351
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Wada Y, Aiba T, Matsuyama TA, Nakajima I, Ishibashi K, Miyamoto K, Yamada Y, Okamura H, Noda T, Satomi K, Morita Y, Kanzaki H, Kusano K, Anzai T, Kamakura S, Ishibashi-Ueda H, Shimizu W, Horie M, Yasuda S, Ogawa H. Clinical and Pathological Impact of Tissue Fibrosis on Lethal Arrhythmic Events in Hypertrophic Cardiomyopathy Patients With Impaired Systolic Function. Circ J 2015; 79:1733-41. [PMID: 26016925 DOI: 10.1253/circj.cj-15-0104] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The natural history of hypertrophic cardiomyopathy (HCM) varies from an asymptomatic benign course to a poor prognosis. Myocardial fibrosis may play a critical role in ventricular tachyarrhythmias (VT/VF); however, the clinical significance of tissue fibrosis by right ventricular (RV) biopsy in the long-term prognosis of HCM patients remains unclear. METHODS AND RESULTS We enrolled 185 HCM patients (mean age, 57±14 years). The amount of fibrosis (%area) was quantified using a digital microscope. Hemodynamic, echocardiographic, and electrophysiologic parameters were also evaluated. Patients with severe fibrosis had longer QRS duration and positive late potential (LP) on signal-averaged ECG, resulting in a higher incidence of VT/VF. At the 5±4 year follow-up, VT/VF occurred in 31 (17%) patients. Multivariate Cox regression analysis revealed that tissue fibrosis (hazard ratio (HR): 1.65; P=0.003 per 10% increase), lower left ventricular ejection fraction (HR: 0.64; P=0.001 per 10% increase), and positive SAECG (HR: 3.14; P=0.04) led to a greater risk of VT/VF. The combination of tissue fibrosis severity and lower left ventricular ejection fraction could be used to stratify the risk of lethal arrhythmic events in HCM patients. CONCLUSIONS Myocardial fibrosis in RV biopsy samples may contribute to abnormal conduction delay and spontaneous VT/VF, leading to a poor prognosis in HCM patients.
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Affiliation(s)
- Yuko Wada
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
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352
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Florian A, Ludwig A, Stubbe-Dräger B, Boentert M, Young P, Waltenberger J, Rösch S, Sechtem U, Yilmaz A. Characteristic cardiac phenotypes are detected by cardiovascular magnetic resonance in patients with different clinical phenotypes and genotypes of mitochondrial myopathy. J Cardiovasc Magn Reson 2015; 17:40. [PMID: 26001801 PMCID: PMC4490728 DOI: 10.1186/s12968-015-0145-x] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Accepted: 05/06/2015] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Mitochondrial myopathies (MM) are a heterogeneous group of inherited conditions resulting from a primary defect in the mitochondrial respiratory chain with consecutively impaired cellular energy metabolism. Small sized studies using mainly electrocardiography (ECG) and echocardiography have revealed cardiac abnormalities ranging from conduction abnormalities and arrhythmias to hypertrophic or dilated cardiomyopathy in these patients. Recently, characteristic patterns of cardiac involvement were documented by cardiovascular magnetic resonance (CMR) in patients with chronic progressive external ophthalmoplegia (CPEO)/Kearns-Sayre syndrome (KSS) and with mitochondrial encephalopathy with lactic acidosis and stroke-like episodes (MELAS). The present study aimed to characterize the prevalence and pattern of cardiac abnormalities and to test the additional diagnostic value of CMR in this patient population. The hypothesis that different neuromuscular MM syndromes present with different cardiac disease phenotypes was evaluated. METHODS Sixty-four MM patients (50 ± 15 years, 44% male) and 25 matched controls (52 ± 14 years, 36% male) prospectively underwent cardiac evaluations including CMR (comprising cine- and late-gadolinium-enhancement (LGE) imaging). Based on the neuromuscular phenotype and genotype, the patients were grouped: (a) CPEO/KSS (N = 33); (b) MELAS/-like (N = 11); c) myoclonic epilepsy with ragged-red fibers (MERRF) (N = 3) and d) other non-specific MM forms (N = 17). RESULTS Among the 64 MM patients, 34 (53%) had at least one abnormal CMR finding: 18 (28%) demonstrated an impaired left ventricular ejection-fraction (LV-EF <60%), 14 (22%) had unexplained LV hypertrophy and 21 (33%) were LGE-positive. Compared to controls, MM patients showed significantly higher maximal wall thickness (10 ± 3 vs. 8 ± 2 mm, p = 0.005) and concentricity (LV mass to end-diastolic volume: 0.84 ± 0.27 vs. 0.67 ± 0.11, p < 0.0001) with frequent presence of non-ischemic LGE (30% vs. 0%, p = 0.001). CPEO/KSS showed a predominantly intramural pattern of LGE mostly confined to the basal LV inferolateral wall (8/10; 80%) in addition to a tendency toward concentric remodelling. MELAS/-like patients showed the highest frequency of cardiac disease (in 10/11 (91%)), a mostly concentric LV hypertrophy (6/9; 67%) with or without LV systolic dysfunction and a predominantly focal, patchy LGE equally distributed among LV segments (8/11; 73%). Patients with MERRF and non-specific MM had no particular findings. Pathological CMR findings indicating cardiac involvement were detected significantly more often than pathological ECG results or elevated cardiac serum biomarkers (34 (53%) vs. 18 (28%) vs. 21 (33%); p = 0.008). CONCLUSION Cardiac involvement is a frequent finding in MM patients - and particularly present in KSS/CPEO as well as MELAS/-like patients. Despite a high variability in clinical presentation, CPEO/KSS patients typically show an intramural pattern of LGE in the basal inferolateral wall whereas MELAS patients are characterized by overt concentric hypertrophy and a rather unique, focally accentuated and diffusely distributed LGE.
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Affiliation(s)
- Anca Florian
- Department of Cardiology and Angiology, University Hospital Münster, Albert-Schweitzer-Campus 1, building A1, 48149, Münster, Germany.
| | - Anna Ludwig
- Division of Cardiology, Robert-Bosch-Krankenhaus, Stuttgart, Germany.
| | - Bianca Stubbe-Dräger
- Department of Sleep Medicine and Neuromuscular Disorders, University Hospital Münster, Münster, Germany.
| | - Matthias Boentert
- Department of Sleep Medicine and Neuromuscular Disorders, University Hospital Münster, Münster, Germany.
| | - Peter Young
- Department of Sleep Medicine and Neuromuscular Disorders, University Hospital Münster, Münster, Germany.
| | - Johannes Waltenberger
- Department of Cardiology and Angiology, University Hospital Münster, Albert-Schweitzer-Campus 1, building A1, 48149, Münster, Germany.
| | - Sabine Rösch
- Division of Cardiology, Robert-Bosch-Krankenhaus, Stuttgart, Germany.
| | - Udo Sechtem
- Division of Cardiology, Robert-Bosch-Krankenhaus, Stuttgart, Germany.
| | - Ali Yilmaz
- Department of Cardiology and Angiology, University Hospital Münster, Albert-Schweitzer-Campus 1, building A1, 48149, Münster, Germany.
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353
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Endogenous contrast T1rho cardiac magnetic resonance for myocardial fibrosis in hypertrophic cardiomyopathy patients. J Cardiol 2015; 66:520-6. [PMID: 25981868 DOI: 10.1016/j.jjcc.2015.03.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Revised: 02/16/2015] [Accepted: 03/02/2015] [Indexed: 02/05/2023]
Abstract
BACKGROUND Late gadolinium enhancement (LGE) is a standard method to evaluate myocardial fibrosis, but restricted due to contrast agent contraindications. Non-contrast T1rho can generate endogenous contrast, and detect fibrosis in chronic myocardial infarction. However, T1rho for hypertrophic cardiomyopathy (HCM) patients is still unreported. The present study aimed to investigate T1rho for fibrotic assessment and the clinical implication in HCM patients. METHODS 18 HCM patients and 8 controls underwent T1rho, cine, and LGE cardiac magnetic resonance (CMR). T1rho relaxation time maps were created. Left ventricular (LV) parameters assessed included wall thickness, wall thickening, chamber volumes, ejection function, and fibrotic size. New York Heart Association (NYHA) functional classification was conducted. RESULTS Hyper-T1rho value was identified in 12 HCM patients, consistent with LGE. The mean T1rho values of controls, LGE-negative patients, and remote myocardium of LGE-positive patients were 42.2±1.6ms, 43.9±2.5ms, and 42.5±1.2ms respectively, and these values showed no significant difference (all p>0.05). T1rho-3-SD and T1rho-4-SD fibrotic sizes (32.5±14.0% and 25.1±11.5%) did not differ from LGE fibrotic size (28.1±11.2%) (both p>0.05). For the fibrotic size, T1rho-3-SD method obtained the strongest correlation with LGE (r=0.88, p<0.001), and T1rho-4-SD obtained the minimal mean difference with LGE (-3.1%; -15.2 to 9.1%), compared with other SDs. All the fibrotic sizes assessed by both methods correlated directly with LV maximal end-diastolic thickness (all p<0.05). Negative correlation was found between T1rho-4-SD fibrotic size and LV ejection fraction (r=-0.49, p=0.11). T1rho-4-SD fibrotic size showed positive correlation with NYHA class (r=0.46, p=0.13). CONCLUSIONS T1rho CMR has potential to detect fibrosis in HCM patients. 4-SD may be the appropriate threshold for assessment.
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354
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Zhang YD, Li M, Qi L, Wu CJ, Wang X. Hypertrophic cardiomyopathy: Cardiac structural and microvascular abnormalities as evaluated with multi-parametric MRI. Eur J Radiol 2015; 84:1480-1486. [PMID: 26003194 DOI: 10.1016/j.ejrad.2015.04.028] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Revised: 03/28/2015] [Accepted: 04/27/2015] [Indexed: 01/16/2023]
Abstract
PURPOSE To determine the relationship between myocardial structural and microvascular abnormality in hypertrophic cardiomyopathy (HCM) by multi-parametric cardiac MRI. MATERIALS AND METHODS Twenty-four HCM and eighteen controls were retrospectively included. Left ventricle mass (LVM), LV end-systolic and end-diastolic volume (LVESV, LVEDV), LV ejection fraction (LVEF), and 16-segment wall thickness at ES and ED (SESWT, SEDWT) were assessed with a 2D cine-MRI. Myocardial perfusion (reflected by K(trans)), interstitial volume (Ve) and mean transmit time (MTT) were evaluated with a model-dependent dynamic contrast-enhanced MRI. Myocardial fibrosis was assessed with late gadolinium enhancement (LGE) imaging. RESULTS K(trans) was significantly decreased in LGE-present (0.74±0.15mL/g/min) against LGE-absent (0.55±0.14mL/g/min, p=0.030) and normal group (0.81±0.32mL/g/min, p<0.001), but was unchanged in LGE-absent against normal group (p>0.05). Ve and MTT were significantly increased in LGE-present (Ve: 26.7±15.7%; MTT: 28.6±21.3s) against LGE-absent (37.6±18.3%; 49.8±30.5s) and normal group (19.7±6.9%; 15.1±3.9s; all p<0.001), and were significantly increased in LGE-absent against normal group (p<0.001). LGE significantly correlated to K(trans), Ve, MTT, and SESWT (ρ=0.232, -0.247, -0.443, and -0.207, respectively). K(trans) negatively correlated to SEDWT and SESWT (ρ=-0.224 and -0.231). Ve and MTT positively correlated to SEDWT (Ve: ρ=0.223; MTT: ρ=0.239) and SESWT (Ve: ρ=0.248; MTT: ρ=0.254). CONCLUSIONS Consistent relationship was determined between myocardial structural abnormality and microvascular dysfunction in HCM.
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Affiliation(s)
- Yu-Dong Zhang
- Department of Radiology, the First Affiliated Hospital with Nanjing Medical University, China.
| | - Meijiao Li
- Department of Radiology, Peking University First Hospital, China.
| | - Liang Qi
- Department of Radiology, the First Affiliated Hospital with Nanjing Medical University, China.
| | - Chen-Jiang Wu
- Department of Radiology, the First Affiliated Hospital with Nanjing Medical University, China.
| | - Xiaoying Wang
- Department of Radiology, Peking University First Hospital, China.
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Abstract
The differentiation between hypertrophic and restrictive cardiomyopathies is often challenging in the routine clinical setting. Advances in the field of multimodal imaging have improved the diagnostics of these diseases and understanding of the underlying pathophysiology. Each imaging method, such as echocardiography, cardiac magnetic resonance imaging (CMR), cardiac computed tomography (CT) and coronary angiography including cardiac catheterization for pressure measurements, is of significant value in clinical diagnostics and also regarding therapeutic approaches and prognostic implications. This review gives an overview of developments of the past few years, describes recent insights and puts these findings into a scientific context. Particularly CMR has added valuable information to current knowledge by its unique potential of contrast-enhanced tissue characterization. Another promising CMR tool, parametric mapping has appeared on the horizon and may further deepen our understanding of cardiac pathophysiology as well as offer new therapeutic options to patients.
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356
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Kato S, Saito N, Kirigaya H, Gyotoku D, Iinuma N, Kusakawa Y, Iguchi K, Nakachi T, Fukui K, Futaki M, Iwasawa T, Taguri M, Kimura K, Umemura S. Prognostic significance of quantitative assessment of focal myocardial fibrosis in patients with heart failure with preserved ejection fraction. Int J Cardiol 2015; 191:314-9. [PMID: 26005800 DOI: 10.1016/j.ijcard.2015.05.048] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Revised: 05/06/2015] [Accepted: 05/07/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND The aim of this study was to investigate the prognostic value of myocardial focal fibrosis quantified by late gadolinium enhanced (LGE) magnetic resonance imaging (MRI) in patients with heart failure with preserved ejection fraction (HFpEF). METHODS One-hundred eleven HFpEF patients (mean age: 70 ± 14 years, 55 (50%) female) were enrolled. We excluded patients with previous history of coronary artery disease and/or ischemic pattern of hyper enhancement on LGE MRI. Myocardial enhancement was defined using signal intensity >2SD above the mean signal intensity of a remote myocardium. Major adverse cardiovascular events were defined as cardiovascular death and heart failure requiring hospitalization. RESULTS During a mean follow up period of 851 ± 609 days, 10 events (2 cardiovascular death, 8 hospitalization for heart failure decompensation) were observed. Area under the receiver operating characteristics curve of LGE% for the detection of future events was 0.721 (95% CI: 0.628-0.802). Multivariate Cox proportional hazard analysis showed that LGE% is an independent predictor of future events after the adjustment with prognostic 5 factors - age, diabetes mellitus, New York Heart Association classification, history of heart failure hospitalization and left ventricular ejection fraction - which were identified in the I-PRESERVE study (Irbesartan in Heart Failure with Preserved Ejection Fraction Study) (hazard ratio=7.913, 95% CI: 1.603-39.05, P=0.012). CONCLUSIONS Larger size of LGE was significantly associated with high rate of future cardiovascular death and heart failure hospitalization, suggesting that the quantification of myocardial focal fibrosis by LGE MRI could be useful for the risk stratification in HFpEF patients.
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Affiliation(s)
- Shingo Kato
- Department of Cardiology, Kanagawa Cardiovascular and Respiratory Center, Japan.
| | - Naka Saito
- Department of Cardiology, Kanagawa Cardiovascular and Respiratory Center, Japan
| | - Hidekuni Kirigaya
- Department of Cardiology, Kanagawa Cardiovascular and Respiratory Center, Japan
| | - Daiki Gyotoku
- Department of Cardiology, Kanagawa Cardiovascular and Respiratory Center, Japan
| | - Naoki Iinuma
- Department of Cardiology, Kanagawa Cardiovascular and Respiratory Center, Japan
| | - Yuka Kusakawa
- Department of Cardiology, Kanagawa Cardiovascular and Respiratory Center, Japan
| | - Kohei Iguchi
- Department of Cardiology, Kanagawa Cardiovascular and Respiratory Center, Japan
| | - Tatsuya Nakachi
- Department of Cardiology, Kanagawa Cardiovascular and Respiratory Center, Japan
| | - Kazuki Fukui
- Department of Cardiology, Kanagawa Cardiovascular and Respiratory Center, Japan
| | - Masaaki Futaki
- Department Radiology, Kanagawa Cardiovascular and Respiratory Center, Japan
| | - Tae Iwasawa
- Department Radiology, Kanagawa Cardiovascular and Respiratory Center, Japan
| | - Masataka Taguri
- Department of Biostatistics and Epidemiology, Yokohama City University, Japan
| | - Kazuo Kimura
- Division of Cardiology, Yokohama City University Medical Center, Japan
| | - Satoshi Umemura
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Hospital, Japan
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357
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In pursuit of the holy grail. JACC Cardiovasc Imaging 2015; 8:523-525. [PMID: 25937191 DOI: 10.1016/j.jcmg.2015.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Revised: 02/20/2015] [Accepted: 02/20/2015] [Indexed: 11/21/2022]
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358
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Rydman R, Gatzoulis MA, Ho SY, Ernst S, Swan L, Li W, Wong T, Sheppard M, McCarthy KP, Roughton M, Kilner PJ, Pennell DJ, Babu-Narayan SV. Systemic Right Ventricular Fibrosis Detected by Cardiovascular Magnetic Resonance Is Associated With Clinical Outcome, Mainly New-Onset Atrial Arrhythmia, in Patients After Atrial Redirection Surgery for Transposition of the Great Arteries. Circ Cardiovasc Imaging 2015; 8:CIRCIMAGING.114.002628. [DOI: 10.1161/circimaging.114.002628] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
We hypothesized that fibrosis detected by late gadolinium enhancement (LGE) cardiovascular magnetic resonance predicts outcomes in patients with transposition of the great arteries post atrial redirection surgery. These patients have a systemic right ventricle (RV) and are at risk of arrhythmia, premature RV failure, and sudden death.
