Dilated cardiomyopathy: long-term follow-up and predictors of survival

Double overexpression of miR-19a and miR-20a in induced pluripotent stem cell-derived mesenchymal stem cells effectively preserves the left ventricular function in dilated cardiomyopathic rat

BACKGROUND

This study tested the hypothesis that double overexpression of miR-19a and miR-20a (dOex-mIRs) in human induced pluripotent stem cell (iPS)-derived mesenchymal stem cells (MSCs) effectively preserved left ventricular ejection fraction (LVEF) in dilated cardiomyopathy (DCM) (i.e., induced by doxorubicin) rat.

METHODS AND RESULTS

In vitro study was categorized into groups G1 (iPS-MSC), G2 (iPS-MSC^dOex-mIRs), G3 (iPS-MSC + H₂O₂/100uM), and G4 (iPS-MSC^dOex-mIRs + H₂O₂/100uM). The in vitro results showed the cell viability was significantly lower in G3 than in G1 and G2, and that was reversed in G4 but it showed no difference between G1/G2 at time points of 6 h/24 h/48 h, whereas the flow cytometry of intra-cellular/mitochondrial oxidative stress (DCFA/mitoSOX) and protein expressions of mitochondrial-damaged (cytosolic-cytochrome-C/DRP1/Cyclophilin-D), oxidative-stress (NOX-1/NOX2), apoptotic (cleaved-caspase-3/PARP), fibrotic (p-Smad3/TGF-ß), and autophagic (ratio of LC3B-II/LC3BI) biomarkers exhibited an opposite pattern of cell-proliferation rate (all p< 0.001). Adult-male SD rats (n=32) were equally divided into groups 1 (sham-operated control), 2 (DCM), 3 (DCM + iPS-MSCs/1.2 × 10⁶ cells/administered by post-28 day's DCM induction), and 4 (DCM + iPS-MSC^dOex-mIRs/1.2 × 10⁶ cells/administered by post-28 day's DCM induction) and euthanized by day 60 after DCM induction. LV myocardium protein expressions of oxidative-stress signaling (p22-phox/NOX-1/NOX-2/ASK1/p-MMK4,7/p-JNK1,2/p-cJUN), upstream (TLR-4/MAL/MyD88/TRIF/TRAM/ TFRA6/IKK_α/ß/NF-κB) and downstream (TNF-α/IL-1ß/MMP-9) inflammatory signalings, apoptotic (cleaved-PARP/mitochondrial-Bax), fibrotic (Smad3/TGF-ß), mitochondrial-damaged (cytosolic-cytochrome-C/DRP1/cyclophilin-D), and autophagic (beclin1/Atg5) biomarkers were highest in group 2, lowest in group 1 and significantly lower in group 4 than in group 3, whereas the LVEF exhibited an opposite pattern of oxidative stress (all p< 0.0001).

CONCLUSION

iPS-MSC^dOex-mIRs therapy was superior to iPS-MSC therapy for preserving LV function in DCM rat.

Atrial fibrillation in patients with systolic heart failure: pathophysiology mechanisms and management

Heart failure (HF) and atrial fibrillation (AF) demonstrate a constantly increasing prevalence during the 21^st century worldwide, as a result of the aging population and the successful interventions of the clinical practice in the deterioration of adverse cardiovascular outcomes. HF and AF share common risk factors and pathophysiological mechanisms, creating the base of a constant interrelation. AF impairs systolic and diastolic function, resulting in the increasing incidence of HF, whereas the structural and neurohormonal changes in HF with preserved or reduced ejection fraction increase the possibility of the AF development. The temporal relationship of the development of either condition affects the diagnostic algorithms, the prognosis and the ideal therapeutic strategy that leads to euvolaemia, management of non-cardiovascular comorbidities, control of heart rate or restoration of sinus rate, ventricular synchronization, prevention of sudden death, stroke, embolism, or major bleeding and maintenance of a sustainable quality of life. The indicated treatment for the concomitant HF and AF includes rate or/and rhythm control as well as thromboembolism prophylaxis, while the progress in the understanding of their pathophysiological interdependence and the introduction of the genetic profiling, create new paths in the diagnosis, the prognosis and the prevention of these diseases.

Prognostic impact of right bundle branch block in hospitalized patients with idiopathic dilated cardiomyopathy: a single-center cohort study

Objective

Idiopathic dilated cardiomyopathy (IDCM) is a primary myocardial disease resulting in symptoms of heart failure. Right bundle branch block (RBBB) is associated with increased cardiovascular risk and all-cause mortality. Therefore, the present study was performed to identify the prognostic impact of RBBB in patients with IDCM.

Methods

In total, 165 hospitalized patients with IDCM were evaluated. Receiver operating characteristic curve analysis was used to determine the cutoff point, and Cox regression was used to assess risk factors.

Results

After a median follow-up of 73.1 months (interquartile range, 36.1–88.7 months), 59 (35.8%) patients had died. All-cause mortality was significantly higher in patients with than without RBBB (log-rank χ2 = 9.400), P<0.05. Significant independent predictors of all-cause mortality in patients with IDCM were RBBB (hazard ratio, 2.898; 95% confidence interval, 1.201–6.995) and the left ventricular end-diastolic dimension (LVEDD) (hazard ratio, 1.034; 95% confidence interval, 1.004–1.066) at admission. Patients with RBBB and an LVEDD of ≥63 mm had the highest mortality (log-rank χ2 = 14.854), P<0.05.

Conclusion

RBBB was an independent predictor of all-cause mortality, and the combination of RBBB and LVEDD provided more clinically relevant information than RBBB alone for assessing the risk of all-cause mortality in patients with IDCM.

Towards cardiac MRI based risk stratification in idiopathic dilated cardiomyopathy

Sudden cardiac death (SCD) secondary to arrhythmia remains a risk in those with dilated cardiomyopathy (DCM), an implantable cardiac defibrillator (ICD) is an effective strategy to prevent SCD. Current guidelines recommend selection for ICD based on ejection fraction (EF) less than 35%, however, most SCD occurs in those with EF>35%. Although meta-analysis has demonstrated a survival benefit for primary prevention ICD in DCM, no randomised trial has shown a significant reduction in overall mortality including the most recent 'Danish Study to Assess the Efficacy of ICDs in Patients With Non-Ischemic Systolic Heat Failure on Mortality' study. Clearly, a more sophisticated selection strategy is required. Cardiac MRI (CMR) is an ideal non-invasive imaging technique which allows calculation of EF as well as tissue characterisation with gadolinium contrast, parametric mapping and feature tracking. Late gadolinium enhancement detects mid-wall fibrosis in approximately 30% of those with DCM, three meta-analyses have demonstrated an association between fibrosis in DCM and SCD, and those without fibrosis are at low risk of SCD. T1 mapping and extracellular volume (ECV) calculation are methods of demonstrating diffuse fibrosis in the myocardium. Raised ECV and native T1 have been associated with worse outcomes but the relationship to SCD has not been well studied. Undoubtedly, more research is required but CMR has several tools which offer incremental value above EF to improve risk stratification and consequent outcomes and resource utilisation in those with DCM.

