Determinants of end-stage idiopathic dilated cardiomyopathy: a multivariate analysis of 104 patients

Impact of Functional Mitral Regurgitation on Left Ventricular Strain in Nonischemic Dilated Cardiomyopathy Patients with Type 2 Mellitus Diabetes: A Magnetic Resonance Feature Tracking Study

BACKGROUND

The impact of functional mitral regurgitation and type 2 mellitus diabetes (T2DM) on left ventricular (LV) strain in nonischemic dilated cardiomyopathy (NIDCM) patients remains unclear.

PURPOSE

To evaluate the impact of mitral regurgitation severity on LV strain, and explore additive effect of T2DM on LV function across varying mitral regurgitation severity levels in NIDCM patients.

STUDY TYPE

Retrospective.

POPULATION

352 NIDCM (T2DM-) patients (49.1 ± 14.6 years, 67% male) (207, 85, and 60 no/mild, moderate, and severe mitral regurgitation) and 96 NIDCM (T2DM+) patients (55.2 ± 12.4 years, 77% male) (47, 30, and 19 no/mild, moderate, and severe mitral regurgitation).

FIELD STRENGTH/SEQUENCE

3.0 T/balanced steady-state free precession sequence.

ASSESSMENT

LV geometric parameters and strain were measured and compared among groups. Determinants of LV strain were investigated.

STATISTICAL TEST

Student's t-test, Mann-Whitney U test, one-way ANOVA, Kruskal-Wallis test, univariable and multivariable linear regression. P < 0.05 was considered statistically significant.

RESULTS

LV GLPS and longitudinal PDSR decreased gradually with increasing mitral regurgitation severity in NIDCM patients with T2DM(GLPS: -5.7% ± 2.1% vs. -4.3% ± 1.6% vs. -2.6% ± 1.3%; longitudinal PDSR:0.5 ± 0.2 sec-1 vs. 0.4 ± 0.2 sec-1 vs. 0.3 ± 0.1 sec-1). NIDCM (T2DM+) demonstrated decreased GCPS and GLPS in the no/mild subgroup, reduced LV GCPS, GLPS, and longitudinal PDSR in the moderate subgroup, and reduced GRPS, GCPS, GLPS, and longitudinal PDSR in the severe subgroup compared with NIDCM (T2DM-) patients. Multivariable regression analysis identified that mitral regurgitation severity (β = -0.13, 0.15, and 0.25 for GRPS, GCPS, and GLPS) and the presence of T2DM (β = 0.14 and 0.13 for GCPS and GLPS) were independent determinants of LV strains in NIDCM patients.

DATA CONCLUSION

Increased mitral regurgitation severity is associated with reduced LV strains in NIDCM patients with T2DM. The presence of T2DM exacerbated the decline of LV function across various mitral regurgitation levels in NIDCM patients, resulting in reduced LV strains.

LEVEL OF EVIDENCE: 3

TECHNICAL EFFICACY

Stage 3.

Clinical characteristics, etiological profile, treatment and long term outcomes in patients with non ischemic systolic heart failure; Himachal Pradesh Heart failure registry (HP-HF registry)

BACKGROUND

The data on clinical characteristics, treatment practices and out comes in patients with Non- ischemic Systolic Heart Failure (NISHF) is limited. We report clinical characteristics, treatment and outcomes in patients with NISHF.

METHODS

1004 patients with NISHF were prospectively enrolled and their demographics, clinical characteristics, and treatment were recorded systematically. Patients were followed annually for a median of 3 years (1 year to 8 years) for allcause death, major adverse cardiovascular events (MACE); composite of all-cause death, hospitalization of heart failure, and or for stroke.

RESULTS

Patients of NISHF were middle-aged (58.8±16.2 years) population with severely depressed left ventricular ejection fraction (29.3±7.02%) and 31.1% had symptoms of advanced Heart failure. Hypertension (43.6%), obesity and or overweight (28.0%), Diabetes (15.0%), and valvular heart disease (11.8%) were the common risk factors. The guideline directed medical treatment was prescribed in more than 80% of the study cohort. Incidence of all cause death and MACE was 7 (6.8, 8.8) per 100 person years and 11(10, 13) per 100 person years respectively. The cumulative incidence of deaths and MACE was 35% (30%, 40%) and 49% (44%, 53%) at 8 years of follow-up.

CONCLUSIONS

Patients of NISHF were middle-aged population with severely depressed LV systolic function with significant incident morbidity and mortality. Early detection of risk factors and their risk management and enhancing the use of guideline directed treatment may improve the outcomes.

Results of different therapeutic strategies for left ventricular aneurysm with mitral regurgitation

OBJECTIVE

This study aims to compare the midterm outcomes of left ventricular reconstruction (LVR) added to coronary artery bypass grafting (CABG) with those of CABG alone in patients with left ventricular aneurysm (LVA) and mild or moderate mitral regurgitation (MR). We also assessed the impact of LVR on the degree of MR.

METHODS

A total of 130 patients (77 who underwent CABG plus LVR and 53 who underwent CABG alone) with concomitant mild or moderate MR were included in the study population. All-cause mortality was considered the primary endpoint. Major adverse cardiovascular and cerebrovascular events (MACCEs), including death, myocardial infarction, stroke, and subsequent mitral valve surgery, were considered secondary endpoints. Kaplan-Meier analysis was performed to evaluate event-free survival. MR was graded 0 to 4+ by echocardiogram.

RESULTS

The median follow-up time among all patients was 22 months. There was a significant difference between the CABG plus LVR and CABG alone groups with regard to all-cause mortality ( P = 0.019). However, the statistical difference was not observed in cardiogenic mortality ( P = 0.186) and MACCEs ( P = 0.107). In the grade of MR, the two groups both resulted in the decreased grade of MR, but the CABG plus LVR group had a significant number of patients improving to 0 or 1+ ( P = 0.030).

CONCLUSION

The clinical outcomes of CABG alone are comparable with those of CABG plus LVR in patients with LVA and mild or moderate MR. However, CABG+LVR demonstrated greater reduction in MR severity after surgery than CABG alone.

An Implementation of Patient-Specific Biventricular Mechanics Simulations With a Deep Learning and Computational Pipeline

Parameterised patient-specific models of the heart enable quantitative analysis of cardiac function as well as estimation of regional stress and intrinsic tissue stiffness. However, the development of personalised models and subsequent simulations have often required lengthy manual setup, from image labelling through to generating the finite element model and assigning boundary conditions. Recently, rapid patient-specific finite element modelling has been made possible through the use of machine learning techniques. In this paper, utilising multiple neural networks for image labelling and detection of valve landmarks, together with streamlined data integration, a pipeline for generating patient-specific biventricular models is applied to clinically-acquired data from a diverse cohort of individuals, including hypertrophic and dilated cardiomyopathy patients and healthy volunteers. Valve motion from tracked landmarks as well as cavity volumes measured from labelled images are used to drive realistic motion and estimate passive tissue stiffness values. The neural networks are shown to accurately label cardiac regions and features for these diverse morphologies. Furthermore, differences in global intrinsic parameters, such as tissue anisotropy and normalised active tension, between groups illustrate respective underlying changes in tissue composition and/or structure as a result of pathology. This study shows the successful application of a generic pipeline for biventricular modelling, incorporating artificial intelligence solutions, within a diverse cohort.

Relationships between Pulmonary Hypertension Risk, Clinical Profiles, and Outcomes in Dilated Cardiomyopathy

Pulmonary hypertension (PH) in patients with heart failure (HF) contributes to a poorer prognosis. However, in those with dilated cardiomyopathy (DCM), the true prevalence and role of PH is unclear. Therefore, this study aimed to analyze the profile of DCM patients at various levels of PH risk, determined via echocardiography, and its impact on outcomes. The 502 DCM in- and out-patient records were retrospectively analyzed. Information on patient status was gathered after 45.9 ± 31.3 months. Patients were divided into 3 PH-risk groups based on results from echocardiography measurements: low (L, n = 239, 47.6%), intermediate (I, n = 153, 30.5%), and high (H, n = 110, 21.9%). Symptom duration, atrial fibrillation, ventricular tachyarrhythmia, ejection fraction, right atrial area, and moderate or severe mitral regurgitation were found to be independently associated with PH risk. During the follow-up period, 83 (16.5%) DCM patients died: 29 (12.1%) in L, 31 (20.3%) in I, and 23 (20.9%) in H. L-patients had a significantly lower risk of all-cause death (L to H: HR 0.55 (95%CI 0.32–0.98), p = 0.01), while no differences in prognosis were found between I and H. In conclusion, over one in five DCM patients had a high PH risk, and low PH risk was associated with better prognoses.

