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Christersson M, Gustafsson S, Lampa E, Almstedt M, Cars T, Bodegård J, Arefalk G, Sundström J. Usefulness of Heart Failure Categories Based on Left Ventricular Ejection Fraction. J Am Heart Assoc 2024; 13:e032257. [PMID: 38591322 DOI: 10.1161/jaha.123.032257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Accepted: 01/03/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND Heart failure guidelines have recently introduced a narrow category with mildly reduced left ventricular ejection fraction (LVEF) (heart failure with mildly reduced ejection fraction; LVEF 41%-49%) between the previous categories of reduced (heart failure with reduced ejection fraction; LVEF ≤40%) and preserved (heart failure with preserved ejection fraction; LVEF ≥50%) ejection fraction. Grouping of continuous measurements into narrow categories can be questioned if their variability is high. METHODS AND RESULTS We constructed a cohort of all 9716 new cases of chronic heart failure with an available LVEF in Stockholm, Sweden, from January 1, 2015, until December 31, 2020. All values of LVEF were collected over time, and patients were followed up until death, moving out of Stockholm, or end of study. Mixed models were used to quantify within-person variance in LVEF, and multistate Markov models, with death as an absorbing state, to quantify the stability of LVEF categories. LVEF values followed a normal distribution. The SD of the within-person variance in LVEF over time was 7.4%. The mean time spent in any LVEF category before transition to another category was on average <1 year for heart failure with mildly reduced ejection fraction. Probabilities of transitioning between categories during the first year were substantial; patients with heart failure with mildly reduced ejection fraction had a probability of <25% of remaining in that category 1 year later. CONCLUSIONS LVEF follows a normal distribution and has considerable variability over time, which may impose a risk for underuse of efficient treatment. The heart failure with mildly reduced ejection fraction category is especially inconstant. Assumptions of a patient's current LVEF should take this variability and the normal distribution of LVEF into account.
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Affiliation(s)
| | | | - Erik Lampa
- Department of Medical Sciences Uppsala University Uppsala Sweden
| | | | | | - Johan Bodegård
- Cardiovascular, Renal and Metabolism, Medical Department BioPharmaceuticals, AstraZeneca Oslo Norway
| | - Gabriel Arefalk
- Department of Medical Sciences Uppsala University Uppsala Sweden
| | - Johan Sundström
- Department of Medical Sciences Uppsala University Uppsala Sweden
- The George Institute for Global Health, University of New South Wales Sydney Australia
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Vancheri F, Longo G, Henein MY. Left ventricular ejection fraction: clinical, pathophysiological, and technical limitations. Front Cardiovasc Med 2024; 11:1340708. [PMID: 38385136 PMCID: PMC10879419 DOI: 10.3389/fcvm.2024.1340708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Accepted: 01/12/2024] [Indexed: 02/23/2024] Open
Abstract
Risk stratification of cardiovascular death and treatment strategies in patients with heart failure (HF), the optimal timing for valve replacement, and the selection of patients for implantable cardioverter defibrillators are based on an echocardiographic calculation of left ventricular ejection fraction (LVEF) in most guidelines. As a marker of systolic function, LVEF has important limitations being affected by loading conditions and cavity geometry, as well as image quality, thus impacting inter- and intra-observer measurement variability. LVEF is a product of shortening of the three components of myocardial fibres: longitudinal, circumferential, and oblique. It is therefore a marker of global ejection performance based on cavity volume changes, rather than directly reflecting myocardial contractile function, hence may be normal even when myofibril's systolic function is impaired. Sub-endocardial longitudinal fibers are the most sensitive layers to ischemia, so when dysfunctional, the circumferential fibers may compensate for it and maintain the overall LVEF. Likewise, in patients with HF, LVEF is used to stratify subgroups, an approach that has prognostic implications but without a direct relationship. HF is a dynamic disease that may worsen or improve over time according to the underlying pathology. Such dynamicity impacts LVEF and its use to guide treatment. The same applies to changes in LVEF following interventional procedures. In this review, we analyze the clinical, pathophysiological, and technical limitations of LVEF across a wide range of cardiovascular pathologies.