Prognostic value of myocardial strain and late gadolinium enhancement on cardiovascular magnetic resonance imaging in patients with idiopathic dilated cardiomyopathy with moderate to severely reduced ejection fraction

BACKGROUND

It has been reported that left ventricular (LV) myocardial strain and late gadolinium enhancement (LGE) on cardiovascular magnetic resonance (CMR) imaging have prognostic value in patients with heart failure (HF). However, previous studies included patients with various systolic functions. This study aimed to investigate the prognostic value of LV myocardial strain and LGE on CMR imaging in patients with idiopathic dilated cardiomyopathy (DCM) with reduced ejection fraction (EF < 40%).

METHODS

From a prospectively followed cohort who underwent CMR between November 2008 and December 2015, subjects with LV EF < 40% and a diagnosis of idiopathic DCM were eligible for this study. The CMR images were analyzed for LV and right ventricular (RV) function, presence and extent of LGE, and LV myocardial strain. The primary outcome was a composite of all-cause death and heart transplantation. The secondary outcome was hospitalization for HF.

RESULTS

A total of 172 patients were included, in whom mean LV EF was 23.7 ± 7.9% (EF 30-40% n = 47; EF < 30% n = 125). During a median follow-up of 47 months, the primary outcome occurred in 43 patients (16 heart transplantations, 29 all-cause deaths), and there were 41 hospitalizations for HF. Univariate Cox proportional hazard regression analysis showed that mean arterial pressure, serum sodium concentration, log of plasma NT-proBNP level, and presence of LGE (HR 2.277, 95% CI: 1.221-4.246) were significantly associated with the primary outcome. However, LV strain had no significant association (HR 1.048, 95% CI: 0.945-1.163). Multivariable analysis showed that presence of LGE (HR 4.73, 95% CI: 1.11-20.12) and serum sodium (HR 0.823, 95% CI: 0.762-0.887) were independently associated with the primary outcome.

CONCLUSIONS

LGE in CMR imaging was a good predictor of adverse outcomes for patients with idiopathic DCM and reduced EF. Identification of LGE could thus improve risk stratification in high-risk patients. LV strain had no significant prognostic value in patients with moderate to severe systolic dysfunction.

Mortality and Atrial Fibrillation in the FIACA Study: Evidence of a Differential Effect According to Admission Diagnosis

INTRODUCTION AND OBJECTIVES

Atrial fibrillation (AF) is an independent risk factor for mortality in several diseases. However, data published in acute decompensated heart failure (DHF) are contradictory. Our objective was to investigate the impact of AF on mortality in patients admitted to hospital for DHF compared with those admitted for other reasons.

METHODS

This retrospective cohort study included all patients admitted to hospital within a 10-year period due to DHF, acute myocardial infarction (AMI), or ischemic stroke (IS), with a median follow-up of 6.2 years.

RESULTS

We included 6613 patients (74 ± 11 years; 54.6% male); 2177 with AMI, 2208 with DHF, and 2228 with IS. Crude postdischarge mortality was higher in patients with AF hospitalized for AMI (incident rate ratio, 2.48; P < .001) and IS (incident rate ratio, 1.84; P < .001) than in those without AF. No differences were found in patients with DHF (incident rate ratio, 0.90; P = .12). In adjusted models, AF was not an independent predictor of in-hospital mortality by clinical diagnosis. However, AF emerged as an independent predictor of postdischarge mortality in patients with AMI (HR, 1.494; P = .001) and IS (HR, 1.426; P < .001), but not in patients admitted for DHF (HR, 0.964; P = .603).

CONCLUSIONS

AF was as an independent risk factor for postdischarge mortality in patients admitted to hospital for AMI and IS but not in those admitted for DHF.

Comparison of clinical outcomes in peripartum cardiomyopathy and age-matched dilated cardiomyopathy: A 15-year nationwide population-based study in Asia

Peripartum cardiomyopathy (PPCM), often classified as a form of dilated cardiomyopathy (DCM), is the myocardial dysfunction that occurs in late pregnancy and through the first few postpartum months.The aim of this study is to investigate the differences in the clinical outcomes of PPCM and DCM.Electronic medical records from 1997 to 2011 were retrieved from the Taiwan National Health Insurance Research Database. Patients with PPCM were compared with age- and clinical characteristics-matched patients with DCM. Primary outcomes were 1- and 3-year heart failure (HF) readmission, cardiac death, all-cause mortality, and major adverse cardiovascular events. Secondary outcomes were myocardial infarction, new onset of dialysis, heart transplant, and cerebrovascular accident. Follow-up period was divided into "within the first year" and "after the first year."A total of 527,979 patients (253,166 females) were hospitalized with a principal diagnosis of HF during 1997 to 2011 period. After excluding patients aged <18 and >50 years, patients with other forms of HF, and those with a history of cerebrovascular accidents or coronary artery disease, 797 patients with PPCM and 1267 patients with DCM were evaluated. Propensity score matching yielded 391 patients in each group. Patients with DCM had a significantly worse prognosis compared to those with PPCM for all primary and secondary outcomes at the 1- and 3-year follow-ups. After 1 year, the HF readmission rate did not significantly differ between the 2 diseases, suggesting that HF medications should be aggressively instituted in patients with PPCM.This is the first study to directly compare the clinical outcomes between age-matched patients with PPCM and DCM. Patients with PPCM had a significantly better prognosis across all cardiovascular endpoints compared to patients with DCM.

The effects of smoking and drinking on all-cause mortality in patients with dilated cardiomyopathy: a single-center cohort study

SUBJECT

Recent studies have shown that smoking and drinking are associated with poorer outcomes in patients with cardiomyopathy. The purpose of this study was to determine all-cause mortality in dilated cardiomyopathy (DCM) associated with smoking and drinking.

METHODS

An observational cohort study was undertaken in DCM patients from November 2003 to September 2011. A total of 1118 patients were enrolled, with a mean follow-up of 3.5 ± 2.3 years. Standard demographics were obtained, and transthoracic echocardiography and routine blood testing were performed shortly after admission. Outcome assessment was based on the all-cause death after admission.

RESULTS

The patients were divided into three groups: non-smokers (n = 593), mild-to-moderate smokers (n = 159) and heavy smokers (n = 366). The all-cause mortality rates showed no differences between the three groups (23.8, 20.8 and 24 %, respectively; log-rank χ (2) = 1.281, P = 0.527). There was also no significant difference in mortality between non-drinkers (n = 747), mild drinkers (n = 142) and moderate drinkers (n = 229) (23.7, 23.2 and 22.3 %, respectively; log-rank χ (2) = 2.343, P = 0.310). In the Cox analysis, neither the smoking (HR 0.971, P = 0.663) nor the drinking status (HR 0.891, P = 0.140) was a significant independent predictor of all-cause mortality in patients with DCM.

