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Ajmone Marsan N, Graziani F, Meucci MC, Wu HW, Lillo R, Bax JJ, Burzotta F, Massetti M, Jukema JW, Crea F. Valvular heart disease and cardiomyopathy: reappraisal of their interplay. Nat Rev Cardiol 2024; 21:37-50. [PMID: 37563454 DOI: 10.1038/s41569-023-00911-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/03/2023] [Indexed: 08/12/2023]
Abstract
Cardiomyopathies and valvular heart diseases are typically considered distinct diagnostic categories with dedicated guidelines for their management. However, the interplay between these conditions is increasingly being recognized and they frequently coexist, as in the paradigmatic examples of dilated cardiomyopathy and hypertrophic cardiomyopathy, which are often complicated by the occurrence of mitral regurgitation. Moreover, cardiomyopathies and valvular heart diseases can have a shared aetiology because several genetic or acquired diseases can affect both the cardiac valves and the myocardium. In addition, the association between cardiomyopathies and valvular heart diseases has important prognostic and therapeutic implications. Therefore, a better understanding of their shared pathophysiological mechanisms, as well as of the prevalence and predisposing factors to their association, might lead to a different approach in the risk stratification and management of these diseases. In this Review, we discuss the different scenarios in which valvular heart diseases and cardiomyopathies coexist, highlighting the need for an improved classification and clustering of these diseases with potential repercussions in the clinical management and, particularly, personalized therapeutic approaches.
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Affiliation(s)
- Nina Ajmone Marsan
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands.
| | - Francesca Graziani
- Department of Cardiovascular Science, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Maria Chiara Meucci
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Cardiovascular Science, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Hoi W Wu
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Rosa Lillo
- Department of Cardiovascular Science, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Catholic University of the Sacred Heart, Rome, Italy
| | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
- Heart Center, University of Turku and Turku University Hospital, Turku, Finland
| | - Francesco Burzotta
- Department of Cardiovascular Science, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Catholic University of the Sacred Heart, Rome, Italy
| | - Massimo Massetti
- Department of Cardiovascular Science, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Catholic University of the Sacred Heart, Rome, Italy
| | - J Wouter Jukema
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
- Netherlands Heart Institute, Utrecht, The Netherlands
| | - Filippo Crea
- Department of Cardiovascular Science, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Catholic University of the Sacred Heart, Rome, Italy
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Conway J, Min S, Villa C, Weintraub RG, Nakano S, Godown J, Tatangelo M, Armstrong K, Richmond M, Kaufman B, Lal AK, Balaji S, Power A, Baez Hernandez N, Gardin L, Kantor PF, Parent JJ, Aziz PF, Jefferies JL, Dragulescu A, Jeewa A, Benson L, Russell MW, Whitehill R, Rossano J, Howard T, Mital S. The Prevalence and Association of Exercise Test Abnormalities With Sudden Cardiac Death and Transplant-Free Survival in Childhood Hypertrophic Cardiomyopathy. Circulation 2023; 147:718-727. [PMID: 36335467 PMCID: PMC9977414 DOI: 10.1161/circulationaha.122.062699] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Hypertrophic cardiomyopathy (HCM) can be associated with an abnormal exercise response. In adults with HCM, abnormal results on exercise stress testing are predictive of heart failure outcomes. Our goal was to determine whether an abnormal exercise response is associated with adverse outcomes in pediatric patients with HCM. METHODS In an international cohort study including 20 centers, phenotype-positive patients with primary HCM who were <18 years of age at diagnosis were included. Abnormal exercise response was defined as a blunted blood pressure response and new or worsened ST- or T-wave segment changes or complex ventricular ectopy. Sudden cardiac death (SCD) events were defined as a composite of SCD and aborted sudden cardiac arrest. Using Kaplan-Meier survival, competing outcomes, and Cox regression analyses, we analyzed the association of abnormal exercise test results with transplant and SCD event-free survival. RESULTS Of 724 eligible patients, 630 underwent at least 1 exercise test. There were no major differences in clinical characteristics between those with or without an exercise test. The median age at exercise testing was 13.8 years (interquartile range, 4.7 years); 78% were male and 39% were receiving beta-blockers. A total of 175 (28%) had abnormal test results. Patients with abnormal test results had more severe septal hypertrophy, higher left atrial diameter z scores, higher resting left ventricular outflow tract gradient, and higher frequency of myectomy compared with participants with normal test results (P<0.05). Compared with normal test results, abnormal test results were independently associated with lower 5-year transplant-free survival (97% versus 88%, respectively; P=0.005). Patients with exercise-induced ischemia were most likely to experience all-cause death or transplant (hazard ratio, 4.86 [95% CI, 1.69-13.99]), followed by those with an abnormal blood pressure response (hazard ratio, 3.19 [95% CI, 1.32-7.71]). Exercise-induced ischemia was also independently associated with lower SCD event-free survival (hazard ratio, 3.32 [95% CI, 1.27-8.70]). Exercise-induced ectopy was not associated with survival. CONCLUSIONS Exercise abnormalities are common in childhood HCM. An abnormal exercise test result was independently associated with lower transplant-free survival, especially in those with an ischemic or abnormal blood pressure response with exercise. Exercise-induced ischemia was also independently associated with SCD events. These findings argue for routine exercise testing in childhood HCM as part of ongoing risk assessment.
