Echocardiography-derived variables predict outcome in patients with nonischemic dilated cardiomyopathy with or without a restrictive filling pattern

Left ventricular diastolic function and cardiotoxic chemotherapy

BACKGROUND

Left ventricular ejection fraction falls when the myocardium has already lost a significant portion of its functional capacity. There are conflicting data on whether diastolic dysfunction precedes systolic dysfunction after cardiotoxic chemotherapy. We aimed to study systolic and diastolic dysfunction after cardiotoxic chemotherapy and whether diastolic dysfunction can predict subsequent risk of systolic dysfunction. It was an observational prospective cohort study, and patients receiving cardiotoxic chemotherapy were included. Baseline, demographic, and clinical details were recorded. Echocardiographic measurements of left ventricular systolic function, global longitudinal strain, and diastolic function were noted at baseline, three months, and 6 months.

RESULTS

We included eighty patients. The mean age of the patients was 54.92 ± 7.6 years, predominantly females (80%). The mean left ventricular ejection fraction fell from 64.92 ± 1.96 to 60.97 ± 4.94 at 6 months. Low ejection fraction was seen in 8 (10%) patients at 6 months. The mean global longitudinal strain (GLS) at baseline was - 18.81 ± 0.797 and fell to - 17.65 ± 2.057 at 6 months, with 12 (15%) patients having low GLS (< - 18). Grade 1 diastolic dysfunction was seen in 22 (27.5%) patients, and grade 2 diastolic dysfunction was seen in 3 (3.8%) patients at 6 months. There was a significant decrease in E/A ratio (inflow early diastolic velocity/Inflow late diastolic velocity), mitral tissue Doppler velocity, and an increase in isovolumic relaxation time, mitral valve deceleration time, and E/e' (inflow early diastolic velocity/tissue Doppler mitral annular velocity), at three months and 6 months. Ejection fraction at 6 months was significantly and negatively correlated with diastolic dysfunction at three months (r = - 0.595, p = 0.02).

CONCLUSIONS

Cardiotoxic chemotherapy is associated with early diastolic dysfunction. Early diastolic dysfunction predicts subsequent left ventricular systolic dysfunction.

Prognostic impact of the E/e' ratio in patients with chronic severe aortic regurgitation undergoing aortic valve replacement

OBJECTIVES

The study objective was to evaluate the clinical implication of left ventricular diastolic dysfunction in patients with chronic severe aortic regurgitation undergoing aortic valve replacement.

METHODS

We reviewed the medical records of 323 patients (age, 56.3 ± 14.1 years; 111 female) who underwent aortic valve replacement for chronic severe aortic regurgitation between 2005 and 2019. Left ventricular diastolic dysfunction was assessed by the ratio of peak left ventricular inflow velocity over mitral annular velocity (E/e'). The study end point was the composite of death and heart failure requiring hospital admission.

RESULTS

The E/e' ratio was significantly correlated with age, left atrial dimension, left ventricular end-diastolic volume, mitral regurgitation grade, and tricuspid regurgitation grade (all P < .001). During follow-up (1748.3 patient-years), death and heart failure occurred in 36 patients (2.06/patient-year) and 9 patients (0.53/patient-year), respectively. In multivariable analysis, E/e' ratio (per 5 increment, hazard ratio, 1.32; 95% confidence interval, 1.02-1.71; P = .03), age (hazard ratio, 1.06; 95% confidence interval, 1.03-1.10; P < .001), and left ventricular ejection fraction (hazard ratio, 0.94; 95% confidence interval, 0.90-0.98; P = .002) were independent predictors of death and heart failure. The 5-year heart failure-free survival was 94.9% ± 1.7% in patients with E/e' less than 15% and 84.2% ± 4.2% in patients with E/e' 15 or greater (P < .001).

CONCLUSIONS

The E/e' ratio was significantly associated with adverse outcomes in patients with chronic severe aortic regurgitation undergoing aortic valve replacement and may be useful as a prognostic marker in such patients.

