DOI: 10.1016/j.ijcard.2016.07.090] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Accepted: 07/04/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Limited data is available regarding prognosis of patients with severe left ventricular (LV) systolic dysfunction and varying LV dimensions. Purpose of this study was to compare outcomes of patients with non-ischemic dilated cardiomyopathy (DCM) with respect to LV size. METHODS 145 patients of DCM cohort with LV ejection fraction <35% were divided into 3 groups. Group 1 with normal LV dimensions, group 2 with mild-moderately enlarged left ventricle and group 3 with severely dilated left ventricle. Primary endpoint was composite of all cause mortality and heart failure hospitalizations at end of follow-up. RESULTS Forty-four patients (30.3%) with normal LV diastolic diameter (51.9±5.3mm) were included in group 1, 57(39.3%) with mild-moderately enlarged LV (61.4±3.7mm) in group 2 and 44(30.3%) with severely enlarged LV (71.3±7.4mm) in group 3. Mean follow-up was 42.2±31.6months. Primary end point occurred in 4 patients (9.1%) in group 1, 8 patients (14%) in group 2 and 9 patients (20.5%) in group 3, p=0.23 by log-rank test. Hazard ratio for primary endpoint in group 2 as compared to group 1 was 1.71(95% CI, 0.51 to 5.67; p=0.39) and in group 3 as compared to group 1 was 1.61(95% CI, 0.89 to 2.91; p=0.11). Of patients with more than two years of follow-up, 2 of 29 patients(6.9%) died in group 1, 3 of 35 patients(8.6%) in group 2 and 3 of 34 patients(8.8%) died in group 3, p=0.95. CONCLUSIONS Intermediate term prognosis of patients with severe LVSD and severely dilated left ventricle is good, with outcomes similar to patients with normal or mild-moderately dilated left ventricle.
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Affiliation(s)
- Ankur Gupta
- Department of Cardiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Prafull Sharma
- Department of Cardiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ajay Bahl
- Department of Cardiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India.
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Riffel JH, Keller MGP, Rost F, Arenja N, Andre F, Aus dem Siepen F, Fritz T, Ehlermann P, Taeger T, Frankenstein L, Meder B, Katus HA, Buss SJ. Left ventricular long axis strain: a new prognosticator in non-ischemic dilated cardiomyopathy? J Cardiovasc Magn Reson 2016; 18:36. [PMID: 27268238 PMCID: PMC4897821 DOI: 10.1186/s12968-016-0255-0] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Accepted: 05/27/2016] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Long axis strain (LAS) has been shown to be a fast assessable parameter representing global left ventricular (LV) longitudinal function in cardiovascular magnetic resonance (CMR). However, the prognostic value of LAS in cardiomyopathies with reduced left ventricular ejection fraction (LVEF) has not been evaluated yet. METHODS AND RESULTS In 146 subjects with non-ischemic dilated cardiomyopathy (NIDCM, LVEF ≤45 %) LAS was assessed retrospectively from standard non-contrast SSFP cine sequences by measuring the distance between the epicardial border of the left ventricular apex and the midpoint of a line connecting the origins of the mitral valve leaflets in end-systole and end-diastole. The final values were calculated according to the strain formula. The primary endpoint of the study was defined as a combination of cardiac death, heart transplantation or aborted sudden cardiac death and occurred in 24 subjects during follow-up. Patients with LAS values > -5 % showed a significant higher rate of cardiac events independent of the presence of late gadolinium enhancement (LGE). The multivariate Cox regression analysis revealed that LVEDV/BSA (HR: 1.01, p < 0.05), presence of LGE (HR: 2.51, p < 0.05) and LAS (HR: 1.28, p < 0.05) were independent predictors for cardiac events. In a sequential cox regression analysis LAS offered significant incremental information (p < 0.05) for the prediction of outcome in addition to LGE and LVEDV/BSA. Using a dichotomous three point scoring model for risk stratification, including LVEF <35 %, LAS > -10 % and the presence of LGE, patients with 3 points had a significantly higher risk for cardiac events than those with 2 or less points. CONCLUSION Assessment of long axis function with LAS offers significant incremental information for the prediction of cardiac events in NIDCM and improves risk stratification beyond established CMR parameters.
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MESH Headings
- Adult
- Aged
- Biomechanical Phenomena
- Cardiomyopathy, Dilated/diagnostic imaging
- Cardiomyopathy, Dilated/etiology
- Cardiomyopathy, Dilated/physiopathology
- Cardiomyopathy, Dilated/surgery
- Chi-Square Distribution
- Contrast Media/administration & dosage
- Death, Sudden, Cardiac/etiology
- Female
- Heart Transplantation
- Humans
- Kaplan-Meier Estimate
- Magnetic Resonance Imaging, Cine
- Male
- Middle Aged
- Mitral Valve/diagnostic imaging
- Mitral Valve/physiopathology
- Multivariate Analysis
- Observer Variation
- Predictive Value of Tests
- Prognosis
- Proportional Hazards Models
- Reproducibility of Results
- Retrospective Studies
- Risk Assessment
- Risk Factors
- Stroke Volume
- Time Factors
- Ventricular Dysfunction, Left/diagnostic imaging
- Ventricular Dysfunction, Left/etiology
- Ventricular Dysfunction, Left/physiopathology
- Ventricular Dysfunction, Left/surgery
- Ventricular Function, Left
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Affiliation(s)
- Johannes H Riffel
- Department of Cardiology, University of Heidelberg, INF 410, 69120, Heidelberg, Germany
| | - Marius G P Keller
- Department of Cardiology, University of Heidelberg, INF 410, 69120, Heidelberg, Germany
| | - Franziska Rost
- Department of Cardiology, University of Heidelberg, INF 410, 69120, Heidelberg, Germany
| | - Nisha Arenja
- Department of Cardiology, University of Heidelberg, INF 410, 69120, Heidelberg, Germany
| | - Florian Andre
- Department of Cardiology, University of Heidelberg, INF 410, 69120, Heidelberg, Germany
| | - Fabian Aus dem Siepen
- Department of Cardiology, University of Heidelberg, INF 410, 69120, Heidelberg, Germany
| | - Thomas Fritz
- Department of Cardiology, University of Heidelberg, INF 410, 69120, Heidelberg, Germany
| | - Philipp Ehlermann
- Department of Cardiology, University of Heidelberg, INF 410, 69120, Heidelberg, Germany
| | - Tobias Taeger
- Department of Cardiology, University of Heidelberg, INF 410, 69120, Heidelberg, Germany
| | - Lutz Frankenstein
- Department of Cardiology, University of Heidelberg, INF 410, 69120, Heidelberg, Germany
| | - Benjamin Meder
- Department of Cardiology, University of Heidelberg, INF 410, 69120, Heidelberg, Germany
- DZHK (German Centre for Cardiovascular Research), partner site, Heidelberg, Germany
| | - Hugo A Katus
- Department of Cardiology, University of Heidelberg, INF 410, 69120, Heidelberg, Germany
- DZHK (German Centre for Cardiovascular Research), partner site, Heidelberg, Germany
| | - Sebastian J Buss
- Department of Cardiology, University of Heidelberg, INF 410, 69120, Heidelberg, Germany.
- Department of Cardiology, Angiology and Pneumology, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.
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