Relationship between native papillary muscle T1 time and severity of functional mitral regurgitation in patients with non-ischemic dilated cardiomyopathy

BACKGROUND

Functional mitral regurgitation is one of the severe complications of non-ischemic dilated cardiomyopathy (DCM). Non-contrast native T1 mapping has emerged as a non-invasive method to evaluate myocardial fibrosis. We sought to evaluate the potential relationship between papillary muscle T1 time and mitral regurgitation in DCM patients.

METHODS

Forty DCM patients (55 ± 13 years) and 20 healthy adult control subjects (54 ± 13 years) were studied. Native T1 mapping was performed using a slice interleaved T1 mapping sequence (STONE) which enables acquisition of 5 slices in the short-axis plane within a 90 s free-breathing scan. We measured papillary muscle diameter, length and shortening. DCM patients were allocated into 2 groups based on the presence or absence of functional mitral regurgitation.

RESULTS

Papillary muscle T1 time was significantly elevated in DCM patients with mitral regurgitation (n = 22) in comparison to those without mitral regurgitation (n = 18) (anterior papillary muscle: 1127 ± 36 msec vs 1063 ± 16 msec, p < 0.05; posterior papillary muscle: 1124 ± 30 msec vs 1062 ± 19 msec, p < 0.05), but LV T1 time was similar (1129 ± 38 msec vs 1134 ± 58 msec, p = 0.93). Multivariate linear regression analysis showed that papillary muscle native T1 time (β = 0.10, 95 % CI: 0.05-0.17, p < 0.05) is significantly correlated with mitral regurgitant fraction. Elevated papillary muscle T1 time was associated with larger diameter, longer length and decreased papillary muscle shortening (all p values <0.05).

CONCLUSIONS

In DCM, papillary muscle native T1 time is significantly elevated and related to mitral regurgitant fraction.

Methylome analysis reveals alterations in DNA methylation in the regulatory regions of left ventricle development genes in human dilated cardiomyopathy

Dilated cardiomyopathy (DCM) is one of the main causes of heart failure (called cardiomyopathies) in adults. Alterations in epigenetic regulation (i.e., DNA methylation) have been implicated in the development of DCM. Here, we identified a total of 1828 differentially methylated probes (DMPs) using the Infinium 450K HumanMethylation Bead chip by comparing the methylomes between 18 left ventricles and 9 right ventricles. Alterations in DNA methylation levels were observed mainly in lowly methylated regions corresponding to promoter-proximal regions, which become hypermethylated in severely affected left ventricles. Subsequent mRNA microarray analysis showed that the effect of DNA methylation on gene expression regulation is not unidirectional but is controlled by the functional sub-network context. DMPs were significantly enriched in the transcription factor binding sites (TFBSs) we tested. Alterations in DNA methylation were specifically enriched in the cis-regulatory regions of cardiac development genes, the majority of which are involved in ventricular development (e.g., TBX5 and HAND1).

Surgical therapy for heart failure

Today's healthcare delivery system is challenged with an escalating number of heart failure patients who have exhausted medical therapy and overwhelmed the limits of organ transplantation. Scientific and technological advances over the last 20 years have now brought new surgical options to this vast patient population, ranging from ventricular restoration surgery to surgical gene therapy and beyond. This article reviews the myriad of surgical options that are available to these patients, their benefits and shortcomings, as well as potential future directions.

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

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

METHODS

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

RESULTS

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

CONCLUSION

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

Creatine kinase isoforms as circulating markers of deterioration in idiopathic dilated cardiomyopathy

BACKGROUND

A proportion of patients with dilated cardiomyopathy (DCM) may have ongoing myocardial damage secondary to viral or immune mediated myocardial inflammation.

HYPOTHESIS

The prognostic determinants identify patients with decreased survival but do not provide a measure of myocardial damage. To obtain an objective assessment of myocardial damage in DCM, we measured plasma levels of creatine kinase (CK), its isoenzymes (CK-MM and CK-MB), and separated the isoforms of CK-MM and CK-MB.

METHODS

The cohort consisted of 77 consecutive patients (61 men, 16 women) with DCM (World Health Organization criteria), aged 49 +/- 14 years (range 19-60). Patients had been symptomatic for 29 +/- 38 months (range 0.5-200 months) with 48 in New York Heart Association class I/II and 29 in class III/IV at the time of diagnosis. During median follow-up of 27 months from diagnosis (range 0.6-165), 50 patients remained clinically stable and 27 had deteriorated.

RESULTS

A significantly higher proportion of patients with DCM had abnormal MB2/MB1 ratio compared with normal volunteers (11, 14% vs. 1,1%, p = 0.003). Patients who deteriorated had higher MB2/MB1 ratio, (1.22 +/- 0.62 vs. 0.85 +/- 0.56; p = 0.01), and more frequently had abnormal MB2/ MB1 ratio (8, 30% vs. 3, 6%; p = 0.004) and CK and CK-MM activities (5, 19% vs. 2, 4%; p = 0.03) than those who remained stable. Patients with DCM with high CK-MB activity had 3.13-fold increased odds of sudden death or need for cardiac transplantation (95% confidence interval 1.53-6.40, p = 0.008). Thus, CK measurements, in particular CK-MB isoforms, are markers of myocardial damage in a subset of patients with DCM and could be useful in investigating the possibility of persistent myocardial damage in these patients.

The effects of mitral regurgitation alone are sufficient for leaflet remodeling

BACKGROUND

Although chronic mitral regurgitation results in adverse left ventricular remodeling, its effect on the mitral valve leaflets per se is unknown. In a chronic ovine model, we tested whether isolated mitral regurgitation alone was sufficient to remodel the anterior mitral leaflet.

METHODS AND RESULTS

Twenty-nine sheep were randomized to either control (CTRL, n=11) or experimental (HOLE, n=18) groups. In HOLE, a 2.8- to 4.8-mm diameter hole was punched in the middle scallop of the posterior mitral leaflet to create "pure" mitral regurgitation. At 12 weeks, the anterior mitral leaflet was analyzed immunohistochemically to assess markers of collagen and elastin synthesis as well as matrix metalloproteinases and proteoglycans. A semiquantitative grading scale for characteristics such as intensity and delineation of stain between layers was used to quantify differences between HOLE and CTRL specimens across the heterogeneous leaflet structure. At 12 weeks, mitral regurgitation grade was greater in HOLE versus CTRL (3.0+/-0.8 versus 0.4+/-0.4, P<0.001). In HOLE anterior mitral leaflet, saffron-staining collagen (Movat) decreased, consistent with an increase in matrix metalloproteases throughout the leaflet. Type III collagen expression was increased in the midleaflet and free edge and expression of prolyl-4-hydroxylase (indicating collagen synthesis) was increased in the spongiosa layer. The proteoglycan decorin, also involved in collagen fibrillogenesis, was increased compared with CTRL (all P</=0.05).

CONCLUSIONS

In HOLE anterior mitral leaflet, the increased expression of proteins related to collagen synthesis and matrix degradation suggests active matrix turnover. These are the first observations showing that regurgitation alone can stimulate mitral leaflet remodeling. Such leaflet remodeling needs to be considered in reparative surgical techniques.