Methods and Results—
Fifty-five patients (aged 27±7 years) underwent LGE cardiovascular magnetic resonance and were followed for a median 7.8 (interquartile range, 3.8–9.6) years in a prospective single-center cohort study. RV LGE was present in 31 (56%) patients. The prespecified composite clinical end point comprised new-onset sustained tachyarrhythmia (atrial/ventricular) or decompensated heart failure admission/transplantation/death. Univariate predictors of the composite end point (n=22 patients; 19 atrial/2 ventricular tachyarrhythmia, 1 death) included RV LGE presence and extent, RV volumes/mass/ejection fraction, right atrial area, peak V
o
2
, and age at repair. In bivariate analysis, RV LGE presence was independently associated with the composite end point (hazard ratio, 4.95 [95% confidence interval, 1.60–15.28];
P
=0.005), and only percent predicted peak V
o
2
remained significantly associated with cardiac events after controlling for RV LGE (hazard ratio, 0.80 [95% confidence interval, 0.68–0.95];
P
=0.009/5%). In 8 of 9 patients with >1 event, atrial tachyarrhythmia, itself a known risk factor for mortality, occurred first. There was agreement between location and extent of RV LGE at in vivo cardiovascular magnetic resonance and histologically documented focal RV fibrosis in an explanted heart. There was RV LGE progression in a different case restudied for clinical indications.
Conclusions—
Systemic RV LGE is strongly associated with adverse clinical outcome especially arrhythmia in transposition of the great arteries, thus LGE cardiovascular magnetic resonance should be incorporated in risk stratification of these patients.
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Affiliation(s)
- Riikka Rydman
- From the NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital (R.R., M.A.G., S.Y.H., S.E., L.S., W.L., T.W., M.S., K.P.M., P.J.K., D.J.P., S.V.B.-N.), National Heart and Lung Institute (M.A.G., S.Y.H., S.E., L.S., W.L., T.W., M.S., K.P.M., P.J.K., M.R., D.J.P., S.V.B.-N.), Royal Brompton Hospital, Imperial College London, London, United Kingdom; and Section of Clinical Physiology, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden (R.R.)
| | - Michael A. Gatzoulis
- From the NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital (R.R., M.A.G., S.Y.H., S.E., L.S., W.L., T.W., M.S., K.P.M., P.J.K., D.J.P., S.V.B.-N.), National Heart and Lung Institute (M.A.G., S.Y.H., S.E., L.S., W.L., T.W., M.S., K.P.M., P.J.K., M.R., D.J.P., S.V.B.-N.), Royal Brompton Hospital, Imperial College London, London, United Kingdom; and Section of Clinical Physiology, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden (R.R.)
| | - Siew Yen Ho
- From the NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital (R.R., M.A.G., S.Y.H., S.E., L.S., W.L., T.W., M.S., K.P.M., P.J.K., D.J.P., S.V.B.-N.), National Heart and Lung Institute (M.A.G., S.Y.H., S.E., L.S., W.L., T.W., M.S., K.P.M., P.J.K., M.R., D.J.P., S.V.B.-N.), Royal Brompton Hospital, Imperial College London, London, United Kingdom; and Section of Clinical Physiology, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden (R.R.)
| | - Sabine Ernst
- From the NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital (R.R., M.A.G., S.Y.H., S.E., L.S., W.L., T.W., M.S., K.P.M., P.J.K., D.J.P., S.V.B.-N.), National Heart and Lung Institute (M.A.G., S.Y.H., S.E., L.S., W.L., T.W., M.S., K.P.M., P.J.K., M.R., D.J.P., S.V.B.-N.), Royal Brompton Hospital, Imperial College London, London, United Kingdom; and Section of Clinical Physiology, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden (R.R.)
| | - Lorna Swan
- From the NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital (R.R., M.A.G., S.Y.H., S.E., L.S., W.L., T.W., M.S., K.P.M., P.J.K., D.J.P., S.V.B.-N.), National Heart and Lung Institute (M.A.G., S.Y.H., S.E., L.S., W.L., T.W., M.S., K.P.M., P.J.K., M.R., D.J.P., S.V.B.-N.), Royal Brompton Hospital, Imperial College London, London, United Kingdom; and Section of Clinical Physiology, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden (R.R.)
| | - Wei Li
- From the NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital (R.R., M.A.G., S.Y.H., S.E., L.S., W.L., T.W., M.S., K.P.M., P.J.K., D.J.P., S.V.B.-N.), National Heart and Lung Institute (M.A.G., S.Y.H., S.E., L.S., W.L., T.W., M.S., K.P.M., P.J.K., M.R., D.J.P., S.V.B.-N.), Royal Brompton Hospital, Imperial College London, London, United Kingdom; and Section of Clinical Physiology, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden (R.R.)
| | - Tom Wong
- From the NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital (R.R., M.A.G., S.Y.H., S.E., L.S., W.L., T.W., M.S., K.P.M., P.J.K., D.J.P., S.V.B.-N.), National Heart and Lung Institute (M.A.G., S.Y.H., S.E., L.S., W.L., T.W., M.S., K.P.M., P.J.K., M.R., D.J.P., S.V.B.-N.), Royal Brompton Hospital, Imperial College London, London, United Kingdom; and Section of Clinical Physiology, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden (R.R.)
| | - Mary Sheppard
- From the NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital (R.R., M.A.G., S.Y.H., S.E., L.S., W.L., T.W., M.S., K.P.M., P.J.K., D.J.P., S.V.B.-N.), National Heart and Lung Institute (M.A.G., S.Y.H., S.E., L.S., W.L., T.W., M.S., K.P.M., P.J.K., M.R., D.J.P., S.V.B.-N.), Royal Brompton Hospital, Imperial College London, London, United Kingdom; and Section of Clinical Physiology, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden (R.R.)
| | - Karen P. McCarthy
- From the NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital (R.R., M.A.G., S.Y.H., S.E., L.S., W.L., T.W., M.S., K.P.M., P.J.K., D.J.P., S.V.B.-N.), National Heart and Lung Institute (M.A.G., S.Y.H., S.E., L.S., W.L., T.W., M.S., K.P.M., P.J.K., M.R., D.J.P., S.V.B.-N.), Royal Brompton Hospital, Imperial College London, London, United Kingdom; and Section of Clinical Physiology, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden (R.R.)
| | - Michael Roughton
- From the NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital (R.R., M.A.G., S.Y.H., S.E., L.S., W.L., T.W., M.S., K.P.M., P.J.K., D.J.P., S.V.B.-N.), National Heart and Lung Institute (M.A.G., S.Y.H., S.E., L.S., W.L., T.W., M.S., K.P.M., P.J.K., M.R., D.J.P., S.V.B.-N.), Royal Brompton Hospital, Imperial College London, London, United Kingdom; and Section of Clinical Physiology, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden (R.R.)
| | - Philip J. Kilner
- From the NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital (R.R., M.A.G., S.Y.H., S.E., L.S., W.L., T.W., M.S., K.P.M., P.J.K., D.J.P., S.V.B.-N.), National Heart and Lung Institute (M.A.G., S.Y.H., S.E., L.S., W.L., T.W., M.S., K.P.M., P.J.K., M.R., D.J.P., S.V.B.-N.), Royal Brompton Hospital, Imperial College London, London, United Kingdom; and Section of Clinical Physiology, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden (R.R.)
| | - Dudley J. Pennell
- From the NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital (R.R., M.A.G., S.Y.H., S.E., L.S., W.L., T.W., M.S., K.P.M., P.J.K., D.J.P., S.V.B.-N.), National Heart and Lung Institute (M.A.G., S.Y.H., S.E., L.S., W.L., T.W., M.S., K.P.M., P.J.K., M.R., D.J.P., S.V.B.-N.), Royal Brompton Hospital, Imperial College London, London, United Kingdom; and Section of Clinical Physiology, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden (R.R.)
| | - Sonya V. Babu-Narayan
- From the NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital (R.R., M.A.G., S.Y.H., S.E., L.S., W.L., T.W., M.S., K.P.M., P.J.K., D.J.P., S.V.B.-N.), National Heart and Lung Institute (M.A.G., S.Y.H., S.E., L.S., W.L., T.W., M.S., K.P.M., P.J.K., M.R., D.J.P., S.V.B.-N.), Royal Brompton Hospital, Imperial College London, London, United Kingdom; and Section of Clinical Physiology, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden (R.R.)
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Kato S, Saito N, Kirigaya H, Gyotoku D, Iinuma N, Kusakawa Y, Iguchi K, Nakachi T, Fukui K, Futaki M, Iwasawa T, Taguri M, Kimura K, Umemura S. Incremental prognostic value of the SYNTAX score to late gadolinium-enhanced magnetic resonance images for patients with stable coronary artery disease. Heart Vessels 2015; 31:871-80. [DOI: 10.1007/s00380-015-0685-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Accepted: 04/17/2015] [Indexed: 11/24/2022]
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360
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Choi HM, Kim KH, Lee JM, Yoon YE, Lee SP, Park EA, Lee W, Kim YJ, Cho GY, Sohn DW, Kim HK. Myocardial fibrosis progression on cardiac magnetic resonance in hypertrophic cardiomyopathy. Heart 2015; 101:870-6. [DOI: 10.1136/heartjnl-2014-306555] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Accepted: 03/20/2015] [Indexed: 11/04/2022] Open
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361
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Larsen TH, Stugaard M, Rotevatn S, Nygård O, Nordrehaug JE. Clinical Significance of Late Enhancement and Regional Wall Remodeling Assessed by 3T Magnetic Resonance Imaging. CLINICAL MEDICINE INSIGHTS-CARDIOLOGY 2015; 9:17-24. [PMID: 25922586 PMCID: PMC4401245 DOI: 10.4137/cmc.s20291] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Revised: 12/07/2014] [Accepted: 12/13/2014] [Indexed: 01/19/2023]
Abstract
BACKGROUND Clinical follow-up studies comparing left ventricular (LV) function and late gadolinium enhancement (LGE) by high-field 3T cardiac magnetic resonance (CMR) are of general interest due to the increased use of 3T scanners. In this study, the occurrence of LGE and LV regional wall remodeling (RWR) was assessed by 3T CMR in patients undergoing coronary angiography for suspected stable coronary artery disease (CAD). MATERIALS AND METHODS Analysis of myocardial viability by LGE was performed at the segmental level. LVRWR was identified by a significant reduction (≥50%) of the wall thickness. Major adverse cardiovascular events (MACE) were registered during a median follow-up time of 58 (45-62) months. RESULTS Of the 87 patients (59 ± 9 years; 13 women) enrolled, nonviable myocardium was detected in 35 (40%) and significant CAD in 69 (79%). Nonviable myocardium was correlated to angiographic significant stenosis or occlusion. LVRWR was significantly related to a higher number of nonviable segments compared to those without LVRWR: ie, 6.0 ± 3.2 segments versus 2.6 ± 1.3; P < 0.001. In the nonviable group, LVEF was significantly reduced (P < 0.001) compared to the viable group: ie, 50 ± 16% versus 61 ± 8%, and LVEF was significantly correlated to the number of nonviable segments (r = -0.66, P < 0.001). The number of nonviable segments by LGE was significantly associated with MACE by an odds ratio of 1.25 (95% CI, 1.05-1.49; P = 0.013). CONCLUSION The presence of nonviable myocardium as detected by LGE at 3T CMR is associated with angiographically significant CAD, and is associated with the development of LVRWR and reduced LVEF. Assessing the extent of nonviable myocardium by both LGE and LVRWR at the segmental level may therefore contribute to individualized risk stratification and treatment strategies.
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Affiliation(s)
- Terje H Larsen
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
- Department of Biomedicine, University of Bergen, Bergen, Norway
| | - Marie Stugaard
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Svein Rotevatn
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Ottar Nygård
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
- Institute of Clinical Sciences, University of Bergen, Bergen, Norway
| | - Jan Erik Nordrehaug
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
- Institute of Clinical Sciences, University of Bergen, Bergen, Norway
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362
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Małek ŁA, Werys K, Kłopotowski M, Śpiewak M, Miłosz-Wieczorek B, Mazurkiewicz Ł, Petryka-Mazurkiewicz J, Marczak M, Witkowski A. Native T1-mapping for non-contrast assessment of myocardial fibrosis in patients with hypertrophic cardiomyopathy--comparison with late enhancement quantification. Magn Reson Imaging 2015; 33:718-24. [PMID: 25863138 DOI: 10.1016/j.mri.2015.04.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2015] [Revised: 03/10/2015] [Accepted: 04/06/2015] [Indexed: 01/20/2023]
Abstract
BACKGROUND Myocardial fibrosis was shown to influence prognosis in hypertrophic cardiomyopathy (HCM). It is typically assessed by late gadolinium enhancement (LGE) on cardiac magnetic resonance. Native T1-mapping has been proposed, as a contrast-free method of fibrosis assessment. The aim of the study was to define a cut-off value for native T1 relaxation time that best reflects LGE quantification of myocardial fibrosis. METHODS In 25 patients with HCM and 20 controls we performed T1-mapping pre-contrast using ShMOLLI technique. This was followed by LGE assessment in the studied group 10 minutes after gadolinium contrast injection. Relative myocardial fibrosis size was calculated for varying T1 time thresholds (940-1100 ms) and compared with 6 standard deviations (6SD) method for LGE. RESULTS Median fibrosis size calculated with T1-mapping was insignificantly different from LGE only for native T1 time threshold of 1060 ms (p = 0.62). Using this threshold, Bland-Altman plots demonstrated very good agreement between fibrosis sizes from the two methods (slightly better only for 1080 ms threshold). For threshold of 1060 ms we also observed good correlation (rho = 0.73) with LGE 6SD method (insignificantly better for lower thresholds, best for threshold of 980 ms-rho = 0.88). In control group with no diagnosis of HCM, fibrosis size <1% was reached for thresholds of 1040 ms and higher. CONCLUSION Native T1-mapping can be used for non-contrast assessment of myocardial fibrosis in HCM. The 1060 ms threshold of the native T1 relaxation time is characterized by the best balance between agreement and correlation with fibrosis assessed by LGE 6SD method.
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Affiliation(s)
- Łukasz A Małek
- Department of Interventional Cardiology and Angiology, Institute of Cardiology, Warsaw, Poland; Magnetic Resonance Unit, Department of Radiology, Institute of Cardiology, Warsaw, Poland.
| | - Konrad Werys
- Magnetic Resonance Unit, Department of Radiology, Institute of Cardiology, Warsaw, Poland; Institute of Radioelectronics, Warsaw University of Technology, Warsaw, Poland
| | - Mariusz Kłopotowski
- Department of Interventional Cardiology and Angiology, Institute of Cardiology, Warsaw, Poland
| | - Mateusz Śpiewak
- Magnetic Resonance Unit, Department of Radiology, Institute of Cardiology, Warsaw, Poland; Department of Coronary Artery Disease and Structural Heart Diseases, Institute of Cardiology, Warsaw, Poland
| | | | | | - Joanna Petryka-Mazurkiewicz
- Department of Coronary Artery Disease and Structural Heart Diseases, Institute of Cardiology, Warsaw, Poland
| | - Magdalena Marczak
- Magnetic Resonance Unit, Department of Radiology, Institute of Cardiology, Warsaw, Poland
| | - Adam Witkowski
- Department of Interventional Cardiology and Angiology, Institute of Cardiology, Warsaw, Poland
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363
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Peteiro J, Fernandez X, Bouzas-Mosquera A, Monserrat L, Méndez C, Rodriguez-Garcia E, Soler R, Couto D, Castro-Beiras A. Exercise echocardiography and cardiac magnetic resonance imaging to predict outcome in patients with hypertrophic cardiomyopathy†. Eur Heart J Cardiovasc Imaging 2015; 16:423-432. [DOI: 10.1093/ehjci/jeu225] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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364
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Prognostic significance of late gadolinium enhancement quantification in cardiac magnetic resonance imaging of hypertrophic cardiomyopathy with systolic dysfunction. Heart Vessels 2015; 31:758-70. [DOI: 10.1007/s00380-015-0670-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Accepted: 03/20/2015] [Indexed: 10/23/2022]
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365
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Debonnaire P, Katsanos S, Joyce E, VAN DEN Brink OVW, Atsma DE, Schalij MJ, Bax JJ, Delgado V, Marsan NA. QRS Fragmentation and QTc Duration Relate to Malignant Ventricular Tachyarrhythmias and Sudden Cardiac Death in Patients with Hypertrophic Cardiomyopathy. J Cardiovasc Electrophysiol 2015; 26:547-55. [PMID: 25648421 DOI: 10.1111/jce.12629] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2014] [Revised: 01/19/2015] [Accepted: 01/27/2015] [Indexed: 10/24/2022]
Abstract
BACKGROUND QRS fragmentation (fQRS) and prolonged QTc interval on surface ECG are prognostic in various cardiomyopathies other than hypertrophic cardiomyopathy (HCM). The association between fQRS and prolonged QTc duration with occurrence of ventricular tachyarrhythmias or sudden cardiac death (VTA/SCD) in patients with HCM was explored. METHODS AND RESULTS One hundred and ninety-five clinical HCM patients were studied. QTc duration was derived applying Bazett's formula; fQRS was defined as presence of various RSR' patterns, R or S notching and/or >1 additional R wave in any non-aVR lead in patients without pacing or (in)complete bundle branch block. The endpoints comprised SCD, ECG documented sustained VTA (tachycardia or fibrillation) or appropriate implantable cardioverter defibrillator (ICD) therapies (antitachycardia pacing [ATP] or shock) for VTA in ICD recipients (n = 58 [30%]). QT prolonging drugs recipients were excluded. After a median follow-up of 5.7 years (IQR 2.7-9.1), 26 (13%) patients experienced VTA or SCD. Patients with fQRS in ≥3 territories (inferior, lateral, septal, and/or anterior) (p = 0.004) or QTc ≥460 ms (p = 0.009) had worse cumulative survival free of VTA/SCD than patients with fQRS in <3 territories or QTc <460 ms. fQRS in ≥3 territories (ß 4.5, p = 0.020, 95%CI 1.41-14.1) and QTc ≥460 ms (ß 2.7, p = 0.037, 95%CI 1.12-6.33) were independently associated with VTA/SCD. Likelihood ratio test indicated assessment of fQRS and QTc on top of conventional SCD risk factors provides incremental predictive value for VTA/SCD (p = 0.035). CONCLUSIONS Both fQRS in ≥3 territories and QTc duration are associated with VTA/SCD in HCM patients, independently of and incremental to conventional SCD risk factors.