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Affiliation(s)
- Federico Vancheri
- Department of Internal Medicine, S.Elia Hospital, Caltanissetta, Italy
| | - Giovanni Longo
- Cardiovascular and Interventional Department, S.Elia Hospital, Caltanissetta, Italy
| | - Michael Y. Henein
- Institute of Public Health and Clinical Medicine, Umea University, Umea, Sweden
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Morales FL, Bivona DJ, Abdi M, Malhotra R, Monfredi O, Darby A, Mason PK, Mangrum JM, Mazimba S, Stadler RW, Epstein FH, Bilchick KC, Oomen PJA. Noninvasive Electrical Mapping Compared with the Paced QRS Complex for Optimizing CRT Programmed Settings and Predicting Multidimensional Response. J Cardiovasc Transl Res 2023; 16:1448-1460. [PMID: 37674046 PMCID: PMC10721664 DOI: 10.1007/s12265-023-10418-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 07/21/2023] [Indexed: 09/08/2023]
Abstract
The aim was to test the hypothesis that left ventricular (LV) and right ventricular (RV) activation from body surface electrical mapping (CardioInsight 252-electrode vest, Medtronic) identifies optimal cardiac resynchronization therapy (CRT) pacing strategies and outcomes in 30 patients. The LV80, RV80, and BIV80 were defined as the times to 80% LV, RV, or biventricular electrical activation. Smaller differences in the LV80 and RV80 (|LV80-RV80|) with synchronized LV pacing predicted better LV function post-CRT (p = 0.0004) than the LV-paced QRS duration (p = 0.32). Likewise, a lower RV80 was associated with a better pre-CRT RV ejection fraction by CMR (r = - 0.40, p = 0.04) and predicted post-CRT improvements in myocardial oxygen uptake (p = 0.01) better than the biventricular-paced QRS (p = 0.38), while a lower LV80 with BIV pacing predicted lower post-CRT B-type natriuretic peptide (BNP) (p = 0.02). RV pacing improved LV function with smaller |LV80-RV80| (p = 0.009). In conclusion, 3-D electrical mapping predicted favorable post-CRT outcomes and informed effective pacing strategies.
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Affiliation(s)
- Frances L Morales
- University of Virginia Health System, Charlottesville, VA, 22901, USA
| | - Derek J Bivona
- University of Virginia Health System, Charlottesville, VA, 22901, USA
| | - Mohamad Abdi
- University of Virginia Health System, Charlottesville, VA, 22901, USA
| | - Rohit Malhotra
- University of Virginia Health System, Charlottesville, VA, 22901, USA
| | - Oliver Monfredi
- University of Virginia Health System, Charlottesville, VA, 22901, USA
| | - Andrew Darby
- University of Virginia Health System, Charlottesville, VA, 22901, USA
| | - Pamela K Mason
- University of Virginia Health System, Charlottesville, VA, 22901, USA
| | - J Michael Mangrum
- University of Virginia Health System, Charlottesville, VA, 22901, USA
| | - Sula Mazimba
- University of Virginia Health System, Charlottesville, VA, 22901, USA
| | | | | | | | - Pim J A Oomen
- Department of Biomedical Engineeering, Edwards Lifesciences Foundation Cardiovascular Innovation and Research Center, University of California, Irvine, Irvine, CA, USA
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Ding Z, Si J, Zhang X, Hu Y, Zhang X, Zhang Y, Liu Y. Prognostic implications of left ventricular ejection fraction trajectory changes in heart failure. Front Cardiovasc Med 2023; 10:1232404. [PMID: 37680560 PMCID: PMC10481864 DOI: 10.3389/fcvm.2023.1232404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 07/31/2023] [Indexed: 09/09/2023] Open
Abstract
Aims The latest guidelines recommended to assess the trajectory of left ventricular ejection fraction (LVEF) in patients with heart failure (HF). However, there is limited data on the trajectory of LVEF in real-world settings. In this study, we investigated the frequency and prognostic implications of changes in LVEF trajectory. Methods Patients were divided into intensified LVEF, static LVEF, and worsening LVEF groups based on the transitions of HF types from baseline to follow-up. The intensified and worsening LVEF groups were further subdivided into mild (≤10% absolute changes of LVEF) and significant (>10% absolute changes of LVEF) increase or decrease groups according to the magnitude of change. The incidences and associations of changes in LVEF with patient outcomes were analyzed. Results Among the 2,429 patients in the study cohort, 38.3% of HF with reduced ejection fraction (HFrEF) and 37.6% of HF with mildly reduced ejection fraction (HFmrEF) showed an improvement in their LVEF. In contrast, a decline in LVEF was observed in 19.3% of HF patients with preserved ejection fraction (HFpEF) and 34.9% of those with HFmrEF. Cox regression analysis showed that the intensified LVEF group was associated with a lower risk of composite endpoints, while the worsening LVEF group yielded opposite findings. Subgroup analysis revealed that compared to those with mild changes in LVEF, baseline HFrEF patients with significant increase showed a lower risk of composite outcome, while baseline HFpEF patients were the opposite. Conclusions The trajectories of LVEF changes are strongly correlated with outcomes in patients with HF who had prior history of HF admission. The most significant prognostic implications observed in patients with significant LVEF changes. Trajectory LVEF and type of HF changes are useful tools recommended for prognostication.
