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Lee C, Dow S, Shah K, Henkin S, Taub C. Complications of exercise and pharmacologic stress echocardiography. Front Cardiovasc Med 2023; 10:1228613. [PMID: 37600036 PMCID: PMC10435903 DOI: 10.3389/fcvm.2023.1228613] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 07/24/2023] [Indexed: 08/22/2023] Open
Abstract
Stress echocardiography is a diagnostic cardiovascular exam that is commonly utilized for multiple indications, including but not limited to the assessment of obstructive coronary artery disease, valvular disease, obstructive hypertrophic cardiomyopathy, and diastolic function. Stress echocardiography can be performed via both exercise and pharmacologic modalities. Exercise stress is performed with either treadmill or bicycle-based exercise. Pharmacologic stress is performed via either dobutamine or vasodilator-mediated (i.e., dipyridamole, adenosine) stress testing. Each of these modalities is associated with a low overall prevalence of major, life-threatening adverse outcomes, though adverse events are most common with dobutamine stress echocardiography. In light of the recent COVID-19 pandemic, the risk of infectious complications to both the patient and stress personnel cannot be negated; however, when certain precautions are taken, the risk of infectious complications appears minimal. In this article, we review each of the stress echocardiographic modalities, examine major potential adverse outcomes and contraindications, assess the risks of stress testing in the setting of a global pandemic, and examine the utilization and safety of stress testing in special patient populations (i.e., language barriers, pediatric patients, pregnancy).
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Affiliation(s)
| | | | | | | | - Cynthia Taub
- Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Dartmouth College, Lebanon, NH, United States
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Dybro AM, Rasmussen TB, Nielsen RR, Pedersen ALD, Andersen MJ, Jensen MK, Poulsen SH. Metoprolol Improves Left Ventricular Longitudinal Strain at Rest and during Exercise in Obstructive Hypertrophic Cardiomyopathy. J Am Soc Echocardiogr 2023; 36:196-204. [PMID: 36444740 DOI: 10.1016/j.echo.2022.09.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 08/18/2022] [Accepted: 09/11/2022] [Indexed: 02/06/2023]
Abstract
BACKGROUND Patients with obstructive hypertrophic cardiomyopathy (HCM) often experience symptoms of heart failure upon exertion despite having normal left ventricular (LV) ejection fractions. Longitudinal strain (LS) may be a more sensitive marker of systolic dysfunction in patients with LV hypertrophy. The aims of this study were to characterize LV segmental LS and global LS (GLS) at rest and during exercise and to assess if first-line treatment with β-blockers improves LV systolic performance. METHODS Twenty-nine patients with obstructive HCM and New York Heart Association functional class ≥ II symptoms were enrolled in a double-blind, placebo-controlled, randomized crossover trial. Patients received metoprolol 150 mg or placebo for two consecutive 2-week periods in random order. Echocardiographic assessment with speckle-tracking-derived LS was performed at rest and during peak exercise at the end of each treatment period. RESULTS During placebo treatment, resting values of segmental LS showed an apical-basal difference of -10.3% (95% CI, -12.7% to -7.8%; P < .0001), with a severely abnormal value of the basal segment of -9.3 ± 4.2%. Treatment with metoprolol was associated with more negative LS values of the apical segment (-2.8%; 95% CI, -4.2% to -1.3%; P < .001) and the mid segment (-1.1%; 95% CI, -2.0% to -0.3%; P = .007). During peak exercise there was a deterioration in LV GLS, but treatment with metoprolol was associated with more negative peak exercise LV GLS (-1.3 %; 95% CI, -2.6% to -0.1%; P = .03). CONCLUSIONS Systolic performance assessed by LV GLS showed impaired values at rest and during exercise, with severely depressed values of the basal and mid segments. Treatment with metoprolol improved LV GLS upon exercise, indicating a beneficial effect of β-blocker treatment on LV systolic function.
