Systolic and diastolic dysfunction in patients with clinical diagnosis of dilated cardiomyopathy. Relation to symptoms and prognosis

Prognostic value of diastolic wall strain in patients with chronic heart failure with reduced ejection fraction

Left ventricular (LV) diastolic dysfunction plays a crucial role in heart failure with reduced ejection fraction (HFrEF). LV stiffness is a main component of diastolic function, but its role and prognostic value in HFrEF patients remains unclear. This study aimed to determine whether diastolic wall strain (DWS) as a noninvasive and simple marker of LV stiffness can predict the prognosis of HFrEF patients who were administrated chronic beta blockade enough. We enrolled 75 HFrEF patients who were administrated chronic beta blockade. We evaluated the echocardiographic parameters and plasma brain natriuretic peptide (BNP) before the induction of beta blockade and also obtained pulmonary artery wedge pressure (PAWP) from the right heart catheterization. DWS was obtained from standard M-mode echocardiography as follows: DWS = [(LV posterior wall thickness (LVPWT) at end-systole - LVPWT at end-diastole)/LVPWT] at end-systole. DWS did not correlate with other echocardiographic parameters and PAWP. We defined primary outcome as HF hospitalization or cardiovascular death and followed for 7 years. The incidence rate was higher in low DWS than high DWS patients (p = 0.04). Other echocardiographic parameters could not be significant predictors of HFrEF outcome under the condition of enough beta blocker therapy. In multivariate analysis, DWS was the independent contributor to the event-free time. Impaired LV stiffness evaluated with DWS was associated with worse outcome and DWS might be an independent prognostic factor in HFrEF patients with chronic beta blockade.

Cardiovascular Imaging in the Electrophysiology Laboratory

In recent years, rapid technological advances have allowed the development of new electrophysiological procedures that would not have been possible without the parallel development of imaging techniques used to plan and guide these procedures and monitor their outcomes. Ablation of atrial fibrillation is among the interventions with the greatest need for imaging support. Echocardiography allows the appropriate selection of patients and the detection of thrombi that would contraindicate the intervention; cardiac magnetic resonance imaging and computed tomography are also essential in planning this procedure, by allowing a detailed anatomical study of the pulmonary veins. In addition, in cardiac resynchronization therapy, echocardiography plays a central role in both patient selection and, later, in device adjustment and in assessing the effectiveness of the technique. More recently, ablation of ventricular tachycardias has been established as a treatment option; this would not be possible without planning using an imaging study such as cardiac magnetic resonance imaging of myocardial scarring.

Systolic-diastolic functional coupling in healthy children and in those with dilated cardiomyopathy

Systolic and diastolic function affect dilated cardiomyopathy (DCM) outcomes. However, systolic-diastolic coupling, as a distinct characteristic, may itself affect function but is poorly characterized. We hypothesized that echocardiographic left ventricular (LV) longitudinal systolic tissue velocities (S') correlate with diastolic longitudinal velocities (E') and that their relationship is associated with ventricular function and that this relationship is impaired in pediatric DCM. We analyzed data from the Pediatric Heart Network Ventricular Volume Variability study, using linear regression and generalized additive modeling to assess relationships between S' and E' at the lateral and septal mitral annulus. We explored relationships between the systolic:diastolic (S:D) coupling ratio (S':E' relative to age) and ventricular function. Up to 4 echocardiograms from 130 DCM patients (mean age: 9.3 ± 6.1 yr) and 1 echocardiogram from each of 591 healthy controls were analyzed. S' and E' were linearly related in controls (r = 0.64, P < 0.001) and DCM (r = 0.83, P < 0.001). In DCM, the magnitude of association between S' and E' was reduced with progressive ventricular remodeling. The S:D ratio was more strongly associated with LV function in controls vs. DCM. The septal S:D ratio was higher (presumed worse) in DCM vs. controls (0.69 ± 0.13 vs. 0.62 ± 0.12, P = 0.001). A higher septal S:D ratio was associated with worse LV dimensions (parameter estimate: 0.0061, P = 0.004), mass (parameter estimate: 0.0074, P = 0.002), ejection fraction (parameter estimate: -0.0303, P = 0.024), and inflow propagation (parameter estimate: -0.3538, P < .001). S:D coupling becomes weaker in DCM with LV remodeling and dysfunction. The S:D coupling ratio may be useful to assess coupling, warranting study in relation to patient outcomes.

Red cell distribution width (RDW) correlates with markers of diastolic dysfunction in patients with impaired left ventricular systolic function

Objective

Red-cell distribution width (RDW) has been identified as a novel prognostic marker in a heterogeneous group of heart failure patients. In this group, diastolic dysfunction is associated with worse outcome. As the evidence is limited, the aim of the present study was to assess the relationship of RDW to diastolic markers in patients with left ventricular dysfunction (LVD) diagnosed during cardiac catheterization.

Methods

Clinical and angiographic data were collected retrospectively on a total of 291 stable patients (mean age 62 years, 199 males) with systolic dysfunction documented during cardiac catheterization in a regional medical center between January 2006 and December 2010.

Results

Positive association was seen between RDW and Left ventricular end diastolic pressure (LVEDP), estimated systolic pulmonary arterial pressure(sPAP), and left atrial dimension (LAD) (r: 0.18, 0.24, 0.28, respectively; p:<0.05).Three year retrospective survival analysis for 108 patients admitted in the first 2 years showed a statistically significant decrease in survival patients with high RDW(> 14.5) vs. normal RDW (73%vs.88%;log rank p:0.03). This was seen even in the asymptomatic subgroup (71% vs. 94%; log rank p: 0.01).

Conclusion

RDW correlates with markers of diastolic dysfunction in patients with LVD. Additionally, in patients asymptomatic LVD, high RDW is still associated with lower survival.

Relationship between Myocardial Extracellular Space Expansion Estimated with Post-Contrast T1 Mapping MRI and Left Ventricular Remodeling and Neurohormonal Activation in Patients with Dilated Cardiomyopathy

OBJECTIVE

Post-contrast T1 values are closely related to the degree of myocardial extracellular space expansion. We determined the relationship between post-contrast T1 values and left ventricular (LV) diastolic function, LV remodeling, and neurohormonal activation in patients with dilated cardiomyopathy (DCM).