CONCLUSION

In conclusion, there were no significant differences in mortality between the smoking- and drinking-related patient groups, indicating no effect of smoking and drinking on all-cause mortality in patients with DCM in the present large-scale study.

Atrial fibrillation and prognosis in patients 80+ years old with chronic heart failure

INTRODUCTION

It is well known that the prevalence of atrial fibrillation (AF) increases with age. The purpose was to evaluate the impact of AF at the 1-year outcome of patients aged 80? who suffered from chronic heart failure (CHF).

MATERIALS AND METHODS

The study included 220 consecutive patients at age 80–92 (mean 82.8 years, 45.5 % men) hospitalized for heart failure. The prospective analysis contains demographic and clinical data, basic laboratory tests with hsTnT and NT-proBNP, 12-lead resting electrocardiogram, echocardiography and coronary angiography results and the number of deaths at the 1-year followup. Patients were analyzed depending on AF in the resting electrocardiogram at hospital entry.

RESULTS

AF was recorded in 52 patients (24 %). The relationship with AF was found for more advanced NYHA class III and IV (p\0.001), higher concentrations of hsCRP (p = 0.0005), hsTnT (p = 0.007) and NT-proBNP (p = 0.0098), higher heart rate in the electrocardiogram (p = 0.000) and longer hospitalization (p = 0.025), older age (p = 0.003) and lower left ventricular ejection fraction (p = 0.006). Annual mortality was 13 % and was higher if AF occurred (17 %). However, there was no association between deaths and AF (p = 0.3297). From the multivariate stepwise analysis, independent risk factors for annual mortality were male gender (OR = 3.432; p = 0.043), left ventricular systolic dimension (OR = 1.871; p = 0.004) and dyslipidemia (OR = 0.252; p = 0.043).

CONCLUSIONS

In the oldest patients aged 80? who suffered from CHF, the incidence of atrial fibrillation and annual mortality was high. The independent variables, which enhanced the risk of death at the 1-year follow-up, were male sex and left ventricular systolic dimension, but not atrial fibrillation.

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

BACKGROUND

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

METHODS AND RESULTS

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

CONCLUSIONS

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

Clinical significance of cardiomegaly caused by cardiac adiposity

Enlarged cardiac silhouette on chest x-ray (CXR) in the absence of cardiopulmonary disease is often dismissed as "pseudocardiomegaly." We aimed to assess the impact of epicardial adipose tissue (EAT) on radiographic heart size and to determine the clinical significance of cardiomegaly caused by EAT. In total 112 patients (52 ± 13 years old, 53% women, body mass index 32 ± 8 kg/m(2)) with structurally normal hearts by transthoracic echocardiography underwent cardiac computed tomography (CCT). EAT volume was measured by CCT and cardiothoracic ratio (CTR) and cardiac transverse and lateral horizontal transverse diameters were measured on posteroanterior and lateral view CXR. EAT volume (mean 122 ± 49 ml) correlated directly with age, body mass index, hypertension, hyperlipidemia (p <0.05 for all comparisons), transverse diameter (r = 0.50, p <0.001), CTR (r = 0.45, p <0.001), and lateral horizontal transverse diameter (r = 0.38, p <0.001). EAT volume was larger in those with increased (n = 22) compared to those with normal (n = 90) CTR (154 ± 54 vs 115 ± 54 ml, p = 0.0005). Patients with cardiomegaly were also older (58 ± 13 vs 50 ± 12 years old, p = 0.009) and more often had diabetes (32% vs 9%, p = 0.03), hypertension (86% vs 46%, p = 0.001), hyperlipidemia (68% vs 44%, p = 0.04), or obstructive coronary artery disease by CCT (32% vs 11%, p = 0.04). Coronary artery calcium score was also higher in those with cardiomegaly (median 56 [first tertile 0, third tertile 298] vs 0 [0, 55], p = 0.006). In conclusion, cardiomegaly on CXR can be caused by excessive EAT. This is associated with several coronary risk factors and with coronary calcification and stenosis. Cardiomegaly in this setting may be regarded as another noninvasive marker of coronary atherosclerosis.

Coronary reserve impairment prevents the improvement of left ventricular dysfunction and adversely affects the long-term outcome of patients with hypertensive dilated cardiomyopathy

In hypertension, left ventricular (LV) hypertrophy develops as an adaptive mechanism to compensate for increased afterload and thus preserve systolic function. Associated structural changes such as microvascular disease might potentially interfere with this mechanism, producing pathological hypertrophy. A poorer outcome is expected to occur when LV function is put in jeopardy by impaired coronary reserve. The aim of this study was to evaluate the role of coronary reserve in the long-term outcome of patients with hypertensive dilated cardiomyopathy. Between 1996 and 2000, 45 patients, 30 of them male, with 52+/-11 years and LV fractional shortening <30% were enrolled and followed until 2006. Coronary flow velocity reserve was assessed by transesophageal Doppler of the left anterior descending coronary artery. Sixteen patients showed >/=10% improvement in LV fractional shortening after 17+/-6 months. Coronary reserve was the only variable independently related to this improvement. Total mortality was 38% in 10 years. The Cox model identified coronary reserve (hazard ratio=0.814; 95% CI=0.72-0.92), LV mass, low diastolic blood pressure, and male gender as independent predictors of mortality. In hypertensive dilated cardiomyopathy, coronary reserve impairment adversely affects survival, possibly by interfering with the improvement of LV 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.

[Risk stratification in congestive heart failure]

Congestive heart failure remains a severe condition. Risk stratification is necessary to assess the prognosis and discuss the potential timing of heart transplant. Numerous criteria have been used, which may be combined to define prognostic scores which, however, are rarely used in routine. A few items, however, may be used to stratify the risk of mortality and sudden death.

The long-term outcome of patients with hypertensive cardiomyopathy

The prognosis of dilated cardiomyopathy due to hypertension (HT-DCM) is surprisingly unknown, particularly in the absence of coronary disease and diabetes. We aimed at investigating the long-term outcome and the predictors of mortality in patients with left ventricular systolic dysfunction exclusively due to hypertension. From October 1995 to May 2001, 90 consecutive patients with echocardiographic fractional shortening (FS) < 30% and 29 control patients with FS > or = 30% were included. Obstructive coronary disease was excluded by dipyridamole myocardial perfusion imaging in all patients and coronary angiography in 60. After a mean follow-up of 4.3+/-1.6 years, the total mortality rate of HT-DCM was twice as much higher than that of patients without left ventricular systolic dysfunction (P = 0.01). In HT-DCM, the 5-year mortality rate was 26%. Univariate analyses selected age and creatinine for being positively related to mortality, and body mass index, FS and blood pressure during follow-up for being negatively related to mortality. Neither the improvement of left ventricular FS nor the decrease in left ventricular mass index was related to survival. Multivariate analysis identified (hazard ratio; 95% confidence interval) age (1.08; 1.02-1.13), body mass index (0.86; 0.75-0.98), and baseline FS (0.88; 0.78-0.98) as independent predictors of mortality. In conclusion, poor survival in HT-DCM can be anticipated by the severity of left ventricular systolic dysfunction and advanced age. Instead of ominous signs, high blood pressure and body mass may predict a more favourable prognosis.