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Affiliation(s)
- Anne M Dybro
- Department of Cardiology, Aarhus University Hospital, Aarhus N, Denmark; Department of Clinical Medicine, Health, Aarhus University, Aarhus, Denmark.
| | - Torsten B Rasmussen
- Department of Cardiology, Aarhus University Hospital, Aarhus N, Denmark; Department of Clinical Medicine, Health, Aarhus University, Aarhus, Denmark
| | - Roni R Nielsen
- Department of Cardiology, Aarhus University Hospital, Aarhus N, Denmark; Department of Clinical Medicine, Health, Aarhus University, Aarhus, Denmark
| | - Anders L D Pedersen
- Department of Cardiology, Aarhus University Hospital, Aarhus N, Denmark; Department of Clinical Medicine, Health, Aarhus University, Aarhus, Denmark
| | - Mads J Andersen
- Department of Cardiology, Aarhus University Hospital, Aarhus N, Denmark
| | - Morten K Jensen
- Department of Cardiology, Aarhus University Hospital, Aarhus N, Denmark
| | - Steen H Poulsen
- Department of Cardiology, Aarhus University Hospital, Aarhus N, Denmark; Department of Clinical Medicine, Health, Aarhus University, Aarhus, Denmark
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Moreno Garijo J, Ibáñez C, Perdomo JM, Abel MD, Meineri M. Preintervention imaging and intraoperative management care of the hypertrophic obstructive cardiomyopathy patient. Asian Cardiovasc Thorac Ann 2021; 30:35-42. [PMID: 34558997 PMCID: PMC8941714 DOI: 10.1177/02184923211047126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
With an estimated overall mortality of less than 1 percent per year, hypertrophic cardiomyopathy, is the most common genetic cardiomyopathy. Intraoperative transesophageal echocardiography is the standard of care for assessing patients with hypertrophic obstructive cardiomyopathy undergoing surgical septal myectomy, allowing surgical planning, intraoperative hemodynamic monitoring, and postprocedural assessment of the repair, including detection of immediate complications. At various phases during surgical septal myectomy, the changing hemodynamic conditions may lead to worsening or improvement in left ventricle outflow tract obstruction by change in preload or afterload, systolic anterior motion of the mitral valve, or sympathetic stimulation. These characteristics represent unique challenges in the management of these patients, requiring a comprehensive understanding of the management of all the conditions required to decrease the left ventricle outflow tract gradient avoiding obstruction, which include the maintenance of sinus rhythm, adequate rate avoiding tachycardia and bradycardia, and avoidance of systemic hypotension preserving preload and afterload, with adequate vasoactive agents. The aim of this review is to summarize the perioperative assessment and management of patients undergoing hypertrophic obstructive myopathy surgery.
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Affiliation(s)
- Jacobo Moreno Garijo
- Department of Anesthesia and Pain Management, 33540Toronto General Hospital, University of Toronto, Toronto, Canada
| | - Cristina Ibáñez
- Department of Anesthesiology, Hospital Clínic, 16493University of Barcelona, Barcelona, Spain
| | - Juan M Perdomo
- Department of Anesthesiology, Hospital Clínic, 16493University of Barcelona, Barcelona, Spain
| | - Martin D Abel
- Department of Anesthesiology and Perioperative Medicine, 156400Mayo Clinic, Jacksonville, FL, USA
| | - Massimiliano Meineri
- Department of Anesthesiology and Critical Care, 40628Herzzentrum Leipzig, Leipzig, Germany
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Moreno Garijo J, Amador Y, Fan CS, Silverton N, Ralph-Edwards A, Woo A, Mashari A, Meineri M. Association Between Three-Dimensional Left Ventricular Outflow Tract Area and Gradients After Myectomy in Hypertrophic Obstructive Cardiomyopathy. J Cardiothorac Vasc Anesth 2020; 35:1654-1662. [PMID: 33431273 DOI: 10.1053/j.jvca.2020.12.