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Affiliation(s)
- Zijie Ding
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Jinping Si
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Xuexia Zhang
- Department of Cardiology, Shandong Health Group Zibo Hospital, Zibo, China
| | - Yuze Hu
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Xinxin Zhang
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Yanli Zhang
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Ying Liu
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
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Bivona DJ, Tallavajhala S, Abdi M, Oomen PJA, Gao X, Malhotra R, Darby A, Monfredi OJ, Mangrum JM, Mason P, Mazimba S, Salerno M, Kramer CM, Epstein FH, Holmes JW, Bilchick KC. Cardiac magnetic resonance defines mechanisms of sex-based differences in outcomes following cardiac resynchronization therapy. Front Cardiovasc Med 2022; 9:1007806. [PMID: 36186999 PMCID: PMC9521735 DOI: 10.3389/fcvm.2022.1007806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Accepted: 08/22/2022] [Indexed: 11/17/2022] Open
Abstract
Background Mechanisms of sex-based differences in outcomes following cardiac resynchronization therapy (CRT) are poorly understood. Objective To use cardiac magnetic resonance (CMR) to define mechanisms of sex-based differences in outcomes after CRT and describe distinct CMR-based phenotypes of CRT candidates based on sex and non-ischemic/ischemic cardiomyopathy type. Materials and methods In a prospective study, sex-based differences in three short-term CRT response measures [fractional change in left ventricular end-systolic volume index 6 months after CRT (LVESVI-FC), B-type natriuretic peptide (BNP) 6 months after CRT, change in peak VO2 6 months after CRT], and long-term survival were evaluated with respect to 39 baseline parameters from CMR, exercise testing, laboratory testing, electrocardiograms, comorbid conditions, and other sources. CMR was also used to quantify the degree of left-ventricular mechanical dyssynchrony by deriving the circumferential uniformity ratio estimate (CURE-SVD) parameter from displacement encoding with stimulated echoes (DENSE) strain imaging. Statistical methods included multivariable linear regression with evaluation of interaction effects associated with sex and cardiomyopathy type (ischemic and non-ischemic cardiomyopathy) and survival analysis. Results Among 200 patients, the 54 female patients (27%) pre-CRT had a smaller CMR-based LVEDVI (p = 0.04), more mechanical dyssynchrony based on the validated CMR CURE-SVD parameter (p = 0.04), a lower frequency of both late gadolinium enhancement (LGE) and ischemic cardiomyopathy (p < 0.0001), a greater RVEF (p = 0.02), and a greater frequency of LBBB (p = 0.01). After categorization of patients into four groups based on cardiomyopathy type (ischemic/non-ischemic cardiomyopathy) and sex, female patients with non-ischemic cardiomyopathy had the lowest CURE-SVD (p = 0.003), the lowest pre-CRT BNP levels (p = 0.01), the lowest post-CRT BNP levels (p = 0.05), and the most favorable LVESVI-FC (p = 0.001). Overall, female patients had better 3-year survival before adjustment for cardiomyopathy type (p = 0.007, HR = 0.45) and after adjustment for cardiomyopathy type (p = 0.009, HR = 0.67). Conclusion CMR identifies distinct phenotypes of female CRT patients with non-ischemic and ischemic cardiomyopathy relative to male patients stratified by cardiomyopathy type. The more favorable short-term response and long-term survival outcomes in female heart failure patients with CRT were associated with lower indexed CMR-based LV volumes, decreased presence of scar associated with prior myocardial infarction and ICM, and greater CMR-based dyssynchrony with the CURE-SVD.