MATERIALS AND METHODS

Fifty-nine patients with DCM (mean age, 55 ± 15 years; 41 males and 18 females) who underwent both 1.5T magnetic resonance imaging and echocardiography were enrolled. The post-contrast 10-minute T1 value was generated from inversion time scout images obtained using the Look-Locker inversion recovery sequence and a curve-fitting algorithm. The T1 sample volume was obtained from three interventricular septal points, and the mean T1 value was used for analysis. The N-Terminal pro-B-type natriuretic peptide (NT-proBNP) level was measured in 40 patients.

RESULTS

The mean LV ejection fraction was 24 ± 9% and the post-T1 value was 254.5 ± 46.4 ms. The post-contrast T1 value was significantly correlated with systolic longitudinal septal velocity (s'), peak late diastolic velocity of the mitral annulus (a'), the diastolic elastance index (Ed, [E/e']/stroke volume), LV mass/volume ratio, LV end-diastolic wall stress, and LV end-systolic wall stress. In a multivariate analysis without NT-proBNP, T1 values were independently correlated with Ed (β = -0.351, p = 0.016) and the LV mass/volume ratio (β = 0.495, p = 0.001). When NT-proBNP was used in the analysis, NT-proBNP was independently correlated with the T1 values (β = -0.339, p = 0.017).

CONCLUSION

Post-contrast T1 is closely related to LV remodeling, diastolic function, and neurohormonal activation in patients with DCM.

Clinical characteristics and outcomes of patients with and without diabetes in the Surgical Treatment for Ischemic Heart Failure (STICH) trial

AIMS

Hypothesis 1 of the Surgical Treatment for Ischemic Heart Failure (STICH) trial enrolled 1212 patients with an LVEF of ≤35% and CAD amenable to coronary artery bypass grafting (CABG). Patients were randomized to CABG and optimal medical therapy (MED) or MED alone. The objective was to assess whether or not patients with diabetes mellitus (DM) enrolled in the STICH trial would have greater benefit from CABG than patients without DM.

METHODS AND RESULTS

The characteristics and clinical outcomes of patients with and without DM randomized to CABG and MED or MED alone were compared. DM was present in 40%. At baseline, patients with DM had more triple vessel CAD, higher LVEF, and smaller left ventricular volumes. In patients with DM, the primary outcome of all-cause mortality occurred in 39% of patients in the MED group and 39% in the CABG group [hazard ratio (HR) with CABG 0.96, 95% confidence interval (CI) 0.73-1.26]. In patients without DM, the primary outcome occurred in 41% of patients in the MED group and 32% in the CABG group (HR with CABG 0.80, 95% CI 0.63-1.02). While numerically it would appear that the treatment effect of CABG is blunted in patients with DM, there was no significant interaction between DM and treatment group on formal statistical testing.

CONCLUSIONS

Patients with DM enrolled in the STICH trial had more triple vessel disease, smaller hearts, and higher LVEF than those without DM. CABG did not exert greater benefit in patients with DM.

Induction of Ankrd1 in Dilated Cardiomyopathy Correlates with the Heart Failure Progression

Progression of idiopathic dilated cardiomyopathy (IDCM) is marked with extensive left ventricular remodeling whose clinical manifestations and molecular basis are poorly understood. We aimed to evaluate the clinical potential of titin ligands in monitoring progression of cardiac remodeling associated with end-stage IDCM. Expression patterns of 8 mechanoptotic machinery-associated titin ligands (ANKRD1, ANKRD2, TRIM63, TRIM55, NBR1, MLP, FHL2, and TCAP) were quantitated in endomyocardial biopsies from 25 patients with advanced IDCM. When comparing NYHA disease stages, elevated ANKRD1 expression levels marked transition from NYHA < IV to NYHA IV. ANKRD1 expression levels closely correlated with systolic strain depression and short E wave deceleration time, as determined by echocardiography. On molecular level, myocardial ANKRD1 and serum adiponectin correlated with low BAX/BCL-2 ratios, indicative of antiapoptotic tissue propensity observed during the worsening of heart failure. ANKRD1 is a potential marker for cardiac remodeling and disease progression in IDCM. ANKRD1 expression correlated with reduced cardiac contractility and compliance. The association of ANKRD1 with antiapoptotic response suggests its role as myocyte survival factor during late stage heart disease, warranting further studies on ANKRD1 during end-stage heart failure.

Assessment of global longitudinal strain using standardized myocardial deformation imaging: a modality independent software approach

BACKGROUND

Myocardial deformation measurement is superior to left ventricular ejection fraction in identifying early changes in myocardial contractility and prediction of cardiovascular outcome. The lack of standardization hinders its clinical implementation. The aim of the study is to investigate a novel standardized deformation imaging approach based on the feature tracking algorithm for the assessment of global longitudinal (GLS) and global circumferential strain (GCS) in echocardiography and cardiac magnetic resonance imaging (CMR).

METHODS

70 subjects undergoing CMR were consecutively investigated with echocardiography within a median time of 30 min. GLS and GCS were analyzed with a post-processing software incorporating the same standardized algorithm for both modalities. Global strain was defined as the relative shortening of the whole endocardial contour length and calculated according to the strain formula.

RESULTS

Mean GLS values were -16.2 ± 5.3 and -17.3 ± 5.3 % for echocardiography and CMR, respectively. GLS did not differ significantly between the two imaging modalities, which showed strong correlation (r = 0.86), a small bias (-1.1 %) and narrow 95 % limits of agreement (LOA ± 5.4 %). Mean GCS values were -17.9 ± 6.3 and -24.4 ± 7.8 % for echocardiography and CMR, respectively. GCS was significantly underestimated by echocardiography (p < 0.001). A weaker correlation (r = 0.73), a higher bias (-6.5 %) and wider LOA (± 10.5 %) were observed for GCS. GLS showed a strong correlation (r = 0.92) when image quality was good, while correlation dropped to r = 0.82 with poor acoustic windows in echocardiography. GCS assessment revealed only a strong correlation (r = 0.87) when echocardiographic image quality was good. No significant differences for GLS between two different echocardiographic vendors could be detected.

CONCLUSIONS

Quantitative assessment of GLS using a standardized software algorithm allows the direct comparison of values acquired irrespective of the imaging modality. GLS may, therefore, serve as a reliable parameter for the assessment of global left ventricular function in clinical routine besides standard evaluation of the ejection fraction.