Anesthetic Management of Patients with Dilated Cardiomyopathy Undergoing Noncardiac Surgery

Dilated cardiomyopathy (DCM), a primary myocardial disease, is characterized by dilation of the left or both ventricles and systolic dysfunction with or without congestive heart failure. DCM per se is a well-recognized risk factor for sudden cardiac death and poor surgical outcomes following noncardiac surgery. Surgical trauma/stress represents unique challenges for DCM patient management. Unfortunately, there is a big knowledge gap in managing DCM patients undergoing non-cardiac surgery. Therefore, the aim of our review is to provide basic facts and current advances in DCM, as well as a practical guideline to perioperative care providers, for the management of surgical patients with DCM, who are quite rare compared with the general surgical population. This review summarizes recent advances in the medical management of DCM as well as perioperative assessment and management strategies for DCM patients undergoing noncardiac surgery. Optimal surgical outcomes depend on multiple-disciplinary care to minimize perioperative cardiovascular disturbances.

Diastolic Dysfunction Criteria and Heart failure Readmission in Patients with Heart Failure and Reduced Ejection Fraction

Background:

Advanced diastolic dysfunction (DDys) correlates with elevated LV filling pressures and predicts heart failure readmission (HF-R). As grade 2-3 DDys has predictive value for HF-R, and requires 2 of 3 criteria (left atrial volume index >34 ml/m2, E/e’>14, or tricuspid regurgitation velocity >2.8 m/s), we hypothesized that all 3 criteria would predict greater HF risk than any 2 criteria.

Methods:

In this single-center retrospective study that included 380 patients in sinus rhythm with HF and reduced ejection, we recorded patient characteristics, Doppler-echo, and HF-R with follow-up to 2167 days (median=1423 days; interquartile range=992-1821 days).

Results:

For grade 1 DDys (223 patients), any single criteria resulted in greater HF-R as compared to 0 criteria (HR=2.52, (1.56-3.88) p<0.0001) with an AUC (area under curve)=0.637, p<0.001. For grade 2 DDys (94 patients), there was greater HF-R for all 3 (vs. 0 criteria: HR=4.0 (2.90-8.36), p<0.0001). There was greater HF-R for 3 vs any 2 criteria (HR=1.81, (1.10-3.39), p=0.0222). For all 3 criteria, there was moderate predictability for HF-R (AUC=0.706, p<0.0001) which was more predictive than any 2 criteria (AUC difference 0.057, (0.011-0.10), p=0.009). For grade 3 DDys (63 patients), E/A>2+2-3 criteria identified a subgroup with the greatest risk of HF-R (HR=5.03 (4.62-22.72), p<0.0001) compared with 0 DDys criteria with moderate predictability for 2-3 criteria (AUC=0.726, p<0.0001) exceeding E/A>2+0-1 criteria (AUC difference=0.120, (0.061-0.182), p<0.001).

Conclusion:

Increasing the number of abnormal criteria increased the risk and predictive value of HF-R for grade 1-3 DDys in patients with HF with reduced ejection fraction.

Diastolic function grading by American Society of Echocardiography guidelines and prediction of heart failure readmission and all-cause mortality in a community-based cohort

BACKGROUND

Diastolic function (DF) guidelines have been simplified but lack extensive outcome data. Using a rural university heart failure (HF) database, we assessed whether DF grading could predict HF, HF readmission, and all-cause mortality (ACM).

METHODS

In this single-center retrospective study that included 613 patients in sinus rhythm hospitalized for HF (HF with preserved-254 patients, with mid-range-216 patients, and reduced ejection fraction-143 patients), we recorded demographics, Doppler-echo, Framingham HF score, laboratories, HF readmission, and ACM with follow-up to 2167 days.