The efficacy of mitral valve surgery in children with dilated cardiomyopathy and severe mitral regurgitation

Severe mitral regurgitation predicts poor outcomes in adults with left ventricular dysfunction. Frequently, adult patients now undergo initial mitral valve surgery instead of heart transplant. Pediatric data are limited. This study evaluates the efficacy of mitral valve surgery for severe mitral regurgitation in children with dilated cardiomyopathy. This is a single-institution experience in seven children (range, 0.5-10.9 years) with severe mitral regurgitation and dilated cardiomyopathy who underwent mitral valve surgery between January 1988 and February 2005, with follow-up to January 2006. Children with dilated cardiomyopathy had a depressed fractional shortening preoperatively (24.4% +/- 6.1%) that remained depressed (22.9% +/- 7.6%) 1.3 +/- 1.2 years after surgery (p = 0.50). Left ventricular end-diastolic (6.5 +/- 1.5 to 4.8 +/- 1.8 z-scores, p < 0.01) and end-systolic (6.8 +/- 1.5 to 5.5 +/- 2.1 z-scores, p < 0.05) dimensions improved. Hospitalization frequency had a median decrease of 6.0 hospitalizations per year (p < 0.02). Three patients were transplanted 0.2, 2.4, and 3.5 years after surgery. There was no perioperative mortality. Mitral valve surgery in children with dilated cardiomyopathy was performed safely and improved symptoms, stabilizing ventricular dysfunction in most patients. Mitral valve surgery should be considered prior to heart transplant in children with dilated cardiomyopathy and severe mitral regurgitation.

The echocardiographic determinants of functional mitral regurgitation differ in ischemic and non-ischemic cardiomyopathy

BACKGROUND

Functional mitral regurgitation (MR) is one of the common and severe complications in patients with dilated cardiomyopathy. The detailed mechanisms that cause functional MR remain to be elucidated. Using two-dimensional transthoracic echocardiography, we investigated the differences in major determinants of MR severity between ischemic cardiomyopathy (ICM) and non-ICM patients.

METHODS

We enrolled 103 patients (91 males; age 64+/-12 years) with significant left ventricular (LV) dilatation. They were divided into ICM group (n=69) with significant coronary disease, and non-ICM (n=34) group without coronary disease. We devised a novel and simple parameter; the short-axis sphericity index (SI), to evaluate global LV remodeling, and used coaptation depth (CD) and tenting area (TA) to evaluate mitral deformity.

RESULTS

In all cases, CD, TA and left atrium diameter (LAD) correlated positively with maximum regurgitation area (MRA) (r=0.54, 0.57, 0.57; P<0.0001). A negative correlation was observed between MRA and SI (r=-0.33, P=0.0008). There was no significant relationship between MRA and LV ejection fraction (EF). In non-ICM cases, SI tended to be lower with reduced EF. Multivariate stepwise linear regression analysis showed the following equations; ICM: MRA=-9.4+0.81CD+0.21LAD (r2=0.47, P<0.0001), non-ICM: MRA=-7.2+0.17LVDs (LV end systolic diameter) -8.7SI+0.27LAD (r2=0.63, P<0.0001).

CONCLUSIONS

The strongest determinants of functional MR severity differ in ICM and non-ICM. While LV diameter and SI (global LV remodeling index) mainly determine the severity in non-ICM, CD that reflects mitral deformity is the major determinant in ICM.

Evaluation of survival rate and prognostic indicators for surgical treatment of left-to-right patent ductus arteriosus in dogs: 52 cases (1995-2003)

OBJECTIVE

To determine factors associated with long-term survival in dogs treated surgically for patent ductus arteriosus (PDA).

DESIGN

Retrospective case series. Animals-52 dogs treated surgically for left-to-right shunting PDA.

PROCEDURE

Data pertaining to age, breed, sex, body weight, clinical examination findings, type and duration of medical treatment, results of thoracic radiography and echocardiography, and surgical and postoperative complications were collected from records. Follow-up information was obtained from medical records or telephone interviews with owners or referring veterinarians.

RESULTS

22 dogs had mitral valve regurgitation. Mean weight and age were not significantly different between dogs with or without mitral valve regurgitation. Twenty-four (46.2%) dogs had clinical signs related to cardiac insufficiency. Left atrial dilatation was observed in 56.3% of dogs that were radiographed. Sonographic imaging was used to diagnose left atrial dilatation in 23 dogs and left ventricular dilatation in 25 dogs. The 1- and 2-year survival rates were 92% and 87%, respectively. Diagnosis of mitral valve regurgitation before surgery was not associated with the probability of survival. Age, weight, lethargy, preoperative treatment with angiotensin-converting enzyme inhibitors, and right atrial dilatation on radiographs at the time of surgery were negatively associated with probability of survival.

CONCLUSIONS AND CLINICAL RELEVANCE

Surgical treatment of PDA was curative in young dogs without clinical signs of heart failure. Surgical correction of PDA should be recommended as early as possible after diagnosis, and mitral valve regurgitation is not a contraindication for surgery.

Surgical Ventricular Remodeling for Patients with Clinically Advanced Congestive Heart Failure and Severe Left Ventricular Dysfunction

BACKGROUND

Surgical ventricular remodeling (SVR) is an accepted therapy for post-infarction ventricular remodeling. Current literature on SVR outcomes has focused on heterogeneous populations with regard to left ventricular function and New York Heart Association (NYHA) class. We assessed outcomes after SVR in patients with advanced congestive heart failure (CHF) (NYHA Class III/IV) and a pre-operative ejection fraction (EF) < or =20%.

METHODS

Data were analyzed for 51 consecutive SVR patients from January 2002 to June 2004. Cardiac catheterization, echocardiography and magnetic resonance imaging (MRI) identified 62.7% (32 of 51) of patients with an EF < or =20%, with the majority having an EF < or =15% (65.6%; 21 of 32). Cox regression analysis was performed to determine predictors of mortality in patients with an EF < or =20%. Follow-up was 100% (32 of 32) complete.

RESULTS

Mean age was 61.9 +/- 10.3 (range 40 to 80) years with a male:female ratio of 27:5. Operative mortality was 6.3% (2 of 32). Twenty-two percent (7 of 32) had concomitant mitral valve procedures. Follow-up demonstrated a statistically significant improvement in left ventricular volumes and EF in survivors. Cox regression analysis identified the following to be significant predictors of mortality: pre-operative left ventricular end-systolic volume index >130 ml/m2; pre-operative diabetes; and intra-aortic balloon pump usage. Pre-operatively, all patients (32 of 32) were categorized as NYHA Class III/IV, with 69% (22 of 32) improving to NYHA Class I/II at follow-up (p < 0.01). Survival did not differ statistically between patients with an EF < or =20% and an EF >20% (n = 19).

CONCLUSIONS

Our results indicate that SVR improves left ventricular function and functional status for patients with advanced CHF and a pre-operative EF < or =20%. Therefore, SVR is a viable surgical alternative for patients with severe left ventricular dysfunction.

Mitral valve repair for ischemic mitral regurgitation in dilated cardiomyopathy

Ischemic mitral regurgitation contributes to poor survival in patients with heart failure. The intermediate-term outcome of mitral reconstruction in 15 patients who had ischemic dilated cardiomyopathy with mitral regurgitation requiring surgical intervention was studied. They underwent mitral valve repair along with coronary artery bypass surgery. The mitral valve coaptation depth was considered an important parameter in deciding on repair. Ages ranged from 43 to 72 years. Left ventricular ejection fractions were 15-38% (mean, 26.5% +/- 4.3%). The operative technique in all 15 patients was posterior annuloplasty using Dacron felt. At a mean follow-up of 4.6 +/- 1.2 months (1-8 months), postoperative transesophageal echocardiography revealed mild mitral regurgitation in 2 patients and none in 13. There was a significant improvement in New York Heart Association functional class from 3.9 +/- 1.1 to 1.9 +/- 0.3. Mitral valve repair by posterior felt annuloplasty provides favorable results in the intermediate-term in selected patients with ischemic cardiomyopathy and severe left ventricular dysfunction.

Echocardiographic predictors of morbidity and mortality in patients with advanced heart failure: the Beta-blocker Evaluation of Survival Trial (BEST)

OBJECTIVES

The aim of this study was to determine echocardiographic predictors of outcome in patients with advanced heart failure (HF) due to severe left ventricular (LV) systolic dysfunction in the Beta-blocker Evaluation of Survival Trial (BEST).