Left ventricular diastolic function in hypertension: methodological considerations and clinical implications

The assessment of left ventricular (LV) diastolic function should be an integral part of a routine examination of hypertensive patient; indeed when LV diastolic function is impaired, it is possible to have heart failure even with preserved LV ejection fraction. Left ventricular diastolic dysfunction (LVDD) occurs frequently and is associated to heart disease. Doppler echocardiography is the best tool for early LVDD diagnosis. Hypertension affects LV relaxation and when left ventricular hypertrophy (LVH) occurs, it decreases compliance too, so it is important to calculate Doppler echocardiography parameters, for diastolic function evaluation, in all hypertensive patients. The purpose of our review was to discuss about the strong relationship between LVDD and hypertension, and their relationship with LV systolic function. Furthermore, we aimed to assess the relationship between the arterial stiffness and LV structure and function in hypertensive patients.

Prognostic impact of combined late gadolinium enhancement on cardiovascular magnetic resonance and peak oxygen consumption in ambulatory patients with nonischemic dilated cardiomyopathy

BACKGROUND

Peak oxygen consumption (peak VO₂) and late gadolinium enhancement (LGE) on cardiovascular magnetic resonance (CMR) are prognostic in heart failure. We investigated whether LGE-CMR and peak VO₂combined had additive value in risk stratifying patients with nonischemic dilated cardiomyopathy (DCM).

METHODS AND RESULTS

Fifty-seven DCM patients underwent CMR and cardiopulmonary exercise testing. Cardiac events were cardiac death, hospitalization for decompensated heart failure, or lethal arrhythmia. Twenty-five (44%) were LGE-positive. The median peak VO₂was 18.5 mL·kg(-1)·min(-1). On multivariate analysis, positive LGE (P = .048) and peak VO₂(P = .003) were independent cardiac event predictors. Cardiac event risk was significantly higher with positive LGE and peak VO₂< 18.5 mL ·kg⁻¹ ·min⁻¹ than with negative LGE and peak VO₂≥ 18.5 mL · kg⁻¹ · min⁻¹ (hazard ratio 12.5; 95% CI 1.57-100; P = .017). In 3 patient groups (group A: no LGE, peak VO₂≥ 18.5 mL · kg⁻¹ · min⁻¹, n = 18; group B: positive LGE or peak VO₂< 18.5 mL · kg⁻¹ · min⁻¹, n = 24; group C: positive LGE and peak VO₂< 18.5 mL · kg⁻¹ · min⁻¹, n = 15) during follow-up (71 ± 32 months), group C had higher cardiac event rates than the others.

CONCLUSIONS

Combined assessment of LGE-CMR and peak VO₂provides additive prognostic information in ambulatory DCM.

Acute improvement of left ventricular relaxation as a predictor of volume reduction after cardiac resynchronization therapy: a pilot study assessing the value of left ventricular hemodynamic parameter

BACKGROUND

Cardiac resynchronization therapy (CRT) improves cardiac function, but CRT recipients with advanced heart failure (HF) do not always respond well. Because the best parameters for the prediction of CRT response are not established, we investigated whether improvement of invasive left ventricular (LV) hemodynamic diastolic parameters could identify CRT responders.

METHODS

A total of 34 consecutive patients (age, 69 ± 9 years; 70% men) who received CRT devices for HF were assessed as to whether acute invasive hemodynamic parameters with and without CRT function could predict LV volume responders.

RESULTS

These patients demonstrated an improvement in LV dP/dtmax (11.1 ± 11.7%), LV dP/dtmin (4.6 ± 12.1%), and tau (3.7 ± 11.6%) by biventricular pacing. Nineteen patients (55%) were classified as CRT responders, which was defined by a >15% decrease in LV end-systolic volume (ESV) at the 6-month follow-up evaluation. The area under the receiver operator characteristic curve to detect CRT volume response was 0.93 for the shortening of tau, which was superior to any other hemodynamic parameter. The multivariate analysis revealed that this improvement in tau was the strongest predictive factor for identifying CRT volume responders. Of note, the magnitude of tau shortening during biventricular pacing was significantly correlated with the reduction in LVESV at the 6-month follow-up evaluation.

CONCLUSIONS

The extent of acute improvement in LV isovolumic relaxation time, as assessed by tau, was associated with favorable response to CRT. The assessment of invasive diastolic function could provide valuable information about CRT volume response.

Cardiac I123-MIBG correlates better than ejection fraction with symptoms severity in systolic heart failure

Background

The association of autonomic activation, left ventricular ejection fraction (LVEF) and heart failure functional class is poorly understood.

Objective

Our aim was to correlate symptom severity with cardiac sympathetic activity, through iodine-123-metaiodobenzylguanidine (¹²³I-MIBG) scintigraphy and with LVEF in systolic heart failure (HF) patients without previous beta-blocker treatment.

Methods

Thirty-one patients with systolic HF, class I to IV of the New York Heart Association (NYHA), without previous beta-blocker treatment, were enrolled and submitted to ¹²³I-MIBG scintigraphy and to radionuclide ventriculography for LVEF determination. The early and delayed heart/mediastinum (H/M) ratio and the washout rate (WR) were performed.

Results

According with symptom severity, patients were divided into group A, 13 patients in NYHA class I/II, and group B, 18 patients in NYHA class III/IV. Compared with group B patients, group A had a significantly higher LVEF (25% ± 12% in group B vs. 32% ± 7% in group A, p = 0.04). Group B early and delayed H/M ratios were lower than group A ratios (early H/M 1.49 ± 0.15 vs. 1.64 ± 0.14, p = 0.02; delayed H/M 1.39 ± 0.13 vs. 1.58 ± 0.16, p = 0.001, respectively). WR was significantly higher in group B (36% ± 17% vs. 30% ± 12%, p= 0.04). The variable that showed the best correlation with NYHA class was the delayed H/M ratio (r= -0.585; p=0.001), adjusted for age and sex.

Conclusion

This study showed that cardiac ¹²³I-MIBG correlates better than ejection fraction with symptom severity in systolic heart failure patients without previous beta-blocker treatment.

Do optimal prognostic thresholds in continuous physiological variables really exist? Analysis of origin of apparent thresholds, with systematic review for peak oxygen consumption, ejection fraction and BNP

Background

Clinicians are sometimes advised to make decisions using thresholds in measured variables, derived from prognostic studies.