Changes in right ventricular dimensions and performance after passive cardiac containment

BACKGROUND

Previous studies have shown that the cardiac support device (CSD) improves left ventricular structure and function in patients with heart failure by preventing further cardiac enlargement. The aim of this study was to identify effects on the right ventricle (RV).

METHODS

Ten male patients with idiopathic dilated cardiomyopathy underwent electron-beam computed tomographic (CT) examination within 1 month before, and 6 to 9 months after CSD implantation. The RV end-diastolic and end-systolic volumes (EDV, ESV) and diameters (EDD, ESD), stroke volume (SV), ejection fraction (EF), total and forward RV output (RVO, fRVO), and tricuspid regurgitation fraction (TRF) were calculated.

RESULTS

The EDV measurements decreased from 182.1 +/- 49.6 to 137.5 +/- 37.0 mL, ESV from 114.8 +/- 47.0 to 68.3 +/- 23.8 mL, EDD from 48.2 +/- 6.6 to 41.6 +/- 7.1 mm, and ESD from 39.6 +/- 6.9 to 32.7 +/- 6.5 mm (p < 0.05 for each). Ejection fraction increased from 38.5 +/- 8.9 to 52.0% +/- 7.7% and fRVO from 4.0 +/- 0.8 to 4.6 +/- 1.1 L/min (each with p < 0.05). TRF decreased from 18.2 +/- 14.1 to 10.4% +/- 13.5%, whereas SV and RVO remained nearly unchanged. Postoperatively, RV volumes, EF, and fRVO were not different from 15 age- and gender-matched normal control patients.

CONCLUSIONS

Implantation of a CSD leads to a decrease in RV size and improved RV performance. These data together with the results of previous studies demonstrating improved left ventricular structure and function confirm the biventricular nature of recovery with the CSD.

Prevalence, prognostic significance, and treatment of atrial fibrillation in congestive heart failure with particular reference to the DIAMOND-CHF study

Atrial fibrillation is a growing health problem and the most common cardiac arrhythmia, affecting 5% of persons above the age of 65 years. The number of hospital discharges for atrial fibrillation has more than doubled in the past decade. It occurs very often in patients with congestive heart failure and the prevalence increases with the severity of the disease. These two conditions seem to be linked together, and congestive heart failure may either be the cause or the consequence of atrial fibrillation. The prognosis of atrial fibrillation is controversial, but studies indicate that atrial fibrillation is a risk factor in congestive heart failure patients. In the last 10-15 years, significant advances in the treatment of heart failure have improved survival, whereas effective management of atrial fibrillation in heart failure patients still awaits similar progress. Empirically, two strategies have evolved for treatment of atrial fibrillation: 1) rhythm control, which means conversion to sinus rhythm and maintenance of sinus rhythm; and 2) rate control, which means reduction of heart rate to an acceptable frequency. It is unknown whether one of these strategies is better than the other. In this review the authors discuss the prevalence, impact, and treatment of atrial fibrillation in heart failure patients.

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.

Surgical treatment of congestive heart failure

Cardiac transplantation is the definitive surgical treatment for patients with severe left ventricular dysfunction and congestive heart failure. Unfortunately, however, the supply of donor hearts remains severely limited, so transplantation is an option for only a minority of these patients. Even after being approved for a heart transplant, patients often have a long wait until a suitable donor heart can be found. This waiting period entails a significant mortality rate. Because the supply of donor hearts is not expected to increase, surgeons have introduced several alternatives to heart transplantation, including partial left ventriculectomy, mitral valve repair, myocardial revascularization, and endoventricular circular patch plasty. For maximal benefit, surgeons must refine the selection criteria for determining which patients are the best candidates for each of these procedures.

Reductive annuloplasty of double orifices in patients with primary dilated cardiomyopathy

BACKGROUND

Patients with primary dilated cardiomyopathy exhibit extensive remodeling of the left ventricle, mitral and tricuspid annular dilation and both mitral and tricuspid regurgitation. These factors significantly contribute to heart failure, and are predictors of early lethal outcome. The aim of this study is to show hemodynamic and clinical improvement after reductive annuloplasty of both mitral and tricuspid orifices in primary dilated cardiomyopathy.

METHODS

There were 76 patients with primary dilated cardiomyopathy. Mitral annuloplasty using a Carpentier-Edwards sizer was performed on 9 patients, and posterior semicircular reductive annuloplasty was performed on 67 patients. Modified De Vega's tricuspid annuloplasty was performed on all patients.

RESULTS

Immediate and long-term results showed significant improvement in hemodynamic values and myocardial contractility after operation.

CONCLUSIONS

Reductive annuloplasty of both mitral and tricuspid orifices corrects remodeling of the left ventricle of the heart, changes sphericity and geometry of the left ventricle, improves hemodynamic action of the left and right ventricle, and slows down progression of heart failure. We recommend reductive annuloplasty of both mitral and tricuspid orifices before or soon after the first decompensation.

Examination of left ventricular contractile reserve by Doppler myocardial imaging in patients with dilated cardiomyopathy

Detection of left ventricular contractile reserve by means of dobutamine stress echocardiography is a well known technique. The aim of the present study was to detect velocity changes during the administration of dobutamine, to establish if Doppler myocardial imaging is a suitable method for determining left ventricular contractile reserve, and to determine if the technique provides more information than traditional stress echocardiography. Twenty-five patients (all males; mean age, 53.4 years) were examined for a clinical diagnosis of idiopathic dilated cardiomyopathy with a poor left ventricular systolic function (ejection fraction less than 30%). Doses of 5-10 and 20 mg/kg/min dobutamine were administered and elevated at 4-minute intervals. Ejection fraction was calculated using the Simpson rule. The peak systolic and the early and late diastolic velocities were measured in the basal segment of the septum and the inferior wall at baseline and at full dose of dobutamine. Results indicated that peak systolic velocity increased significantly, both in the septum (0.11±0.03 vs. 0.20±0.05 m/sec; p=0.001) and in the inferior wall (0.10±0.05 vs. 0.17±0.06 m/sec; p=0.03). Late diastolic velocities also increased significantly, both in the septum (0.17±0.05 vs. 0.22±0.07 m/sec; p=0.01) and in the inferior wall (0.18±0.08 vs.0.21±0.02 m/sec; p=0.01). There was a significant linear correlation between the relative increases in basal ejection fraction value and in peak systolic velocity upon dobutamine stimulation. Patients were divided into responders and nonresponders based on responses in either ejection fraction (25% relative increase) or peak systolic velocity (5 cm/s increase). This study concludes that 1) Doppler myocardial imaging is an adequate and simple technique to examine left ventricular contractile reserve; and 2) measurement of peak systolic velocity during dobutamine stimulation seems to be a simple and good indicator of left ventricular contractile reserve. (c)2001 CHF, Inc.