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Affiliation(s)
- Philippe Debonnaire
- Leiden University Medical Centre, Department of Cardiology, Leiden, the Netherlands.,Sint-Jan Hospital Bruges, Department of Cardiology, Bruges, Belgium
| | - Spyridon Katsanos
- Leiden University Medical Centre, Department of Cardiology, Leiden, the Netherlands
| | - Emer Joyce
- Leiden University Medical Centre, Department of Cardiology, Leiden, the Netherlands
| | | | - Douwe E Atsma
- Leiden University Medical Centre, Department of Cardiology, Leiden, the Netherlands
| | - Martin J Schalij
- Leiden University Medical Centre, Department of Cardiology, Leiden, the Netherlands
| | - Jeroen J Bax
- Leiden University Medical Centre, Department of Cardiology, Leiden, the Netherlands
| | - Victoria Delgado
- Leiden University Medical Centre, Department of Cardiology, Leiden, the Netherlands
| | - Nina Ajmone Marsan
- Leiden University Medical Centre, Department of Cardiology, Leiden, the Netherlands
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Tandon A, Villa CR, Hor KN, Jefferies JL, Gao Z, Towbin JA, Wong BL, Mazur W, Fleck RJ, Sticka JJ, Benson DW, Taylor MD. Myocardial fibrosis burden predicts left ventricular ejection fraction and is associated with age and steroid treatment duration in duchenne muscular dystrophy. J Am Heart Assoc 2015; 4:jah3890. [PMID: 25814625 PMCID: PMC4579941 DOI: 10.1161/jaha.114.001338] [Citation(s) in RCA: 102] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Background Patients with Duchenne muscular dystrophy exhibit progressive cardiac and skeletal muscle dysfunction. Based on prior data, cardiac dysfunction in Duchenne muscular dystrophy patients may be influenced by myocardial fibrosis and steroid therapy. We examined the longitudinal relationship of myocardial fibrosis and ventricular dysfunction using cardiac magnetic resonance in a large Duchenne muscular dystrophy cohort. Methods and Results We reviewed 465 serial cardiac magnetic resonance studies (98 Duchenne muscular dystrophy patients with ≥4 cardiac magnetic resonance studies) for left ventricular ejection fraction (LVEF) and presence of late gadolinium enhancement (LGE), a marker for myocardial fibrosis. LVEF was modeled by examining LGE status, myocardial fibrosis burden (as assessed by the number of LGE‐positive left ventricular segments), patient age, and steroid treatment duration. An age‐only model demonstrated that LVEF declined 0.58±0.10% per year. In patients with both LGE‐negative and LGE‐positive studies (n=51), LVEF did not decline significantly over time if LGE was absent but declined 2.2±0.31% per year when LGE was present. Univariate modeling showed significant associations between LVEF and steroid treatment duration, presence of LGE, and number of LGE‐positive left ventricular segments; multivariate modeling showed that LVEF declined by 0.93±0.09% for each LGE‐positive left ventricular segment, whereas age and steroid treatment duration were not significant. The number of LGE‐positive left ventricular segments increased with age, and longer steroid treatment duration was associated with lower age‐related increases. Conclusion Progressive myocardial fibrosis, as detected by LGE, was strongly correlated with the LVEF decline in Duchenne muscular dystrophy patients. Longer steroid treatment duration was associated with a lower age‐related increase in myocardial fibrosis burden.
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Affiliation(s)
- Animesh Tandon
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH (A.T., C.R.V., J.L.J., Z.G., J.A.T., J.J.S., M.D.T.)
| | - Chet R Villa
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH (A.T., C.R.V., J.L.J., Z.G., J.A.T., J.J.S., M.D.T.)
| | - Kan N Hor
- The Heart Center, Nationwide Children's Hospital, Columbus, OH (K.N.H.)
| | - John L Jefferies
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH (A.T., C.R.V., J.L.J., Z.G., J.A.T., J.J.S., M.D.T.)
| | - Zhiqian Gao
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH (A.T., C.R.V., J.L.J., Z.G., J.A.T., J.J.S., M.D.T.)
| | - Jeffrey A Towbin
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH (A.T., C.R.V., J.L.J., Z.G., J.A.T., J.J.S., M.D.T.)
| | - Brenda L Wong
- Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH (B.L.W.)
| | - Wojciech Mazur
- The Heart and Vascular Center at the Christ Hospital, Cincinnati, OH (W.M.)
| | - Robert J Fleck
- The Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH (R.J.F.)
| | - Joshua J Sticka
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH (A.T., C.R.V., J.L.J., Z.G., J.A.T., J.J.S., M.D.T.)
| | - D Woodrow Benson
- Herma Heart Center, Children's Hospital of Wisconsin, Milwaukee, WI (W.B.)
| | - Michael D Taylor
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH (A.T., C.R.V., J.L.J., Z.G., J.A.T., J.J.S., M.D.T.)
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367
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Bogaert J, Olivotto I. MR Imaging in Hypertrophic Cardiomyopathy: From Magnet to Bedside. Radiology 2015; 273:329-48. [PMID: 25340269 DOI: 10.1148/radiol.14131626] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Hypertrophic cardiomyopathy ( HCM hypertrophic cardiomyopathy ), the most common genetically transmitted cardiac disorder, has been the focus of extensive research over the past 50 years. HCM hypertrophic cardiomyopathy is a multifaceted disease with highly heterogeneous genetic background, phenotypic expression, clinical presentation, and long-term outcome. Though most patients have an indolent course with a life expectancy comparable to that of the general population, early diagnosis and accurate risk profiling are essential to identify the sizeable subset at increased risk of sudden cardiac death or disease progression and heart failure-related complications, requiring aggressive management options. Imaging has a central role in the diagnosis and prognostic assessment of HCM hypertrophic cardiomyopathy patients, as well as screening of potentially affected family members. In this context, magnetic resonance (MR) imaging has recently emerged as an ideal complement to transthoracic echocardiography. Its multiparametric approach, fusing spatial, contrast, and temporal resolution, provides the clinician with detailed characterization of the HCM hypertrophic cardiomyopathy phenotype and assessment of its functional consequences including causes and site of dynamic obstruction, presence and extent of myocardial perfusion abnormalities, and fibrosis. Moreover, MR is key in differentiating HCM hypertrophic cardiomyopathy from "phenocopies"-that is, hearts with similar morphology but profoundly different etiology, such as amyloid or Anderson-Fabry disease. Long term, the incremental information provided by MR is relevant to planning of septal reduction therapies, identification of the early stages of end-stage progression, and stratification of arrhythmic risk. The aim of this review is to depict the increasingly important role of MR imaging in relation to the complexity of HCM hypertrophic cardiomyopathy , highlighting its role in clinical decision making.
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Affiliation(s)
- Jan Bogaert
- From the Department of Radiology, Gasthuisberg University Hospitals Leuven, Herestraat 49, B-3000 Leuven, Belgium (J.B.); and Referral Center for Myocardial Diseases, Azienda Universitaria Careggi, Florence, Italy (I.O.)
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368
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Chiribiri A, Leuzzi S, Conte MR, Bongioanni S, Bratis K, Olivotti L, De Rosa C, Lardone E, Di Donna P, Villa ADM, Cesarani F, Nagel E, Gaita F, Bonamini R. Rest perfusion abnormalities in hypertrophic cardiomyopathy: correlation with myocardial fibrosis and risk factors for sudden cardiac death. Clin Radiol 2015; 70:495-501. [PMID: 25659937 PMCID: PMC4398331 DOI: 10.1016/j.crad.2014.12.018] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Revised: 12/16/2014] [Accepted: 12/29/2014] [Indexed: 01/27/2023]
Abstract
Aim To measure the prevalence of abnormal rest perfusion in a population of consecutive patients with known hypertrophic cardiomyopathy (HCM) referred for cardiovascular MRI (CMR), and to assess any associations between abnormal rest perfusion and the presence, pattern, and severity of myocardial scar and the presence of risk factors for sudden death. Materials and methods Eighty consecutive patients with known HCM referred for CMR underwent functional imaging, rest first-pass perfusion, and late gadolinium enhancement (LGE). Results Thirty percent of the patients had abnormal rest perfusion, all of them corresponding to areas of mid-myocardial LGE and to a higher degree of segmental hypertrophy. Rest perfusion abnormalities correlated with more extensive and confluent LGE. The subgroup of patients with myocardial fibrosis and rest perfusion abnormalities (fibrosis+/perfusion+) had more than twice the incidence of episodes of non-sustained ventricular tachycardia on Holter monitoring in comparison to patients with myocardial fibrosis and normal rest perfusion (fibrosis+/perfusion–) and patients with no fibrosis and normal rest perfusion (fibrosis–/perfusion–). Conclusions First-pass perfusion CMR identifies abnormal rest perfusion in a significant proportion of patients with HCM. These abnormalities are associated with the presence and distribution of myocardial scar and the degree of hypertrophy. Rest perfusion abnormalities identify patients with increased incidence of episodes of non-sustained ventricular tachycardia on Holter monitoring, independently from the presence of myocardial fibrosis. 30% of patients with HCM have perfusion abnormalities related to scar. No rest perfusion abnormalities were observed in areas of viable myocardium. Scar-related perfusion abnormalities were associated with the incidence of NSVT.
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Affiliation(s)
- A Chiribiri
- King's College London, Wellcome Trust/EPSRC Medical Engineering Centre, Division of Imaging Sciences, St Thomas' Hospital, UK; Department of Internal Medicine, University of Torino, Italy.
| | - S Leuzzi
- Division of Cardiology, Cardinal Massaia Hospital, University of Torino, Asti, Italy
| | - M R Conte
- Division of Cardiology, A.O. Ordine Mauriziano di Torino Presidio Umberto I, Torino, Italy
| | - S Bongioanni
- Division of Cardiology, A.O. Ordine Mauriziano di Torino Presidio Umberto I, Torino, Italy
| | - K Bratis
- King's College London, Wellcome Trust/EPSRC Medical Engineering Centre, Division of Imaging Sciences, St Thomas' Hospital, UK
| | - L Olivotti
- King's College London, Wellcome Trust/EPSRC Medical Engineering Centre, Division of Imaging Sciences, St Thomas' Hospital, UK; Department of Cardiology, Santa Corona Hospital, Pietra Ligure, Italy
| | - C De Rosa
- Division of Cardiology, A.O. Ordine Mauriziano di Torino Presidio Umberto I, Torino, Italy
| | - E Lardone
- Division of Cardiology, A.O. Ordine Mauriziano di Torino Presidio Umberto I, Torino, Italy
| | - P Di Donna
- Division of Cardiology, Cardinal Massaia Hospital, University of Torino, Asti, Italy
| | - A D M Villa
- King's College London, Wellcome Trust/EPSRC Medical Engineering Centre, Division of Imaging Sciences, St Thomas' Hospital, UK
| | - F Cesarani
- Department of Radiology, Cardinal Massaia Hospital, Asti, Italy
| | - E Nagel
- King's College London, Wellcome Trust/EPSRC Medical Engineering Centre, Division of Imaging Sciences, St Thomas' Hospital, UK
| | - F Gaita
- Department of Internal Medicine, University of Torino, Italy; Division of Cardiology, Cardinal Massaia Hospital, University of Torino, Asti, Italy
| | - R Bonamini
- Department of Internal Medicine, University of Torino, Italy
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Cardim N, Galderisi M, Edvardsen T, Plein S, Popescu BA, D'Andrea A, Bruder O, Cosyns B, Davin L, Donal E, Freitas A, Habib G, Kitsiou A, Petersen SE, Schroeder S, Lancellotti P, Camici P, Dulgheru R, Hagendorff A, Lombardi M, Muraru D, Sicari R. Role of multimodality cardiac imaging in the management of patients with hypertrophic cardiomyopathy: an expert consensus of the European Association of Cardiovascular Imaging Endorsed by the Saudi Heart Association. Eur Heart J Cardiovasc Imaging 2015; 16:280. [PMID: 25650407 DOI: 10.1093/ehjci/jeu291] [Citation(s) in RCA: 190] [Impact Index Per Article: 21.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Taking into account the complexity and limitations of clinical assessment in hypertrophic cardiomyopathy (HCM), imaging techniques play an essential role in the evaluation of patients with this disease. Thus, in HCM patients, imaging provides solutions for most clinical needs, from diagnosis to prognosis and risk stratification, from anatomical and functional assessment to ischaemia detection, from metabolic evaluation to monitoring of treatment modalities, from staging and clinical profiles to follow-up, and from family screening and preclinical diagnosis to differential diagnosis. Accordingly, a multimodality imaging (MMI) approach (including echocardiography, cardiac magnetic resonance, cardiac computed tomography, and cardiac nuclear imaging) is encouraged in the assessment of these patients. The choice of which technique to use should be based on a broad perspective and expert knowledge of what each technique has to offer, including its specific advantages and disadvantages. Experts in different imaging techniques should collaborate and the different methods should be seen as complementary, not as competitors. Each test must be selected in an integrated and rational way in order to provide clear answers to specific clinical questions and problems, trying to avoid redundant and duplicated information, taking into account its availability, benefits, risks, and cost.
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MESH Headings
- Cardiac Imaging Techniques/methods
- Cardiac Imaging Techniques/standards
- Cardiomyopathy, Hypertrophic/diagnosis
- Cardiomyopathy, Hypertrophic/therapy
- Consensus
- Echocardiography, Doppler/methods
- Echocardiography, Doppler/standards
- Europe
- Female
- Humans
- Image Interpretation, Computer-Assisted
- Magnetic Resonance Imaging, Cine/methods
- Magnetic Resonance Imaging, Cine/standards
- Male
- Multimodal Imaging/methods
- Multimodal Imaging/standards
- Positron-Emission Tomography/methods
- Positron-Emission Tomography/standards
- Practice Guidelines as Topic/standards
- Role
- Saudi Arabia
- Societies, Medical/standards
- Tomography, X-Ray Computed/methods
- Tomography, X-Ray Computed/standards
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Tummala LS, Young RK, Singh T, Jani S, Srichai MB. Role of Non-invasive Imaging in the Work-Up of Cardiomyopathies. Curr Atheroscler Rep 2015; 17:486. [DOI: 10.1007/s11883-014-0486-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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371
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Fattal J, Henry MA, Ou S, Bradette S, Papas K, Marcotte F, Garceau P, Pressacco J. Magnetic Resonance Imaging of Hypertrophic Cardiomyopathy: Beyond Left Ventricular Wall Thickness. Can Assoc Radiol J 2015; 66:71-8. [DOI: 10.1016/j.carj.2014.07.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2013] [Revised: 06/01/2014] [Accepted: 07/30/2014] [Indexed: 10/24/2022] Open
Abstract
During the past decade, cardiac magnetic resonance has gained increasing popularity in the diagnosis of hypertrophic cardiomyopathy because of its greater accuracy and better characterization of cardiac morphology compared with other imaging modalities. In this pictorial essay, a global clinical portrait of hypertrophic cardiomyopathy will be drawn. The various radiologic findings associated with each variant of hypertrophic cardiomyopathy, and the clinical edge offered by cardiac magnetic resonance will be discussed.