Objectives

We studied why there are conflicting apparently-optimal prognostic thresholds, for example in exercise peak oxygen uptake (pVO₂), ejection fraction (EF), and Brain Natriuretic Peptide (BNP) in heart failure (HF).

Data Sources and Eligibility Criteria

Studies testing pVO₂, EF or BNP prognostic thresholds in heart failure, published between 1990 and 2010, listed on Pubmed.

Methods

First, we examined studies testing pVO₂, EF or BNP prognostic thresholds. Second, we created repeated simulations of 1500 patients to identify whether an apparently-optimal prognostic threshold indicates step change in risk.

Results

33 studies (8946 patients) tested a pVO₂ threshold. 18 found it prognostically significant: the actual reported threshold ranged widely (10–18 ml/kg/min) but was overwhelmingly controlled by the individual study population's mean pVO₂ (r = 0.86, p<0.00001). In contrast, the 15 negative publications were testing thresholds 199% further from their means (p = 0.0001). Likewise, of 35 EF studies (10220 patients), the thresholds in the 22 positive reports were strongly determined by study means (r = 0.90, p<0.0001). Similarly, in the 19 positives of 20 BNP studies (9725 patients): r = 0.86 (p<0.0001).

Second, survival simulations always discovered a “most significant” threshold, even when there was definitely no step change in mortality. With linear increase in risk, the apparently-optimal threshold was always near the sample mean (r = 0.99, p<0.001).

Limitations

This study cannot report the best threshold for any of these variables; instead it explains how common clinical research procedures routinely produce false thresholds.

Key Findings

First, shifting (and/or disappearance) of an apparently-optimal prognostic threshold is strongly determined by studies' average pVO₂, EF or BNP. Second, apparently-optimal thresholds always appear, even with no step in prognosis.

Conclusions

Emphatic therapeutic guidance based on thresholds from observational studies may be ill-founded. We should not assume that optimal thresholds, or any thresholds, exist.

The role of echocardiography in the diagnosis and prognosis of patients with heart failure

The number of patients with congestive heart failure has increased in epidemic proportions. Echocardiography plays an important role in the diagnosis and management of these patients. Recent studies have also confirmed the independent prognostic information of the echocardiographic findings.

Evaluating the hemodynamical response of a cardiovascular system under support of a continuous flow left ventricular assist device via numerical modeling and simulations

Dilated cardiomyopathy is the most common type of the heart failure which can be characterized by impaired ventricular contractility. Mechanical circulatory support devices were introduced into practice for the heart failure patients to bridge the time between the decision to transplant and the actual transplantation which is not sufficient due to the state of donor organ supply. In this study, the hemodynamic response of a cardiovascular system that includes a dilated cardiomyopathic heart under support of a newly developed continuous flow left ventricular assist device—Heart Turcica Axial—was evaluated employing computer simulations. For the evaluation, a numerical model which describes the pressure-flow rate relations of Heart Turcica Axial, a cardiovascular system model describing the healthy and pathological hemodynamics, and a baroreflex model regulating the heart rate were used. Heart Turcica Axial was operated between 8000 rpm and 11000 rpm speeds with 1000 rpm increments for assessing the pump performance and response of the cardiovascular system. The results also give an insight about the range of the possible operating speeds of Heart Turcica Axial in a clinical application. Based on the findings, operating speed of Heart Turcica Axial should be between 10000 rpm and 11000 rpm.

Relationship between clinically assessed heart failure severity and the Tei index in Nigerian patients

Background

The Tei index is a Doppler-derived myocardial performance index. It is a measure of the combined systolic and diastolic myocardial performance of both the left and right ventricles. The incidence of heart failure (HF) is increasing globally, and its severity can be clinically assessed using the New York Heart Association (NYHA) functional classification and more objectively using echocardiographic assessment of systolic and diastolic functions. Thus, a measure of the combined systolic and diastolic myocardial performance could be a useful predictor of the severity of the clinical status of patients with HF.

Results

Seventy-five newly presenting patients with HF of NYHA class II to IV and 60 normal controls were consecutively recruited. Using conventional two-dimensional and Doppler echocardiography techniques, the left ventricular parameters assessed were the isovolumic relaxation time (IVRT), isovolumic contraction time (IVCT), ejection time (ET), ejection fraction (EF), and end-diastolic volume (EDV). The Tei index was determined using the formula IVCT + IVRT/ET. The mean Tei index of patients was significantly higher than that of controls (0.884 ± 0.321 vs. 0.842 ± 0.14; p < 0.001). The Tei index ranged from 0.33 to 1.94 in patients and from 0.56 to 1.24 in controls. The mean EF was lower in patients than in controls (50.47% ± 19.01% vs. 68.35% ± 7.75%; p = 0.001). The mean EDV was higher in patients than in controls (171.39 ± 100.96 vs. 94.15 ± 28.54; p < 0.001). Comparison of the mean Tei indices of patients with HF of NYHA classes II, III, and IV showed statistically significant differences among all three groups (p < 0.001).

Conclusions

The Tei index seems to be a clinically relevant indicator of cardiac function. It is reflective of the severity of HF as clinically assessed using the NYHA functional classification in patients with HF.

Left ventricular diastolic function and long-term outcomes in patients with normal exercise echocardiographic findings

The objective of the present study was to determine whether diastolic dysfunction (DD) is associated with outcomes in the absence of myocardial ischemia. We studied 2,835 patients undergoing exercise echocardiography from January 2006 through December 2006 who had normal systolic function (ejection fraction ≥50%) and an absence of exercise-induced wall motion abnormalities. Diastolic function was graded as normal, mild DD, or moderate to severe DD. Medical records review and patient contact were undertaken to determine mortality, cardiovascular events (i.e., death, myocardial infarction, or stroke), incident heart failure (HF), and hospitalization. The mean ± SD age was 58.9 ± 12.8 years, and 54.0% were women. DD was present in 40.0% of the participants, with mild DD in 28.2% and moderate to severe DD in 11.8%. During a median follow-up of 4.4 years, 81 deaths and 114 cardiovascular events occurred, and DD was associated with greater rates of mortality, cardiovascular events, and HF events or hospitalizations (all p <0.001). On multivariate analysis, mild or moderate to severe DD (referent, normal function) was associated with HF or hospitalization (hazard ratio 1.45, 95% confidence interval 1.18 to 1.78, p <0.001 for mild DD; hazard ratio 1.75, 95% confidence interval 1.37 to 2.24, p <0.001 for moderate to severe DD) but was not independently associated with death or cardiovascular events. The diastolic index of filling pressure (E/e') was independently associated with mortality, cardiovascular events, and HF or hospitalization. In conclusion, among patients without demonstrable myocardial ischemia, left ventricular DD was associated with greater event rates during long-term follow up but did not independently predict hard end points other than HF or hospitalization. E/e' was independently associated with the clinical outcomes and might be an important echocardiographically derived parameter to identify in patients undergoing exercise echocardiography.