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.

Mitral valve repair in heart failure

Mitral regurgitation (MR) is a frequent complication of end-stage heart failure. Historically, these patients were either managed medically or with mitral valve replacement, both associated with poor outcomes. Mitral valve repair via an 'undersized' annuloplasty repair is safe and effectively corrects MR in heart-failure patients. All of the observed changes contribute to reverse remodeling and restoration of the normal left-ventricular geometric relationship. Mitral valve repair offers a new strategy for patients with MR and end-stage heart failure.

Surgical management of heart failure

Surgical therapy for congestive heart failure can offer gratifying results in selected elderly patients. Several trials have shown a survival advantage for surgical revascularization compared with medical therapy in the treatment of ischemic cardiomyopathy. Aortic valve replacement is highly effective in treating elderly patients with heart failure caused by severe aortic stenosis, and stentless aortic valves seem to provide a survival advantage in elderly patients with low-gradient aortic stenosis. Mitral valve repair with or without coronary revascularization has been used successfully in patients with severe mitral regurgitation. Transplantation is a viable but rarely used option for elderly patients with congestive heart failure. Totally implantable ventricular assist devices are an exciting new option for elderly patients with congestive heart failure who are not heart transplantation candidates.

Early outcome of initiating amiodarone for atrial fibrillation in advanced heart failure

BACKGROUND

Little information exists about the early outcomes of initiating amiodarone for atrial fibrillation in patients with advanced heart failure. This study assessed the initial rate of success and complications of amiodarone therapy initiated for patients with atrial fibrillation during hospitalization for heart failure.

METHODS

We reviewed medical records for 37 consecutive patients with left ventricular ejection fractions </=40% who underwent initiation of amiodarone for atrial fibrillation during hospitalization on a heart failure service.

RESULTS

Atrial fibrillation was present in 35 (95%) and atrial flutter in 2 (5%), with mean duration of 30 months. New York Heart Association class was 3.1 (+/-1.1). Left ventricular ejection fraction was 24% +/- 7%. All patients had received oral amiodarone with an initial dose of 1.2 +/- 0.2 g/day. Bradyarrhythmia led to discontinuation of digoxin in 12 (32%) patients and to permanent pacemaker placement in 7 (19%) patients. Conversion to sinus rhythm occurred spontaneously in 2 patients and after electrical cardioversion in 26 patients, for an initial success of 76%. After a median follow-up of 9.5 months, 21 of 37 (57%) patients remained in sinus or atrial-paced rhythm. Amiodarone complications occurred after discharge in 5 (14%) patients, 4 with hypothyroidism.

CONCLUSIONS

Amiodarone with electrical cardioversion has a high initial success rate for treatment of atrial fibrillation in patients with heart failure with advanced systolic dysfunction. The major early side effect was bradyarrhythmia, frequently requiring discontinuation of digoxin or permanent pacemaker placement.

Role of the etiology of cardiomyopathies on exercise capacity and oxygen consumption in patients with severe congestive heart failure

Peak oxygen consumption is of great importance for the decision of heart transplantation in congestive heart failure. Moreover, the level of exercise capacity seems to depend on the etiology of congestive heart failure. This study compared 14 heart failure patients with idiopathic dilated cardiomyopathy (group 1) to 14 heart failure patients with cardiomyopathy due to ischemic heart disease (group 2), matched for sex (13 male, one female in each group), age +/-10 years, left ventricular ejection fraction +/-5% and pulmonary artery mean pressure +/-5 mm Hg, to assess exercise capacity and oxygen consumption independently of the age, sex and the level of left ventricular dysfunction. Right ventricular function was also assessed. No difference existed in terms of right ventricular parameters. Maximal exercise parameters were significantly higher in group 1 than in group 2. Peak oxygen consumption was statistically higher in group 1 than in group 2. In the whole population, a significant correlation was found between peak oxygen consumption and right ventricular ejection fraction (r=0. 44, P<0.02) but not between peak oxygen consumption and left ventricular ejection fraction. For similar levels of left ventricular dysfunction, exercise capacity and oxygen consumption appear to be better in idiopathic dilated cardiomyopathy than in ischemic cardiomyopathy, thereby suggesting that functional tolerance of left ventricular dysfunction might depend on the etiology of severe congestive heart failure.

Arrhythmias in heart failure: current concepts of mechanisms and therapy

About one half of deaths in patients with heart failure are sudden, mostly due to ventricular tachycardia (VT) degenerating to ventricular fibrillation or immediate ventricular fibrillation. In severe heart failure, sudden cardiac death also may occur due to bradyarrhythmias. Other dysrhythmias complicating heart failure include atrial and ventricular extrasystoles, atrial fibrillation (AF), and sustained and nonsustained ventricular tachyarrhythmias. The exact mechanism of the increased vulnerability to arrhythmias is not known. Depending on the etiology of heart failure, different preconditions, including ischemia or structural alterations such as fibrosis or myocardial scarring, may be prominent. Reentrant mechanisms around scar tissue, afterdepolarizations, and triggered activity due to changes in calcium metabolism significantly contribute to arrhythmogenesis. Furthermore, alterations in potassium currents leading to action potential prolongation and an increase in dispersion of repolarization play a significant role. Treatment of arrhythmias is necessary either because patients are symptomatic or to reduce the risk for sudden cardiac death. The individual history, left ventricular function, electrophysiologic testing, and the signal-averaged ECG give useful information for identifying patients at risk for sudden cardiac death. The implantable cardioverter defibrillator (ICD) has evolved as a promising therapy for life-threatening arrhythmias. A potential role may exist for antiarrhythmic drugs, mainly amiodarone. There is growing evidence that patients with sustained VT or a history of resuscitation have the best outcome with ICD therapy regardless of the degree of heart failure. Many of these patients require additional antiarrhythmic therapy because of AF or nonsustained VTs that may activate the device. Catheter ablation or map-guided endocardial resection are additional options in selected patients but seldom represent the only therapeutic strategy.

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.

Enteroviral RNA replication in the myocardium of patients with left ventricular dysfunction and clinically suspected myocarditis

BACKGROUND

Previous studies dealing with the detection of enteroviral RNA in human endomyocardial biopsies have not differentiated between latent persistence of the enteroviral genome and active viral replication. Enteroviruses that are considered important factors for the development of myocarditis have a single-strand RNA genome of positive polarity that is transcribed by a virus-encoded RNA polymerase into a minus-strand mRNA during active viral replication. The synthesis of multiple copies of minus-strand enteroviral RNA therefore occurs only at sites of active viral replication but not in tissues with mere persistence of the viral genome.