BACKGROUND

Previous studies indicate that echocardiographic measurements of LV size and function, mitral deceleration time, and mitral regurgitation (MR) predict adverse outcomes in HF. However, complete quantitative echocardiograms evaluating all of these parameters have not been reported in a prospective randomized clinical trial in the era of modern HF therapy.

METHODS

Complete echocardiograms were performed in 336 patients at 26 sites and analyzed by a core laboratory. A Cox proportional-hazards regression model was used to determine which echocardiographic variables predicted the primary end point of death or the secondary end point of death, HF hospitalization, or transplant. Significant variables were then entered into a multivariable model adjusted for clinical and demographic covariates.

RESULTS

On multivariable analysis adjusted for clinical covariates, only LV end-diastolic volume index predicted death (events = 75), with a cut point of 120 ml/m(2). Three echocardiographic variables predicted the combined end point of death (events = 75), HF hospitalization (events = 97), and transplant (events = 9): LV end-diastolic volume index, mitral deceleration time, and the vena contracta width of MR. Optimal cut points for these variables were 120 ml/m(2), 150 ms, and 0.4 cm, respectively.

CONCLUSIONS

Echocardiographic predictors of outcome in advanced HF include LV end-diastolic volume index, mitral deceleration time, and vena contracta width. These variables indicate that LV remodeling, increased LV stiffness, and MR are independent predictors of outcome in patients with advanced HF.

End-stage cardiomyopathy and secondary mitral insufficiency surgical alternative with prosthesis implant and left ventricular remodeling

Secondary mitral insufficiency is a strong risk factor for death in end-stage cardiomyopathies. The possible correction of mitral regurgitation is now being accepted as an alternative to cardiac transplantation in a special subset of patients. We proposed a new surgical approach that consisted of implantation of a mitral prosthesis smaller than the annulus, as well as preservation and traction of the papillary muscles to reduce sphericity of the left ventricle. Between December 1995 and August 2001, 71 cases were operated on including the following etiologies: ischemic (38), idiopathic (29), Chaga's disease (2), viral (1), and postpartum (1). All patients were in an end-stage phase with more than two hospital admissions in the last three months; seven were in intensive care units receiving drugs and intra-aortic balloon counterpulsation, and one was in cardiogenic shock. The patients were analyzed according to clinical criteria, echocardiographic findings, and morphology of the left ventricle. Hospital mortality was 16.9% (12/71) and mid-term follow-up showed evidence of improvement in clinical status and some echocardiographic parameters. This technique, despite a high mortality rate (due to other clinical conditions at the time of surgery), offers a promising therapeutic alternative for the treatment of patients in refractory heart failure with cardiomyopathy associated with secondary mitral regurgitation.

Left ventricular restoration for ischemic cardiomyopathy--comparison of presence and absence of mitral valve procedure

OBJECTIVE

Association of mitral regurgitation (MR) with ischemic cardiomyopathy (ICM) increases the degree of heart failure and its surgical management remains controversial. The aim of this study was to report the surgical results in patients with or without MR in association with ICM.

PATIENTS AND METHODS

Ninety-two patients with ischemic cardiomyopathy (left ventricular [LV] ejection fraction less than 30% with global akinesis) underwent LV restoration. Pre-operative New York Heart Association (NYHA) functional class was either in class-3 or -4 in all patients. MR was moderate to severe in 38 patients (MR-group) and none or mild in 54 patients (noMR-group). Moderate to severe MR was repaired in addition to the complete coronary artery bypass (CABG) and LV restoration. All patients were followed up and echocardiogram was repeated every 6 months after the surgery.

RESULTS

The procedure of LV restoration was selected pre- and intra-operative examination and endoventricular circular patch plasty was performed in 76, partial left ventricle resection in three, and septal anterior exclusion in 13. CABG was performed in 85 patients with mean 2.4+/-1.1 grafts in MR-group and 3.2+/-0.4 grafts in noMR-group (P<0.0001). In MR-group mitral valve plasty was performed in 24 and replacement in 14. Undersized (26 or 28 mm) circumferential mitral ring was used in 16 patients for mitral plasty. Emergent operation required in 15 patients (13 in MR-group and two in noMR group) and the hospital mortality was 18.4% in MR-group and 3.7% in no MR-group. Mitral regurgitation recurred in two patients with posterior ring annuloplasty and they underwent valve replacement. The post-operative NYHA functional class improved to class-1 or -2 in 65 patients and cumulative survival in 5 years including emergent and hospital deaths was 60.9% in MR-group and 70.1% in noMR-group.

CONCLUSION

In association of MR to ICM, emergent operation required more often and perioperative mortality rate was high. However, the aggressive combined mitral operation in addition to CABG and LV restoration showed the improvement of clinical symptom and quality of life after the surgery.

Mitral annuloplasty in patients with ischemic versus dilated cardiomyopathy

OBJECTIVE

Mitral regurgitation is a frequent finding in patients with end-stage cardiomyopathy predicting poor survival. Conventional treatment consists medical treatment or cardiac transplantation. However, despite severely decreased left ventricular function, mitral annuloplasty may improve survival and reduce the need for allografts.

METHODS

From January 1996 to July 2002, 121 patients with severe end-stage dilated (DCM) or ischemic cardiomyopathy (ICM), mitral regurgitation > or =2, and left ventricular ejection fraction < or =30% underwent mitral valve annuloplasty using a flexible posterior ring. DCM was diagnosed in 30 patients (25%), whereas ICM was found in 91 patients (75%). Concomitant tricuspid valve repair was performed in 14 (46.6%) patients in the DCM, and in 11 (12%) in the ICM group (P=0.0001), coronary artery bypass grafting in three (10%) in the DCM, and in 78 patients (86%) in the ICM group (P<0.00001). The mean follow-up time was 567+/-74 days in the DCM and 793+/-63 days in the ICM group (ns).

RESULTS

Early mortality was 6.6% (8/121), and was equal for both groups. Improvement in NYHA class (DCM 3.3+0.1-1.8+/-0.16; ICM from 3.2+0.04 to 1.7+/-0.07) were equal between groups after 1 year. Seventeen (15%) late deaths occurred during the follow-up period. There was no difference in the 2-year actuarial survival between groups (DCM/ICM 0.93/0.85). Risk factors for mitral reconstruction failure, defined as regurgitation > or =2 after 1 year, were preoperative NYHA IV in the DCM group (P=0.03), a preoperative posterior infarction (P=0.025), decreased left ventricular function (P=0.043), larger ring size (P=0.026) and preoperative renal failure (P=0.05) in the ICM group. Risk factors for death were larger ring size (P=0.02) and an increased LVEDD (P=0.027) in the DCM group and the postoperative use of IABP (P=0.002), renal failure (P=0.001), and a larger preoperative LVESD (P=0.035) in the ICM group.

CONCLUSION

Mitral reconstruction with a posterior annuloplasty using a flexible ring is effective in patients with severely depressed left ventricle function and has an acceptable operative mortality. Mid-term results are superior to medical treatment alone and comparable to cardiac transplantation.

Prognostic significance of heart rate variability in dilated cardiomyopathy

BACKGROUND

Identifying high-risk individuals among patients with nonischemic dilated cardiomyopathy (DCM) is a major and unsolved task of clinical cardiology. We aimed to determine prognostic significance of heart rate variability (HRV) for predicting cardiac events in DCM patients with markedly depressed left ventricular function.

METHODS

In 69 DCM patients in sinus rhythm, with normal coronary angiography and mean ejection fraction 32 (11%) cardiac events defined as cardiac death or heart transplantation during a mean 20-month follow-up were related to baseline time-domain HRV parameters calculated from 24-h digital Holter monitoring.

RESULTS

There were 18 (26%) cardiac events (10 deaths and 8 heart transplantations). In multivariate Cox analysis, standard deviation of normal-to-normal intervals (SDNN) (hazard ratio: 1.35; 95% confidence interval 1.11-1.63; P=0.002) and ejection fraction (hazard ratio: 4.21; confidence interval 1.64-10.78; P=0.003) were significant and independent predictors of cardiac events. One-year event-free survival was significantly lower in patients with SDNN<80 ms compared to those with SDNN>or=80 ms (35% vs. 89%, respectively; P<0.00005). Low SDNN was identifying high-risk patients among those with both depressed and relatively preserved left ventricular function.