Real-time 3-dimensional dynamics of functional mitral regurgitation: a prospective quantitative and mechanistic study

Background

Three‐dimensional transthoracic echocardiography (3D‐TTE) with dedicated software permits quantification of mitral annulus dynamics and papillary muscle motion throughout the cardiac cycle.

Methods and Results

Mitral apparatus 3D‐TTE was acquired in controls (n=42), patients with left ventricle dysfunction and functional mitral regurgitation (LVD‐FMR; n=43) or without FMR (LVD‐noMR, n=35). Annulus in both normal and LVD‐noMR subjects displayed saddle shape accentuation in early‐systole (ratio of height to intercommissural diameter, 10.6±3.7 to 13.5±4.0 in normal and 9.1±4.3 to 12.6±3.6 in LVD‐noMR; P<0.001 for diastole to early‐systole motion, P=NS between those groups). In contrast, saddle shape was unchanged from diastole in FMR patients (10.0±6.4 to 8.0±5.2; P=NS, P<0.05 compared to both other groups). Papillary tips moved symmetrically towards to the midanterior annulus in control and LVD‐noMR subjects, maintaining constant ratio of the distances between both tips to midannulus (PtAR) throughout systole. In LVD‐FMR patients midsystolic posterior papillary tip to anterior annulus distance was increased, resulting in higher PtAR (P=0.05 compared to both other groups). Mechanisms of early‐ and midsystolic FMR differed between different etiologies of LV dysfunction. In patients with anterior MI and global dysfunction annular function and dilatation were the dominant parameters, while papillary muscle motion was the predominant determinant of FMR in patients with inferior MI.

Conclusions

Inadequate early‐systolic annular contraction and saddle‐shape accentuation in patients with impaired LV contribute to early–mitral incompetency. Asymmetric papillary tip movement towards the midanterior annulus is a major determinant of mid‐ and late‐systolic functional mitral regurgitation.

The pulsed Doppler and tissue Doppler-derived septal E/e' ratio is significantly related to invasive measurement of ventricular end-diastolic pressure in biventricular rather than univentricular physiology in patients with congenital heart disease

OBJECTIVES

The value of conventional non-invasive Doppler parameters to predict ventricular end-diastolic pressure (EDP) and diastolic function in congenital heart diseases is limited. The aim of our prospective study was to investigate whether the ratio of mitral early blood inflow velocity to early diastolic velocity of the mitral annulus (E/e') as assessed by pulsed tissue Doppler is related to EDP in patients with different congenital heart disease (CHD) undergoing left heart catheterization.

METHODS

A total of 115 hospital inpatients (64 male) with different CHD referred for cardiac catheterization were simultaneously examined by echocardiography for non-invasive estimation of ventricular EDP during heart catheterization. The mean age at catheterization was 8.71 years (range 3 days to 18 years). These patients were divided into two groups according to the different hemodynamic and morphology conditions: group A consisted of patients with biventricular heart and group B of patients with univentricular heart.

RESULTS

For all the studied patients, a significant positive correlation was found between E/e' and EDP (r = 0.54, P < 0.001). EDP correlated rather weakly with combined measurements E/global LV early diastolic velocity (r = 0.27, P = 0.02). A significant relationship was also found between ventricular EDP and early mitral inflow velocity E (r = 0.36, P = 0.001). The ratio of pulmonary venous flow velocities s/d was not found to be related to invasively measured EDP (r = -0.16, P = 0.13). Group A (n = 96) had similar results, but for group B (n = 19), these parameters did not show a relationship to EDP. The analysis of these parameters showed that the larger area under the curve (AUC) was found for the ratio of E/e' (AUC = 0.77) compared with E/global e' (AUC = 0.57). E/e' > 10.7 had 69 % sensitivity and 81 % specificity for EDP > 10 mmHg.

CONCLUSION

Doppler and tissue Doppler-derived E/e' ratio is related to simultaneous invasive measurement of EDP in a heterogeneous group of patients with CHD and may provide an additional surrogate non-invasive estimation of ventricular diastolic performance in the routine follow-up of these patients.

Review on CFD simulation in heart with dilated cardiomyopathy and myocardial infarction

The heart is a sophisticated functional organ that plays a crucial role in the blood circulatory system. Hemodynamics within the heart chamber can be indicative of exert cardiac health. Due to the limitations of current cardiac imaging modalities, computational fluid dynamics (CFD) have been widely used for the purposes of cardiac function assessment and heart disease diagnosis, as they provide detailed insights into the cardiac flow field. An understanding of ventricular hemodynamics and pathological severities can be gained through studies that employ the CFD method. In this research the hemodynamics of two common myocardial diseases, dilated cardiomyopathy (DCM) and myocardial infarction (MI) were investigated, during both the filling phase and the whole cardiac cycle, through a prescribed geometry and fluid structure interaction (FSI) approach. The results of the research indicated that early stage disease identification and the improvement of cardiac assisting devices and therapeutic procedures can be facilitated through the use of the CFD method.

Cerebral blood flow as a marker for recovery of left ventricular systolic dysfunction in patients with idiopathic dilated cardiomyopathy

BACKGROUND

This study was intended to investigate whether cerebral blood flow (CBF) could predict the recovery of left ventricular (LV) systolic dysfunction in patients with idiopathic dilated cardiomyopathy (DCMP).

METHODS AND RESULTS

Between July 2001 and March 2009, 107 patients who had been diagnosed with idiopathic DCMP underwent radionuclide angiography to assess their CBF. The recovery of LV systolic dysfunction was defined as recovery of the ejection fraction (EF) measured by transthoracic echocardiography to a level of 40% or greater and an increase of 10% or greater in its absolute value during follow-up. The EF was followed for at least 36 months if it did not recover. Thirty-four patients (31.8%) recovered and had greater CBF than the nonrecovered patients (41.9 ± 3.4 vs. 37.1 ± 4.9 mL/min/100g, P < .001). On multivariate logistic analysis, CBF (odds ratio 1.216) and symptom duration (odds ratio 0.952) were independent predictors of the recovery of LV systolic dysfunction. There was also a weak negative correlation between CBF and symptom duration (r = -0.334, P < .001). Furthermore, CBF was associated with LVEF improvement seen at the 1- and 2-year follow-up times according to multiple linear regression analysis.