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 12/04/2020] [Accepted: 12/07/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Determine whether the intraoperative three-dimensional left ventricular outflow tract cross-sectional area may be inversely correlated with pressure gradients as a determinant of surgical success after septal myectomy in hypertrophic cardiomyopathy patients. DESIGN Perioperative data were obtained by retrospective review. SETTING Toronto General Hospital, University of Toronto, Toronto, Canada, a tertiary hospital. PARTICIPANTS The study comprised 67 patients with hypertrophic obstructive cardiomyopathy. INTERVENTIONS Transthoracic and intraoperative transesophageal echocardiographic assessment of pressure gradients. Transesophageal measurement of the three-dimensional left ventricular outflow tract cross-sectional area. MEASUREMENTS AND MAIN RESULTS The smallest left ventricular outflow tract area increased on average 1.883 cm2 (98.3%) after septal myectomy. There was a significant correlation between the increase in the area and the transesophageal pressure gradients (r = -0.32; p = 0.01) after myectomy, but none with postoperative transthoracic gradients at rest (r = -0.10; p = 0.42). Postoperative transesophageal and transthoracic gradients were significantly correlated (r = 0.26; p = 0.04). The best risk factors to predict high residual gradients were preoperative transesophageal gradient >97 mmHg, postoperative transesophageal area <3.16 cm2, and moderate or more residual transesophageal mitral regurgitation (specificity 89%, 81%, and 78%, respectively). CONCLUSIONS Three-dimensional left ventricular outflow tract area measurements with transesophageal echocardiography after myectomy correlated fairly well with postoperative transesophageal pressure gradients. Patients with residual transthoracic elevated gradients after surgery at follow-up had a smaller transesophageal area and higher transesophageal pressure gradients immediately after the procedure. However, transesophageal pressure gradients after myectomy correlated poorly with follow-up transthoracic gradients at rest.
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Affiliation(s)
- J Moreno Garijo
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada.
| | - Y Amador
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada
| | - C S Fan
- Department of Biostatistics, Toronto General Hospital, Toronto, ON, Canada
| | - N Silverton
- Department of Anesthesiology, University of Utah Health, Salt Lake City, UT
| | - A Ralph-Edwards
- Department of Cardiac Surgery, Toronto General Hospital, Toronto, ON, Canada
| | - A Woo
- Department of Cardiology, Toronto General Hospital, Toronto, ON, Canada
| | - A Mashari
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada
| | - M Meineri
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada
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Sherrid MV, Riedy K, Rosenzweig B, Ahluwalia M, Arabadjian M, Saric M, Balaram S, Swistel DG, Reynolds HR, Kim B. Hypertrophic cardiomyopathy with dynamic obstruction and high left ventricular outflow gradients associated with paradoxical apical ballooning. Echocardiography 2018; 36:47-60. [PMID: 30548699 DOI: 10.1111/echo.14212] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 10/11/2018] [Accepted: 10/13/2018] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Acute left ventricular (LV) apical ballooning with normal coronary angiography occurs rarely in obstructive hypertrophic cardiomyopathy (OHCM); it may be associated with severe hemodynamic instability. METHODS, RESULTS We searched for acute LV ballooning with apical hypokinesia/akinesia in databases of two HCM treatment programs. Diagnosis of OHCM was made by conventional criteria of LV hypertrophy in the absence of a clinical cause for hypertrophy and mitral-septal contact. Among 1519 patients, we observed acute LV ballooning in 13 (0.9%), associated with dynamic left ventricular outflow tract (LVOT) obstruction and high gradients, 92 ± 37 mm Hg, 10 female (77%), age 64 ± 7 years, LVEF 31.6 ± 10%. Septal hypertrophy was mild compared to that of the rest of our HCM cohort, 15 vs 20 mm (P < 0.00001). An elongated anterior mitral leaflet or anteriorly displaced papillary muscles occurred in 77%. Course was complicated by cardiogenic shock and heart failure in 5, and refractory heart failure in 1. High-dose beta-blockade was the mainstay of therapy. Three patients required urgent surgical relief of LVOT obstruction, 2 for refractory cardiogenic shock, and one for refractory heart failure. In the three patients, surgery immediately normalized refractory severe LV dysfunction, and immediately reversed cardiogenic shock and heart failure. All have normal LV systolic function at 45-month follow-up, and all have survived. CONCLUSIONS Acute LV apical ballooning, associated with high dynamic LVOT gradients, may punctuate the course of obstructive HCM. The syndrome is important to recognize on echocardiography because it may be associated with profound reversible LV decompensation.