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Affiliation(s)
- Julie Fattal
- Department of Medicine, Université Laval, Québec, Québec Canada
| | - Marc-Antoine Henry
- Department of Radiology, Université de Montréal, Montréal, Québec, Canada
| | - Sopheap Ou
- Department of Radiology, Université de Sherbrooke, Sherbrooke, Québec, Canada
| | - Simon Bradette
- Department of Medicine, Université de Montréal, Montréal, Québec, Canada
| | - Konstantin Papas
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | - François Marcotte
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | - Patrick Garceau
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | - Josephine Pressacco
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
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373
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Cheong BYC, Angelini P. Magnetic Resonance Imaging of the Myocardium, Coronary Arteries, and Anomalous Origin of Coronary Arteries. Coron Artery Dis 2015. [DOI: 10.1007/978-1-4471-2828-1_13] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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374
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375
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Burt JR, Zimmerman SL, Kamel IR, Halushka M, Bluemke DA. Myocardial T1 mapping: techniques and potential applications. Radiographics 2015; 34:377-95. [PMID: 24617686 DOI: 10.1148/rg.342125121] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Myocardial fibrosis is a common endpoint in a variety of cardiac diseases and a major independent predictor of adverse cardiac outcomes. Short of histopathologic analysis, which is limited by sampling bias, most diagnostic modalities are limited in their depiction of myocardial fibrosis. Cardiac magnetic resonance (MR) imaging has the advantage of providing detailed soft-tissue characterization, and a variety of novel quantification methods have further improved its usefulness. Contrast material-enhanced cardiac MR imaging depends on differences in signal intensity between regions of scarring and adjacent normal myocardium. Diffuse myocardial fibrosis lacks these differences in signal intensity. Measurement of myocardial T1 times (T1 mapping) with gadolinium-enhanced inversion recovery-prepared sequences may depict diffuse myocardial fibrosis and has good correlation with ex vivo fibrosis content. T1 mapping calculates myocardial T1 relaxation times with image-based signal intensities and may be performed with standard cardiac MR imagers and radiologic workstations. Myocardium with diffuse fibrosis has greater retention of contrast material, resulting in T1 times that are shorter than those in normal myocardium. Early studies have suggested that diffuse myocardial fibrosis may be distinguished from normal myocardium with T1 mapping. Large multicenter studies are needed to define the role of T1 mapping in developing prognoses and therapeutic assessments. However, given its strengths as a noninvasive method for direct quantification of myocardial fibrosis, T1 mapping may eventually play an important role in the management of cardiac disease.
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Affiliation(s)
- Jeremy R Burt
- From the Russell H. Morgan Department of Radiology and Radiological Sciences (J.R.B., S.L.Z., I.R.K., D.A.B.) and Department of Pathology (M.H.), Johns Hopkins University School of Medicine, Baltimore, Md; and Radiology and Imaging Sciences, Clinical Center, and National Institute of Biomedical Imaging and Bioengineering, National Institutes of Health, 10 Center Dr, Room 1C355, Bethesda, MD 20892 (D.A.B.)
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376
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Abstract
Hypertrophic cardiomyopathy (HCM) is a hereditary primary myocardial disease that is most commonly due to mutations within genes encoding sarcomeric contractile proteins and is characterised by left ventricular hypertrophy in the absence of a cardiac or systemic cause. Although the overall prognosis is relatively good with an annual mortality rate <1 %, the propensity to potentially fatal ventricular arrhythmias is the most feared complication. The identification of patients at risk of arrhythmogenic sudden cardiac death (SCD) is an essential component in disease management. Aborted SCD and malignant ventricular arrhythmias are the most powerful risk factors for SCD and ICD implantation is recommended in such circumstances. The selection of patients who may benefit from ICD therapy for primary prevention purposes is more challenging. The heterogeneous nature of the disease and the variation in trigger factors provides an adequate explanation for the low predictive accuracy of most conventional risk factors in isolation. A new risk model for risk stratification proposed by the European Society of Cardiology HCM outcome group shows promise but requires validation in different cohorts. The ICD is the only effective therapy in preventing SCD for the disease with a relatively low adverse event rate, but most deaths occur in relatively young patients. However, it is also difficult to ignore the complications with the ICD, therefore, the strive to perfect risk stratification in HCM should continue to ensure that only the most high-risk patients receive an ICD.
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Affiliation(s)
- Alexandros Klavdios Steriotis
- CRY Centre for Inherited Cardiovascular Conditions & Sports Cardiology, St George's University of London, London, UK
| | - Sanjay Sharma
- CRY Centre for Inherited Cardiovascular Conditions & Sports Cardiology, St George's University of London, London, UK
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377
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Kawasaki T, Harimoto K, Honda S, Sato Y, Yamano M, Miki S, Kamitani T. Notched QRS for the Assessment of Myocardial Fibrosis in Hypertrophic Cardiomyopathy. Circ J 2015; 79:847-53. [DOI: 10.1253/circj.cj-14-1109] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Affiliation(s)
| | | | - Sakiko Honda
- Department of Cardiology, Matsushita Memorial Hospital
| | - Yoshimi Sato
- Department of Cardiology, Matsushita Memorial Hospital
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378
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379
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Hinojar R, Botnar R, Kaski JC, Prasad S, Nagel E, Puntmann VO. Individualized cardiovascular risk assessment by cardiovascular magnetic resonance. Future Cardiol 2015; 10:273-89. [PMID: 24762254 DOI: 10.2217/fca.13.102] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Cardiovascular magnetic resonance (CMR) is gaining clinical importance in preventive medicine. Evidence on diagnostic accuracy and prognostic value, in addition to the development of faster imaging, increased availability of equipment and imaging expertise have led to a wide-spread use of CMR in a growing number of clinical indications. The first part of this review summarizes the role of CMR biomarkers for risk assessment focusing on the patients groups that benefit from the use of CMR. In the second part, the future directions for CMR are discussed and their role in prevention of cardiovascular disease.
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Affiliation(s)
- Rocio Hinojar
- Cardiovascular Imaging Department, Division of Imaging Sciences & Biomedical Engineering, King's College London, London, UK
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380
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Morita N, Mandel WJ, Kobayashi Y, Karagueuzian HS. Cardiac fibrosis as a determinant of ventricular tachyarrhythmias. J Arrhythm 2014; 30:389-394. [PMID: 25642299 DOI: 10.1016/j.joa.2013.12.008] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Animal and emerging clinical studies have demonstrated that increased ventricular fibrosis in a setting of reduced repolarization reserve promotes early afterdepolarizations (EADs) and triggered activity that can initiate ventricular tachycardia and ventricular fibrillation (VT/VF). Increased ventricular fibrosis plays a key facilitatory role in allowing oxidative and metabolic stress-induced EADs to manifest as triggered activity causing VT/VF. The lack of such an arrhythmogenic effect by the same stressors in normal non-fibrotic hearts highlights the importance of fibrosis in the initiation of VT/VF. These findings suggest that antifibrotic therapy combined with therapy designed to increase ventricular repolarization reserve may act synergistically to reduce the risk of sudden cardiac death.
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Affiliation(s)
- Norishige Morita
- Division of Cardiology, Department of Medicine, Tokai University Hachioji Hospital, Tokyo, Japan
| | - William J Mandel
- Translational Arrhythmia Research Section, Division of Cardiology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Yoshinori Kobayashi
- Division of Cardiology, Department of Medicine, Tokai University Hachioji Hospital, Tokyo, Japan
| | - Hrayr S Karagueuzian
- Division of Cardiology, Department of Medicine, Tokai University Hachioji Hospital, Tokyo, Japan
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381
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Gati S, Rajani R, Carr-White GS, Chambers JB. Adult Left Ventricular Noncompaction. JACC Cardiovasc Imaging 2014; 7:1266-75. [DOI: 10.1016/j.jcmg.2014.09.005] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2014] [Revised: 09/17/2014] [Accepted: 09/22/2014] [Indexed: 01/22/2023]
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382
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Diagnosing burned-out hypertrophic cardiomyopathy: Daughter's phenotype solidifies father's diagnosis. J Cardiol Cases 2014; 11:78-80. [PMID: 30546535 DOI: 10.1016/j.jccase.2014.10.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Revised: 10/13/2014] [Accepted: 10/16/2014] [Indexed: 11/20/2022] Open
Abstract
Patients with hypertrophic cardiomyopathy classically have preserved systolic function in the setting of impaired diastolic function and decreased left ventricular end-diastolic volume. However, in a small sub-population, patients paradoxically develop systolic dysfunction, left ventricular dilatation, and ventricular wall thinning. This pattern is one that is likened to dilated cardiomyopathy and is known as end-stage hypertrophic cardiomyopathy or "burned-out cardiomyopathy." The role of cardiac magnetic resonance imaging is well defined in narrowing the differential diagnosis of impaired left ventricular function, including that of hypertrophic cardiomyopathy. However, the importance of obtaining a family history and obtaining details of diagnosis for both preceding and future generations cannot be under-estimated. We report a case of end-stage hypertrophic cardiomyopathy that highlights how important family history can be in making a diagnosis. <Learning objective: While most cases of burned-out hypertrophic cardiomyopathy occur long after a patient has been initially seen and subsequently followed by cardiologists for hypertrophic cardiomyopathy, a small proportion of patients initially present with this entity. This is one such case, and it highlights the importance of thorough investigation into a patient's family history.>.
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383
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Yoon YE, Hong YJ, Kim HK, Kim JA, Na JO, Yang DH, Kim YJ, Choi EY. 2014 korean guidelines for appropriate utilization of cardiovascular magnetic resonance imaging: a joint report of the korean society of cardiology and the korean society of radiology. Korean Circ J 2014; 44:359-85. [PMID: 25469139 PMCID: PMC4248609 DOI: 10.4070/kcj.2014.44.6.359] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Revised: 10/17/2014] [Accepted: 10/19/2014] [Indexed: 12/19/2022] Open
Abstract
Cardiac magnetic resonance (CMR) imaging is now widely used in several fields of cardiovascular disease assessment due to recent technical developments. CMR can give physicians information that cannot be found with other imaging modalities. However, there is no guideline which is suitable for Korean people for the use of CMR. Therefore, we have prepared a Korean guideline for the appropriate utilization of CMR to guide Korean physicians, imaging specialists, medical associates and patients to improve the overall medical system performances. By addressing CMR usage and creating these guidelines we hope to contribute towards the promotion of public health. This guideline is a joint report of the Korean Society of Cardiology and the Korean Society of Radiology.
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Affiliation(s)
- Yeonyee E Yoon
- Department of Cardiology, Cardiovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Yoo Jin Hong
- Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hyung-Kwan Kim
- Division of Cardiology, Department of Internal Medicine, Cardiovascular Center, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Jeong A Kim
- Department of Radiology, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - Jin Oh Na
- Cardiovascular Center, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Dong Hyun Yang
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young Jin Kim
- Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Eui-Young Choi
- Division of Cardiology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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384
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Abstract
Cardiovascular magnetic resonance using late gadolinium enhancement (LGE) provides a unique opportunity to assess myocardial tissue in vivo. LGE enables tissue characterization in ischemic and nonischemic cardiomyopathies and other cardiac diseases. LGE is associated with adverse clinical outcomes across a range of different cardiac conditions and may improve risk stratification for death, sudden cardiac death, or serious adverse events beyond traditional prognostic markers. Generally, matching data for the prognostic impact of LGE are frequently reached in cardiac disorders. In other diseases, only a limited number of trials are available, but it is anticipated that the prognostic impact of delayed enhancement will become evident. The development and validation of new cardiovascular magnetic resonance methods for diffuse myocardial fibrosis measurements would even improve the prognostic impact of LGE. The evaluation of diffuse myocardial fibrosis has a great potential in large-scale diseases, including their initial phases, with the possibility to identify patients at risk for subsequent development of clinical heart failure, to assess repeatedly the stage and progression of cardiac diseases, and to monitor the effect of treatment.
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385
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Fujita T, Konno T, Yokawa J, Masuta E, Nagata Y, Fujino N, Funada A, Hodatsu A, Kawashiri MA, Yamagishi M, Hayashi K. Increased extent of myocardial fibrosis in genotyped hypertrophic cardiomyopathy with ventricular tachyarrhythmias. J Cardiol 2014; 66:63-8. [PMID: 25458192 DOI: 10.1016/j.jjcc.2014.10.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Revised: 09/24/2014] [Accepted: 10/02/2014] [Indexed: 01/11/2023]
Abstract
BACKGROUND Occurrence of malignant ventricular tachyarrhythmias such as ventricular tachycardia and fibrillation (VT/VF) in hypertrophic cardiomyopathy (HCM) can be related to the extent of myocardial fibrosis. Although late gadolinium enhancement (LGE) on cardiovascular magnetic resonance (CMR) imaging has been used to detect myocardial fibrosis, few data exist regarding relationships between CMR-determined myocardial fibrosis and VT/VF in genotyped HCM populations. OBJECTIVE We retrospectively investigated whether the extent of LGE can be increased in HCM patients with VT/VF compared to those without VT/VF in the genotyped HCM population. METHODS AND RESULTS We studied 35 HCM patients harboring sarcomere gene mutations (TNNI3=22, MYBPC3=12, MYH7=1) who underwent both CMR imaging and 24-h ambulatory electrocardiographic monitoring. VT/VF were identified in 6 patients (2 men, mean age 55.0 years). The extent of LGE was significantly increased in patients with VT/VF (n=6) compared with those without VT/VF (n=29) (18.6±14.4% vs. 8.3±11.4%, p=0.04), although the LGE extent was not an independent predictor for the occurrence of VT/VF. Applying a cut-off point ≥3.25%, episodes of VT/VF were identified with a sensitivity of 100%, specificity of 51.7%, positive predictive value of 30%, negative predictive value of 100%, and the area under the curve of 0.767 (95% confidence interval: 0.590-0.944). CONCLUSION These results demonstrate that myocardial fibrosis determined by CMR imaging may be increased in genotyped HCM patients with episodes of VT/VF. A further prospective study will be needed to clarify the association between the LGE extent and arrhythmic events in HCM patients harboring sarcomere gene mutations.
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Affiliation(s)
- Takashi Fujita
- Division of Cardiovascular Medicine, Kanazawa University Graduate School of Medicine, Kanazawa, Japan
| | - Tetsuo Konno
- Division of Cardiovascular Medicine, Kanazawa University Graduate School of Medicine, Kanazawa, Japan; Research and Education Center for Innovative and Preventive Medicine, Kanazawa University, Kanazawa, Japan
| | - Junichiro Yokawa
- Division of Cardiovascular Medicine, Kanazawa University Graduate School of Medicine, Kanazawa, Japan; Division of Cardiology, Fukui Prefectural Hospital, Fukui, Japan
| | - Eiichi Masuta
- Division of Cardiovascular Medicine, Kanazawa University Graduate School of Medicine, Kanazawa, Japan
| | - Yoji Nagata
- Division of Cardiovascular Medicine, Kanazawa University Graduate School of Medicine, Kanazawa, Japan
| | - Noboru Fujino
- Division of Cardiovascular Medicine, Kanazawa University Graduate School of Medicine, Kanazawa, Japan
| | - Akira Funada
- Division of Cardiovascular Medicine, Kanazawa University Graduate School of Medicine, Kanazawa, Japan
| | - Akihiko Hodatsu
- Division of Cardiovascular Medicine, Kanazawa University Graduate School of Medicine, Kanazawa, Japan
| | - Masa-aki Kawashiri
- Division of Cardiovascular Medicine, Kanazawa University Graduate School of Medicine, Kanazawa, Japan
| | - Masakazu Yamagishi
- Division of Cardiovascular Medicine, Kanazawa University Graduate School of Medicine, Kanazawa, Japan; Research and Education Center for Innovative and Preventive Medicine, Kanazawa University, Kanazawa, Japan.
| | - Kenshi Hayashi
- Division of Cardiovascular Medicine, Kanazawa University Graduate School of Medicine, Kanazawa, Japan
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386
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Dhillon A, Sweet W, Popovic ZB, Smedira NG, Thamilarasan M, Lytle BW, Tan C, Starling RC, Lever HM, Moravec CS, Desai MY. Association of noninvasively measured left ventricular mechanics with in vitro muscle contractile performance: a prospective study in hypertrophic cardiomyopathy patients. J Am Heart Assoc 2014; 3:e001269. [PMID: 25389286 PMCID: PMC4338715 DOI: 10.1161/jaha.114.001269] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Hypertrophic cardiomyopathy (HCM) is a primary myopathic process in which regional left ventricular dysfunction may exist without overt global left ventricular dysfunction. In obstructive HCM patients who underwent surgical myectomy (SM), we sought to determine if there is a significant association between echocardiographic longitudinal strain, histopathology, and in vitro myocardial performance (resting tension and developed tension) of the surgical specimen. Methods and Results HCM patients (n=122, 54±14 years, 54% men) undergoing SM were prospectively recruited. Longitudinal systolic strain and diastolic strain rates were measured at that basal septum (partially removed at SM) by using velocity vector imaging on preoperative echocardiography. Semiquantitative histopathologic grading of myocyte disarray and fibrosis and in vitro measurements of resting tension and developed tension were made in septal tissue obtained at SM. Mean basal septal systolic strain and diastolic strain rate were −8.3±5% and 0.62±0.4/s, while mild or greater degree of myocyte disarray and interstitial fibrosis were present in 85% and 87%, respectively. Mean resting tension and developed tension were 2.8±1 and 1.4±0.8 g/mm2. On regression analysis, basal septal systolic strain, diastolic strain rate, disarray, and fibrosis were associated with developed tension (β=0.19, 0.20, −0.33, and −0.40, respectively, all P<0.01) and resting tension (β=0.21, 0.22, −0.25, and −0.28, respectively, all P<0.01). Conclusion In obstructive HCM patients who underwent SM, left ventricular mechanics (echocardiographic longitudinal systolic strain and diastolic strain rates), assessed at the basal septum (myocardium removed during myectomy) and histopathologic findings characteristic for HCM (disarray and fibrosis) were significantly associated with in vitro myocardial resting and developed contractile performance.