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Affiliation(s)
- Jennifer Conway
- Department of Pediatrics, Stollery Children’s Hospital, Edmonton, Canada (J.C.)
| | - Sandar Min
- Genetics and Genome Biology, Hospital for Sick Children, Toronto, Canada (S. Min, S. Mital)
| | - Chet Villa
- Department of Pediatrics, Cincinnati Children’s Hospital, OH (C.V.)
| | - Robert G. Weintraub
- Department of Cardiology, The Royal Children’s Hospital, Melbourne, Australia (R.G.W.)
| | - Stephanie Nakano
- Department of Pediatrics, Children’s Hospital Colorado, Aurora (S.N.)
| | - Justin Godown
- Department of Pediatrics, Monroe Carrell Jr Children’s Hospital at Vanderbilt, Nashville, TN (J.G.)
| | - Mark Tatangelo
- Ted Rogers Computational Program, Peter Munk Cardiac Centre, University Health Network, Toronto, Canada (M.T.)
| | - Kathryn Armstrong
- Department of Pediatrics, BC Children’s Hospital, Vancouver, British Columbia, Canada (K.A.)
| | - Marc Richmond
- Department of Pediatrics, Morgan Stanley Children’s Hospital, Columbia University Medical Centre, New York, NY (M.R.)
| | - Beth Kaufman
- Department of Pediatrics, Lucile Packard Children’s Hospital, Stanford University, Palo Alto, CA (B.K.)
| | - Ashwin K. Lal
- Department of Pediatrics, Primary Children’s Hospital, University of Utah, Salt Lake City (A.K.L.)
| | - Seshadri Balaji
- Department of Pediatrics, Oregon Health and Science University, Portland (S.B.)
| | - Alyssa Power
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX (A.P., N.B.H.)
| | - Nathanya Baez Hernandez
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX (A.P., N.B.H.)
| | - Letizia Gardin
- Department of Pediatrics, Children’s Hospital of Eastern Ontario, Ottawa, Canada (L.G.)
| | - Paul F. Kantor
- Department of Pediatrics, Children’s Hospital of Los Angeles, CA (P.F.K.)
| | - John J. Parent
- Department of Pediatrics, Riley Children’s Hospital, Indianapolis, IN (J.J.P.)
| | - Peter F. Aziz
- Department of Pediatrics, Cleveland Clinic Children’s Hospital, OH (P.F.A.)
| | - John L. Jefferies
- Department of Pediatrics, University of Tennessee Health Sciences Centre, Memphis (J.L.J.)
| | - Andreea Dragulescu
- Department of Pediatrics, Hospital for Sick Children, University of Toronto, Canada (A.D., A.J., L.B., S. Mital)
| | - Aamir Jeewa
- Department of Pediatrics, Hospital for Sick Children, University of Toronto, Canada (A.D., A.J., L.B., S. Mital)
| | - Lee Benson
- Department of Pediatrics, Hospital for Sick Children, University of Toronto, Canada (A.D., A.J., L.B., S. Mital)
| | - Mark W. Russell
- Department of Pediatrics, University of Michigan Health System, Ann Arbor (M.W.R.)
| | - Robert Whitehill
- Department of Pediatrics, Children’s Healthcare of Atlanta, GA (R.W.)
| | - Joseph Rossano
- Department of Pediatrics, Children’s Hospital of Philadelphia, PA (J.R.)
| | - Taylor Howard
- Department of Pediatrics, Texas Children’s Hospital, Houston (T.H.)
| | - Seema Mital
- Genetics and Genome Biology, Hospital for Sick Children, Toronto, Canada (S. Min, S. Mital).,Department of Pediatrics, Hospital for Sick Children, University of Toronto, Canada (A.D., A.J., L.B., S. Mital).,Ted Rogers Centre for Heart Research, Toronto, Canada (S. Mital)
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