CONCLUSIONS

Broadly available time-domain HRV analysis adds independent prognostic information improving risk stratification of DCM patients and therefore it should be incorporated in routine clinical evaluation to determine patients' priority for heart transplantation.

Prognostic value of low-dose dobutamine echocardiography in patients with idiopathic dilated cardiomyopathy

STUDY OBJECTIVES

Dobutamine echocardiography is widely used for the evaluation of myocardial contractile reserve. The purpose of the study was to determine the prognostic value of low-dose dobutamine echocardiography in patients with idiopathic dilated cardiomyopathy (IDCM).

PATIENTS

The study group consisted of 77 consecutive patients with recently diagnosed IDCM (mean [+/- SD] age, 49 +/- 9 years; men, 82%) and left ventricular (LV) ejection fractions of < 40%.

INTERVENTIONS

Two-dimensional and Doppler echocardiographic variables were measured before and after the infusion of dobutamine at the rate of 10 microg/kg/min for 5 min.

MEASUREMENTS AND RESULTS

During a mean follow-up period of 63 +/- 7 months (range, 49 to 75 months) 30 patients (39%) died and five patients (6%) underwent successful heart transplantations. Using multivariate regression analysis, the only significant factors related to fatal outcome or the need for cardiac transplantation were the following: (1) LV end-systolic volume of > 150 mL after low-dose dobutamine infusion (odds ratio [OR], 2.2; confidence interval [CI], 1.2 to 4.1; p = 0.011); (2) no decrease of LV end-diastolic volume after dobutamine infusion (OR, 1.9; CI, 1.1 to 3.4; p = 0.031); (3) atrial fibrillation (OR, 2.7; CI, 1.4 to 5.3; p = 0.003); and (4) male gender (OR, 2.6; CI, 1.2 to 5.5; p = 0.017). A scoring system was proposed with one point assigned for each of the above-mentioned factors. The mortality rates for total scores of 0, 1, 2, 3, and 4 were 0%, 19%, 48%, 83%, and 100%, respectively.

CONCLUSION

The response of the LV to low-dose dobutamine infusion adds clinically valuable prognostic information to the evaluation of the patient with IDCM.

Prognostic implication of myocardial texture analysis in idiopathic dilated cardiomyopathy

BACKGROUND AND AIM

Abnormal myocardial acoustic properties have been reported in patients with idiopathic dilated cardiomyopathy (IDC). The aim of this study was to investigate the relationship between quantitative ultrasonic textural alterations of myocardium and clinical outcome in IDC.

METHODS

Baseline clinical and echocardiographic variables were obtained from 28 patients with IDC. By using a videodensitometric approach, quantitative myocardial texture analysis was performed on images obtained from septum and posterior wall (PW). Cyclic variation (CV) index of mean gray level (MGL) was calculated according to the formula: (MGLdiast-MGLsyst)/MGLdiastx100. All patients were followed for an average of 11+/-5 months for the occurrence of cardiac death or repeated hospitalization due to worsening of heart failure.

RESULTS

During follow-up, 10 patients experienced cardiac events (6 cardiac deaths and 4 heart failure events). The CV indexes of both septum and PW were significantly lower in patients with cardiac events than those of event free patients (6.8+/-9.6% vs. 13.6+/-8.2%, P<0.05 and 5.3+/-6.4% vs.15.7+/-7.2% P<0.001, respectively). Univariate analysis defined the following variables as predictors of outcome: PW-CV index (chi2=13.0, P=0.0003), transmitral E/A ratio (chi2=12.5, P=0.0004), symptom status (chi2=8.7, P=0.003), and septum-CV index (chi2=4.7, P=0.03). Multivariate stepwise regression analysis showed that the PW-CV index (chi2=7.5, P=0.006) and E/A ratio (chi2=6.5, P=0.01) were the independent predictors of outcome. The event-free survival rate of patients with PW-CV index <11% was significantly lower than those with an index > or = 11 (35.7% vs. 92.8%, P=0,001).

CONCLUSION

The assessment of severely depressed CV index provides valuable prognostic information in patients with IDC.

Mitral valve procedure in dilated cardiomyopathy: repair or replacement?

BACKGROUND

Mitral valve (MV) procedure for dilated cardiomyopathy is becoming popular. We analyzed the indications to MV repair or replacement according to our 10-year experience.

METHODS

From January 1990 to May 2000, 49 patients with dilated cardiomyopathy (12 idiopathic and 37 ischemic) underwent MV operation, 29 repair and 20 replacement. Preoperative evaluation included measurement of MV coaptation depth (CD) as a mirror of the abnormalities of MV apparatus leading to functional mitral regurgitation.

RESULTS

Thirty-day mortality was 4.2% (2 patients). One-, 3-, 5-, and 10-year actuarial survival was, respectively, 90%, 87%, 78%, and 73%. The possibility of survival with at least one New York Heart Association functional class improvement was 88%, 76%, 71%, and 65%. Return of functional mitral regurgitation after MV repair was nearly inevitable; however, using a scale from 0 to 4, mean postoperative functional mitral regurgitation was 1.2+/-0.8 when preoperative MVCD was 10 mm or less and 2.5+/-0.7 when preoperative MVCD was 11 mm or higher (p < 0.05). Globally, functional results were not influenced by the strategy of treatment (MV repair or replacement).

CONCLUSIONS

Mitral valve operation can give satisfying survival and good palliation of dilated cardiomyopathy. The MVCD can be helpful in the choice of the surgical strategy on the MV.

Radiographic measurements of cardiac size as predictors of outcome in patients with dilated cardiomyopathy

BACKGROUND

Cardiac dilatation is a predictor of poor outcome in patients with dilated cardiomyopathy. Whereas cardiac chamber dimensions or volumes can be assessed by various noninvasive and invasive techniques, simple chest radiography also may provide a valuable assessment of cardiac size.

METHODS AND RESULTS

To determine the relative power of radiographic heart measurements for predicting outcome in dilated cardiomyopathy, we retrospectively studied 88 adult patients with chest radiographs obtained within 35 days of echocardiography. Standard radiographic variables were measured for each patient, and the cardiothoracic (CT) ratio, frontal cardiac area, and volume were calculated. During a mean 4.1-year follow-up, 62 of the 88 (71%) patients died. CT ratio was the best predictor of mortality among the radiographic cardiac measurements. By multivariate analysis, a model including echocardiographic ejection fraction, New York Heart Association (NYHA) functional class, and history of heart failure was highly predictive of survival. When added to this model, CT ratio also was independently associated with mortality, but not radiographic cardiac area or volume. When radiographic variables were each added to CT ratio, they did not add incremental predictive value to the model that included CT ratio alone. Echocardiographic measurement of left ventricular (LV) size, especially when indexed for body size, was independently predictive of outcome, but it did not supersede the predictive power of CT ratio.

CONCLUSION

The simply derived radiographic CT ratio is a useful predictor of outcome in patients with dilated cardiomyopathy and compares favorably with other clinical and selected echocardiographic variables.

Prognostic value of left atrial appendage function in patients with dilated cardiomyopathy

The purpose of the present study was to determine whether parameters of left atrial appendage (LAA) function, assessed by transesophageal echocardiography (TEE), could predict the clinical outcome in patients with dilated cardiomyopathy (DCM). Fifty-five patients (20 had ischemic cardiomyopathy; mean age, 56+/-14 years) who underwent TEE to evaluate LAA function from 1992 to 1996 were studied. After a mean follow-up period of 34+/-13 months, 16 patients died; the cause was cardiac in 14 and noncardiac in 2. Patients who died of cardiac cause had a lower LAA emptying velocity than survivors (38+/-18 vs 54+/-18 cm/s, p=0.01). There were, however, no significant differences between survivors and nonsurvivors with regard to the maximal LAA area (4.3+/-1.3 vs 4.5+/-0.9 cm2, p=0.55), minimal LAA area (2.4+/-1.1 vs 2.9+1.1 cm2, p=0.13), and LAA ejection fraction (46+/-16 vs 36+/-18%, p=0.05). On the Cox proportional hazards model analysis, LAA emptying velocity <50 cm/s (chi-square 5.9, p=0.02), LAA ejection fraction <43% (chi-square 5.6, p=0.02), female gender (chi-square 5.2, p=0.02), pulmonary artery wedge pressure > or =14 mmHg (chi-square 4.8, p=0.03), E/A ratio > or =1.3 (chi-square 4.6, p=0.03), deceleration time <148 ms (chi-square 4.6, p=0.03), and cardiothoracic ratio > or =54% (chi-square 4.3, p=0.04) were significantly related to cardiac death. The stepwise multivariate analysis revealed that LAA emptying velocity (chi-square 6.1, p=0.01) and gender (chi-square 5.4, p=0.02) were the independent predictors for outcome. In conclusion, the parameters of LAA function may be useful predictors of the clinical outcome in patients with DCM.