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Affiliation(s)
- Mark V Sherrid
- Hypertrophic Cardiomyopathy Program, Division of Cardiology, New York University Langone Health, New York University School of Medicine, New York City, New York
| | - Katherine Riedy
- Hypertrophic Cardiomyopathy Program, Division of Cardiology, New York University Langone Health, New York University School of Medicine, New York City, New York
| | - Barry Rosenzweig
- Hypertrophic Cardiomyopathy Program, Division of Cardiology, New York University Langone Health, New York University School of Medicine, New York City, New York
| | - Monica Ahluwalia
- Hypertrophic Cardiomyopathy Program, Division of Cardiology, New York University Langone Health, New York University School of Medicine, New York City, New York
| | - Milla Arabadjian
- Hypertrophic Cardiomyopathy Program, Division of Cardiology, New York University Langone Health, New York University School of Medicine, New York City, New York
| | - Muhamed Saric
- Hypertrophic Cardiomyopathy Program, Division of Cardiology, New York University Langone Health, New York University School of Medicine, New York City, New York
| | - Sandhya Balaram
- Mount Sinai St. Luke's, Icahn School of Medicine at Mount Sinai, New York City, New York
| | - Daniel G Swistel
- Hypertrophic Cardiomyopathy Program, Division of Cardiac Surgery, New York University Langone Health, New York University School of Medicine, New York City, New York
| | - Harmony R Reynolds
- Hypertrophic Cardiomyopathy Program, Division of Cardiology, New York University Langone Health, New York University School of Medicine, New York City, New York
| | - Bette Kim
- Mount Sinai West, Icahn School of Medicine at Mount Sinai, New York City, New York
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Maron BJ, Maron MS. The Remarkable 50 Years of Imaging in HCM and How it Has Changed Diagnosis and Management: From M-Mode Echocardiography to CMR. JACC Cardiovasc Imaging 2017; 9:858-872. [PMID: 27388665 DOI: 10.1016/j.jcmg.2016.05.003] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Revised: 05/02/2016] [Accepted: 05/12/2016] [Indexed: 11/28/2022]
Abstract
The almost 50-year odyssey of cardiac imaging in hypertrophic cardiomyopathy (HCM), revisited and described here, has been remarkable, particularly when viewed in the timeline of advances that occurred during a single generation of investigators. At each step along the way, from M-mode to 2-dimensional echocardiography to Doppler imaging, and finally over the last 10 years with the emergence of high-resolution tomographic cardiac magnetic resonance (CMR), evolution of the images generated by each new technology constituted a paradigm change over what was previously available. Together, these advances have transformed the noninvasive diagnosis and management of HCM in a number of important clinical respects. These changes include a more complete definition of the phenotype, resulting in more reliable clinical identification of patients and family members, defining mechanisms (and magnitude) of left ventricular outflow obstruction, and novel myocardial tissue characterization (including in vivo detection of fibrosis/scarring); notably, these advances afford more precise recognition of at-risk patients who are potential candidates for life-saving primary prevention defibrillator therapy. This evolution in imaging as applied to HCM has indelibly changed cardiovascular practice for this morphologically and clinically complex genetic disease.
