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Lucarelli K, Troisi F, Scarcia M, Grimaldi M. Transcatheter mitral valve repair for the treatment of severe mitral regurgitation and exertional pre-syncope in a patient with non-obstructive hypertrophic cardiomyopathy: a case report. Eur Heart J Case Rep 2022; 6:ytab446. [PMID: 35071975 PMCID: PMC8775652 DOI: 10.1093/ehjcr/ytab446] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 06/14/2021] [Accepted: 10/25/2021] [Indexed: 11/13/2022]
Abstract
Background Hypertrophic cardiomyopathy (HCM) has a complex pathophysiology and heterogeneous phenotypic expression. In obstructive HCM with significant mitral regurgitation (MR), MitraClip device implantation reduces MR severity and symptoms. There are no data regarding MitraClip implantation in patients with non-obstructive HCM and significant MR. Case summary A 78-year-old woman with non-obstructive HCM and significant functional MR (3+) was admitted to our centre for dyspnoea and episodes of pre-syncope under light stress. Transthoracic and transoesophageal echocardiography showed a normal left ventricular ejection fraction and normal right heart pressures, an inverted mitral filling pattern, and a central prevalent jet (A2-P2 origin) of MR. Exercise echocardiography performed to verify exercise tolerance was interrupted at the 50-W stage due to severe hypotension and pre-syncope. After transcatheter edge-to-edge repair using the MitraClip system, the patient exhibited a reduction in MR Grade from 3+ to 1+. Follow-up up to 1-year post-procedure revealed noticeable improvements in exercise tolerance and symptoms. There were no further episodes of pre-syncope. Discussion In non-obstructive HCM, the pathophysiological role of MR in symptom generation is unknown. In this patient, we speculated that significant MR contributed to the mechanisms responsible for severe hypotension and pre-syncope during exercise. A reduction in MR after MitraClip implantation was associated with symptomatic improvements. Our findings further highlight the potential utility of the exercise stress test in therapeutic decision-making for patients with non-obstructive HCM and MR.
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Affiliation(s)
- Katya Lucarelli
- Cardiology Department, Ospedale F. Miulli, Strada Prov. 127, Acquaviva delle Fonti, Bari 70021, Italy
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van de Sande DAJP, Hoogsteen J, Doevendans PA, Kemps HMC. The influence of LV geometry on the occurrence of abnormal exercise tests in athletes. BMC Cardiovasc Disord 2019; 19:6. [PMID: 30612547 PMCID: PMC6322237 DOI: 10.1186/s12872-018-0983-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 12/17/2018] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Previous studies revealed a high rate of abnormal exercise test (ET) results in the absence of obstructive coronary artery disease (CAD) in asymptomatic athletes. The physiological background of this phenomenon is not well established. In particular, it is unclear whether sports-induced morphological cardiac adaptations are determinants of abnormal ET results. The main objective of this study was to investigate if healthy asymptomatic recreational and competitive athletes with abnormal ET results without obstructive CAD have a higher LV mass when compared with athletes with normal ET results. METHODS Seventy-three athletes with abnormal ET results without presence of obstructive CAD underwent echocardiographic assessment of LV mass, systolic and diastolic measurements. These data were compared with data from 73 athletes with normal ET results, matched for gender, age, body composition, sports characteristics and exercise capacity. RESULTS No significant increase in LV mass (161.9 ± 39 g vs. 166.9 ± 42.1 g, p = 0.461) was found between groups. Athletes with abnormal ET results had a significant thicker IVSd (9.7 ± 1.8 mm vs. 9.0 ± 1.7 mm, p = 0.014), higher IVSd/PWTd ratio (1.08 ± 0.20 vs. 1.00 ± 0.12, p = 0.011) and deceleration time (DT) was prolonged ((225.14 ± 55.08 vs. 199.96 ± 34.65, p = 0.003). CONCLUSION Athletes with abnormal ET result did not show a higher in LV mass when compared to athletes with a normal ET result. However, a pattern of asymmetric cardiac remodeling, together with altered diastolic function is present. Due to small differences, cardiac remodeling only plays a limited role in the occurrence of positive ET results in athletes.