METHODS AND RESULTS

We investigated enteroviral RNA replication versus enteroviral RNA persistence in endomyocardial biopsies of 45 patients with left ventricular dysfunction and clinically suspected myocarditis. Using reverse-transcriptase polymerase chain reaction in conjunction with Southern blot hybridization, we established a highly sensitive assay to specifically detect plus-strand versus minus-strand enteroviral RNA in the biopsies. Plus-strand enteroviral RNA was detected in endomyocardial biopsies of 18 (40%) of 45 patients, whereas minus-strand RNA as an indication of active enteroviral RNA replication was detected in only 10 (56%) of these 18 plus-strand-positive patients. Enteroviral RNA was not found in biopsies of the control group (n=26).

CONCLUSIONS

These data demonstrate that a significant fraction of patients with left ventricular dysfunction and clinically suspected myocarditis had active enteroviral RNA replication in their myocardium (22%). Differentiation between patients with active viral replication and latent viral persistence should be particularly important in future studies evaluating different therapeutic strategies. In addition, molecular genetic detection of enteroviral genome and differentiation between replicating versus persistent viruses is possible in a single endomyocardial biopsy.

Atrial fibrillation is associated with an increased risk for mortality and heart failure progression in patients with asymptomatic and symptomatic left ventricular systolic dysfunction: a retrospective analysis of the SOLVD trials. Studies of Left Ventricular Dysfunction

OBJECTIVE

This study undertook to determine if the presence of atrial fibrillation in patients with asymptomatic and symptomatic left ventricular dysfunction was associated with increased mortality and, if so, whether the increase could be attributed to progressive heart failure or arrhythmic death.

BACKGROUND

Atrial fibrillation is a common condition in heart failure with the potential to impact hemodynamics and progression of left ventricular systolic dysfunction as well as the electrophysiologic substrate for arrhythmias. The available data do not conclusively define the effect of atrial fibrillation on prognosis in heart failure.

METHODS

A retrospective analysis of the Studies of Left Ventricular Dysfunction Prevention and Treatment Trials was conducted that compared patients with atrial fibrillation to those in sinus rhythm at baseline for the risk of all-cause mortality, progressive pump-failure death and arrhythmic death.

RESULTS

The patients with atrial fibrillation at baseline, compared to those in sinus rhythm, had greater all-cause mortality (34% vs. 23%, p < 0.001), death attributed to pump-failure (16.7% vs. 9.4%, p < 0.001) and were more likely to reach the composite end point of death or hospitalization for heart failure (45% vs. 33%, p < 0.001), but there was no significant difference between the groups in arrhythmic deaths. After multivariate analysis, atrial fibrillation remained significantly associated with all-cause mortality (relative risk [RR] 1.34, 95% confidence interval [CI] 1.12 to 1.62, p=0.002), progressive pump-failure death (RR 1.42, 95% CI 1.09 to 1.85, p=0.01), the composite end point of death or hospitalization for heart failure (RR 1.26, 95% CI 1.03 to 1.42, p=0.02), but not arrhythmic death (RR 1.13; 95% CI 0.75 to 1.71; p=0.55).

CONCLUSIONS

The presence of atrial fibrillation in patients with asymptomatic and symptomatic left ventricular systolic dysfunction is associated with an increased risk for all-cause mortality, largely explained by an increased risk for pump-failure death. These data suggest that atrial fibrillation is associated with progression of left ventricular systolic dysfunction.

Intermediate-term outcome of mitral reconstruction in cardiomyopathy

OBJECTIVE

Severe mitral regurgitation is a frequent complication of end-stage cardiomyopathy that contributes to heart failure and predicts a poor survival. We studied the intermediate-term outcome of mitral reconstruction in 48 patients who had cardiomyopathy with severe mitral regurgitation and were operated on between June 1993 and June 1997.

METHODS

Ages ranged from 33 to 79 years (63 +/- 6 years) with left ventricular ejection fractions of 8% to 25% (16% +/- 3%). All patients were receiving maximal drug therapy and were in New York Heart Association class III-IV with severe, refractory 4+ mitral regurgitation. Operatively, all 48 had undersized flexible annuloplasty rings inserted, 7 had coronary bypass grafts for incidental disease, 11 had prior bypass grafts, and 11 also had tricuspid valve repair.

RESULTS

One operative death occurred as a result of right ventricular failure. Postoperative transesophageal echocardiography revealed mild mitral regurgitation in 7 patients and no mitral regurgitation in 41. There were 10 late deaths, 2 to 47 months after mitral reconstruction. The 1- and 2-year actuarial survivals have been 82% and 71%. At a mean follow-up of 22 months, the number of hospitalizations for heart failure has decreased, and 1 patient has had heart transplantation. Significantly, New York Heart Association class improved from 3.9 +/- 0.3 before the operation to 2.0 +/- 0.6 after the operation. Twenty-four months after the operation, left ventricular volume and sphericity have decreased, whereas ejection fraction and cardiac output have increased.

CONCLUSION

Whether this favorable modification of left ventricular function and geometry will persist remains unknown. However, mitral repair for cardiomyopathy with mitral regurgitation allows new strategies for these patients.

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.

Heart transplant candidates at high risk can be identified at the time of initial evaluation

The increasing discrepancy between the numbers of patients selected for cardiac transplantation and the available donor organs requires validation of markers of high risk at the time of initial evaluation that may help to determine which patients profit from aggressive therapy. We retrospectively examined the case records of 91 heart transplant candidates selected out of a total of 140 consecutive patients referred for evaluation. Of these 91 patients, 48 were transplanted during follow-up. Of the remaining 43 patients, 25 died after a mean survival time of 1.6 +/- 2.5 months. The causes of death were pump failure in 18 (72%) and sudden cardiac death in 7 (28%). Multivariate analysis identified 4 out of 26 parameters at initial evaluation that distinguished the 25 nonsurvivors from the 18 survivors. These were: mean arterial pressure (P = 0.03), pulmonary capillary wedge pressure (P = 0.002), mean pulmonary artery pressure (P = 0.001), and fractional shortening (P = 0.007). The mode of death could not be predicted. We conclude that there are prognostic markers at initial evaluation that allow more restrictive selection of patients for cardiac transplantation and mechanical bridging.

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.