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Affiliation(s)
- Ashwat Dhillon
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH (A.D., W.S., Z.B.P., N.G.S., M.T., B.W.L., R.C.S., H.M.L., C.S.M., M.Y.D.)
| | - Wendy Sweet
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH (A.D., W.S., Z.B.P., N.G.S., M.T., B.W.L., R.C.S., H.M.L., C.S.M., M.Y.D.)
| | - Zoran B Popovic
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH (A.D., W.S., Z.B.P., N.G.S., M.T., B.W.L., R.C.S., H.M.L., C.S.M., M.Y.D.)
| | - Nicholas G Smedira
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH (A.D., W.S., Z.B.P., N.G.S., M.T., B.W.L., R.C.S., H.M.L., C.S.M., M.Y.D.)
| | - Maran Thamilarasan
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH (A.D., W.S., Z.B.P., N.G.S., M.T., B.W.L., R.C.S., H.M.L., C.S.M., M.Y.D.)
| | - Bruce W Lytle
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH (A.D., W.S., Z.B.P., N.G.S., M.T., B.W.L., R.C.S., H.M.L., C.S.M., M.Y.D.)
| | - Carmela Tan
- Pathology Institute, Cleveland Clinic, Cleveland, OH (C.T.)
| | - Randall C Starling
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH (A.D., W.S., Z.B.P., N.G.S., M.T., B.W.L., R.C.S., H.M.L., C.S.M., M.Y.D.)
| | - Harry M Lever
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH (A.D., W.S., Z.B.P., N.G.S., M.T., B.W.L., R.C.S., H.M.L., C.S.M., M.Y.D.)
| | - Christine S Moravec
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH (A.D., W.S., Z.B.P., N.G.S., M.T., B.W.L., R.C.S., H.M.L., C.S.M., M.Y.D.)
| | - Milind Y Desai
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH (A.D., W.S., Z.B.P., N.G.S., M.T., B.W.L., R.C.S., H.M.L., C.S.M., M.Y.D.)
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387
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Nomura A, Konno T, Fujita T, Tanaka Y, Nagata Y, Tsuda T, Hodatsu A, Sakata K, Nakamura H, Kawashiri MA, Fujino N, Yamagishi M, Hayashi K. Fragmented QRS predicts heart failure progression in patients with hypertrophic cardiomyopathy. Circ J 2014; 79:136-43. [PMID: 25381793 DOI: 10.1253/circj.cj-14-0822] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Although fragmented QRS complex (frag-QRS) reflecting intra-ventricular conduction delay has been shown to be a prognostic marker for cardiac events, few data exist regarding the impact of frag-QRS on cardiac events in hypertrophic cardiomyopathy (HCM). METHODS AND RESULTS Ninety-four HCM patients (56 male; mean age, 58 ± 17 years) were retrospectively investigated. Frag-QRS was defined as the presence of various RsR' patterns in at least 2 contiguous ECG leads. Major arrhythmic events (MAE) were defined as sudden cardiac death, and combined sustained ventricular tachycardia/ventricular fibrillation. New-onset atrial fibrillation (AF) was diagnosed based on ECG during provisional or routine medical examination. Heart failure (HF) with hospitalization was defined as hospital admission due to subjective or objective symptoms. Frag-QRS was detected in 31 patients (33%).TNNI3 was the most frequent disease-causing gene. Median follow-up was 4.6 years. The 4-year cumulative survival rates of cardiac death, MAE, new-onset AF and HF with hospitalization were 97.6%, 94.6%, 87.5% and 89.3%, respectively. On multivariate analysis, frag-QRS was significantly associated with HF with hospitalization (adjusted hazard ratios [95% confidence intervals]: 5.4 [1.2-36], P=0.03). Moreover, HF-free survival was significantly lower in the frag-QRS (+) group compared to the frag-QRS (-) group (79.0% vs. 95.1%, P=0.03). CONCLUSIONS Frag-QRS is associated with HF with hospitalization in HCM patients who had a unique distribution of gene mutations.
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Affiliation(s)
- Akihiro Nomura
- Division of Cardiovascular Medicine, Kanazawa University Graduate School of Medicine
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388
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Yoon YE, Hong YJ, Kim HK, Kim JA, Na JO, Yang DH, Kim YJ, Choi EY, The Korean Society of Cardiology and the Korean Society of Radiology. 2014 Korean guidelines for appropriate utilization of cardiovascular magnetic resonance imaging: a joint report of the Korean Society of Cardiology and the Korean Society of Radiology. Korean J Radiol 2014; 15:659-88. [PMID: 25469078 PMCID: PMC4248622 DOI: 10.3348/kjr.2014.15.6.659] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Accepted: 09/25/2014] [Indexed: 12/18/2022] Open
Abstract
Cardiac magnetic resonance (CMR) imaging is now widely used in several fields of cardiovascular disease assessment due to recent technical developments. CMR can give physicians information that cannot be found with other imaging modalities. However, there is no guideline which is suitable for Korean people for the use of CMR. Therefore, we have prepared a Korean guideline for the appropriate utilization of CMR to guide Korean physicians, imaging specialists, medical associates and patients to improve the overall medical system performances. By addressing CMR usage and creating these guidelines we hope to contribute towards the promotion of public health. This guideline is a joint report of the Korean Society of Cardiology and the Korean Society of Radiology.
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Affiliation(s)
- Yeonyee E Yoon
- Department of Cardiology, Cardiovascular Center, Seoul National University Bundang Hospital, Seongnam 463-707, Korea
| | - Yoo Jin Hong
- Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul 120-752, Korea
| | - Hyung-Kwan Kim
- Division of Cardiology, Department of Internal Medicine, Cardiovascular Center, Seoul National University College of Medicine, Seoul National University Hospital, Seoul 110-744, Korea
| | - Jeong A Kim
- Department of Radiology, Ilsan Paik Hospital, Inje University College of Medicine, Goyang 411-706, Korea
| | - Jin Oh Na
- Cardiovascular Center, Korea University Guro Hospital, Korea University College of Medicine, Seoul 152-703, Korea
| | - Dong Hyun Yang
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 138-736, Korea
| | - Young Jin Kim
- Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul 120-752, Korea
| | - Eui-Young Choi
- Division of Cardiology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 135-720, Korea
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389
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Bacharova L, Ugander M. Left ventricular hypertrophy: The relationship between the electrocardiogram and cardiovascular magnetic resonance imaging. Ann Noninvasive Electrocardiol 2014; 19:524-33. [PMID: 25367364 PMCID: PMC6932615 DOI: 10.1111/anec.12223] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Conventional assessment of left ventricular hypertrophy (LVH) using the electrocardiogram (ECG), for example, by the Sokolow-Lyon, Romhilt-Estes or Cornell criteria, have relied on assessing changes in the amplitude and/or duration of the QRS complex of the ECG to quantify LV mass. ECG measures of LV mass have typically been validated by imaging with echocardiography or cardiovascular magnetic resonance imaging (CMR). However, LVH can be the result of diverse etiologies, and LVH is also characterized by pathological changes in myocardial tissue characteristics on the genetic, molecular, cellular, and tissue level beyond a pure increase in the number of otherwise normal cardiomyocytes. For example, slowed conduction velocity through the myocardium, which can be due to diffuse myocardial fibrosis, has been shown to be an important determinant of conventional ECG LVH criteria regardless of LV mass. Myocardial tissue characterization by CMR has emerged to not only quantify LV mass, but also detect and quantify the extent and severity of focal or diffuse myocardial fibrosis, edema, inflammation, myocarditis, fatty replacement, myocardial disarray, and myocardial deposition of amyloid proteins (amyloidosis), glycolipids (Fabry disease), or iron (siderosis). This can be undertaken using CMR techniques including late gadolinium enhancement (LGE), T1 mapping, T2 mapping, T2* mapping, extracellular volume fraction (ECV) mapping, fat/water-weighted imaging, and diffusion tensor CMR. This review presents an overview of current and emerging concepts regarding the diagnostic possibilities of both ECG and CMR for LVH in an attempt to narrow gaps in our knowledge regarding the ECG diagnosis of LVH.
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Affiliation(s)
- Ljuba Bacharova
- International Laser CenterBratislavaSlovak Republic
- Institute of PathophysiologyMedical SchoolComenius UniversityBratislavaSlovak Republic
| | - Martin Ugander
- Department of Clinical PhysiologyKarolinska Institute and Karolinska University HospitalStockholmSweden
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390
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O'Neill L, O'Hanlon R, Owens P, Maree A. An unexpected case of ventricular fibrillation cardiac arrest in a Caucasian female. BMJ Case Rep 2014; 2014:bcr-2014-206762. [PMID: 25362683 DOI: 10.1136/bcr-2014-206762] [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
Affiliation(s)
- Louisa O'Neill
- Department of Cardiology, Waterford Regional Hospital, Waterford, Ireland
| | - Rory O'Hanlon
- Department of Cardiology, Blackrock Clinic, Dublin, Ireland
| | - Patrick Owens
- Department of Cardiology, Waterford Regional Hospital, Waterford, Ireland
| | - Andrew Maree
- Department of Cardiology, Waterford Regional Hospital, Waterford, Ireland
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Todiere G, Pisciella L, Barison A, Del Franco A, Zachara E, Piaggi P, Re F, Pingitore A, Emdin M, Lombardi M, Aquaro GD. Abnormal T2-STIR magnetic resonance in hypertrophic cardiomyopathy: a marker of advanced disease and electrical myocardial instability. PLoS One 2014; 9:e111366. [PMID: 25356653 PMCID: PMC4214734 DOI: 10.1371/journal.pone.0111366] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Accepted: 10/01/2014] [Indexed: 01/27/2023] Open
Abstract
Background Myocardial hyperintensity on T2-weighted short-tau inversion recovery (STIR) (HyT2) cardiac magnetic resonance (CMR) images has been demonstrated in patients with hypertrophic cardiomyopathy (HCM) and is considered a sign of acute damage. The aim of the current study was to evaluate the relationship between HyT2 and both a) markers of ventricular electrical instability and b) clinical and CMR parameters. Methods Sixty-five patients underwent a thorough clinical examination, consisting of 24-h ECG recording and CMR examination including functional evaluation, T2-STIR images and late gadolinium enhancement (LGE). Results HyT2 was detected in 27 patients (42%), and subjects with HyT2 showed a greater left ventricle (LV) mass index (p<0.001), lower LV ejection fraction (p = 0.05) and greater extent of LGE (p<0.001) compared to those without HyT2. Twenty-two subjects (34%) presented non-sustained ventricular tachycardia (NSVT) on the 24-h ECG recording, 21 (95%) of whom exhibited HyT2. Based on the logistic regression analysis, HyT2 (odds ratio [OR]: 165, 95% CI 11–2455, p<0.001) and LGE extent (1.1, 1.0–1.3, p<0.001) served as independent predictors of NSVT, while the presence of LGE was not associated with NSVT occurrence (p = 0.49). The presence of HyT2 was associated with lower heart rate variability (p = 0.006) and a higher number of arrhythmic risk factors (p<0.001). Conclusions In HCM patients, HyT2 upon CMR examination is associated with more advanced disease and increased arrhythmic burden.
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Affiliation(s)
- Giancarlo Todiere
- Fondazione G. Monasterio Regione Toscana-National Research Council, Pisa, Italy
- * E-mail:
| | - Lorena Pisciella
- Cardiologia 2 Azienda Ospedaliera San Camillo-Forlanini, Rome, Italy
| | - Andrea Barison
- Fondazione G. Monasterio Regione Toscana-National Research Council, Pisa, Italy
| | | | | | - Paolo Piaggi
- Endocrinology Unit, University Hospital, Pisa, Italy
| | - Federica Re
- Cardiologia 2 Azienda Ospedaliera San Camillo-Forlanini, Rome, Italy
| | | | - Michele Emdin
- Fondazione G. Monasterio Regione Toscana-National Research Council, Pisa, Italy
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392
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Abstract
Fibrotic remodelling of the extracellular matrix is a healing mechanism necessary immediately after myocardial injury. However, prolonged increase in myocardial fibrotic activity results in stiffening of the myocardium and heralds adverse outcomes related to systolic and diastolic dysfunction, as well as arrhythmogenesis. Cardiac MRI provides a noninvasive phenotyping tool for accurate and easy detection and quantification of myocardial fibrosis by probing the retention of gadolinium-contrast agent in myocardial tissue. Late-gadolinium enhancement (LGE) cardiac MRI has been used extensively in a large number of studies for measurement of myocardial scarring. T1 mapping, a fairly new technique that can be used to identify the exact T1 value of the tissue, provides a direct measurement of the extracellular volume fraction of the myocardium. In contrast to LGE, T1 mapping can be used to measure diffuse myocardial fibrosis and differentiate between disease processes. In this Review, we describe the basic principles of imaging myocardial fibrosis using contrast-enhanced MRI and summarize its use for prognostic purposes.
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Affiliation(s)
- Bharath Ambale-Venkatesh
- Department of Radiology, Johns Hopkins University, 600 North Wolfe Street, Blalock 524D1, Baltimore, MD 21287, USA
| | - João A C Lima
- Department of Cardiology and Radiology, Johns Hopkins University, 600 North Wolfe Street, Blalock 524D1, Baltimore, MD 21287, USA
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393
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Relation of strain by feature tracking and clinical outcome in children, adolescents, and young adults with hypertrophic cardiomyopathy. Am J Cardiol 2014; 114:1275-80. [PMID: 25159233 DOI: 10.1016/j.amjcard.2014.07.051] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Revised: 07/16/2014] [Accepted: 07/16/2014] [Indexed: 11/21/2022]
Abstract
Evaluation of hypertrophic cardiomyopathy (HC) in young patients is limited by lack of age-specific norms for wall thickness on cardiovascular magnetic resonance (CMR) images. Left ventricular strain may have a role in identifying and risk stratifying patients with HC, but few data exist for strain measurement on CMR images. In 30 patients (14.1 ± 3.2 years) with clinically diagnosed HC and 24 controls (15.6 ± 2.8 years), strain (radial, longitudinal, and circumferential) was evaluated by 2 experienced readers using CMR feature tracking. In patients with HC, hypertrophied segments had decreased radial (28.0 ± 5.2% vs 58.6 ± 3.9%, p = 0.0002), circumferential (-23.7 ± 1.1% vs -28.3 ± 0.8%, p = 0.004), and longitudinal (-11.2 ± 1.2% vs -21.7 ± 0.8%, p <0.0001) strains versus control segments. Hypertrophied segments had decreased longitudinal (basal segments -12.2 ± 1.9% vs -22.6 ± 1.2%, p = 0.0002), radial (basal segments 22.7 ± 10.8% vs 78.8 ± 7.2%, p = 0.0001), and circumferential (basal segments -22.4 ± 1.7% vs -30.6 ± 1%, p = 0.0004) strains versus nonhypertrophied segments in patients with HC. Longitudinal strain had the lowest intraobserver and interobserver variabilities (coefficient of variability -15.7% and -18.5%). After a median follow-up of 28.1 months (interquartile range [IQR] 4.2 to 33.1), 7 patients with HC with an adverse event outcome (5 ventricular tachycardia, 1 appropriate implantable cardioverter-defibrillator discharge, and 1 death) had reduced global radial (median 39.7%, IQR 39.6% to 46.6% vs 65.4%, IQR 46.1% to 83.4%, p = 0.01) and longitudinal strains (median -16.5%, IQR -18.7% to -15.5% vs -19.7%, IQR -23.8% to -17.5%, p = 0.046) compared with patients with HC without an event. In conclusion, CMR feature tracking detects differences in global and segmental strains and may represent a novel method to predict clinical outcome in patients with HC. Further study is necessary to evaluate longitudinal changes in this population.
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394
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Mikami Y, Kolman L, Joncas SX, Stirrat J, Scholl D, Rajchl M, Lydell CP, Weeks SG, Howarth AG, White JA. Accuracy and reproducibility of semi-automated late gadolinium enhancement quantification techniques in patients with hypertrophic cardiomyopathy. J Cardiovasc Magn Reson 2014; 16:85. [PMID: 25315701 PMCID: PMC4189726 DOI: 10.1186/s12968-014-0085-x] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Accepted: 09/23/2014] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND The presence and extent of late gadolinium enhancement (LGE) has been associated with adverse events in patients with hypertrophic cardiomyopathy (HCM). Signal intensity (SI) threshold techniques are routinely employed for quantification; Full-Width at Half-Maximum (FWHM) techniques are suggested to provide greater reproducibility than Signal Threshold versus Reference Mean (STRM) techniques, however the accuracy of these approaches versus the manual assignment of optimal SI thresholds has not been studied. In this study, we compared all known semi-automated LGE quantification techniques for accuracy and reproducibility among patients with HCM. METHODS Seventy-six HCM patients (51 male, age 54 ± 13 years) were studied. Total LGE volume was quantified using 7 semi-automated techniques and compared to expert manual adjustment of the SI threshold to achieve optimal segmentation. Techniques tested included STRM based thresholds of >2, 3, 4, 5 and 6 SD above mean SI of reference myocardium, the FWHM technique, and the Otsu-auto-threshold (OAT) technique. The SI threshold chosen by each technique was recorded for all slices. Bland-Altman analysis and intra-class correlation coefficients (ICC) were reported for each semi-automated technique versus expert, manually adjusted LGE segmentation. Intra- and inter-observer reproducibility assessments were also performed. RESULTS Fifty-two of 76 (68%) patients showed LGE on a total of 202 slices. For accuracy, the STRM >3SD technique showed the greatest agreement with manual segmentation (ICC = 0.97, mean difference and 95% limits of agreement = 1.6 ± 10.7 g) while STRM >6SD, >5SD, 4SD and FWHM techniques systematically underestimated total LGE volume. Slice based analysis of selected SI thresholds similarly showed the STRM >3SD threshold to most closely approximate manually adjusted SI thresholds (ICC = 0.88). For reproducibility, the intra- and inter-observer reproducibility of the >3SD threshold demonstrated an acceptable mean difference and 95% limits of agreement of -0.5 ± 6.8 g and -0.9 ± 5.6 g, respectively. CONCLUSIONS FWHM segmentation provides superior reproducibility, however systematically underestimates total LGE volume compared to manual segmentation in patients with HCM. The STRM >3SD technique provides the greatest accuracy while retaining acceptable reproducibility and may therefore be a preferred approach for LGE quantification in this population.
