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Inducible Left Ventricular Outflow Tract Obstruction in Patients Undergoing Liver Transplantation: Prevalence, Predictors, and Association With Cardiovascular Events. Transplantation 2021; 105:354-362. [PMID: 32229775 DOI: 10.1097/tp.0000000000003245] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Inducible left ventricular outflow tract obstruction (LVOTO) is often encountered in liver transplantation (LT) candidates during cardiac workup. While the impact of LVOTO on adverse cardiovascular hemodynamics is well reported, it is unclear whether it predisposes to perioperative cardiovascular complications. METHODS Consecutive patients with end-stage liver disease undergoing dobutamine stress echocardiography (DSE) were evaluated at an LT center between 2010 and 2017. Perioperative major adverse cardiovascular events (MACEs) at 30 days and all-cause death were recorded from a prospectively maintained LT database. RESULTS We evaluated 560 patients who underwent DSE during LT workup, with LVOTO identified in 24.3% (n = 136). Of these, 309 patients progressed to transplant. Patients with LVOTO demonstrated a lower peak systolic blood pressure (SBP) and an overall reduction in SBP on DSE. A total of 85 MACEs were recorded in 72 patients (23.3%) including 3 deaths, 19 cases of heart failure, 11 cardiac arrests, 8 acute coronary syndromes, and 44 arrhythmias. MACE occurred in 15/64 patients (23.4%) with LVOTO and 57/245 (23.3%) without (P = 0.92). There was an increased risk of perioperative cardiac arrest in patients with LVOTO (7.4% versus 2.4%, P = 0.04). Intraoperatively, patients with LVOTO required higher doses of vasopressors (P = 0.01) and received greater volumes of fluid (10.5 ± 8.1 versus 8.4 ± 6.4 L, P = 0.03). CONCLUSIONS Patients with end-stage liver disease and LVOTO demonstrate a reduction in SBP during physiological stress that may translate to hemodynamic instability during LT. LVOTO was not associated with an increased rate of perioperative MACE or death.
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Murphy AC, Lancefield TF, Chao M, Foroudi F, Koshy AN, Undrill S, Horrigan M, Yeo B, Yudi MB, Kearney L, Farouque O. Assessment of Cardiac Function in Chemotherapy Naive Women With Breast Cancer Undergoing Contemporary Radiation Therapy. JACC CardioOncol 2020; 2:509-510. [PMID: 34396259 PMCID: PMC8352316 DOI: 10.1016/j.jaccao.2020.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Impaired Cardiac Reserve on Dobutamine Stress Echocardiography Predicts the Development of Hepatorenal Syndrome. Am J Gastroenterol 2020; 115:388-397. [PMID: 31738284 DOI: 10.14309/ajg.0000000000000462] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Cardiac dysfunction has been implicated in the genesis of hepatorenal syndrome (HRS). It is unclear whether a low cardiac output (CO) or attenuated contractile response to hemodynamic stress can predict its occurrence. We studied cardiovascular hemodynamics in cirrhosis and assessed whether a diminished cardiac reserve with stress testing predicted the development of HRS on follow-up. METHODS Consecutive patients undergoing liver transplant workup with dobutamine stress echocardiography (DSE) were included. CO was measured at baseline and during low-dose dobutamine infusion at 10 μg/kg/min. HRS was diagnosed using guideline-based criteria. RESULTS A total of 560 patients underwent DSE, of whom 488 were included after preliminary assessment. There were 64 (13.1%) patients with established HRS. The HRS cohort had a higher baseline CO (8.0 ± 2 vs 6.9 ± 2 L/min; P < 0.001) and demonstrated a blunted response to low-dose dobutamine (ΔCO 29 ± 22% vs 44 ± 32%, P < 0.001) driven primarily by inotropic incompetence. Optimal cutpoint for ΔCO in patients with HRS was determined to be <25% and was used to define a low cardiac reserve. Among the 424 patients without HRS initially, 94 (22.1%) developed HRS over a mean follow-up of 1.5 years. Higher proportion with a low cardiac reserve developed HRS (52 [55.0%] vs 56 [16.9%]; hazard ratio 4.5; 95% confidence interval 3.0-6.7; P < 0.001). In a Cox multivariable model, low cardiac reserve remained the strongest predictor for the development of HRS (hazard ratio 3.9; 95% confidence interval 2.2-7.0; P < 0.001). DISCUSSION Patients with HRS demonstrated a higher resting CO and an attenuated cardiac reserve on stress testing. On longitudinal follow-up, low cardiac reserve was an independent predictor for the development of HRS. Assessment of cardiac reserve with DSE may provide a novel noninvasive risk marker for developing HRS in patients with advanced liver disease.HRS is a life-threatening complication of liver disease. We studied whether an inability to increase cardiac contraction in response to stress can assist in the prediction of HRS. We demonstrate that patients with liver disease who exhibit cardiac dysfunction during stress testing had a 4-fold increased risk of developing HRS. This may improve our ability for early diagnosis and treatment of patients at a higher risk of developing HRS.