RESULTS

Diastolic dysfunction (Ddys) parameters (left atrial volume index [LAVI] > 34 ml/m² , tricuspid regurgitation [TR] velocity > 2.8 m/sec, and E/e' > 14) had moderate sensitivity (46.2%-65.0%) for predicting HF among all phenotypes combined with DF grading having moderate predictability and additive to a clinical composite for HF prediction (AUC = .677, P < 0.0001; difference = .043, P < 0.001) for combined phenotypes. Ddys parameters and Ddys severity (2016 ASE criteria: grade II and III) were significantly associated with HF readmission for decompensated HF within 60-2167 days of follow-up (LAVI > 34 ml/m² : HR 1.56 [1.26-2.19]; E/e' > 14: HR 1.44 [1.21-1.99]; TR > 2.8 m/sec: H1.43 [1.19-1.88]; LV Dys grade II: HR 2.12 [1.42-2.96]; LV Ddys grade III: HR 2.39 [1.57-4.82]).

CONCLUSION

The findings of this study highlight the clinical and prognostic relevance of determining the severity of LV Ddys in patients with HF with regard to HF verification and HF readmission.

Combining diastolic dysfunction and natriuretic peptides to risk stratify patients with heart failure with reduced ejection fraction

BACKGROUND

Diastolic dysfunction (DD) might help to risk stratify patients with heart failure (HF) with reduced ejection fraction (HFrEF). Nonetheless, HF guidelines/risk scores don't consider DD. We aimed to show the independent prognostic value of DD for nonfatal HF/death in patients with HFrEF on top of natriuretic peptides (NP).

METHODS

We analyzed 1155 baseline echocardiograms of the MADIT-CRT study (LVEF≤30%, QRS ≥ 130 ms, NYHA class I/II), classifying DD according to 2016 ASE/EACVI classification.

RESULTS

Patients were 64 ± 11 years-old, 24% females, LVEF was 24 ± 5%, 58% had abnormal BNP (≥100 pg/ml). While 45% had impaired relaxation, 33% had pseudonormal filling, 12% restrictive pattern, 6% indeterminate diastolic function, 4% were not classifiable due to missing data. During a follow-up of 2.1 ± 1.0 years, there were 233 HF/death. Compared to patients without pseudonormal/restrictive filling and with normal NP (23%), patients with pseudonormal/restrictive filling, alone (15%) or combined to elevated NP (30%), were at higher risk of events (respectively p_adj = 0.025 and p_adj < 0.001), as opposed to those with abnormal NP alone (22%; p_adj = 0.55). Adding DD to conventional markers of risk and NP improved prediction (C-statistic 0.733 versus 0.708, p = 0.024). DD was the first parameter to be considered to risk stratify MADIT-CRT population, according to Classification-And-Regression-Tree analysis.

CONCLUSIONS

Among HFrEF patients with mild symptoms, pseudonormal/restrictive filling, either alone or combined with elevated NP, was associated with high risk of events, as opposed to isolated elevation of NP. DD provided incremental risk prediction for death/HF beyond commonly used markers. These data might suggest to integrate DD into HF guidelines/risk scores.

Comprehensive Assessment of Changes in Left Ventricular Diastolic Function With Contemporary Breast Cancer Therapy

OBJECTIVES

This study determined the effects of doxorubicin and/or trastuzumab on diastolic function and the relationship between diastolic function and systolic dysfunction.

BACKGROUND

Doxorubicin and trastuzumab can result in left ventricular ejection fraction (LVEF) declines. However, the effects of these therapies on diastolic function remain incompletely defined.

METHODS

In a rigorously phenotyped, longitudinal cohort study of 362 breast cancer participants treated with doxorubicin, doxorubicin followed by trastuzumab, or trastuzumab alone, changes in diastolic function were evaluated using linear models estimated via generalized estimating equations. Associations between baseline and changes in diastolic function with LVEF and longitudinal strain were also determined using generalized estimating equations. The Kaplan-Meier estimator derived the proportion of participants who experienced incident diastolic dysfunction. Cox proportional hazards models estimated the associations between participant characteristics and diastolic dysfunction risk, and between diastolic function and cancer therapy-related cardiac dysfunction risk, defined by an LVEF decline of ≥10% to <50%.