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Affiliation(s)
- Yoko Mikami
- Stephenson Cardiac Imaging Centre at the Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada.
| | - Louis Kolman
- Stephenson Cardiac Imaging Centre at the Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada.
| | - Sebastien X Joncas
- Stephenson Cardiac Imaging Centre at the Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada.
| | - John Stirrat
- Imaging Research Laboratory - Robarts Research Institute, Western University, London, ON, Canada.
| | - David Scholl
- Imaging Research Laboratory - Robarts Research Institute, Western University, London, ON, Canada.
| | - Martin Rajchl
- Imaging Research Laboratory - Robarts Research Institute, Western University, London, ON, Canada.
| | - Carmen P Lydell
- Stephenson Cardiac Imaging Centre at the Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada.
- Diagnostic Imaging, University of Calgary, Calgary, AB, Canada.
| | - Sarah G Weeks
- Stephenson Cardiac Imaging Centre at the Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada.
- Cardiac Sciences, University of Calgary, Calgary, AB, Canada.
| | - Andrew G Howarth
- Stephenson Cardiac Imaging Centre at the Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada.
- Cardiac Sciences, University of Calgary, Calgary, AB, Canada.
| | - James A White
- Stephenson Cardiac Imaging Centre at the Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada.
- Cardiac Sciences, University of Calgary, Calgary, AB, Canada.
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395
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Stirrat J, Rajchl M, Bergin L, Patton DJ, Peters T, White JA. High-resolution 3-dimensional late gadolinium enhancement scar imaging in surgically corrected Tetralogy of Fallot: clinical feasibility of volumetric quantification and visualization. J Cardiovasc Magn Reson 2014; 16:76. [PMID: 25315164 PMCID: PMC4180957 DOI: 10.1186/s12968-014-0076-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Accepted: 08/28/2014] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The extent of surgical scarring in Tetralogy of Fallot (TOF) may be a marker of adverse outcomes and provide substrate for ventricular arrhythmia. In this study we evaluate the feasibility of high resolution three dimensional (3D) late gadolinium enhancement (LGE) cardiovascular magnetic resonance (CMR) for volumetric scar quantification in patients with surgically corrected TOF. METHODS Fifteen consecutive patients underwent 3D LGE imaging with 3 Tesla CMR using a whole-heart, respiratory-navigated technique. A novel, signal-histogram based segmentation technique was tested for the quantification and modeling of surgical scar. Total scar volume was compared to the gold standard manual expert segmentation. The feasibility of segmented scar fusion to matched coronary CMR data for volumetric display was explored. RESULTS Image quality sufficient for 3D scar segmentation was acquired in fourteen patients. Mean patient age was 32.2 ± 11.9 years (range 21 to 57 years) with mean right ventricle (RV) ejection fraction (EF) of 53.9 ± 9.2% and mean RV end diastolic volume of 117.0 ± 41.5 mL/m². The mean total scar volume was 11.1 ± 8.2 mL using semi-automated 3D segmentation with excellent correlation to manual expert segmentation (r = 0.99, bias = 0.89 mL, 95% CI -1.66 to 3.44). The mean segmentation time was significantly reduced using the novel semi-automated segmentation technique (10.1 ± 2.6 versus 45.8 ± 12.6 minutes). Excellent intra-observer and good inter-observer reproducibility was observed. CONCLUSION 3D high resolution LGE imaging with semi-automated scar segmentation is clinically feasible among patients with surgically corrected TOF and shows excellent accuracy and reproducibility. This approach may offer a valuable clinical tool for risk prediction and procedural planning among this growing population.
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Affiliation(s)
- John Stirrat
- Imaging Laboratories, Robarts Research Institute, Western University, London, Ontario, Canada.
| | - Martin Rajchl
- Imaging Laboratories, Robarts Research Institute, Western University, London, Ontario, Canada.
| | - Lynn Bergin
- Division of Cardiology, Department of Medicine, Western University, Calgary, Canada.
| | - David J Patton
- Cardiac Imaging Centre, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada.
- Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada.
| | - Terry Peters
- Imaging Laboratories, Robarts Research Institute, Western University, London, Ontario, Canada.
| | - James A White
- Division of Cardiology, Department of Medicine, Western University, Calgary, Canada.
- Cardiac Imaging Centre, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada.
- Division of Cardiology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada.
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396
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Predictive value of myocardial delayed enhancement in Duchenne muscular dystrophy. Pediatr Cardiol 2014; 35:1279-85. [PMID: 24830760 DOI: 10.1007/s00246-014-0929-z] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2014] [Accepted: 04/29/2014] [Indexed: 01/28/2023]
Abstract
In other cardiomyopathies, cardiac magnetic resonance imaging (CMR)-derived myocardial delayed enhancement (MDE), a marker of myocardial fibrosis, is a risk factor for sudden cardiac death (SCD). In Duchenne muscular dystrophy (DMD), the prognostic value of MDE for ventricular arrhythmias and death is unknown. This study aimed to evaluate associations between MDE and electrocardiographic (ECG) changes, ventricular remodeling, risk of arrhythmias, and death in DMD. This retrospective study included all subjects with DMD who had undergone a CMR between January 2006 and December 2011 and had available ECG and 24-h Holter records from the same period. Left ventricular (LV) MDE was semiquantitatively graded from 0 to 4. Comparisons of demographic and clinical characteristics between MDE and no-MDE groups were made. Cox regression analysis was performed to assess factors associated with death. This study investigated 32 boys with a median age of 13.8 years (range, 7.2-17.4 years) and found MDE present in 25 (78 %) of the boys. Compared with the no-MDE subjects, the MDE subjects were older (15.7 ± 3.3 vs 12.1 ± 4.8 years) and had a wider QT dispersion (QTd: 74 ± 30 vs 55 ± 33 ms), a higher incidence of ventricular tachycardia (40 vs 0 %), a lower LV ejection fraction (46 ± 12 vs 56 ± 9 %), a larger LV end-diastolic volume (124 ± 58 vs 68 ± 14 ml/m(2)), and a larger end-systolic volume (57 ± 29 vs 28 ± 10 ml/m(2)) (p < 0.05 for all). During the study period, six of the subjects (19 %) died. The factors associated with mortality were increased age, advanced grade of MDE, higher LV end-systolic volume, lower LV ejection fraction, use of beta-blockers, and ventricular tachycardia. Myocardial fibrosis detected by CMR is an independent predictor of adverse cardiac remodeling, ventricular arrhythmias, and death in DMD. Cardiac MRI using MDE can be applied as a screening tool to detect patients at risk for ventricular arrhythmias, more advanced disease, adverse LV remodeling, and death.
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397
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Quantification of myocardial delayed enhancement and wall thickness in hypertrophic cardiomyopathy: Multidetector computed tomography versus magnetic resonance imaging. Eur J Radiol 2014; 83:1778-85. [DOI: 10.1016/j.ejrad.2014.05.035] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Revised: 05/23/2014] [Accepted: 05/27/2014] [Indexed: 11/18/2022]
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398
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Chan RH, Maron BJ, Olivotto I, Pencina MJ, Assenza GE, Haas T, Lesser JR, Gruner C, Crean AM, Rakowski H, Udelson JE, Rowin E, Lombardi M, Cecchi F, Tomberli B, Spirito P, Formisano F, Biagini E, Rapezzi C, De Cecco CN, Autore C, Cook EF, Hong SN, Gibson CM, Manning WJ, Appelbaum E, Maron MS. Prognostic value of quantitative contrast-enhanced cardiovascular magnetic resonance for the evaluation of sudden death risk in patients with hypertrophic cardiomyopathy. Circulation 2014; 130:484-95. [PMID: 25092278 DOI: 10.1161/circulationaha.113.007094] [Citation(s) in RCA: 695] [Impact Index Per Article: 69.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Hypertrophic cardiomyopathy (HCM) is the most common cause of sudden death in the young, although not all patients eligible for sudden death prevention with an implantable cardioverter-defibrillator are identified. Contrast-enhanced cardiovascular magnetic resonance with late gadolinium enhancement (LGE) has emerged as an in vivo marker of myocardial fibrosis, although its role in stratifying sudden death risk in subgroups of HCM patients remains incompletely understood. METHODS AND RESULTS We assessed the relation between LGE and cardiovascular outcomes in 1293 HCM patients referred for cardiovascular magnetic resonance and followed up for a median of 3.3 years. Sudden cardiac death (SCD) events (including appropriate defibrillator interventions) occurred in 37 patients (3%). A continuous relationship was evident between LGE by percent left ventricular mass and SCD event risk in HCM patients (P=0.001). Extent of LGE was associated with an increased risk of SCD events (adjusted hazard ratio, 1.46/10% increase in LGE; P=0.002), even after adjustment for other relevant disease variables. LGE of ≥15% of LV mass demonstrated a 2-fold increase in SCD event risk in those patients otherwise considered to be at lower risk, with an estimated likelihood for SCD events of 6% at 5 years. Performance of the SCD event risk model was enhanced by LGE (net reclassification index, 12.9%; 95% confidence interval, 0.3-38.3). Absence of LGE was associated with lower risk for SCD events (adjusted hazard ratio, 0.39; P=0.02). Extent of LGE also predicted the development of end-stage HCM with systolic dysfunction (adjusted hazard ratio, 1.80/10% increase in LGE; P<0.03). CONCLUSIONS Extensive LGE measured by quantitative contrast enhanced CMR provides additional information for assessing SCD event risk among HCM patients, particularly patients otherwise judged to be at low risk.
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Affiliation(s)
- Raymond H Chan
- From the PERFUSE Study Group, Harvard Medical School, Boston, MA (R.H.C., S.N.H., C.M.B., W.J.M., E.A.); Department of Medicine, Cardiovascular Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (R.H.C., S.N.H., C.M.B., W.J.M., E.A.); Hypertrophic Cardiomyopathy Center, Minneapolis Heart Institute Foundation, Minneapolis, MN (B.J.M., T.H., J.R.L.); Referral Center for Myocardial Diseases, Azienda Ospedaliera Universitaria Careggi, Florence Italy (I.O., F.C., B.T.); Harvard Clinical Research Institute and Boston University Biostatistics, Boston, MA (M.J.P.); Ospedale Sant'Andrea Universita "La Sapienza," Rome, Italy (G.E.A., C.N.D.C., C.A.); Division of Cardiology, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada (C.G., A.M.C., H.R.); Hypertrophic Cardiomyopathy Center, Division of Cardiology, Tufts Medical Center, Boston, MA (J.E.U., E.R., M.S.M.); Fondazione C.N.R./Regione Toscana G. Monasterio, Pisa, Italy (M.L.); Ente Ospedaliero Ospedali Galliera, Genoa, Italy (P.S., F.F.); Policlinico S. Orsola-Malpighi, Bologna, Italy (E.B., C.R.); and Department of Epidemiology, Harvard School of Public Health, Boston, MA (E.F.C.)
| | - Barry J Maron
- From the PERFUSE Study Group, Harvard Medical School, Boston, MA (R.H.C., S.N.H., C.M.B., W.J.M., E.A.); Department of Medicine, Cardiovascular Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (R.H.C., S.N.H., C.M.B., W.J.M., E.A.); Hypertrophic Cardiomyopathy Center, Minneapolis Heart Institute Foundation, Minneapolis, MN (B.J.M., T.H., J.R.L.); Referral Center for Myocardial Diseases, Azienda Ospedaliera Universitaria Careggi, Florence Italy (I.O., F.C., B.T.); Harvard Clinical Research Institute and Boston University Biostatistics, Boston, MA (M.J.P.); Ospedale Sant'Andrea Universita "La Sapienza," Rome, Italy (G.E.A., C.N.D.C., C.A.); Division of Cardiology, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada (C.G., A.M.C., H.R.); Hypertrophic Cardiomyopathy Center, Division of Cardiology, Tufts Medical Center, Boston, MA (J.E.U., E.R., M.S.M.); Fondazione C.N.R./Regione Toscana G. Monasterio, Pisa, Italy (M.L.); Ente Ospedaliero Ospedali Galliera, Genoa, Italy (P.S., F.F.); Policlinico S. Orsola-Malpighi, Bologna, Italy (E.B., C.R.); and Department of Epidemiology, Harvard School of Public Health, Boston, MA (E.F.C.)
| | - Iacopo Olivotto
- From the PERFUSE Study Group, Harvard Medical School, Boston, MA (R.H.C., S.N.H., C.M.B., W.J.M., E.A.); Department of Medicine, Cardiovascular Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (R.H.C., S.N.H., C.M.B., W.J.M., E.A.); Hypertrophic Cardiomyopathy Center, Minneapolis Heart Institute Foundation, Minneapolis, MN (B.J.M., T.H., J.R.L.); Referral Center for Myocardial Diseases, Azienda Ospedaliera Universitaria Careggi, Florence Italy (I.O., F.C., B.T.); Harvard Clinical Research Institute and Boston University Biostatistics, Boston, MA (M.J.P.); Ospedale Sant'Andrea Universita "La Sapienza," Rome, Italy (G.E.A., C.N.D.C., C.A.); Division of Cardiology, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada (C.G., A.M.C., H.R.); Hypertrophic Cardiomyopathy Center, Division of Cardiology, Tufts Medical Center, Boston, MA (J.E.U., E.R., M.S.M.); Fondazione C.N.R./Regione Toscana G. Monasterio, Pisa, Italy (M.L.); Ente Ospedaliero Ospedali Galliera, Genoa, Italy (P.S., F.F.); Policlinico S. Orsola-Malpighi, Bologna, Italy (E.B., C.R.); and Department of Epidemiology, Harvard School of Public Health, Boston, MA (E.F.C.)
| | - Michael J Pencina
- From the PERFUSE Study Group, Harvard Medical School, Boston, MA (R.H.C., S.N.H., C.M.B., W.J.M., E.A.); Department of Medicine, Cardiovascular Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (R.H.C., S.N.H., C.M.B., W.J.M., E.A.); Hypertrophic Cardiomyopathy Center, Minneapolis Heart Institute Foundation, Minneapolis, MN (B.J.M., T.H., J.R.L.); Referral Center for Myocardial Diseases, Azienda Ospedaliera Universitaria Careggi, Florence Italy (I.O., F.C., B.T.); Harvard Clinical Research Institute and Boston University Biostatistics, Boston, MA (M.J.P.); Ospedale Sant'Andrea Universita "La Sapienza," Rome, Italy (G.E.A., C.N.D.C., C.A.); Division of Cardiology, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada (C.G., A.M.C., H.R.); Hypertrophic Cardiomyopathy Center, Division of Cardiology, Tufts Medical Center, Boston, MA (J.E.U., E.R., M.S.M.); Fondazione C.N.R./Regione Toscana G. Monasterio, Pisa, Italy (M.L.); Ente Ospedaliero Ospedali Galliera, Genoa, Italy (P.S., F.F.); Policlinico S. Orsola-Malpighi, Bologna, Italy (E.B., C.R.); and Department of Epidemiology, Harvard School of Public Health, Boston, MA (E.F.C.)
| | - Gabriele Egidy Assenza
- From the PERFUSE Study Group, Harvard Medical School, Boston, MA (R.H.C., S.N.H., C.M.B., W.J.M., E.A.); Department of Medicine, Cardiovascular Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (R.H.C., S.N.H., C.M.B., W.J.M., E.A.); Hypertrophic Cardiomyopathy Center, Minneapolis Heart Institute Foundation, Minneapolis, MN (B.J.M., T.H., J.R.L.); Referral Center for Myocardial Diseases, Azienda Ospedaliera Universitaria Careggi, Florence Italy (I.O., F.C., B.T.); Harvard Clinical Research Institute and Boston University Biostatistics, Boston, MA (M.J.P.); Ospedale Sant'Andrea Universita "La Sapienza," Rome, Italy (G.E.A., C.N.D.C., C.A.); Division of Cardiology, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada (C.G., A.M.C., H.R.); Hypertrophic Cardiomyopathy Center, Division of Cardiology, Tufts Medical Center, Boston, MA (J.E.U., E.R., M.S.M.); Fondazione C.N.R./Regione Toscana G. Monasterio, Pisa, Italy (M.L.); Ente Ospedaliero Ospedali Galliera, Genoa, Italy (P.S., F.F.); Policlinico S. Orsola-Malpighi, Bologna, Italy (E.B., C.R.); and Department of Epidemiology, Harvard School of Public Health, Boston, MA (E.F.C.)
| | - Tammy Haas
- From the PERFUSE Study Group, Harvard Medical School, Boston, MA (R.H.C., S.N.H., C.M.B., W.J.M., E.A.); Department of Medicine, Cardiovascular Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (R.H.C., S.N.H., C.M.B., W.J.M., E.A.); Hypertrophic Cardiomyopathy Center, Minneapolis Heart Institute Foundation, Minneapolis, MN (B.J.M., T.H., J.R.L.); Referral Center for Myocardial Diseases, Azienda Ospedaliera Universitaria Careggi, Florence Italy (I.O., F.C., B.T.); Harvard Clinical Research Institute and Boston University Biostatistics, Boston, MA (M.J.P.); Ospedale Sant'Andrea Universita "La Sapienza," Rome, Italy (G.E.A., C.N.D.C., C.A.); Division of Cardiology, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada (C.G., A.M.C., H.R.); Hypertrophic Cardiomyopathy Center, Division of Cardiology, Tufts Medical Center, Boston, MA (J.E.U., E.R., M.S.M.); Fondazione C.N.R./Regione Toscana G. Monasterio, Pisa, Italy (M.L.); Ente Ospedaliero Ospedali Galliera, Genoa, Italy (P.S., F.F.); Policlinico S. Orsola-Malpighi, Bologna, Italy (E.B., C.R.); and Department of Epidemiology, Harvard School of Public Health, Boston, MA (E.F.C.)