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Affiliation(s)
- Barry J Maron
- Hypertrophic Cardiomyopathy Institute, Tufts Medical Center, Division of Cardiology, Boston, Massachusetts.
| | - Martin S Maron
- Hypertrophic Cardiomyopathy Institute, Tufts Medical Center, Division of Cardiology, Boston, Massachusetts
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8
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Po JRF, Kim B, Aslam F, Arabadjian M, Winson G, Cantales D, Kushner J, Kornberg R, Sherrid MV. Doppler Systolic Signal Void in Hypertrophic Cardiomyopathy: Apical Aneurysm and Severe Obstruction without Elevated Intraventricular Velocities. J Am Soc Echocardiogr 2015; 28:1462-73. [DOI: 10.1016/j.echo.2015.08.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Indexed: 12/28/2022]
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Argulian E, Messerli FH, Aziz EF, Winson G, Agarwal V, Kaddaha F, Kim B, Sherrid MV. Antihypertensive therapy in hypertrophic cardiomyopathy. Am J Cardiol 2013; 111:1040-5. [PMID: 23340036 DOI: 10.1016/j.amjcard.2012.12.026] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2012] [Revised: 12/05/2012] [Accepted: 12/05/2012] [Indexed: 01/13/2023]
Abstract
Patients with coexisting hypertrophic cardiomyopathy (HC) and hypertension present diagnostic and therapeutic dilemmas. A retrospective cohort study of patients with HC with coexisting hypertension referred to a specialized HC program was conducted. HC and hypertension were confirmed by strict criteria. Echocardiographic data were reviewed for peak instantaneous left ventricular outflow tract gradients, at rest and with provocation. Symptom control, left ventricular outflow tract gradients, and hypertension control were compared between the first and last visits. One hundred fifteen patients (94 obstructed and 21 nonobstructed) met the eligibility criteria for the study and were included in the analysis, with the mean follow-up duration of 36 months. Because of the treatment strategy, there was a significant decrease in the number of patients treated with direct vasodilators and an increase in the use of β blockers and disopyramide. Twenty-one obstructed patients (22%) required septal reduction therapy. Overall, in obstructed patients, peak instantaneous left ventricular outflow tract gradient at rest decreased from 48 to 14 mm Hg (p <0.01), which was accompanied by significant improvement in functional class (2.4 vs 1.8, p <0.01). The prevalence of uncontrolled hypertension decreased from 56% at the initial visit to 37% at the last visit (p = 0.01). The cohort had a low rate of adverse cardiovascular outcomes such as death, acute coronary syndromes, and stroke. In conclusion, the present study demonstrates that stepwise, symptom-oriented therapy is feasible and effective in patients with coexisting HC and hypertension.
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Affiliation(s)
- Edgar Argulian
- Hypertrophic Cardiomyopathy Program, Division of Cardiology, St. Luke's-Roosevelt Hospital Center, Columbia University College of Physicians and Surgeons, New York, NY, USA
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10
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Abstract
Treatments for hypertrophic cardiomyopathy are largely selected based on patient symptoms and echocardiographic findings. Moreover, all the advanced treatments for heart failure symptoms depend on such imaging for planning and monitoring response to therapy. Risk of sudden death correlates with maximum left ventricular (LV) wall thickness. Massive LV thickening of 30 mm or more is an indication for primary prevention of sudden death with an implanted defibrillator. In this review, we will underscore potential pitfalls in echocardiographic diagnosis. Also we will review, a newly appreciated pathophysiologic mechanism in obstruction dynamic systolic dysfunction due to gradient.
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Affiliation(s)
- Mark V Sherrid
- Division of Cardiology, St Luke's-Roosevelt Hospital Center, Columbia University, College of Physicians and Surgeons, 1000 10th Ave, New York City, NY 10019, USA.