Predictors of short-term outcome in Chinese patients with ambulatory heart failure for heart transplantation with ejection fraction <25%

Heart transplantation (HT) provides longer survival than that of the natural history in patients with dilated cardiomyopathy (DCM). However, the optimal timing for cardiac transplantation and predictors of mortality in patients with end-stage cardiomyopathy (ESCM) has been poorly defined. The primary purpose of this study focused on the natural history of ambulatory patients with ESCM for HT assessment. Secondly, we tried to determine prognostic factors of individuals with the poorest short-term outcome and the optimal timing for HT in patients with ESCM. Finally, clinical treatment with angiotensin converting-enzyme inhibitors (ACEIs), carvedilol and amiodarone in the prevention of mortality caused by ESCM, were retrospectively evaluated. The short-term outcomes of 119 referral patients with ESCM for four years were observed. The patients had New York Heart Association class III to IV dyspnea at initial assessment for HT. Left ventricular ejection fraction (LVEF) was 17 +/- 6% and cardiac index (CI) was 2.0 +/- 0.6l/min/m2. After optimization of medical treatment, the patients were divided into two major groups according to CI equal to or less than 2.0l/min/m2 and more than 2.0l/min/m2. HTs were accepted in 88 patients and the patients were divided into two groups: medical treatment (group 1, 56 patients) or HT (group 3, 32 patients); HT was not accepted in the other 31 patients (group 2). We studied the probability of the survival curve and prognostic variables of the groups with medical treatment in the follow-up of 12 +/- 9 months. During follow-up, 49 patients were alive without HT. The remaining 38 patients died; 27 patients were in group 1 and 11 patients were in group 2. Eight deaths in group 2 were sudden. The actuarial survival rate among the non-HT population was 73%, 68%, 63 %, and 56 % at 3, 6, 9 and 12 months, respectively. The actuarial survival rate among group 1 was 70 %, 59 %, 55 %, and 52 % at 3, 6, 9 and 12 months, respectively. The actuarial survival rate among group 2 was 87 %, 85 %, 77 %, and 65 % at 3, 6, 9 and 12 months, respectively. A comparison, excluding patients with HT, was performed with those who had survived < 1 year and > or 1 year after assessment, and those who had died. Two parameters were independent predictors of prognosis on univariate and multivariate analysis: total pulmonary vascular resistance (TPR) > or = 14 Wood units (W) and CI < 1.65 l/min/m2 at 6 and 12 months after assessment. Treatment with amiodarone for ventricular tachycardia (VT) showed no convincing role in the prevention of sudden death in our patients. Also, treatment with ACEIs or carvedilol for heart failure was unconvincing to improve the short-term outcome in this study. Our results suggest in properly selected patients that HT should be considered within six months among patients with severe heart failure. Hemodynamic parameters associated with right cardiac function are important determinants of mortality caused by progressive heart failure. Predictors such as CI and TPR may be considered as important markers of mortality in prediction of short-term outcome in patients with ESCM, as other predictors reported in the literature.

Left ventricular end-systolic wall stress is a potent prognostic variable in patients with dilated cardiomyopathy

Dilated cardiomyopathy is an important cause of morbidity and mortality among patients with heart failure. Left ventricular dilation is viewed as a compensatory response to maintain stroke volume, and left ventricular dilation is directly related to the increase of wall stress. However, only a few studies have examined whether wall stress can be a prognostic variable in patients with dilated cardiomyopathy. This study was designed to elucidate whether left ventricular systolic wall stress was related to the prognosis in patients with dilated cardiomyopathy. Twenty-five normal control subjects and 68 patients with dilated cardiomyopathy participated in this study. Hemodynamic parameters and left ventricular systolic wall stress were determined using echocardiography. In addition, the extent score determined by thallium-201 myocardial scintigraphy was measured as an index of cumulative loss of myocardium. During the 53-month follow-up period, 13 patients died of cardiac events. In a stepwise multivariable analysis, end-systolic wall stress and fractional shortening were significant predictors of survival. The extent score was markedly greater in the patients who died than in alive patients. There was a significant correlation between end-systolic wall stress and extent score (r=0.501, p=0.0001). Left ventricular end-systolic wall stress is an important predictor of mortality in patients with dilated cardiomyopathy.

Comparison of mortality rates and progression of left ventricular dysfunction in patients with idiopathic dilated cardiomyopathy and dilated versus nondilated right ventricular cavities

This study assesses the influence of right ventricular (RV) dilation on the progression of left ventricular (LV) dysfunction and survival in patients with idiopathic dilated cardiomyopathy (IDC). Using transthoracic echocardiography, we studied 100 patients with IDC aged 20 to 80 years (mean 55 +/- 14); 67% were men. In the apical 4-chamber view, diastolic LV and RV chamber area measurements classified patients into 2 groups: group RV enlargement+ (RV area/LV area > 0.5) included 54 patients; group RV enlargement- (no RV enlargement) had RV area/LV area < or = 0.5. Echocardiographic studies were repeated in all patients after a mean of 33 +/- 16 months. At the time of the initial study, the 2 groups did not differ in age, gender, incidence of atrial fibrillation and diabetes, left ventricular mass, and LV ejection fraction, but the RV enlargement+ group had more severe tricuspid regurgitation and less LV enlargement. After 47 +/- 22 months (range 12 to 96), patients in group RV enlargement+ had lower LV ejection fraction (29% vs 34%, p = 0.006) than patients with initial RV enlargement-. At clinical follow-up, mortality was higher (43%) in patients with initial RV enlargement+ than the RV enlargement- patients (15%), p = 0.002. For survivors, the mitral deceleration time averaged 157 +/- 36 ms; for nonsurvivors or patients who required transplant, the mitral deceleration time averaged 97 +/- 12 ms (p < 0.0001). With use of a multivariate Cox model adjusting for LV ejection fraction, LV size, and age, the relative risk ratio of mortality from initial RV enlargement+ was 4.4 (95% confidence limits 1.7 to 11.1) (p = 0.002). Thus, patients with significant RV dilation had nearly triple the mortality over 4 years and more rapidly deteriorating LV function than patients with less initial RV dilation. In IDC, RV enlargement is a strong marker for adverse prognosis that may represent a different morphologic subset.

Left atrial size is the major predictor of cardiac death and overall clinical outcome in patients with dilated cardiomyopathy: a long-term follow-up study

HYPOTHESIS

This study was undertaken to determine whether echo-derived left atrial dimension and other echocardiographic, clinical, and hemodynamic parameters detected at the time of entry into the study may influence prognosis in patients with dilated cardiomyopathy during a long-term follow-up.

METHODS

This was a prospective cohort analysis of 123 patients with dilated cardiomyopathy. Clinical evaluation, chest x-ray, M-mode and two-dimensional echocardiogram, exercise test, 72-h ambulatory electrocardiogram monitoring, and cardiac catheterization study were performed in all patients. The study was divided into two phases: in the first phase, patients were divided into two groups according to the left atrial size (> or = 45 mm; < 45 mm), with cardiac death as the end point. In the second phase, all patients were further divided into two groups according to their clinical course. A multivariate analysis was performed to determine independent correlated parameters of cardiac mortality and overall clinical outcome.