Beneficial cumulative role of both nitroglycerin and dobutamine on right ventricular systolic function in congestive heart failure patients awaiting heart transplantation

End-stage idiopathic dilated cardiomyopathy or ischemic heart disease usually present with very low cardiac output and severe ventricular dysfunction which may require pharmacological support before heart transplantation. Right ventricular ejection fraction might be an important factor of functional capacity and survival in congestive heart failure. In order to test the immediate response of right ventricular hemodynamic parameters to nitroglycerin and dobutamine usually used to treat severe left ventricular dysfunction, we studied 17 congestive heart failure patients (15 men, two women; mean age 55 +/- 13 years) with end-stage idiopathic dilated cardiomyopathy (n = 10) or end-stage ischemic heart disease (n = 7), left ventricular ejection fraction < 35% (mean 22 +/- 8%), and sinus rhythm. A well validated thermodilution technique using a dedicated catheter with a fast catheter-computer response, permitting instantaneous measurements of right ventricular ejection fraction, was used. Right ventricular hemodynamic parameters were recorded at baseline, after an intravenous bolus injection of 3 mg nitroglycerin and after an intravenous infusion of dobutamine administered after nitroglycerin until normalization of cardiac index or a maximal dose of 15 micrograms/kg/min. Pulmonary artery mean pressure significantly decreased after nitroglycerin (43 +/- 9 mmHg at baseline vs. 31 +/- 10 mmHg after nitroglycerin, P < 0.0001) and did not subsequently change after dobutamine (32 +/- 10 mmHg after dobutamine, ns). Cardiac index was not affected by nitroglycerin (1.7 +/- 0. l/min/m2 at baseline vs. 2.0 +/- 0.3 l/min/m2 after nitroglycerin, ns), but dramatically increased after dobutamine (3.0 +/- 1.0 l/min/m2 after dobutamine, P < 0.0001). Concomitantly to the changes of these two parameters, right ventricular ejection fraction progressively increased (14 +/- 8% at baseline vs. 20 +/- 10% after nitroglycerin (P < 0.0006) vs. 28 +/- 13% after dobutamine (P < 0.0001)). Progressive increase of right ventricular ejection fraction after administration of nitroglycerin followed by administration of dobutamine suggests the beneficial cumulative role of both medications on right ventricular systolic function in severe congestive heart failure.

Early outcome of mitral valve reconstruction in patients with end-stage cardiomyopathy

Uncontrollable severe mitral regurgitation is a frequent complication of end-stage cardiomyopathy, significantly contributing to heart failure in these patients, and predicts a poor survival. Although elimination of mitral valve regurgitation could be most beneficial in this group, corrective mitral valve surgery has not been routinely undertaken in these very ill patients because of the presumed prohibitive operative mortality. We studied the early outcome of mitral valve reconstruction in 16 consecutive patients with cardiomyopathy and severe, refractory mitral regurgitation operated on between June 1993 and April 1994. There were 11 men and five women, aged 44 to 78 years (64 +/- 8 years) with left ventricular ejection fractions of 9% to 25% (16% +/- 5%). Preoperatively all patients were in New York Heart Association class IV, had severe mitral regurgitation (graded 0 to 4+ according to color flow Doppler transesophageal echocardiography) and two were listed for transplantation. Operatively, a flexible annuloplasty ring was implanted in all patients. Four patients also had single coronary bypass grafting for incidental coronary disease. In four patients the operation was performed through a right thoracotomy because of prior coronary bypass grafting, and four patients also underwent tricuspid valve reconstruction for severe tricuspid regurgitation. No patient required support with an intraaortic balloon pump. There were no operative or hospital deaths and mean hospital stay was 10 days. There were three late deaths at 2, 6, and 7 months after mitral valve reconstruction, and the 1-year actuarial survival has been 75%. At a mean follow-up of 8 months, all remaining patients are in New York Heart Association class I or II, with a mean postoperative ejection fraction of 25% +/- 10%. There have been no hospitalizations for congestive heart failure, and a decrease in medications required has been noted. For patients with cardiomyopathy and severe mitral regurgitation, mitral valve reconstruction as opposed to replacement can be accomplished with low operative and early mortality. Although longer term follow-up is mandatory, mitral valve reconstruction may allow new strategies for patients with end-stage cardiomyopathy and severe mitral regurgitation, yielding improvement in symptomatic status and survival.

Serial evaluation of dilated cardiomyopathy with exercise thallium-201 tomography: correlation with the evolution of left ventricular parameters

The purpose of this prospective study was to correlate (1) the initial findings of exercise thallium-201 tomography with the evolution of left ventricular parameters at long term follow-up in patients with dilated cardiomyopathy and (2) the changes of exercise thallium-201 tomography repeated 1 year later. We studied 19 men with dilated cardiomyopathy and normal coronary angiogram. Two patients died and three patients had heart transplantation during follow-up. The other 14 patients were assessed at baseline and 1-year follow-up. Thallium-201 tomograms were divided into 20 segments for each patient. Two groups were defined according to the evolution of left ventricular ejection fraction: group 1 (n = 7) had unchanged or decreased ejection fraction at follow-up (24 +/- 11% at baseline versus 22 +/- 11% at follow-up, ns) and group 2 (n = 7) had improved ejection fraction at follow-up (25 +/- 9% at baseline versus 49 +/- 8% at follow-up, P < 0.03). The number of total abnormal segments at stress were not statistically different at baseline between groups 1 and 2, and in group 1 between baseline and follow-up. Group 2 at follow-up had a reduced number of total abnormal segments (P < 0.03). The percentage of reversibility was similar in both groups at baseline and follow-up. On exercise thallium-201 tomography, neither the presence nor the reversibility of stress myocardial perfusion abnormalities can predict improvement of left ventricular ejection fraction in dilated cardiomyopathy. However, regression of dilated cardiomyopathy is accompanied by a reduction of stress myocardial perfusion abnormalities.

Clinical and prognostic significance of detection of enteroviral RNA in the myocardium of patients with myocarditis or dilated cardiomyopathy

BACKGROUND

Enteroviral RNA sequences have been demonstrated in the myocardium of patients with myocarditis or dilated cardiomyopathy from presentation to end-stage disease. The prognosis of heart muscle disease has not previously been evaluated in relation to the detection of enterovirus in myocardial biopsy tissue.

METHODS AND RESULTS

We studied 123 consecutive patients with heart muscle disease prospectively. Multiple endomyocardial biopsy samples taken from all patients during diagnostic cardiac catheterization were classified histologically and were examined for enteroviral RNA by use of an enterovirus group-specific hybridization probe. Three enterovirus-negative patients with cardiac amyloidosis were excluded from subsequent analysis. Enteroviral RNA sequences were detectable in 41 (34%) of the remaining 120 patients (group A), while 79 (66%) had no virus detected (group B). The groups did not differ significantly in age, sex, symptomatic presentation, or hemodynamic characteristics; duration of symptoms was significantly shorter in group A (7.8 +/- 9.6 versus 14.9 +/- 19.0 months, P < .05). At follow-up (mean, 25 months; range, 11 to 50 months), patients from group A had an increased mortality compared with those in group B (25% versus 4%, respectively; P = .02). Mortality was also statistically greater in patients with symptomatic cardiac failure (P = .02), those with elevated left ventricular end-diastolic pressures (P = .03), and those in New York Heart Association functional classes III and IV (P = .05). Multivariate regression analysis, however, showed that only the presence of enterovirus RNA and symptomatic heart failure were of independent prognostic value.