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Lu KJ, Chen JXC, Profitis K, Kearney LG, DeSilva D, Smith G, Ord M, Harberts S, Calafiore P, Jones E, Srivastava PM. Right ventricular global longitudinal strain is an independent predictor of right ventricular function: a multimodality study of cardiac magnetic resonance imaging, real time three-dimensional echocardiography and speckle tracking echocardiography. Echocardiography 2014; 32:966-74. [PMID: 25287078 DOI: 10.1111/echo.12783] [Citation(s) in RCA: 85] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVES Accurate assessment of right ventricular (RV) systolic function is important, as it is an established predictor of mortality in cardiac and respiratory diseases. We aimed to compare speckle tracking-derived longitudinal deformation measurements with traditional two-dimensional (2D) echocardiographic parameters, as well as real time three-dimensional echocardiography (RT3DE) and cardiac magnetic resonance imaging (CMR)-derived RV volumes and ejection fraction (EF). METHOD Subjects referred for CMR also underwent echocardiography. On both RT3DE and CMR, we measured RV volumes and EF. On 2D echocardiography, we analyzed RV fractional area change, RV internal diastolic diameter, tricuspid annular plane systolic excursion, tricuspid annular tissue Doppler-derived velocity, myocardial performance index, and RV global longitudinal strain (RV GLS). RESULTS Sixty subjects were recruited (mean age = 45 ± 10 years; 60% male). RV GLS (R = -0.69, P < 0.001) and RT3DE RVEF (R = 0.56, P < 0.001) correlated well with CMR RVEF. RT3DE RV end-diastolic (RVEDV) and end-systolic (RVESV) volumes also correlated with CMR RV volumes: RVEDV, R = 0.74, P < 0.001 and RVESV, R = 0.84, P < 0.001. In addition, RV GLS best predicted the presence of RV dysfunction, defined as RVEF <48% on CMR (hazard ratio = 7.0 [1.5-31.7], P < 0.01). On receiver operator characteristic analysis, a RV GLS of -20% was the most sensitive and specific predictor of RV dysfunction (AUC 0.8 [0.57-1.0], P < 0.02). CONCLUSION RVEF and volumes estimated on RT3DE were closely correlated with CMR measurements. When compared to more traditional markers of RV systolic function and RT3DE, RVGLS produced the highest correlation with CMR RVEF and was a good predictor of RV dysfunction. RV GLS should be considered a complementary modality to RT3DE and CMR in the assessment of RV systolic function.