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Affiliation(s)
| | - Jan Hoogsteen
- Department of Cardiology, Máxima Medical Center, De Run 4600, 5504 DB Veldhoven, The Netherlands
| | - Pieter A. Doevendans
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Hareld M. C. Kemps
- Department of Cardiology, Máxima Medical Center, De Run 4600, 5504 DB Veldhoven, The Netherlands
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VAN DE Sande DAJP, Schoots T, Hoogsteen J, Doevendans PA, Kemps HMC. O2 Pulse Patterns in Male Master Athletes with Normal and Abnormal Exercise Tests. Med Sci Sports Exerc 2019; 51:12-18. [PMID: 30157105 DOI: 10.1249/mss.0000000000001772] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
PURPOSE The clinical relevance of abnormal exercise testing (ET) results (at least 0.1 mV ST segment depression measured during exercise or recovery in three consecutive beats) in athletes without obstructive coronary artery disease (CAD) is not well understood. It is unknown whether this phenomenon reflects a physiological adaptation to sport or a truly ischemic response and a concomitant attenuated stroke volume (SV) response. The aim of this study was to investigate if athletes with abnormal ET results without obstructive CAD showed signs of an attenuated SV response using cardiopulmonary ET parameters. METHODS A total of 78 male master athletes with abnormal ET results without obstructive CAD underwent cardiopulmonary ET. ΔO2 pulse/Δwork rate (WR), ΔV˙O2/ΔWR, and Δheart rate (HR)/ΔWR were assessed and compared with data from 78 male master athletes with normal ET results, matched for age, sports characteristics, and exercise capacity. RESULTS The ΔO2 pulse/ΔWR ratio beyond anaerobic threshold in athletes with abnormal ET results was lower than that in athletes with normal ET results (0.73 ± 0.41 vs 1.12 ± 0.54, respectively, P < 0.001). The ΔV˙O2/ΔWR ratio was also lower in athletes with abnormal ET results (0.9 ± 0.2 vs 1.0 ± 0.3, respectively, P = 0.041). Furthermore, these athletes showed a greater increase in HR in the last 2 min of exercise (ΔHR/ΔWR ratio: 1.19 ± 0.5 vs 0.80 ± 0.6, P < 0.001). CONCLUSION Athletes with abnormal ET results without obstructive CAD showed an attenuated O2 pulse slope, decreased ΔV˙O2/ΔWR ratio, and increased ΔHR/ΔWR ratio beyond anaerobic threshold when compared with athletes with a normal ET result. These results support the hypothesis that at least a part of the athletes with an abnormal ET in absence of obstructive CAD have an attenuated SV response at high-intensity exercise.
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Affiliation(s)
| | - Thijs Schoots
- Department of Cardiology, Máxima Medical Center, Veldhoven, THE NETHERLANDS
| | - Jan Hoogsteen
- Department of Cardiology, Máxima Medical Center, Veldhoven, THE NETHERLANDS
| | - Pieter A Doevendans
- Department of Cardiology, University Medical Center Utrecht, Utrecht, THE NETHERLANDS
| | - Hareld M C Kemps
- Department of Cardiology, Máxima Medical Center, Veldhoven, THE NETHERLANDS
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Peteiro J, Fernandez X, Bouzas-Mosquera A, Monserrat L, Méndez C, Rodriguez-Garcia E, Soler R, Couto D, Castro-Beiras A. Exercise echocardiography and cardiac magnetic resonance imaging to predict outcome in patients with hypertrophic cardiomyopathy†. Eur Heart J Cardiovasc Imaging 2015; 16:423-432. [DOI: 10.1093/ehjci/jeu225] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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Prognostic Value of Exercise Echocardiography in Patients with Hypertrophic Cardiomyopathy. J Am Soc Echocardiogr 2012; 25:182-9. [DOI: 10.1016/j.echo.2011.11.005] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2011] [Indexed: 11/21/2022]
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Predicting the Future in Hypertrophic Cardiomyopathy: From Histopathology To Flow To Function. J Am Soc Echocardiogr 2012; 25:190-3. [DOI: 10.1016/j.echo.2011.12.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Michaelides AP, Stamatopoulos I, Antoniades C, Anastasakis A, Kotsiopoulou C, Theopistou A, Misailidou M, Fourlas C, Elliott PM, Stefanadis C. ST segment "hump" during exercise testing and the risk of sudden cardiac death in patients with hypertrophic cardiomyopathy. Ann Noninvasive Electrocardiol 2009; 14:158-64. [PMID: 19419401 DOI: 10.1111/j.1542-474x.2009.00291.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND The appearance of a discrete upward deflection of the ST segment termed "the ST hump sign" (STHS) during exercise testing has been associated with resting hypertension and exaggerated blood pressure response to exercise. OBJECTIVE We investigated the prevalence and clinical significance of this sign in a population of patients with hypertrophic cardiomyopathy. METHODS Eighty-one patients with hypertrophic cardiomyopathy (HCM) who underwent cardiopulmonary exercise testing were followed in a retrospective cohort study for a mean period of 5.3 years. RESULTS The appearance of the STHS at the peak of exercise testing was observed in 42 patients (52%), particularly in the inferior and the lateral leads. Patients with the STHS had higher fractional shortening and maximum left ventricular wall thickness and exhibited more frequently outflow tract gradient >30 mmHg at rest. Furthermore, the presence of STHS was a strong independent predictor of the risk of sudden cardiac death (SCD), as the latter occurred in eight of the patients with this sign (8/42, 19%) and in none of the patients without it (0/39, 0%) (P < 0.001). CONCLUSION The appearance of a "hump" at the ST segment during exercise testing appears to be a risk factor for SCD in patients with HCM. However, further studies are necessary to validate this finding in larger populations and to elucidate the mechanism of the appearance of the "hump."