CONCLUSIONS

CBF was associated with recovery of LV systolic dysfunction in patients with idiopathic DCMP. Therefore, measurement of CBF would be helpful to predict the clinical course of their disease.

Cardiac MR imaging of nonischemic cardiomyopathies: imaging protocols and spectra of appearances

Recent technologic advances in cardiac magnetic resonance (MR) imaging have resulted in images with high spatial and temporal resolution and excellent myocardial tissue characterization. Cardiac MR is a valuable imaging technique for detection and assessment of the morphology and functional characteristics of the nonischemic cardiomyopathy. It has gained acceptance as a standalone imaging modality that can provide further information beyond the capabilities of traditional modalities such as echocardiography and angiography. Black-blood fast spin-echo MR images allow morphologic assessment of the heart with high spatial resolution, while T2-weighted MR images can depict acute myocardial edema. Contrast material-enhanced images can depict and be used to quantify myocardial edema, infiltration, and fibrosis. This review presents recommended cardiac MR protocols for and the spectrum of imaging appearances of the nonischemic cardiomyopathies.

Evaluation of left and right ventricular ejection fraction and volumes from gated blood-pool SPECT in patients with dilated cardiomyopathy: comparison with cardiac MRI

This prospective study evaluated the accuracy of electrocardiogram-gated blood-pool SPECT (GBPS) for the assessment of left ventricular (LV) and right ventricular (RV) ejection fraction (EF), end-diastolic volume (EDV), and end-systolic volume (ESV) in patients with dilated cardiomyopathy (DCM), using cardiac magnetic resonance (CMR) imaging as the reference standard.

METHODS

Thirty-two patients (24 men and 8 women; mean age, 51 y) with a diagnosis of idiopathic DCM underwent GBPS and CMR. LV and RV parameters including EDV, ESV, and EF from GBPS were calculated using fully automated gradient software and compared with those obtained by CMR.

RESULTS

Biventricular volumes were underestimated by GBPS, compared with CMR (P < 0.001). We found no statistical difference between these 2 methods in the assessment of LV EF (P = 0.23), whereas RV EF was overestimated by GBPS (P < 0.001 vs. CMR). Regression analysis yielded significant correlations between GBPS and CMR in the assessments of biventricular parameters (r = 0.83 for LV EDV, 0.88 for LV ESV, 0.89 for LV EF, 0.86 for RV EDV, 0.86 for RV ESV, and 0.62 for RV EF; all P < 0.001). Comparison of the deviations of RV indices between GBPS and CMR with the ratio of RV EDV to LV EDV showed that there was a statistically significant trend for RV volumes to be underestimated and for RV EF to be overestimated as the biventricular volumetric ratio decreased (r = 0.61 for RV EDV, 0.68 for RV ESV, and -0.55 for RV EF; all P < 0.001).

CONCLUSION

For patients with DCM, GBPS correlated well with CMR for the assessment of biventricular parameters, but RV indices should be cautiously interpreted.

Core lab analysis of baseline echocardiographic studies in the STICH trial and recommendation for use of echocardiography in future clinical trials

BACKGROUND

The Surgical Treatment for Ischemic Heart Failure (STICH) randomized trial was designed to identify an optimal management strategy for patients with ischemic cardiomyopathy. Baseline echocardiographic examinations were required for all patients. The primary aim of this report is to describe the baseline STICH Echocardiography Core Laboratory data. The secondary aim is to provide recommendations regarding how echocardiography should be used in clinical practice and research on the basis of the experience gained from echocardiography in STICH.

METHODS

Between September 2002 and January 2006, 2,136 patients with ejection fractions (EFs) ≤ 35% and coronary artery disease amenable to coronary artery bypass grafting were enrolled. Echocardiography was acquired by 122 clinical enrolling sites, and measurements were performed by the Echocardiography Core Laboratory after a certification process for all clinical sites.

RESULTS

Echocardiography was available for analysis in 2,006 patients (93.9%); 1,734 (86.4%) were men, and the mean age was 60.9 ± 9.5 years. The mean left ventricular end-systolic volume index, measureable in 72.8%, was 84.0 ± 30.9 mL/m(2), and the mean EF was 28.9 ± 8.3%, with 18.5% of patients having EFs > 35%. Single-plane measurements of left ventricular and left atrial volumes were similar to their volumes by biplane measurement (r = 0.97 and r = 0.92, respectively). Mitral regurgitation severity by visual assessment was associated with a wide range of effective regurgitant orifice area, while effective regurgitant orifice area ≥ 0.2 cm(2) indicated at least moderate mitral regurgitation by visual assessment. Deceleration time of mitral inflow velocity had a weak correlation with EF (r = 0.25) but was inversely related to estimated pulmonary artery systolic pressure (r = -0.49).

CONCLUSIONS

In STICH patients with ischemic cardiomyopathy, Echocardiography Core Laboratory analysis of baseline echocardiographic findings demonstrated a wide spectrum of left ventricular shape, function, and hemodynamics, as well as the feasibility and limitations of obtaining essential echocardiographic measurements. It is critical that the use of echocardiographic parameters in clinical practice and research balance the strengths and weaknesses of the technique.

Evaluation of a novel index by tissue Doppler imaging in patients with advanced heart failure: relation to functional class and prognosis

BACKGROUND

Despite the ability of tissue Doppler imaging (TDI) to detect left ventricular (LV) systolic and diastolic myocardial functions in patients with heart failure, the added value of TDI to clinical variables and conventional echocardiography in predicting the symptoms and outcome of advanced heart failure has not been clearly defined.