RESULTS

Cardiac mortality rate was 47.9%: 29% in the group without left atrial dilation and 54.3% in the group with dilated left atrium. Multivariate analysis revealed that left atrium > or = 45 mm, New York Heart Association functional classes III/IV, and the presence of one or more episodes of ventricular tachycardia at Holter monitoring were independent predictors of cardiac mortality, while left atrium > or = 45 mm, left ventricular end-diastolic pressure > 17 mmHg, and exercise tolerance < or = 15 min were independent predictors of poor clinical outcome.

CONCLUSIONS

Our results revealed that left atrial size is the principal independent predictor of prognosis in patients with dilated cardiomyopathy in that patients with left atrial dilation had an increase in mortality and a worse clinical outcome compared with those without left atrial dilation.

Myocardial contractile reserve as prognostic determinant in patients with idiopathic dilated cardiomyopathy without overt heart failure

To assess the prognostic significance of myocardial contractile reserve in patients with idiopathic dilated cardiomyopathy (DCM) without overt heart failure (New York Heart Association functional class I or II), seventy-one patients underwent exercise radionuclide angiography in addition to clinical, radiographic, hemodynamic, and echocardiographic evaluations. Myocardial contractile reserve was assessed as left ventricular ejection fraction (LVEF) during peak exercise minus LVEF at rest (delta LVEF). During an average of 49 months, 18 patients died of the disease. Cox's proportional-hazards regression analysis showed that the delta LVEF was the most powerful and independent discriminator for survival (p = 0.0002). Ejection time (p = 0.0029) and cardiothoracic ratio (p = 0.017) were the second and third most predictive variables, respectively. Evaluation of the delta LVEF, which reflects residual myocardial contractile reserve, can provide important information about the prognosis of patients with DCM and mild symptoms.

Improvement following correction of secondary mitral regurgitation in end-stage cardiomyopathy with mitral annuloplasty

Twenty consecutive patients with severe mitral regurgitation secondary to end-stage dilated cardiomyopathy underwent mitral annuloplasty for refractory symptoms of heart failure. On follow-up 18 +/- 4 months after annuloplasty, 14 patients (70%) were alive, all 14 noted symptomatic improvement, and quantitative echocardiographic/Doppler demonstrated decreases in left ventricular volume and sphericity accompanied by increases in ejection fraction and forward cardiac output.

Comparison of time domain and spectral turbulence analysis of the signal-averaged electrocardiogram for the prediction of prognosis in idiopathic dilated cardiomyopathy

BACKGROUND

Despite significant advances in the treatment of heart failure, the prognosis of patients with idiopathic dilated cardiomyopathy remains poor. Although several of prognostic variables have been shown to be useful in risk stratification of patients with idiopathic dilated cardiomyopathy, their predictive accuracy is low and clinical usefulness uncertain.

HYPOTHESIS

This study was undertaken to assess the signal-averaged electrocardiogram (SAECG) in patients with idiopathic dilated cardiomyopathy and to compare the ability of time domain and spectral turbulence analytic techniques to predict clinical outcome.

METHODS

SAECG analysis was performed in 80 patients with idiopathic dilated cardiomyopathy. Nineteen patients had left bundle-branch block and eight were taking low-dose amiodarone for life-threatening arrhythmias. Conventional time domain and spectral turbulence analyses of the SAECG were performed using Del Mar 183 software.

RESULTS

During a follow-up of 27 +/- 19 months, 24 patients developed progressive heart failure, while the others remained clinically stable. Late potentials were detected in 28% of patients and were equally frequent in patients with and without progressive heart failure (38 vs. 23%, p = 0.20). Spectral turbulence analysis was abnormal in 34% of patients, and patients with abnormal results developed progressive heart failure more frequently than those with normal results (50 vs. 17%, p = 0.01). All spectral turbulence analysis parameters were significantly different in patients with progressive heart failure compared with those who remained clinically stable (p < or = 0.01). Furthermore, progressive heart failure-free survival at 2 years was significantly lower in patients with abnormal compared with normal results (63 vs. 87%; p < 0.05), but was similar in patients with and without late potentials (72 vs. 83%; p = 0.30). The relative risk for developing progressive heart failure using spectral turbulence analysis was 3.4 (95% confidence interval 1.2-9.7) and 2.8 (95% confidence interval 1.1-8.7) using time domain analysis. The sensitivity, specificity, and the positive and negative predictive accuracy for identifying patients who developed progressive heart failure were 50, 83, 50, and 83%, respectively, (p = 0.01) for spectral turbulence analysis, and 36, 85, 45 and 80%, respectively, (p = 0.09) for time domain analysis.

CONCLUSION

Abnormalities in the SAECG of patients with idiopathic dilated cardiomyopathy are common and appear to provide a noninvasive marker for development of progressive heart failure.

Determinants of prognosis in nonischemic dilated cardiomyopathy

BACKGROUND

Dilated cardiomyopathy, a heart muscle disease of unknown cause, is characterized by high mortality and is a major cause of cardiac transplantation. It has become, therefore, increasingly important to identify patients at higher risk. The aim of this study was to assess which of the data obtained at the time of diagnosis are the best predictors of survival.

METHODS AND RESULTS

One hundred forty-four patients with dilated cardiomyopathy (118 men; mean age, 39 years) were assessed clinically, noninvasively, and hemodynamically. The effect of variables derived from the evaluation on outcome (death or heart transplantation) was examined. During a mean follow-up time of 4.1 years, 68 patients (47%) died and 9 (6%) underwent heart transplantation. The 1-, 2-, and 5-year transplant-free survival rate was 79, 69, and 44%, respectively. Cox multivariate regression analysis identified three variables as independent predictors of outcome: (1) pulmonary artery systolic pressure, P = .0001; (2) left ventricular ejection fraction, P = .0013; and (3) left ventricular end-diastolic dimension, P = .007. The prognostic index was constructed from regression coefficients and parameters significant in the Cox model. The minimal prognostic index in the study group was 1.4 and the maximal was 6.0 with a corresponding 1-year survival of 98 and 18%, respectively. The validity of the prognostic index was tested in the consecutive group of 81 patients, who were followed for a mean 2.3 years. The prognostic index of the poor outcome group differed significantly from that in survivors (3.7 vs 2.9, respectively, P < .01). The sensitivity and specificity of model predictions were 68 and 52%, respectively.

CONCLUSIONS

The severity of pulmonary hypertension and left ventricular dysfunction provides an independent insight into the prognosis of patients with dilated cardiomyopathy. The prognostic index is useful when assessing prognosis and may be helpful in the timing of heart transplantation.

Annuloplasty for severe mitral regurgitation due to dilated cardiomyopathy

We present a 74-year-old woman who underwent corrective annuloplasty for severe mitral regurgitation due to dilated cardiomyopathy. Postoperatively, congestive heart failure improved, with her New York Heart Association status changing from IV to II, although her cardiac functional improvement was minimal. Severe mitral regurgitation may be the indication for annuloplasty in symptomatic patients with dilated cardiomyopathy when cardiac transplantation is not indicated.

Changes in left ventricular filling during follow-up study in survivors and nonsurvivors of idiopathic dilated cardiomyopathy

The assessment of left ventricular diastolic function by Doppler echocardiography shows both a nonrestrictive and restrictive type of filling in idiopathic dilated cardiomyopathy. These different filling patterns are related to the symptoms of cardiac failure and the prognosis. It remains to be established whether changes of Doppler parameters during follow-up procedures were of clinical relevance. Doppler echocardiography of left ventricular filling was done in 45 patients with idiopathic dilated cardiomyopathy at the time of their diagnosis and repeatedly during a follow-up study of 38 +/- 19 months. The deceleration time of early filling, the maximum early and atrial Doppler velocities and their ratios, as well as echocardiographic parameters of cardiac dimensions and systolic function, were measured. During the follow-up period, seven patients died and four patients underwent heart transplantation because of progressive heart failure. The deceleration time was shorter in patients who died or had to undergo heart transplantation as compared with survivors (119 +/- 43 ms vs 188 +/- 63 ms; P < .005). There was no difference in changes of clinical symptoms in survivors and nonsurvivors. The systolic function improved only in survivors. The difference in deceleration time remained significant between both groups, and it also remained a prognostic discriminator. Peak early velocity increased in nonsurvivors (from 0.66 +/- 0.20 m/s to 0.95 +/- 0.21 m/s; P < .01), while it remained constant in survivors (0.65 +/- 0.17 m/s and 0.67 +/- 0.25 m/s). The peak early/atrial velocity ratio varied widely in either group during the follow-up study, its changes were closely related to the concomitant changes of clinical symptoms (r = .59; P < .005) with a decrease of the peak early/atrial velocity ratio in patients with clinical improvement and an increase of the peak early/atrial velocity ratio in those without clinical improvement. The Doppler echocardiographic deceleration time discriminated between survivors and nonsurvivors in idiopathic dilated cardiomyopathy at the time of the initial diagnostic procedure, and this difference was persistent during the follow-up study. The serial evaluation of patients with idiopathic dilated cardiomyopathy showed a close association of changes in diastolic filling with changes in clinical symptoms.