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Affiliation(s)
- Andreas P Michaelides
- First Department of Cardiology, Athens Medical School, Hippokratio Hospital, Athens, Greece.
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Nagata M, Shimizu M, Ino H, Yamaguchi M, Hayashi K, Taki J, Mabuchi H. Hemodynamic changes and prognosis in patients with hypertrophic cardiomyopathy and abnormal blood pressure responses during exercise. Clin Cardiol 2006; 26:71-6. [PMID: 12625597 PMCID: PMC6654441 DOI: 10.1002/clc.4960260206] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND An abnormal blood pressure response (BPR) during exercise has been proposed as a risk factor for sudden cardiac death in patients with hypertrophic cardiomyopathy (HCM). Some patients with HCM show systolic dysfunction during exercise. HYPOTHESIS The aim of this study was to clarify the hemodynamic response during exercise and prognosis in patients with HCM and abnormal BPR. METHODS Sixty-five patients with HCM underwent radionuclide monitoring of left ventricular function and measurement of blood pressure during supine ergometer exercise. Thereafter, cardiac events were recorded for an average period of 76 months. RESULTS Seven of 65 patients had abnormal BPR, while the others had normal BPR. Changes of heart rate and systemic vascular resistance during exercise did not differ between the two groups. Stroke volume did not increase in the abnormal BPR group but did in the normal BPR group. During a mean follow-up period of 76 months, three of the seven patients (43%) with abnormal but only one patient (2%) with normal BPR suffered a malignant arrhythmia. CONCLUSIONS Abnormal BPR occurred in about 11% of patients with nonobstructive HCM and was associated with a high prevalence of cardiac events. The predictor of abnormal BPR during exercise may not be an abnormal response of systemic vascular resistance and heart rate, but the lack of an appropriate increase in stroke volume.
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Affiliation(s)
- Mitsuru Nagata
- Molecular Genetics of Cardiovascular Disorders, Division of Cardiovascular Medicine, Kanazawa University, Kanazawa, Japan
| | - Masami Shimizu
- Molecular Genetics of Cardiovascular Disorders, Division of Cardiovascular Medicine, Kanazawa University, Kanazawa, Japan
| | - Hidekazu Ino
- Molecular Genetics of Cardiovascular Disorders, Division of Cardiovascular Medicine, Kanazawa University, Kanazawa, Japan
| | - Masato Yamaguchi
- Molecular Genetics of Cardiovascular Disorders, Division of Cardiovascular Medicine, Kanazawa University, Kanazawa, Japan
| | - Kenshi Hayashi
- Molecular Genetics of Cardiovascular Disorders, Division of Cardiovascular Medicine, Kanazawa University, Kanazawa, Japan
| | - Junichi Taki
- Biotracer Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
| | - Hiroshi Mabuchi
- Molecular Genetics of Cardiovascular Disorders, Division of Cardiovascular Medicine, Kanazawa University, Kanazawa, Japan
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Yamazaki T, Suzuki JI, Shimamoto R, Tsuji T, Ohmoto Y, Toyo-oka T, Omata M, Ohtomo K, Nagai R. Focalized Contractile Impairment at Hypertrophied Myocardium Proven in Consideration of Wall Stress in Patients With Hypertrophic Cardiomyopathy. Int Heart J 2006; 47:247-58. [PMID: 16607052 DOI: 10.1536/ihj.47.247] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
In hypertrophic cardiomyopathy (HCM) a hyperkinetic state is sometimes observed in spite of impaired systolic function in the hypertrophied myocardium. The aim of the present study was to determine the mechanism of this paradox. Seventeen patients with HCM and 10 normal subjects underwent cine magnetic resonance (MR) imaging to measure percent systolic wall thickening and percent fractional shortening. The ratio of systolic radial wall stress of the LV at the hypertrophied myocardium over that at the nonhypertrophied myocardium was evaluated to describe the focal advantageous condition for wall thickening. The ratio was 0.66 +/- 0.36 at the start of contraction and 0.78 +/- 0.31 at early-systole, indicating consistently smaller radial wall stress at the hypertrophied myocardium. Although the condition for contraction was favorable (a ratio less than 1.00), percent systolic wall thickening at the hypertrophied myocardium (23.0 +/- 11.8%) was smaller than that at the nonhypertrophied myocardium (70.5 +/- 32.3%). Smaller end-diastolic dimension (HCM group; 45.2 +/- 4.2 mm, reference group; 48.9 +/- 4.1 mm, P = 0.04) with a statistically identical value of systolic decrease in intraventricular dimension (HCM group; 19.7 +/- 3.9 mm, reference group; 18.9 +/- 3.2 mm, P = 0.60) yielded high percent fractional shortening in patients with HCM (43.5 +/- 7.6%). Although contractile impairment was proven at the hypertrophied region with low radial wall stress in the HCM group, the smaller end-diastolic dimension in this group resulted in high percent fractional shortening.