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Sherrid MV, Balaran SK, Korzeniecki E, Chaudhry FA, Swistel DG. Reversal of Acute Systolic Dysfunction and Cardiogenic Shock in Hypertrophic Cardiomyopathy by Surgical Relief of Obstruction. Echocardiography 2011; 28:E174-9. [DOI: 10.1111/j.1540-8175.2011.01459.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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12
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Joshi S, Patel UK, Yao SS, Castenada V, Isambert A, Winson G, Chaudhry FA, Sherrid MV. Standing and Exercise Doppler Echocardiography in Obstructive Hypertrophic Cardiomyopathy: The Range of Gradients with Upright Activity. J Am Soc Echocardiogr 2011; 24:75-82. [DOI: 10.1016/j.echo.2010.10.006] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2010] [Indexed: 01/07/2023]
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Reflections of Inflections in Hypertrophic Cardiomyopathy. J Am Coll Cardiol 2009; 54:212-9. [DOI: 10.1016/j.jacc.2009.03.052] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2009] [Accepted: 03/18/2009] [Indexed: 11/18/2022]
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Brown ML, Schaff HV. Surgical management of obstructive hypertrophic cardiomyopathy: the gold standard. Expert Rev Cardiovasc Ther 2008; 6:715-22. [PMID: 18510487 DOI: 10.1586/14779072.6.5.715] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
While medication is the first line of therapy in obstructive hypertrophic cardiomyopathy, patients who have symptoms refractory to medical treatment or asymptomatic patients with high resting gradients (>or=30 mmHg) may require septal myectomy. Surgical septal myectomy can be performed safely, with excellent survival, relief from symptoms and low morbidity. Alcohol septal ablation is an alternative to surgical treatment, but late outcomes are uncertain. Although both methods of septal reduction relieve left ventricular outflow tract gradients and improve functional status, the need for permanent pacing appears higher with alcohol ablation compared with surgical myectomy. As our understanding of obstructive hypertrophic cardiomyopathy continues to grow, the indications for intervention will evolve. In our practice, septal myectomy remains the gold standard for treatment of obstructive hypertrophic cardiomyopathy.
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Affiliation(s)
- Morgan L Brown
- Division of Cardiovascular Surgery, 200 1st St SW, Rochester, MN 55905, USA.
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Diagnostic Value of Left Ventricular Outflow Area in Patients with Hypertrophic Cardiomyopathy: A Real-Time Three-Dimensional Echocardiographic Study. J Am Soc Echocardiogr 2008; 21:789-95. [DOI: 10.1016/j.echo.2008.01.012] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2007] [Indexed: 11/23/2022]
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Canivet JL, Lancellotti P, Radermecker M, Damas P. Cyclic Appearance of Left Ventricular Outflow Tract Dynamic Obstruction During Mechanical Ventilation: Evidence for a Preload Dependent Phenomenon. J Intensive Care Med 2008; 23:281-4. [DOI: 10.1177/0885066608318662] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The cyclic appearance of dynamic left ventricular outflow tract obstruction during mechanical ventilation, according to the phasic changes in preload, is described in this article. Hemodialysis-induced fluid removal resulted in preload dependence as evidenced by the pulse pressure variation in a 56-year-old critically ill patient. The clinical picture was suggestive of myocardial failure. Transthoracic echocardiography disclosed dynamic left ventricular outflow tract obstruction associated with systolic anterior motion of the mitral valve. Progressive fluid restitution resulted in a parallel decrease in both the degree of dynamic obstruction and pulse pressure variation. During fluid loading, dynamic obstruction disappeared at first during the inspiratory phase of intermittent positive pressure ventilation corresponding to the phasic increase in left ventricular preload. Further fluid loading resulted in the disappearance of dynamic obstruction during both inspiratory and expiratory phase of intermittent positive pressure ventilation. This is the first reported case clearly relating left ventricular outflow tract dynamic obstruction to preload dependence during mechanical ventilation in a critically ill patient without predisposing anatomical factor.