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Affiliation(s)
- Ken J Lu
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia.,Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Janet X C Chen
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia
| | | | - Leighton G Kearney
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia.,Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Dimuth DeSilva
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia
| | - Gerard Smith
- Department of Radiology, Austin Health, Melbourne, Victoria, Australia
| | - Michelle Ord
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia
| | - Susan Harberts
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia
| | - Paul Calafiore
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia
| | - Elizabeth Jones
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia
| | - Piyush M Srivastava
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia.,Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
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O'Donnell D, Lin T, Swale M, Rae P, Flannery D, Srivastava PM. Long-term clinical response to cardiac resynchronisation therapy under a multidisciplinary model. Intern Med J 2013; 43:1216-23. [PMID: 24015775 DOI: 10.1111/imj.12284] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2013] [Accepted: 08/13/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND Cardiac resynchronisation therapy (CRT) is established in the management of cardiac failure in patients with systolic dysfunction. Clinical response to CRT is not uniform, and response has been difficult to predict. AIM Patient management within a high volume, multidisciplinary service focused on optimal delivery of CRT would improve response rates. METHODS Four hundred and thirty-five consecutive patients who underwent CRT under a multidisciplinary heart failure service were enrolled prospectively over a 5-year period. Medically optimised, symptomatic patients with an ejection fraction (EF) <35%, widened QRS or abnormal dyssynchrony index were included. Left ventricular lead position was targeted anatomically to the segment of latest mechanical activation, and electrically to a site with maximal intrinsic intracardiac electrogram separation. Routine device and clinical follow up, as well as CRT optimisations, were performed at baseline and at 3-monthly intervals. Responders were defined as having an absolute reduction in left ventricular end-diastolic diameter >10% and an improvement in EF >5%. RESULTS With a mean follow up of 53 ± 11 months, response rate to CRT was 81%. Mean EF improved from 26 ± 10% to 37 ± 11%, and mean left ventricular end-diastolic diameter reduced from 68.6 ± 9.2 mm to 57.8 ± 9.3 mm. Predictors of response were sinus rhythm, high dyssynchrony index and intrinsic electrical dyssynchrony >80 ms. Successful LV lead implantation at initial procedure was achieved in 99.1%, and at latest follow up 94.6% of initial LV leads were still active. CONCLUSION CRT undertaken with a unit focus on optimal LV lead positioning and device optimisation, along with a multidisciplinary follow-up model, results in an excellent response rate to CRT.
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Affiliation(s)
- D O'Donnell
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia
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Kearney LG, Lu K, Ord M, Patel SK, Profitis K, Matalanis G, Burrell LM, Srivastava PM. Global longitudinal strain is a strong independent predictor of all-cause mortality in patients with aortic stenosis. Eur Heart J Cardiovasc Imaging 2012; 13:827-33. [PMID: 22736713 DOI: 10.1093/ehjci/jes115] [Citation(s) in RCA: 163] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
AIMS To assess the capacity of global longitudinal strain (GLS) in patients with aortic stenosis (AS) to (i) detect the subclinical left ventricular (LV) dysfunction [LV ejection fraction (LVEF) ≥50% patients]; (ii) predict all-cause mortality and major adverse cardiac events (MACE) (all patients), and (iii) provide incremental prognostic information over current risk markers. METHODS AND RESULTS Patients with AS (n = 146) and age-matched controls (n = 12) underwent baseline echocardiography to assess AS severity, conventional LV parameters and GLS via speckle tracking echocardiography. Baseline demographics, symptom severity class and comorbidities were recorded. Outcomes were identified via hospital record review and subject/physician interview. The mean age was 75 ± 11, 62% were male. The baseline aortic valve (AV) area was 1.0 ± 0.4 cm(2) and LVEF was 59 ± 11%. In patients with a normal LVEF (n = 122), the baseline GLS was controls -21 ± 2%, mild AS -18 ± 3%, moderate AS -17 ± 3% and severe AS -15 ± 3% (P< 0.001). GLS correlated with the LV mass index, LVEF, AS severity, and symptom class (P< 0.05). During a median follow-up of 2.1 (inter-quartile range: 1.8-2.4) years, there were 20 deaths and 101 MACE. Unadjusted hazard ratios (HRs) for GLS (per %) were all-cause mortality (HR: 1.42, P< 0.001) and MACE (HR: 1.09, P< 0.001). After adjustment for clinical and echocardiographic variables, GLS remained a strong independent predictor of all-cause mortality (HR: 1.38, P< 0.001). CONCLUSIONS GLS detects subclinical dysfunction and has incremental prognostic value over traditional risk markers including haemodynamic severity, symptom class, and LVEF in patients with AS. Incorporation of GLS into risk models may improve the identification of the optimal timing for AV replacement.
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Affiliation(s)
- L G Kearney
- Department of Medicine, The University of Melbourne, Austin Health, Victoria, Australia.
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