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Affiliation(s)
- Tadashi Yamazaki
- Department of Internal Medicine, Graduate School of Medicine and Faculty of Medicine, The University of Tokyo, Japan
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Boon D, van Goudoever J, Huijskes R, Piek JJ, van Montfrans GA. Diagnostic value of simultaneous non-invasive continuous, ambulatory finger blood pressure and electrocardiogram monitoring in a patient with hypertrophic obstructive cardiomyopathy. Blood Press Monit 2002; 7:329-33. [PMID: 12488654 DOI: 10.1097/00126097-200212000-00007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The pathophysiology of hypertrophic obstructive cardiomyopathy (HOCM) is complex and heterogeneous, and it may be difficult to disentangle the various pathophysiologic properties leading to complaints. OBJECTIVES To elucidate the sequence of acute pathophysiologic changes leading to complaints in a patient with HOCM. METHODS Cardiopres measurements [the combination of non-invasive, continuous finger artery blood pressure monitoring, and three-lead electrocardiogram (ECG) recordings] were performed during physiologic, supine exercise--before and after replacement of metoprolol by verapamil. Within 24 h of the Cardiopres measurement standard Doppler echocardiography was performed. Finger artery pressure wave was analysed using Beatscope software (BMI-TNO, Amsterdam, The Netherlands), ST analysis was performed with H-Scribe (Mortara Instrument, Bilt, The Netherlands). RESULTS Exercise under metoprolol: finger BP decreased from 130/65 mmHg to 90/60 mmHg, heart rate increased from 65 bpm to 100 bpm and ST analysis revealed significant ST depression in all leads. The occurrence of ST depression preceded the hypotension. Echocardiography showed a dynamic gradient of 70 mmHg. Exercise under verapamil: the patient had less complaints, BP increased from 125/60 mmHg to 165/65 mmHg, heart rate increased from 75 bpm to 107 bpm and ST analysis showed no ST depression > 1 mm. Echocardiography showed no change. CONCLUSIONS The use of the Cardiopres during a physiological stimulus showed improvement in exercise capacity in a patient with HOCM, while the standard test, stress-echocardiography, showed no correlation with clinical status. The Cardiopres is a useful diagnostic and research tool, allowing non-invasive, ambulatory monitoring of blood pressure and ECG changes.
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Affiliation(s)
- Diederik Boon
- Department of Internal Medicine, Academic Medical Center, Amsterdam, The Netherlands. /nl
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Shimizu M, Ino H, Okeie K, Yamaguchi M, Nagata M, Hayashi K, Itoh H, Iwaki T, Oe K, Konno T, Taki J, Mabuchi H. Systolic dysfunction and blood pressure responses to supine exercise in patients with hypertrophic cardiomyopathy. JAPANESE CIRCULATION JOURNAL 2001; 65:325-9. [PMID: 11316132 DOI: 10.1253/jcj.65.325] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Left ventricular function and blood pressure responses were evaluated in 56 patients with non-obstructive hypertrophic cardiomyopathy (HCM) and 12 control subjects by using a radionuclide ventricular function monitor during supine ergometer exercise. Patients with HCM were divided into 2 groups: (i) group A had no decrease in ejection fraction (EF) during exercise; and (ii) group B had a decrease in EF during exercise. During exercise, the change in end-diastolic volume did not differ between the 3 groups. In contrast, the change in end-systolic volume differed between the 3 groups (p<0.0001). The change in systolic blood pressure (SBP) also differed significantly between the 3 groups. The change in SBP in group B was smaller than that in the control group and group A, and changes in the EF and changes in the SBP between rest and peak exercise showed a significant correlation (p<0.005). These results suggest that exercise-induced systolic dysfunction in patients with non-obstructive HCM may contribute to abnormal blood pressure response in those patients.
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Affiliation(s)
- M Shimizu
- Second Department of Internal Medicine, School of Medicine, Kanazawa University, Japan.
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