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Affiliation(s)
- Jean-Luc Canivet
- Departments of General Intensive Care, University Hospital Centre, University of Liege, Domaine Universitaire du Sart-Tilman,
| | - Patrizio Lancellotti
- Department of Cardiology, University Hospital Centre, University of Liege, Domaine Universitaire du Sart-Tilman
| | - Marc Radermecker
- Department of Cardiothoracic and Vascular Surgery, University Hospital Centre, University of Liege, Domaine Universitaire du Sart-Tilman, Liege, Belgium
| | - Pierre Damas
- Departments of General Intensive Care, University Hospital Centre, University of Liege, Domaine Universitaire du Sart-Tilman
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Sirak TE, Sherrid MV. Oral Disopyramide for the Acute Treatment of Severe Outflow Obstruction in Hypertrophic Cardiomyopathy in the ICU Setting. Chest 2008; 133:1243-6. [DOI: 10.1378/chest.07-1188] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
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Bunch TJ, Chandrasekaran K, Ehrsam JE, Hammill SC, Urban LH, Hodge DO, Ommen SR, Pellikka PA. Prognostic significance of exercise induced arrhythmias and echocardiographic variables in hypertrophic cardiomyopathy. Am J Cardiol 2007; 99:835-8. [PMID: 17350377 DOI: 10.1016/j.amjcard.2006.10.046] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2006] [Revised: 10/30/2006] [Accepted: 10/30/2006] [Indexed: 10/23/2022]
Abstract
Hypertrophic cardiomyopathy (HC) often presents with exercise-induced symptoms, including arrhythmias and sudden death. The investigators prospectively studied whether exercise testing is associated with immediate complications and if stress-induced arrhythmias and echocardiographic variables are associated with long-term adverse outcomes. Exercise echocardiography with 6-channel continuous monitoring for arrhythmias was performed in consecutive patients with HC clinically referred for the test. End points included death, myocardial infarction, revascularization, stroke, atrial fibrillation, ventricular tachycardia, and myectomy. Of 86 patients with HC (mean age 56.6 +/- 16.1 years) who underwent exercise echocardiography, arrhythmias occurred in 39 (45%), including 23 (27%) with premature atrial contractions, 2 (2%) with atrial fibrillation, 28 (33%) with premature ventricular contractions (16 also had atrial arrhythmias), and 1 (1.2%) with nonsustained ventricular tachycardia (hemodynamically stable). During a follow-up of 2.6 +/- 2.8 years, major events occurred in 11 patients (3 deaths, 5 revascularizations, 3 strokes). In addition, 12 patients developed atrial fibrillation, 6 developed nonsustained ventricular tachycardia, and 13 underwent myectomies. Variables associated with major events included hypertension, male gender, and worsening wall motion score index with exercise; increased exercise duration was associated with fewer events. ST-T changes on baseline electrocardiography and premature ventricular contractions were associated with atrial fibrillation risk. In conclusion, in this cohort of patients with HC, exercise testing was safe. Test results were associated with risk for adverse events.
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Affiliation(s)
- T Jared Bunch
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Barac I, Upadya S, Pilchik R, Winson G, Passick M, Chaudhry FA, Sherrid MV. Effect of Obstruction on Longitudinal Left Ventricular Shortening in Hypertrophic Cardiomyopathy. J Am Coll Cardiol 2007; 49:1203-11. [PMID: 17367665 DOI: 10.1016/j.jacc.2006.10.070] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2006] [Revised: 10/16/2006] [Accepted: 10/23/2006] [Indexed: 11/23/2022]
Abstract
OBJECTIVES We investigated the cause of the midsystolic drop (MSD) in left ventricular (LV) ejection velocities that are observed with hypertrophic cardiomyopathy (HCM) and severe obstruction. BACKGROUND Dynamic obstruction is an important determinant of symptoms and adverse outcome. The MSD in velocity and flow occurs in patients with gradients >60 mm Hg. The nadir velocity in the LV occurs simultaneously with peak gradient. METHODS We studied 36 patients with obstructive HCM and an MSD and compared them with 15 patients with HCM and no obstruction and with 25 age-matched normal control subjects. We measured LV ejection velocity proximal and distal to LV obstruction as well as tissue Doppler velocities and time intervals. RESULTS The duration of contraction of both the septum and lateral wall is shorter in obstructed patients with the MSD than in nonobstructed HCM patients: septal contraction 203 +/- 68 ms vs. 271 +/- 41 ms (p < 0.001). Parallel reduction in the length of shortening was noted: 1.2 +/- 0.6 cm vs. 1.9 +/- 0.4 cm (p < 0.001). The ejection velocity nadir follows the septal and lateral peak velocities by 100 ms and 60 ms, respectively. The velocity nadir occurs as both walls rapidly decelerate to their premature termination: septal deceleration 79 +/- 35 cm/s2 vs. 48 +/- 21 cm/s2 (p < 0.001). With medical abolition of obstruction the MSD disappears and the duration and length of contraction normalizes. CONCLUSIONS These data indicate that the MSD is caused by premature termination of LV segmental shortening and is a manifestation of systolic dysfunction.