METHODS AND RESULTS

Two hundred and thirty adult patients diagnosed with congestive heart failure were assigned to study groups based on the New York Heart Association functional classes. Pulsed-wave TDI (PWTDI), including average of peak systolic (Sm), early (Em) and late diastolic (Am) velocities from six mitral annular sites was evaluated. PWTDI was also calculated to create a combined index (EAS index) of diastolic and systolic performances. All patients were followed up for cardiac-related death and hospitalisation as a result of heart failure. Patients with functional class III-IV had a significantly higher EAS index (0.21 ± 0.19 vs. 0.13 ± 0.08, p < 0.05) than those with class I-II and the control (0.10 ± 0.04, p < 0.05). Except for Sm and Em, all conventional echocardiographic Doppler parameters and TDI variables significantly correlated with functional class. Moreover, according to multiple stepwise analysis, EAS index and percentage of chronic renal insufficiency (CRF) were the only two independent predictors of functional class (EAS index, p = 0.006; CRF, p = 0.019). During follow-up (median, 30 months), 93 participants had cardiac events. EAS index, LV mass index and CRF were significant predictors of cardiac mortality and hospitalisation [EAS index, hazard ratio (HR) 4.962, p = 0.006; LV mass index, HR 1.007, p = 0.003; CRF, HR 1.616, p = 0.040].

CONCLUSIONS

The EAS index, which reflects systolic and diastolic performances, is a highly effective means of differentiating between patients with functional class I-II and those with III-IV. The index also correlates with cardiac mortality and hospitalisation for worsening heart failure, thus providing additional value to conventional echocardiographic measures.

Who has advanced heart failure?: definition and epidemiology

Summarizing current guidelines and advanced heart failure (AHF) clinical trials/registries, this review focuses on the current definition of AHF and emphasizes the secular trends in this definition over the last two decades. Further, clinical, imaging, hemodynamic, functional capacity and biomarker parameters that may aid clinicians to better recognize patients with AHF are reviewed. Finally, we review the limited data concerning the epidemiology of AHF which to date has been poorly characterized.

Relation of baseline systolic blood pressure and long-term outcomes in ambulatory patients with chronic mild to moderate heart failure

We studied the impact of baseline systolic blood pressure (SBP) on outcomes in patients with mild to moderate chronic systolic and diastolic heart failure (HF) in the Digitalis Investigation Group trial using a propensity-matched design. Of 7,788 patients, 7,785 had baseline SBP data and 3,538 had SBP ≤ 120 mm Hg. Propensity scores for SBP ≤ 120 mm Hg, calculated for each of the 7,785 patients, were used to assemble a matched cohort of 3,738 patients with SBP ≤ 120 and >120 mm Hg who were well-balanced in 32 baseline characteristics. All-cause mortality occurred in 35% and 32% of matched patients with SBPs ≤ 120 and >120 mm Hg respectively, during 5 years of follow-up (hazard ratio [HR] when SBP ≤ 120 was compared to >120 mm Hg 1.10, 95% confidence interval [CI] 0.99 to 1.23, p = 0.088). HRs for cardiovascular and HF mortalities associated with SBP ≤ 120 mm Hg were 1.15 (95% CI 1.01 to 1.30, p = 0.031) and 1.30 (95% CI 1.08 to 1.57, p = 0.006). Cardiovascular hospitalization occurred in 53% and 49% of matched patients with SBPs ≤ 120 and > 120 mm Hg, respectively (HR 1.13, 95% CI 1.03 to 1.24, p = 0.008). HRs for all-cause and HF hospitalizations associated with SBP ≤ 120 mm Hg were 1.10 (95% CI 1.02 to 1.194, p = 0.017) and 1.21 (95% CI 1.07 to 1.36, p = 0.002). In conclusion, in patients with mild to moderate long-term systolic and diastolic HF, baseline SBP ≤ 120 mm Hg was associated with increased cardiovascular and HF mortalities and all-cause, cardiovascular, and HF hospitalizations that was independent of other baseline characteristics.

Association of increased parathyroid hormone with neuroendocrine activation and endothelial dysfunction in elderly men with heart failure

High PTH levels have been reported in patients with chronic heart failure (CHF). Similarly, its levels increase with aging and are related to impaired survival in elderly adults. However, its relationship with neuroendocrine activation and endothelial dysfunction in CHF has not been previously studied. Seventy-three CHF males with New York Heart Association (NYHA) classes II and III and 20 control subjects aged ≥ 55 yr were recruited. PTH, 25-hydroxyvitamin D [25(OH)D], N-terminal pro-brain natriuretic peptide (NT-pro-BNP), adiponectin, and osteoprotegerin were measured. Endothelial function (brachial flow mediated dilation), echocardiography, physical performance, and quality of life were assessed, as well. CHF patients had markedly increased serum PTH (77 ± 33 vs 40 ± 11 pg/ml, p<0.0001), NT-pro-BNP [1809 (2742) vs 67 (74) pg/ml, p<0.0001], adiponectin (17 ± 9 vs 10 ± 2 μg/ml, p<0.0001), osteoprotegerin, whereas 25(OH)D levels were decreased compared to controls. Increased PTH is positively correlated with NTpro- BNP (r=0.399, p<0.0001), adiponectin (r=0.398, p<0.0001), and osteoprotegerin, whereas negatively with 25(OH)D in CHF patients. Additionally, increased serum PTH was associated with endothelial dysfunction, echocardiographic variables of heart failure progression, impaired physical performance, and deteriorated quality of life. In a multivariate linear regression analysis, increased serum PTH was independently associated with neuroendocrine activation (NT-pro-BNP, adiponectin) and endothelial dysfunction in elderly CHF men (R2=0.455). Additionally, demonstrated relations with other well-established variables of heart failure severity suggest the potential role of serum PTH in the pathogenesis and non-invasive monitoring of heart failure progression. Future studies are needed to evaluate the predictive value of serum PTH for clinical outcomes as well as beneficial potential of PTH suppression in CHF patients.

A comparison of echocardiographic measures of diastolic function for predicting all-cause mortality in a predominantly male population

BACKGROUND

Prior studies demonstrating the prognostic value of echocardiographic measures of diastolic function have been limited by sample size, have included only select clinical populations, and have not incorporated newer measures of diastolic function nor determined their independent prognostic value. The objective of this study is to determine the independent prognostic value of established and new echocardiographic parameters of diastolic function.

METHODS

We included 3,604 consecutive patients referred to 1 of 3 echocardiography laboratories over a 2-year period. We obtained measurements of mitral inflow velocities, pulmonary vein filling pattern, mitral annulus motion (e'), and propagation velocity (V(p)). The primary end point was 1-year all-cause mortality.