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Affiliation(s)
- Derek J. Bivona
- Department of Medicine, University of Virginia Health System, Charlottesville, VA, United States
| | - Srikar Tallavajhala
- Department of Medicine, University of Virginia Health System, Charlottesville, VA, United States
| | - Mohamad Abdi
- Department of Biomedical Engineering, University of Virginia, Charlottesville, VA, United States
| | - Pim J. A. Oomen
- Department of Biomedical Engineering, University of California, Irvine, Irvine, CA, United States
| | - Xu Gao
- Department of Medicine, Northwestern University, Chicago, IL, United States
| | - Rohit Malhotra
- Department of Medicine, University of Virginia Health System, Charlottesville, VA, United States
| | - Andrew Darby
- Department of Medicine, University of Virginia Health System, Charlottesville, VA, United States
| | - Oliver J. Monfredi
- Department of Medicine, University of Virginia Health System, Charlottesville, VA, United States
| | - J. Michael Mangrum
- Department of Medicine, University of Virginia Health System, Charlottesville, VA, United States
| | - Pamela Mason
- Department of Medicine, University of Virginia Health System, Charlottesville, VA, United States
| | - Sula Mazimba
- Department of Medicine, University of Virginia Health System, Charlottesville, VA, United States
| | - Michael Salerno
- Department of Medicine and Radiology, Stanford University, Palo Alto, CA, United States
| | - Christopher M. Kramer
- Department of Medicine, University of Virginia Health System, Charlottesville, VA, United States
| | - Frederick H. Epstein
- Department of Biomedical Engineering, University of Virginia, Charlottesville, VA, United States
- Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, VA, United States
| | - Jeffrey W. Holmes
- Department of Medicine, Surgery, and Biomedical Engineering, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Kenneth C. Bilchick
- Department of Medicine, University of Virginia Health System, Charlottesville, VA, United States
- *Correspondence: Kenneth C. Bilchick,
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Bivona DJ, Tallavajhala S, Abdi M, Oomen PJ, Gao X, Malhotra R, Darby AE, Monfredi OJ, Mangrum JM, Mason PK, Mazimba S, Salerno M, Kramer CM, Epstein FH, Holmes JW, Bilchick KC. Machine learning for multidimensional response and survival after cardiac resynchronization therapy using features from cardiac magnetic resonance. Heart Rhythm O2 2022; 3:542-552. [PMID: 36340495 PMCID: PMC9626744 DOI: 10.1016/j.hroo.2022.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background Cardiac resynchronization therapy (CRT) response is complex, and better approaches are required to predict survival and need for advanced therapies. Objective The objective was to use machine learning to characterize multidimensional CRT response and its relationship with long-term survival. Methods Associations of 39 baseline features (including cardiac magnetic resonance [CMR] findings and clinical parameters such as glomerular filtration rate [GFR]) with a multidimensional CRT response vector (consisting of post-CRT left ventricular end-systolic volume index [LVESVI] fractional change, post-CRT B-type natriuretic peptide, and change in peak VO2) were evaluated. Machine learning generated response clusters, and cross-validation assessed associations of clusters with 4-year survival. Results Among 200 patients (median age 67.4 years, 27.0% women) with CRT and CMR, associations with more than 1 response parameter were noted for the CMR CURE-SVD dyssynchrony parameter (associated with post-CRT brain natriuretic peptide [BNP] and LVESVI fractional change) and GFR (associated with peak VO2 and post-CRT BNP). Machine learning defined 3 response clusters: cluster 1 (n = 123, 90.2% survival [best]), cluster 2 (n = 45, 60.0% survival [intermediate]), and cluster 3 (n = 32, 34.4% survival [worst]). Adding the 6-month response cluster to baseline features improved the area under the receiver operating characteristic curve for 4-year survival from 0.78 to 0.86 (P = .02). A web-based application was developed for cluster determination in future patients. Conclusion Machine learning characterizes distinct CRT response clusters influenced by CMR features, kidney function, and other factors. These clusters have a strong and additive influence on long-term survival relative to baseline features.
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