One-year mortality prognosis in heart failure: a neural network approach based on echocardiographic data

OBJECTIVES

This study sought to assess the usefulness and accuracy of artificial neural networks in the prognosis of 1-year mortality in patients with heart failure.

BACKGROUND

Artificial neural networks is a computational technique used to represent and process information by means of networks of interconnected processing elements, similar to neurons. They have found applications in medical decision support systems, particularly in prognosis.

METHODS

Clinical and Doppler-derived echocardiographic data from 95 consecutive patients with diffuse impairment of myocardial contractility were studied. After 1 year, data regarding survival or death were obtained and produced the prognostic variable. The data base was divided randomly into a training data set (47 cases, 8 deaths) and a testing data set (48 cases, 7 deaths). Results of artificial neural network classification were compared with those from linear discriminant analysis, clinical judgment and conventional heuristically based programs.

RESULTS

The study group included 57 male (47 survivors) and 38 female patients (33 survivors). Linear discriminant analysis was not efficient for separating survivors from nonsurvivors because the accuracy at the ideal cutoff value was only 67.4%, with a sensitivity of 67.5%, positive predictive value of 27.8% and negative predictive value of 91.5%. In contrast, all artificial neural networks were able to predict outcome with an accuracy of 90%, specificity of 93% and sensitivity of 71.4%, for the best artificial neural network. Both clinical judgment and automatic heuristic methods were also inferior in performance.

CONCLUSIONS

The artificial neural network method has proved to be reliable for implementing quantitative prognosis of mortality in patients with heart failure. Additional studies with larger numbers of patients are required to better assess the usefulness of artificial neural networks.

Prognosis of idiopathic dilated cardiomyopathy

Previous reports in referral populations have emphasized the poor prognosis of dilated cardiomyopathy. This study evaluated mortality and morbidity in patients presenting at a referral center between 1989 and 1993. One hundred seventy-two consecutive patients were studied. At presentation, 82 were in New York Heart Association functional class III/IV. Mean (+/- SD) left ventricular end-diastolic dimension was 69 +/- 11 mm, ejection fraction was 25 +/- 10%, VO2 max was 21 +/- 9 mL/min/kg, and sodium was 136 +/- 9 mM. Treatments included vasodilators (n = 157, 92%), anticoagulation (n = 50, 29%), amiodarone (n = 52, 30%), and cardiac defibrillator (n = 5, 3%). During the follow-up period (mean, 26 +/- 29 months), 16 patients died and 60 developed progressive heart failure; 46 (27%) required cardiac transplantation. The majority of the patients (102, 59%) were stable or improved. Established prognostic determinants (left ventricular end-diastolic dimension, ejection fraction, sodium, and arrhythmia) were of low predictive value for the development of progressive heart failure or sudden death. The 1- and 2-year probabilities of death or transplantation was 16 and 21%, respectively (death only 6 and 7%, respectively). These observations are subject to referral bias, but suggest that the majority of patients can remain stable. Any improvement in survival compared to earlier experience can be due to earlier diagnosis, availability of transplantation, and new heart failure management strategies.

Histomorphometric features predict 1-year outcome of patients with idiopathic dilated cardiomyopathy considered to be at low priority for cardiac transplantation

Cardiac transplantation for patients with idiopathic dilated cardiomyopathy (IDC) and poor left ventricular function usually is postponed until symptoms have become intolerable. However, the short-term prognosis of this subset of patients has been defined poorly. Accordingly, the 1-year outcome was investigated in 30 patients with IDC with an ejection fraction < or = 25% who showed a stabilized clinical condition at assessment for transplantation and were therefore considered at low priority for surgery. During follow-up, 10 patients (group A) showed a poor outcome: 2 died suddenly, and 8 had hemodynamic failure (4 of whom underwent transplantation and 4 of whom died from heart failure while on the waiting list). The remaining 20 patients (group B) had a benign outcome. At assessment for cardiac transplantation, clinical and electrocardiographic features, left ventricular dimension, and ejection fraction were similar between the two groups. However, group A patients had higher left ventricular end-diastolic pressure (p < 0.03) and lower cardiac index (p < 0.02) and stroke volume index (p < 0.03) with respect to group B patients. In addition, the former had a lower myofibril volume fraction (p < 0.001) and a higher nuclear area (p < 0.001) compared with the latter. Multivariate analysis selected myofibril volume fraction (p < 0.001) and nuclear area (p < 0.005) as the only independent predictors of a poor 1-year outcome. The combination of myofibril volume fraction < or = 89% and nuclear area > 50 microns 2 was found in all group A patients (sensitivity 100%) but in only 2 group B patients (specificity 90%). It is concluded that in patients with IDC considered at low priority for cardiac transplantation: (1) the 1-year freedom from a cardiac event is lower than that currently expected with surgery; (2) histomorphometric features, that is, the concurrency of low myofibril volume fraction and increased nuclear area, predict short-term outcome; and (3) endomyocardial biopsy at assessment for cardiac transplantation might improve the rationalization of the timing of the procedure.

Experimental idiopathic dilated cardiomyopathy under low-calcium condition

Administration of long-term, low-dose Na2EDTA leads to moderate or severe thinning of the right ventricular wall with or without rupture. These morphological manifestations are known to be site-dependent on the constriction of pulmonary arteries (Yamaguchi et al. 1993a). They sometimes ensue from aneurysmal dilatation and/or plexiform-like-lesion in a pulmonary artery (Yamaguchi et al. 1993b). The present contribution reports that experimental animals who survived for a longer period, maximum for 6 months, showed dilatation of the left ventricle with a mode-rately thin ventricular wall as well as right ventricular changes, which are similar to the morphological manifestations in idiopathic dilated cardiomyopathy.

Prognostic value of Doppler echocardiographic assessment of left ventricular filling in idiopathic dilated cardiomyopathy

The relation of left ventricular (LV) diastolic filling with the clinical outcome in patients with idiopathic dilated cardiomyopathy (IDC) was examined. LV diastolic filling was assessed by Doppler echocardiography in 57 patients with IDC at the time that the diagnosis was established by angiocardiography. Patients were followed for 29 +/- 16 months. Fifteen patients died: 12 due to progressive congestive heart failure and 3 suddenly. Four other patients underwent cardiac transplantation because of progressive heart failure (1-year survival 86%). Patients who died of congestive heart failure or underwent cardiac transplantation had a steep increase and decrease in the early filling phase as compared with survivors; the peak early Doppler velocity was higher (0.84 +/- 0.16 vs 0.65 +/- 0.21 m/s; p < 0.005), and the deceleration time of the early velocity peak was shorter (117 +/- 26 vs 188 +/- 62 ms; p < 0.001) than in survivors. Surviving patients and those who died suddenly showed similar patterns of LV filling. Deceleration time and peak early Doppler velocity were the strongest predictors of survival as compared with systolic function and clinical status in a Cox proportional-hazards analysis. Patients with a shortened deceleration time (< or = 140 ms) had a significantly reduced 2-year survival rate of 52% (confidence interval 34 to 71%) as compared with those with a longer deceleration time (94%; confidence interval 89 to 98%) (p < 0.001). Evidence was presented for a relation between LV filling and survival in patients with IDC.