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Affiliation(s)
- Ivan Barac
- Division of Cardiology, St. Luke's-Roosevelt Hospital Center, Columbia University, College of Physicians and Surgeons, New York, New York 10019, USA
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Abstract
All patients with hypertrophic cardiomyopathy (HCM) should have five aspects of care addressed. An attempt should be made to detect the presence or absence of risk factors for sudden arrhythmic death. If the patient appears to be at high risk, discussion of the benefits and risks of ICD are indicated, and many such patients will be implanted. Symptoms are appraised and treated. Bacterial endocarditis prophylaxis is recommended. Patients are advised to avoid athletic competition and extremes of physical exertion. First degree family members should be screened with echocardiography and ECG.
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Affiliation(s)
- Mark V Sherrid
- Hypertrophic Cardiomyopathy Program and Echocardiography Laboratory, Department of Medicine, Division of Cardiology, St. Luke's-Roosevelt Hospital Center, College of Physicians and Surgeons, Columbia University, New York, NY, USA.
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Sherrid MV, Barac I, McKenna WJ, Elliott PM, Dickie S, Chojnowska L, Casey S, Maron BJ. Multicenter study of the efficacy and safety of disopyramide in obstructive hypertrophic cardiomyopathy. J Am Coll Cardiol 2005; 45:1251-8. [PMID: 15837258 DOI: 10.1016/j.jacc.2005.01.012] [Citation(s) in RCA: 230] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2004] [Revised: 12/12/2004] [Accepted: 01/04/2005] [Indexed: 02/07/2023]
Abstract
OBJECTIVES In this study we assessed the long-term efficacy and safety of disopyramide for patients with obstructive hypertrophic cardiomyopathy (HCM). BACKGROUND It has been reported that disopyramide may reduce left ventricular outflow gradient and improve symptoms in patients with HCM. However, long-term efficacy and safety of disopyramide has not been shown in a large cohort. METHODS Clinical and echocardiographic data were evaluated in 118 obstructive HCM patients treated with disopyramide at 4 HCM treatment centers. Mortality in the disopyramide-treated patients was compared with 373 obstructive HCM patients not treated with disopyramide. RESULTS Patients were followed with disopyramide for 3.1 +/- 2.6 years; dose 432 +/- 181 mg/day (97% also received beta-blockers). Seventy-eight patients (66%) were maintained with disopyramide without the necessity for major non-pharmacologic intervention with surgical myectomy, alcohol ablation, or pacing; outflow gradient at rest decreased from 75 +/- 33 to 40 +/- 32 mm Hg (p < 0.0001) and mean New York Heart Association functional class from 2.3 +/- 0.7 to 1.7 +/- 0.6 (p < 0.0001). Forty other patients (34%) could not be satisfactorily managed with disopyramide and required major invasive interventions because of inadequate symptom and gradient control or vagolytic side effects. All-cause annual cardiac death rate between disopyramide and non-disopyramide-treated patients did not differ significantly, 1.4% versus 2.6%/year (p = 0.07). There was also no difference in sudden death rate, 1.0%/year versus 1.8%/year (p = 0.08). CONCLUSIONS Two-thirds of obstructed HCM patients treated with disopyramide could be managed medically with amelioration of symptoms and about 50% reduction in subaortic gradient over >/=3 years. Disopyramide therapy does not appear to be proarrhythmic in HCM and should be considered before proceeding to surgical myectomy or alternate strategies.
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Affiliation(s)
- Mark V Sherrid
- St. Luke's-Roosevelt Hospital Center, Columbia University, College of Physicians and Surgeons, New York, New York 10019, USA.
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Davies CH, Sahn DJ. Bruce King Shively, MD. J Am Soc Echocardiogr 2004. [DOI: 10.1016/j.echo.2004.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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