RESULTS

The mean age of the patients was 68 years, and 95% were male. There were 277 deaths during a mean follow-up of 248 ± 221 days. For patients with reduced left ventricular ejection fraction (LVEF), all measured parameters except for e' were associated with mortality (P < .05) on univariate analysis. For patients with preserved LVEF, the E-wave velocity was significantly associated with mortality (P < .05) on univariate analysis. The deceleration time/E-wave velocity ratio, V(p), and pulmonary vein filling pattern were borderline significant (P < .10). With multivariate analysis, only V(p) was associated with survival for both reduced (P = .02) and preserved LVEF groups (P = .01).

CONCLUSION

In a large, clinically diverse population, most measures of diastolic function were predictive of all-cause mortality without adjustment for patient characteristics. On multivariate analysis, only V(p) was independently associated with total mortality. This association with mortality may be related to factors other than diastolic function and warrants further investigation.

Echocardiographic parameters associated with pulmonary congestion in Chagas cardiomyopathy

INTRODUCTION

Discrepancy between the intensity of pulmonary congestion and the grade of cardiomegaly seems to be a common finding of Chagas cardiomyopathy, in spite of significant systolic dysfunction of the left ventricle. Its mechanism has not been established. The aim of this study was to investigate pulmonary congestion and to analyze if it correlated with Doppler echocardiographic parameters in patients with Chagas dilated cardiomyopathy.

METHODS

Fifty-five patients with positive serology tests for Trypanosoma cruzi and Chagas dilated cardiomyopathy were studied. Chest x-rays, Doppler echocardiogram and plasmatic brain natriuretic peptide levels were obtained in all patients. The degree of pulmonary venous vessels changes on chest x-ray was graded using a pulmonary congestion score, and then compared to Doppler echocardiographic parameters.

RESULTS

Mean age was 48.5 +/- 11.2 years and 29% were women. The majority (95%) of patients were in NYHA functional class I and II. Mild pulmonary congestion by chest x-ray was found in 80% of the patients. In a multivariate analysis, left ventricular ejection fraction, right ventricular TEI index and the color M-mode velocity correlated with the degree of pulmonary congestion.

CONCLUSIONS

Pulmonary venous changes on chest x-rays are frequent, but usually mild in patients with Chagas dilated cardiomyopathy. The degree of pulmonary congestion correlates with Doppler echocardiographic left and right ventricular dysfunction and with color M-mode velocity.

Myocardial delayed enhancement in paucisymptomatic nonischemic dilated cardiomyopathy

OBJECTIVES

We investigated the prognostic role of myocardial fibrosis by delayed enhancement (DE) cardiovascular magnetic resonance (CMR) in nonischemic dilated cardiomyopathy (NICM) patients with no or mild symptoms of heart failure (HF).

METHODS

A prospective cohort of 125 NICM patients (82 males, age 59±14years, mean±SD) with echocardiographic evidence of left ventricular (LV) systolic dysfunction (mean ejection-fraction 33±10%), without (stage B) or with history of mild HF symptoms (stage C, NYHA classes I-II) was enrolled. The end-point was a composite of cardiac death and HF hospitalization.

RESULTS

Fifty (40%) patients showed myocardial DE, representing 12±7% of LV mass. During a median follow-up of 14.2months, 16 (32%) patients with DE experienced a composite event versus only 6 (8%) patients without DE (Kaplan-Meier survival curve, p=0.001). After correction for age, CMR-derived LV and right ventricular volumes, echocardiographic measurements of LV diastolic function and Doppler-estimated systolic pulmonary artery pressure, the presence of DE remained a strong and independent predictor of cardiac death or HF hospitalization (hazard ratio: 5.32, 95% confidence intervals 1.60 to 17.63, p=0.006).

CONCLUSIONS

In NICM patients with no or mild HF symptoms, the presence of myocardial DE is a strong predictor of worse clinical outcome even after correction for other established prognostic determinants. Contrast-enhanced CMR may be useful in prognostic stratification from the early stages of NICM.

Change in blood pressure during hospitalisation for acute heart failure predicts mortality

OBJECTIVE

In patients with acute heart failure (HF) there is an inverse relation between blood pressure (BP) and mortality but the prognostic impact of the change in BP between admission and discharge is not known. The primary objective was to study the impact of the change in BP during a hospitalisation for acute HF on prognosis.

DESIGN

We studied 208 consecutive patients admitted with acute heart failure and discharged alive, age 77 ± 10 years, 49.5% women.

RESULTS

BP at admission was 145 ± 35/85 ± 9 mmHg compared to 132 ± 24/76 ± 13 mmHg at discharge. The average number of BP lowering medications at admission and discharge was 2.1 ± 1.2 and 2.8 ± 1.0 respectively. The average number of BP lowering medications with dose increased at discharge compared to admission was 0.3 ± 0.5. Univariate predictors of all-cause mortality at 12 and/or 40 months were admission SBP and DBP, discharge DBP, decrease in SBP and DBP during hospitalisation, age, eGFR, number of added BP-lowering medications during the hospitalisation and left ventricular ejection fraction (LVEF). Multivariate predictors at 12 and/or 40 month were admission DBP, decrease in DBP, age, eGFR, LVEF and number of new BP-lowering medications added during the hospitalisation.

CONCLUSIONS

A decrease in BP during hospitalisation for acute heart failure was a predictor of all cause mortality. A higher admission BP and the tolerability of added medications probably played a role, and our findings need confirmation in larger studies.

Acute heart failure with low cardiac output: can we develop a short-term inotropic agent that does not increase adverse events?

Acute heart failure represents an increasingly common cause of hospitalization, and may require the use of inotropic drugs in patients with low cardiac output and evidence of organ hypoperfusion. However, currently available therapies may have deleterious effects and increase mortality. An ideal inotropic drug should restore effective tissue perfusion by enhancing myocardial contractility without causing adverse effects. Such a drug is not available yet. New agents with different biological targets are under clinical development. In particular, istaroxime seems to dissociate the inotropic effect exerted by digitalis (inhibition of the membrane sodium/potassium adenosine triphosphatase) from the arrhythmic effect and to ameliorate diastolic dysfunction (via sarcoendoplasmic reticulum calcium adenosine triphosphatase activation). Additionally, the myosin activator omecamtiv mecarbil appears to have promising characteristics, while genetic therapy has been explored in animal studies only. Further investigations are needed to confirm and expand the effectiveness and safety of these agents in patients with acute heart failure and low cardiac output.