| | - John R Lesser
- From the PERFUSE Study Group, Harvard Medical School, Boston, MA (R.H.C., S.N.H., C.M.B., W.J.M., E.A.); Department of Medicine, Cardiovascular Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (R.H.C., S.N.H., C.M.B., W.J.M., E.A.); Hypertrophic Cardiomyopathy Center, Minneapolis Heart Institute Foundation, Minneapolis, MN (B.J.M., T.H., J.R.L.); Referral Center for Myocardial Diseases, Azienda Ospedaliera Universitaria Careggi, Florence Italy (I.O., F.C., B.T.); Harvard Clinical Research Institute and Boston University Biostatistics, Boston, MA (M.J.P.); Ospedale Sant'Andrea Universita "La Sapienza," Rome, Italy (G.E.A., C.N.D.C., C.A.); Division of Cardiology, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada (C.G., A.M.C., H.R.); Hypertrophic Cardiomyopathy Center, Division of Cardiology, Tufts Medical Center, Boston, MA (J.E.U., E.R., M.S.M.); Fondazione C.N.R./Regione Toscana G. Monasterio, Pisa, Italy (M.L.); Ente Ospedaliero Ospedali Galliera, Genoa, Italy (P.S., F.F.); Policlinico S. Orsola-Malpighi, Bologna, Italy (E.B., C.R.); and Department of Epidemiology, Harvard School of Public Health, Boston, MA (E.F.C.)
| | - Christiane Gruner
- From the PERFUSE Study Group, Harvard Medical School, Boston, MA (R.H.C., S.N.H., C.M.B., W.J.M., E.A.); Department of Medicine, Cardiovascular Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (R.H.C., S.N.H., C.M.B., W.J.M., E.A.); Hypertrophic Cardiomyopathy Center, Minneapolis Heart Institute Foundation, Minneapolis, MN (B.J.M., T.H., J.R.L.); Referral Center for Myocardial Diseases, Azienda Ospedaliera Universitaria Careggi, Florence Italy (I.O., F.C., B.T.); Harvard Clinical Research Institute and Boston University Biostatistics, Boston, MA (M.J.P.); Ospedale Sant'Andrea Universita "La Sapienza," Rome, Italy (G.E.A., C.N.D.C., C.A.); Division of Cardiology, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada (C.G., A.M.C., H.R.); Hypertrophic Cardiomyopathy Center, Division of Cardiology, Tufts Medical Center, Boston, MA (J.E.U., E.R., M.S.M.); Fondazione C.N.R./Regione Toscana G. Monasterio, Pisa, Italy (M.L.); Ente Ospedaliero Ospedali Galliera, Genoa, Italy (P.S., F.F.); Policlinico S. Orsola-Malpighi, Bologna, Italy (E.B., C.R.); and Department of Epidemiology, Harvard School of Public Health, Boston, MA (E.F.C.)
| | - Andrew M Crean
- From the PERFUSE Study Group, Harvard Medical School, Boston, MA (R.H.C., S.N.H., C.M.B., W.J.M., E.A.); Department of Medicine, Cardiovascular Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (R.H.C., S.N.H., C.M.B., W.J.M., E.A.); Hypertrophic Cardiomyopathy Center, Minneapolis Heart Institute Foundation, Minneapolis, MN (B.J.M., T.H., J.R.L.); Referral Center for Myocardial Diseases, Azienda Ospedaliera Universitaria Careggi, Florence Italy (I.O., F.C., B.T.); Harvard Clinical Research Institute and Boston University Biostatistics, Boston, MA (M.J.P.); Ospedale Sant'Andrea Universita "La Sapienza," Rome, Italy (G.E.A., C.N.D.C., C.A.); Division of Cardiology, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada (C.G., A.M.C., H.R.); Hypertrophic Cardiomyopathy Center, Division of Cardiology, Tufts Medical Center, Boston, MA (J.E.U., E.R., M.S.M.); Fondazione C.N.R./Regione Toscana G. Monasterio, Pisa, Italy (M.L.); Ente Ospedaliero Ospedali Galliera, Genoa, Italy (P.S., F.F.); Policlinico S. Orsola-Malpighi, Bologna, Italy (E.B., C.R.); and Department of Epidemiology, Harvard School of Public Health, Boston, MA (E.F.C.)
| | - Harry Rakowski
- From the PERFUSE Study Group, Harvard Medical School, Boston, MA (R.H.C., S.N.H., C.M.B., W.J.M., E.A.); Department of Medicine, Cardiovascular Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (R.H.C., S.N.H., C.M.B., W.J.M., E.A.); Hypertrophic Cardiomyopathy Center, Minneapolis Heart Institute Foundation, Minneapolis, MN (B.J.M., T.H., J.R.L.); Referral Center for Myocardial Diseases, Azienda Ospedaliera Universitaria Careggi, Florence Italy (I.O., F.C., B.T.); Harvard Clinical Research Institute and Boston University Biostatistics, Boston, MA (M.J.P.); Ospedale Sant'Andrea Universita "La Sapienza," Rome, Italy (G.E.A., C.N.D.C., C.A.); Division of Cardiology, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada (C.G., A.M.C., H.R.); Hypertrophic Cardiomyopathy Center, Division of Cardiology, Tufts Medical Center, Boston, MA (J.E.U., E.R., M.S.M.); Fondazione C.N.R./Regione Toscana G. Monasterio, Pisa, Italy (M.L.); Ente Ospedaliero Ospedali Galliera, Genoa, Italy (P.S., F.F.); Policlinico S. Orsola-Malpighi, Bologna, Italy (E.B., C.R.); and Department of Epidemiology, Harvard School of Public Health, Boston, MA (E.F.C.)
| | - James E Udelson
- From the PERFUSE Study Group, Harvard Medical School, Boston, MA (R.H.C., S.N.H., C.M.B., W.J.M., E.A.); Department of Medicine, Cardiovascular Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (R.H.C., S.N.H., C.M.B., W.J.M., E.A.); Hypertrophic Cardiomyopathy Center, Minneapolis Heart Institute Foundation, Minneapolis, MN (B.J.M., T.H., J.R.L.); Referral Center for Myocardial Diseases, Azienda Ospedaliera Universitaria Careggi, Florence Italy (I.O., F.C., B.T.); Harvard Clinical Research Institute and Boston University Biostatistics, Boston, MA (M.J.P.); Ospedale Sant'Andrea Universita "La Sapienza," Rome, Italy (G.E.A., C.N.D.C., C.A.); Division of Cardiology, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada (C.G., A.M.C., H.R.); Hypertrophic Cardiomyopathy Center, Division of Cardiology, Tufts Medical Center, Boston, MA (J.E.U., E.R., M.S.M.); Fondazione C.N.R./Regione Toscana G. Monasterio, Pisa, Italy (M.L.); Ente Ospedaliero Ospedali Galliera, Genoa, Italy (P.S., F.F.); Policlinico S. Orsola-Malpighi, Bologna, Italy (E.B., C.R.); and Department of Epidemiology, Harvard School of Public Health, Boston, MA (E.F.C.)
| | - Ethan Rowin
- From the PERFUSE Study Group, Harvard Medical School, Boston, MA (R.H.C., S.N.H., C.M.B., W.J.M., E.A.); Department of Medicine, Cardiovascular Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (R.H.C., S.N.H., C.M.B., W.J.M., E.A.); Hypertrophic Cardiomyopathy Center, Minneapolis Heart Institute Foundation, Minneapolis, MN (B.J.M., T.H., J.R.L.); Referral Center for Myocardial Diseases, Azienda Ospedaliera Universitaria Careggi, Florence Italy (I.O., F.C., B.T.); Harvard Clinical Research Institute and Boston University Biostatistics, Boston, MA (M.J.P.); Ospedale Sant'Andrea Universita "La Sapienza," Rome, Italy (G.E.A., C.N.D.C., C.A.); Division of Cardiology, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada (C.G., A.M.C., H.R.); Hypertrophic Cardiomyopathy Center, Division of Cardiology, Tufts Medical Center, Boston, MA (J.E.U., E.R., M.S.M.); Fondazione C.N.R./Regione Toscana G. Monasterio, Pisa, Italy (M.L.); Ente Ospedaliero Ospedali Galliera, Genoa, Italy (P.S., F.F.); Policlinico S. Orsola-Malpighi, Bologna, Italy (E.B., C.R.); and Department of Epidemiology, Harvard School of Public Health, Boston, MA (E.F.C.)
| | - Massimo Lombardi
- From the PERFUSE Study Group, Harvard Medical School, Boston, MA (R.H.C., S.N.H., C.M.B., W.J.M., E.A.); Department of Medicine, Cardiovascular Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (R.H.C., S.N.H., C.M.B., W.J.M., E.A.); Hypertrophic Cardiomyopathy Center, Minneapolis Heart Institute Foundation, Minneapolis, MN (B.J.M., T.H., J.R.L.); Referral Center for Myocardial Diseases, Azienda Ospedaliera Universitaria Careggi, Florence Italy (I.O., F.C., B.T.); Harvard Clinical Research Institute and Boston University Biostatistics, Boston, MA (M.J.P.); Ospedale Sant'Andrea Universita "La Sapienza," Rome, Italy (G.E.A., C.N.D.C., C.A.); Division of Cardiology, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada (C.G., A.M.C., H.R.); Hypertrophic Cardiomyopathy Center, Division of Cardiology, Tufts Medical Center, Boston, MA (J.E.U., E.R., M.S.M.); Fondazione C.N.R./Regione Toscana G. Monasterio, Pisa, Italy (M.L.); Ente Ospedaliero Ospedali Galliera, Genoa, Italy (P.S., F.F.); Policlinico S. Orsola-Malpighi, Bologna, Italy (E.B., C.R.); and Department of Epidemiology, Harvard School of Public Health, Boston, MA (E.F.C.)
| | - Franco Cecchi
- From the PERFUSE Study Group, Harvard Medical School, Boston, MA (R.H.C., S.N.H., C.M.B., W.J.M., E.A.); Department of Medicine, Cardiovascular Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (R.H.C., S.N.H., C.M.B., W.J.M., E.A.); Hypertrophic Cardiomyopathy Center, Minneapolis Heart Institute Foundation, Minneapolis, MN (B.J.M., T.H., J.R.L.); Referral Center for Myocardial Diseases, Azienda Ospedaliera Universitaria Careggi, Florence Italy (I.O., F.C., B.T.); Harvard Clinical Research Institute and Boston University Biostatistics, Boston, MA (M.J.P.); Ospedale Sant'Andrea Universita "La Sapienza," Rome, Italy (G.E.A., C.N.D.C., C.A.); Division of Cardiology, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada (C.G., A.M.C., H.R.); Hypertrophic Cardiomyopathy Center, Division of Cardiology, Tufts Medical Center, Boston, MA (J.E.U., E.R., M.S.M.); Fondazione C.N.R./Regione Toscana G. Monasterio, Pisa, Italy (M.L.); Ente Ospedaliero Ospedali Galliera, Genoa, Italy (P.S., F.F.); Policlinico S. Orsola-Malpighi, Bologna, Italy (E.B., C.R.); and Department of Epidemiology, Harvard School of Public Health, Boston, MA (E.F.C.)
| | - Benedetta Tomberli
- From the PERFUSE Study Group, Harvard Medical School, Boston, MA (R.H.C., S.N.H., C.M.B., W.J.M., E.A.); Department of Medicine, Cardiovascular Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (R.H.C., S.N.H., C.M.B., W.J.M., E.A.); Hypertrophic Cardiomyopathy Center, Minneapolis Heart Institute Foundation, Minneapolis, MN (B.J.M., T.H., J.R.L.); Referral Center for Myocardial Diseases, Azienda Ospedaliera Universitaria Careggi, Florence Italy (I.O., F.C., B.T.); Harvard Clinical Research Institute and Boston University Biostatistics, Boston, MA (M.J.P.); Ospedale Sant'Andrea Universita "La Sapienza," Rome, Italy (G.E.A., C.N.D.C., C.A.); Division of Cardiology, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada (C.G., A.M.C., H.R.); Hypertrophic Cardiomyopathy Center, Division of Cardiology, Tufts Medical Center, Boston, MA (J.E.U., E.R., M.S.M.); Fondazione C.N.R./Regione Toscana G. Monasterio, Pisa, Italy (M.L.); Ente Ospedaliero Ospedali Galliera, Genoa, Italy (P.S., F.F.); Policlinico S. Orsola-Malpighi, Bologna, Italy (E.B., C.R.); and Department of Epidemiology, Harvard School of Public Health, Boston, MA (E.F.C.)
| | - Paolo Spirito
- From the PERFUSE Study Group, Harvard Medical School, Boston, MA (R.H.C., S.N.H., C.M.B., W.J.M., E.A.); Department of Medicine, Cardiovascular Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (R.H.C., S.N.H., C.M.B., W.J.M., E.A.); Hypertrophic Cardiomyopathy Center, Minneapolis Heart Institute Foundation, Minneapolis, MN (B.J.M., T.H., J.R.L.); Referral Center for Myocardial Diseases, Azienda Ospedaliera Universitaria Careggi, Florence Italy (I.O., F.C., B.T.); Harvard Clinical Research Institute and Boston University Biostatistics, Boston, MA (M.J.P.); Ospedale Sant'Andrea Universita "La Sapienza," Rome, Italy (G.E.A., C.N.D.C., C.A.); Division of Cardiology, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada (C.G., A.M.C., H.R.); Hypertrophic Cardiomyopathy Center, Division of Cardiology, Tufts Medical Center, Boston, MA (J.E.U., E.R., M.S.M.); Fondazione C.N.R./Regione Toscana G. Monasterio, Pisa, Italy (M.L.); Ente Ospedaliero Ospedali Galliera, Genoa, Italy (P.S., F.F.); Policlinico S. Orsola-Malpighi, Bologna, Italy (E.B., C.R.); and Department of Epidemiology, Harvard School of Public Health, Boston, MA (E.F.C.)
| | - Francesco Formisano
- From the PERFUSE Study Group, Harvard Medical School, Boston, MA (R.H.C., S.N.H., C.M.B., W.J.M., E.A.); Department of Medicine, Cardiovascular Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (R.H.C., S.N.H., C.M.B., W.J.M., E.A.); Hypertrophic Cardiomyopathy Center, Minneapolis Heart Institute Foundation, Minneapolis, MN (B.J.M., T.H., J.R.L.); Referral Center for Myocardial Diseases, Azienda Ospedaliera Universitaria Careggi, Florence Italy (I.O., F.C., B.T.); Harvard Clinical Research Institute and Boston University Biostatistics, Boston, MA (M.J.P.); Ospedale Sant'Andrea Universita "La Sapienza," Rome, Italy (G.E.A., C.N.D.C., C.A.); Division of Cardiology, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada (C.G., A.M.C., H.R.); Hypertrophic Cardiomyopathy Center, Division of Cardiology, Tufts Medical Center, Boston, MA (J.E.U., E.R., M.S.M.); Fondazione C.N.R./Regione Toscana G. Monasterio, Pisa, Italy (M.L.); Ente Ospedaliero Ospedali Galliera, Genoa, Italy (P.S., F.F.); Policlinico S. Orsola-Malpighi, Bologna, Italy (E.B., C.R.); and Department of Epidemiology, Harvard School of Public Health, Boston, MA (E.F.C.)
| | - Elena Biagini
- From the PERFUSE Study Group, Harvard Medical School, Boston, MA (R.H.C., S.N.H., C.M.B., W.J.M., E.A.); Department of Medicine, Cardiovascular Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (R.H.C., S.N.H., C.M.B., W.J.M., E.A.); Hypertrophic Cardiomyopathy Center, Minneapolis Heart Institute Foundation, Minneapolis, MN (B.J.M., T.H., J.R.L.); Referral Center for Myocardial Diseases, Azienda Ospedaliera Universitaria Careggi, Florence Italy (I.O., F.C., B.T.); Harvard Clinical Research Institute and Boston University Biostatistics, Boston, MA (M.J.P.); Ospedale Sant'Andrea Universita "La Sapienza," Rome, Italy (G.E.A., C.N.D.C., C.A.); Division of Cardiology, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada (C.G., A.M.C., H.R.); Hypertrophic Cardiomyopathy Center, Division of Cardiology, Tufts Medical Center, Boston, MA (J.E.U., E.R., M.S.M.); Fondazione C.N.R./Regione Toscana G. Monasterio, Pisa, Italy (M.L.); Ente Ospedaliero Ospedali Galliera, Genoa, Italy (P.S., F.F.); Policlinico S. Orsola-Malpighi, Bologna, Italy (E.B., C.R.); and Department of Epidemiology, Harvard School of Public Health, Boston, MA (E.F.C.)