CONCLUSIONS

These data demonstrate that the detection of enterovirus RNA in the myocardium of patients with heart muscle disease at the time of initial investigation is associated with an adverse prognosis and that the presence of enterovirus RNA is an independent predictor of clinical outcome.

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.

Relation between ventriculoarterial coupling and myocardial energetics in patients with idiopathic dilated cardiomyopathy

OBJECTIVES

The purpose of this study was to evaluate left ventricular contractility, arterial loading conditions and the way their interaction affects myocardial energetics.

BACKGROUND

Ventriculoarterial coupling, defined as the ratio of effective arterial elastance to left ventricular end-systolic elastance, is known to reflect the mechanoenergetic performance of the heart. However, relations between the coupling and efficiencies of energy transfer from oxygen consumption to hydraulic energy have not been fully investigated in failing hearts.

METHODS

Pressure-volume data were measured in 23 patients with idiopathic dilated cardiomyopathy by using a conductance catheter, and myocardial oxygen consumption was obtained simultaneously in 16 patients by a double-thermistor coronary sinus catheter. End-systolic elastance was determined by transient inferior cava occlusion.

RESULTS

Data are reported as mean value +/- SE. Ventriculoarterial coupling at baseline was 3.24 +/- 0.28. It decreased from 3.12 +/- 0.43 to 1.86 +/- 0.15 (p < 0.05) for the group receiving dobutamine infusion and from 3.16 +/- 0.45 to 1.78 +/- 0.22 (p < 0.01) for the group receiving the oral phosphodiesterase inhibitor MS-857. The ratio of pressure-volume area to myocardial oxygen consumption had a positive correlation with ventriculoarterial coupling. The ratio of external work to pressure-volume area had a hyperbolic correlation with the coupling. The mechanical efficiency defined as the ratio of external work to myocardial oxygen consumption remained within a narrow range (16.4 +/- 1.2%).

CONCLUSIONS

The degree of ventriculoarterial coupling is far from optimal and the cardiovascular performance is severely depressed mechanically and energetically in patients with idiopathic dilated cardiomyopathy. Although inotropic agents improve the coupling, they have a minimal effect on mechanical efficiency.

Clinical and histologic features of alcohol drinkers with congestive heart failure

To clarify the difference between alcoholic cardiomyopathy and dilated cardiomyopathy and to investigate the characteristics of alcoholic cardiomyopathy, right ventricular endomyocardial biopsy was performed, and the two diseases were compared clinically and histologically. Changes in the cardiothoracic ratio, cardiac index, and systolic blood pressure/end-systolic volume index were greater after treatment in patients with alcoholic cardiomyopathy than in patients with dilated cardiomyopathy. Histologically, myocytic hypertrophy, fibrosis, and nuclear change were less significant in the former than in the latter. Among patients with alcoholic cardiomyopathy, the cardiac index in those with less fibrosis was greater than in those with more fibrosis. Thus patients with alcoholic cardiomyopathy had more preserved and reversible cardiac function and fewer histologic changes than the patients with dilated cardiomyopathy. Reversibility of cardiac function in patients with alcoholic cardiomyopathy correlated inversely with the severity of histologic changes.

Prognostic significance of atrial fibrillation in advanced heart failure. A study of 390 patients

BACKGROUND

Atrial fibrillation is common in advanced heart failure, but its prognostic significance is controversial.

METHODS AND RESULTS

We evaluated the relation of atrial rhythm to overall survival and sudden death in 390 consecutive advanced heart failure patients. Etiology of heart failure was coronary artery disease in 177 patients (45%) and nonischemic cardiomyopathy or valvular heart disease in 213 patients (55%). Mean left ventricular ejection fraction was 0.19 +/- 0.07. Seventy-five patients (19%) had paroxysmal (26 patients) or chronic (49 patients) atrial fibrillation. Compared with patients with sinus rhythm, patients with atrial fibrillation did not differ in etiology of heart failure, mean pulmonary capillary wedge pressure on therapy, or embolic events but were more likely to be receiving warfarin and antiarrhythmic drugs and had a slightly higher left ventricular ejection fraction. After a mean follow-up of 236 +/- 303 days, 98 patients died: 56 (57%) died suddenly, and 36 (37%) died of progressive heart failure. Actuarial 1-year overall survival was 68%, and sudden death-free survival was 79%. Actuarial survival was significantly worse for atrial fibrillation than for sinus rhythm patients (52% versus 71%, p = 0.0013). Similarly, sudden death-free survival was significantly worse for atrial fibrillation than for sinus rhythm patients (69% versus 82%, p = 0.0013). By Cox proportional hazards model, pulmonary capillary wedge pressure on therapy, left ventricular ejection fraction, coronary artery disease, and atrial fibrillation were independent risk factors for total mortality and sudden death. For patients who had pulmonary capillary wedge pressure of less than 16 mm Hg on therapy, atrial fibrillation was associated with poorer 1-year survival (44% versus 83%, p = 0.00001); however, in the high pulmonary capillary wedge pressure group, atrial fibrillation did not confer an increased risk (58% versus 57%).

CONCLUSIONS

Atrial fibrillation is a marker for increased risk of death, especially in heart failure patients who have lower filling pressures on vasodilator and diuretic therapy. Whether aggressive attempts to maintain sinus rhythm will reduce this risk is unknown.

Clinical profile of congestive cardiomyopathy in children

The clinical profile of 23 children with congestive cardiomyopathy was reviewed to detect any factors that might be predictive for their survival. Factors examined include age at onset (less than 2 versus greater than 2 years), gender, severity of the clinical picture including data from the chest radiograph, electrocardiogram (ECG), echocardiogram, hemodynamic study and endomyocardial biopsy. Follow-up study ranged from 1 month to 14 years (mean 43 months). There were 12 survivors and 11 nonsurvivors; the 1 year mortality rate was 30% (7 of 23), and the 5 year mortality rate was 44% (10 of 23). Age at onset, gender, cardiothoracic ratio on chest radiograph, pattern of infarction, ST-T changes or arrhythmia on ECG and left ventricular end-diastolic pressure were nonpredictive of outcome. However, low shortening fraction (mean 11.5% in nonsurvivors versus 20.9% in survivors, p less than 0.01), familial cardiomyopathy and endocardial fibroelastosis indicated a very poor prognosis.

Abstention from alcohol in dilated cardiomyopathy: complete regression of the clinical disease but persistence of myocardial perfusion defects on exercise thallium-201 tomography

This case report describes a 43-year-old man with dilated cardiomyopathy reversed by abstention from alcohol over 1 year but with persistence of previous myocardial perfusion defects on exercise thallium-201 tomography. This suggests that despite the near normalization of left ventricular function, a permanent myocardial disease seems to persist.