| | - Claudio Rapezzi
- From the PERFUSE Study Group, Harvard Medical School, Boston, MA (R.H.C., S.N.H., C.M.B., W.J.M., E.A.); Department of Medicine, Cardiovascular Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (R.H.C., S.N.H., C.M.B., W.J.M., E.A.); Hypertrophic Cardiomyopathy Center, Minneapolis Heart Institute Foundation, Minneapolis, MN (B.J.M., T.H., J.R.L.); Referral Center for Myocardial Diseases, Azienda Ospedaliera Universitaria Careggi, Florence Italy (I.O., F.C., B.T.); Harvard Clinical Research Institute and Boston University Biostatistics, Boston, MA (M.J.P.); Ospedale Sant'Andrea Universita "La Sapienza," Rome, Italy (G.E.A., C.N.D.C., C.A.); Division of Cardiology, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada (C.G., A.M.C., H.R.); Hypertrophic Cardiomyopathy Center, Division of Cardiology, Tufts Medical Center, Boston, MA (J.E.U., E.R., M.S.M.); Fondazione C.N.R./Regione Toscana G. Monasterio, Pisa, Italy (M.L.); Ente Ospedaliero Ospedali Galliera, Genoa, Italy (P.S., F.F.); Policlinico S. Orsola-Malpighi, Bologna, Italy (E.B., C.R.); and Department of Epidemiology, Harvard School of Public Health, Boston, MA (E.F.C.)
| | - Carlo Nicola De Cecco
- From the PERFUSE Study Group, Harvard Medical School, Boston, MA (R.H.C., S.N.H., C.M.B., W.J.M., E.A.); Department of Medicine, Cardiovascular Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (R.H.C., S.N.H., C.M.B., W.J.M., E.A.); Hypertrophic Cardiomyopathy Center, Minneapolis Heart Institute Foundation, Minneapolis, MN (B.J.M., T.H., J.R.L.); Referral Center for Myocardial Diseases, Azienda Ospedaliera Universitaria Careggi, Florence Italy (I.O., F.C., B.T.); Harvard Clinical Research Institute and Boston University Biostatistics, Boston, MA (M.J.P.); Ospedale Sant'Andrea Universita "La Sapienza," Rome, Italy (G.E.A., C.N.D.C., C.A.); Division of Cardiology, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada (C.G., A.M.C., H.R.); Hypertrophic Cardiomyopathy Center, Division of Cardiology, Tufts Medical Center, Boston, MA (J.E.U., E.R., M.S.M.); Fondazione C.N.R./Regione Toscana G. Monasterio, Pisa, Italy (M.L.); Ente Ospedaliero Ospedali Galliera, Genoa, Italy (P.S., F.F.); Policlinico S. Orsola-Malpighi, Bologna, Italy (E.B., C.R.); and Department of Epidemiology, Harvard School of Public Health, Boston, MA (E.F.C.)
| | - Camillo Autore
- From the PERFUSE Study Group, Harvard Medical School, Boston, MA (R.H.C., S.N.H., C.M.B., W.J.M., E.A.); Department of Medicine, Cardiovascular Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (R.H.C., S.N.H., C.M.B., W.J.M., E.A.); Hypertrophic Cardiomyopathy Center, Minneapolis Heart Institute Foundation, Minneapolis, MN (B.J.M., T.H., J.R.L.); Referral Center for Myocardial Diseases, Azienda Ospedaliera Universitaria Careggi, Florence Italy (I.O., F.C., B.T.); Harvard Clinical Research Institute and Boston University Biostatistics, Boston, MA (M.J.P.); Ospedale Sant'Andrea Universita "La Sapienza," Rome, Italy (G.E.A., C.N.D.C., C.A.); Division of Cardiology, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada (C.G., A.M.C., H.R.); Hypertrophic Cardiomyopathy Center, Division of Cardiology, Tufts Medical Center, Boston, MA (J.E.U., E.R., M.S.M.); Fondazione C.N.R./Regione Toscana G. Monasterio, Pisa, Italy (M.L.); Ente Ospedaliero Ospedali Galliera, Genoa, Italy (P.S., F.F.); Policlinico S. Orsola-Malpighi, Bologna, Italy (E.B., C.R.); and Department of Epidemiology, Harvard School of Public Health, Boston, MA (E.F.C.)
| | - E Francis Cook
- From the PERFUSE Study Group, Harvard Medical School, Boston, MA (R.H.C., S.N.H., C.M.B., W.J.M., E.A.); Department of Medicine, Cardiovascular Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (R.H.C., S.N.H., C.M.B., W.J.M., E.A.); Hypertrophic Cardiomyopathy Center, Minneapolis Heart Institute Foundation, Minneapolis, MN (B.J.M., T.H., J.R.L.); Referral Center for Myocardial Diseases, Azienda Ospedaliera Universitaria Careggi, Florence Italy (I.O., F.C., B.T.); Harvard Clinical Research Institute and Boston University Biostatistics, Boston, MA (M.J.P.); Ospedale Sant'Andrea Universita "La Sapienza," Rome, Italy (G.E.A., C.N.D.C., C.A.); Division of Cardiology, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada (C.G., A.M.C., H.R.); Hypertrophic Cardiomyopathy Center, Division of Cardiology, Tufts Medical Center, Boston, MA (J.E.U., E.R., M.S.M.); Fondazione C.N.R./Regione Toscana G. Monasterio, Pisa, Italy (M.L.); Ente Ospedaliero Ospedali Galliera, Genoa, Italy (P.S., F.F.); Policlinico S. Orsola-Malpighi, Bologna, Italy (E.B., C.R.); and Department of Epidemiology, Harvard School of Public Health, Boston, MA (E.F.C.)
| | - Susie N Hong
- From the PERFUSE Study Group, Harvard Medical School, Boston, MA (R.H.C., S.N.H., C.M.B., W.J.M., E.A.); Department of Medicine, Cardiovascular Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (R.H.C., S.N.H., C.M.B., W.J.M., E.A.); Hypertrophic Cardiomyopathy Center, Minneapolis Heart Institute Foundation, Minneapolis, MN (B.J.M., T.H., J.R.L.); Referral Center for Myocardial Diseases, Azienda Ospedaliera Universitaria Careggi, Florence Italy (I.O., F.C., B.T.); Harvard Clinical Research Institute and Boston University Biostatistics, Boston, MA (M.J.P.); Ospedale Sant'Andrea Universita "La Sapienza," Rome, Italy (G.E.A., C.N.D.C., C.A.); Division of Cardiology, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada (C.G., A.M.C., H.R.); Hypertrophic Cardiomyopathy Center, Division of Cardiology, Tufts Medical Center, Boston, MA (J.E.U., E.R., M.S.M.); Fondazione C.N.R./Regione Toscana G. Monasterio, Pisa, Italy (M.L.); Ente Ospedaliero Ospedali Galliera, Genoa, Italy (P.S., F.F.); Policlinico S. Orsola-Malpighi, Bologna, Italy (E.B., C.R.); and Department of Epidemiology, Harvard School of Public Health, Boston, MA (E.F.C.)
| | - C Michael Gibson
- From the PERFUSE Study Group, Harvard Medical School, Boston, MA (R.H.C., S.N.H., C.M.B., W.J.M., E.A.); Department of Medicine, Cardiovascular Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (R.H.C., S.N.H., C.M.B., W.J.M., E.A.); Hypertrophic Cardiomyopathy Center, Minneapolis Heart Institute Foundation, Minneapolis, MN (B.J.M., T.H., J.R.L.); Referral Center for Myocardial Diseases, Azienda Ospedaliera Universitaria Careggi, Florence Italy (I.O., F.C., B.T.); Harvard Clinical Research Institute and Boston University Biostatistics, Boston, MA (M.J.P.); Ospedale Sant'Andrea Universita "La Sapienza," Rome, Italy (G.E.A., C.N.D.C., C.A.); Division of Cardiology, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada (C.G., A.M.C., H.R.); Hypertrophic Cardiomyopathy Center, Division of Cardiology, Tufts Medical Center, Boston, MA (J.E.U., E.R., M.S.M.); Fondazione C.N.R./Regione Toscana G. Monasterio, Pisa, Italy (M.L.); Ente Ospedaliero Ospedali Galliera, Genoa, Italy (P.S., F.F.); Policlinico S. Orsola-Malpighi, Bologna, Italy (E.B., C.R.); and Department of Epidemiology, Harvard School of Public Health, Boston, MA (E.F.C.)
| | - Warren J Manning
- From the PERFUSE Study Group, Harvard Medical School, Boston, MA (R.H.C., S.N.H., C.M.B., W.J.M., E.A.); Department of Medicine, Cardiovascular Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (R.H.C., S.N.H., C.M.B., W.J.M., E.A.); Hypertrophic Cardiomyopathy Center, Minneapolis Heart Institute Foundation, Minneapolis, MN (B.J.M., T.H., J.R.L.); Referral Center for Myocardial Diseases, Azienda Ospedaliera Universitaria Careggi, Florence Italy (I.O., F.C., B.T.); Harvard Clinical Research Institute and Boston University Biostatistics, Boston, MA (M.J.P.); Ospedale Sant'Andrea Universita "La Sapienza," Rome, Italy (G.E.A., C.N.D.C., C.A.); Division of Cardiology, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada (C.G., A.M.C., H.R.); Hypertrophic Cardiomyopathy Center, Division of Cardiology, Tufts Medical Center, Boston, MA (J.E.U., E.R., M.S.M.); Fondazione C.N.R./Regione Toscana G. Monasterio, Pisa, Italy (M.L.); Ente Ospedaliero Ospedali Galliera, Genoa, Italy (P.S., F.F.); Policlinico S. Orsola-Malpighi, Bologna, Italy (E.B., C.R.); and Department of Epidemiology, Harvard School of Public Health, Boston, MA (E.F.C.)
| | - Evan Appelbaum
- From the PERFUSE Study Group, Harvard Medical School, Boston, MA (R.H.C., S.N.H., C.M.B., W.J.M., E.A.); Department of Medicine, Cardiovascular Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (R.H.C., S.N.H., C.M.B., W.J.M., E.A.); Hypertrophic Cardiomyopathy Center, Minneapolis Heart Institute Foundation, Minneapolis, MN (B.J.M., T.H., J.R.L.); Referral Center for Myocardial Diseases, Azienda Ospedaliera Universitaria Careggi, Florence Italy (I.O., F.C., B.T.); Harvard Clinical Research Institute and Boston University Biostatistics, Boston, MA (M.J.P.); Ospedale Sant'Andrea Universita "La Sapienza," Rome, Italy (G.E.A., C.N.D.C., C.A.); Division of Cardiology, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada (C.G., A.M.C., H.R.); Hypertrophic Cardiomyopathy Center, Division of Cardiology, Tufts Medical Center, Boston, MA (J.E.U., E.R., M.S.M.); Fondazione C.N.R./Regione Toscana G. Monasterio, Pisa, Italy (M.L.); Ente Ospedaliero Ospedali Galliera, Genoa, Italy (P.S., F.F.); Policlinico S. Orsola-Malpighi, Bologna, Italy (E.B., C.R.); and Department of Epidemiology, Harvard School of Public Health, Boston, MA (E.F.C.)
| | - Martin S Maron
- From the PERFUSE Study Group, Harvard Medical School, Boston, MA (R.H.C., S.N.H., C.M.B., W.J.M., E.A.); Department of Medicine, Cardiovascular Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (R.H.C., S.N.H., C.M.B., W.J.M., E.A.); Hypertrophic Cardiomyopathy Center, Minneapolis Heart Institute Foundation, Minneapolis, MN (B.J.M., T.H., J.R.L.); Referral Center for Myocardial Diseases, Azienda Ospedaliera Universitaria Careggi, Florence Italy (I.O., F.C., B.T.); Harvard Clinical Research Institute and Boston University Biostatistics, Boston, MA (M.J.P.); Ospedale Sant'Andrea Universita "La Sapienza," Rome, Italy (G.E.A., C.N.D.C., C.A.); Division of Cardiology, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada (C.G., A.M.C., H.R.); Hypertrophic Cardiomyopathy Center, Division of Cardiology, Tufts Medical Center, Boston, MA (J.E.U., E.R., M.S.M.); Fondazione C.N.R./Regione Toscana G. Monasterio, Pisa, Italy (M.L.); Ente Ospedaliero Ospedali Galliera, Genoa, Italy (P.S., F.F.); Policlinico S. Orsola-Malpighi, Bologna, Italy (E.B., C.R.); and Department of Epidemiology, Harvard School of Public Health, Boston, MA (E.F.C.).
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McKenna WJ, Nagueh SF. Cardiac magnetic resonance imaging and sudden death risk in patients with hypertrophic cardiomyopathy. Circulation 2014; 130:455-7. [PMID: 25092277 DOI: 10.1161/circulationaha.114.010977] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- William J McKenna
- From the Institute of Cardiovascular Science, University College London, London, UK (W.J.M.); and Methodist DeBakey Heart and Vascular Center, Houston, TX (S.F.N.).
| | - Sherif F Nagueh
- From the Institute of Cardiovascular Science, University College London, London, UK (W.J.M.); and Methodist DeBakey Heart and Vascular Center, Houston, TX (S.F.N.)
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Barone-Rochette G, Piérard S, De Meester de Ravenstein C, Seldrum S, Melchior J, Maes F, Pouleur AC, Vancraeynest D, Pasquet A, Vanoverschelde JL, Gerber BL. Prognostic significance of LGE by CMR in aortic stenosis patients undergoing valve replacement. J Am Coll Cardiol 2014; 64:144-54. [PMID: 25011718 DOI: 10.1016/j.jacc.2014.02.612] [Citation(s) in RCA: 203] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Revised: 01/17/2014] [Accepted: 02/26/2014] [Indexed: 01/20/2023]
Abstract
BACKGROUND Prior studies have shown that late gadolinium enhancement (LGE) by cardiac magnetic resonance (CMR) can detect focal fibrosis in aortic stenosis (AS), suggesting that it might predict higher mortality risk. OBJECTIVES This study was conducted to evaluate whether LGE-CMR can predict post-operative survival in patients with severe AS undergoing aortic valve replacement (AVR). METHODS We prospectively evaluated survival (all-cause and cardiovascular disease related) according to LGE-CMR status in 154 consecutive AS patients (96 men; mean age: 74 ± 6 years) without a history of myocardial infarction undergoing surgical AVR and in 40 AS patients undergoing transcatheter aortic valve replacement (TAVR). RESULTS LGE was present in 29% of patients undergoing surgical AVR and in 50% undergoing TAVR. During a median follow-up of 2.9 years, 21 patients undergoing surgical AVR and 20 undergoing TAVR died. In surgical AVR, the presence of LGE predicted higher post-operative mortality (odds ratio: 10.9; 95% confidence interval [CI]: 1.2 to 100.0; p = 0.02) and worse all-cause survival (73% vs. 88%; p = 0.02 by log-rank test) and cardiovascular disease related survival (85% vs. 95%; p = 0.03 by log-rank test) on 5-year Kaplan-Meier estimates of survival after surgical AVR. Multivariate Cox analysis identified the presence of LGE (hazard ratio: 2.8; 95% CI: 1.3 to 6.9; p = 0.025) and New York Heart Association functional class III/IV (hazard ratio: 3.2; 95% CI: 1.1 to 8.1; p < 0.01) as the sole independent predictors of all-cause mortality after surgical AVR. The presence of LGE also predicted higher all-cause mortality (p = 0.05) and cardiovascular disease related mortality (p = 0.03) in the subgroup of patients without angiographic coronary artery disease (n = 110) and higher cardiovascular disease related mortality in 25 patients undergoing transfemoral TAVR. CONCLUSIONS The presence of LGE indicating focal fibrosis or unrecognized infarct by CMR is an independent predictor of mortality in patients with AS undergoing AVR and could provide additional information in the pre-operative evaluation of risk in these patients.
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Affiliation(s)
- Gilles Barone-Rochette
- Valvular Heart Disease Clinic, Division of Cardiology, Department of Cardiovascular Diseases, Cliniques Universitaires St. Luc, Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Sophie Piérard
- Valvular Heart Disease Clinic, Division of Cardiology, Department of Cardiovascular Diseases, Cliniques Universitaires St. Luc, Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Christophe De Meester de Ravenstein
- Valvular Heart Disease Clinic, Division of Cardiology, Department of Cardiovascular Diseases, Cliniques Universitaires St. Luc, Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Stéphanie Seldrum
- Valvular Heart Disease Clinic, Division of Cardiology, Department of Cardiovascular Diseases, Cliniques Universitaires St. Luc, Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Julie Melchior
- Valvular Heart Disease Clinic, Division of Cardiology, Department of Cardiovascular Diseases, Cliniques Universitaires St. Luc, Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Frédéric Maes
- Valvular Heart Disease Clinic, Division of Cardiology, Department of Cardiovascular Diseases, Cliniques Universitaires St. Luc, Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Anne-Catherine Pouleur
- Valvular Heart Disease Clinic, Division of Cardiology, Department of Cardiovascular Diseases, Cliniques Universitaires St. Luc, Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - David Vancraeynest
- Valvular Heart Disease Clinic, Division of Cardiology, Department of Cardiovascular Diseases, Cliniques Universitaires St. Luc, Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Agnes Pasquet
- Valvular Heart Disease Clinic, Division of Cardiology, Department of Cardiovascular Diseases, Cliniques Universitaires St. Luc, Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Jean-Louis Vanoverschelde
- Valvular Heart Disease Clinic, Division of Cardiology, Department of Cardiovascular Diseases, Cliniques Universitaires St. Luc, Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Bernhard L Gerber
- Valvular Heart Disease Clinic, Division of Cardiology, Department of Cardiovascular Diseases, Cliniques Universitaires St. Luc, Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium.
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