RESULTS

Over a median of 2.1 years (interquartile range [IQR]: 1.3 to 4.2 years), participants treated with doxorubicin or doxorubicin followed by trastuzumab demonstrated a persistent worsening in diastolic function, with reductions in the E/A ratio, lateral and septal e' velocities, and increases in E/e' (p < 0.01). These changes were not observed with trastuzumab alone. Incident abnormal diastolic function grade occurred in 60% at 1 year, 70% by 2 years, and 80% by 3 years. Abnormal diastolic function grade was associated with a subsequent decrease in LVEF (-2.1%; 95% confidence intervals [CI]: -3.1 to -1.2; p < 0.001) and worsening in longitudinal strain (0.6%; 95% CI: 0.1 to 1.1; p = 0.013) over time. Changes in E/e' ratio were modestly associated with worsening longitudinal strain (0.1%; 95% CI: 0.0 to 0.2; p = 0.022).

CONCLUSIONS

A modest, persistent worsening of diastolic function is observed with contemporary breast cancer therapy. Abnormal and worsening diastolic dysfunction is associated with a small risk of subsequent systolic dysfunction. (Cardiotoxicity of Cancer Therapy [CCT]; NCT01173341).

Survival and Cardiovascular Outcomes of Patients With Secondary Mitral Regurgitation: A Systematic Review and Meta-analysis

Importance

The outcomes of patients with left ventricular (LV) dysfunction and secondary mitral regurgitation (SMR) are still controversial.

Objective

To clarify the role of SMR in the outcomes of patients with ischemic or idiopathic cardiomyopathies.

Data Sources

MEDLINE, ISI Web of Science, and Scopus databases were searched for studies published up to March 2017.

Study Selection

Studies reporting data on outcomes in patients with SMR were included. Duplicate publication data, studies lacking data on SMR grade and its correlation with outcomes, mixed data on SMR and primary mitral regurgitation, studies not clearly reporting the outcome of interest, and studies with fewer than 100 patients were excluded. Of the initial 3820 articles identified, 1.4% were finally included.

Data Extraction and Synthesis

The study met PRISMA requirements. Two of us independently screened articles for fulfillment of inclusion criteria.

Main Outcomes and Measures

The primary outcome, set after data collection, was the incidence of all-cause mortality in patients with and without SMR. Secondary outcomes included hospitalization for heart failure (HF), cardiac mortality, and a composite end point of death, HF hospitalization, and cardiac transplant.

Results

Fifty-three studies and 45 900 patients were included in the meta-analysis. The mean (SD) length of follow-up was 40.8 (22.2) months. In 26 of 36 studies reporting LV function by SMR grade, increasing SMR severity was associated with worse LV function. When SMR was categorized as present or absent, all-cause mortality was significantly higher in the patients with SMR (17 studies, 26 359 patients; risk ratio [RR],1.79; 95% CI, 1.47-2.18; P < .001, I2 = 85%); when SMR was qualitatively graded, the incidence of all-cause mortality was significantly increased in patients having any degree of SMR compared with patients not having SMR (21 studies, 21 081 patients; RR, 1.96; 95% CI, 1.67-2.31; P < .001, I2 = 74%). Finally, when SMR was quantitatively graded, it remained associated with an increased all-cause mortality rate (9 studies, 3649 patients; RR, 1.97; 95% CI, 1.71-2.27; P < .001, I2 = 0%). Moreover, SMR was associated with an increased risk of hospitalization for HF (16 studies, 10 171 patients; RR, 2.26; 95% CI, 1.92-2.67; P < .001, I2 = 41%), cardiac mortality (12 studies, 11 896 patients; RR, 2.62; 95% CI, 1.87-3.69; P < .001, I2 = 74%), and death, HF, and transplant (11 studies, 8256 patients; RR, 1.63; 95% CI, 1.33-1.99; P < .001, I2 = 78%).

Conclusions and Relevance

To our knowledge, this study is the first meta-analysis to date to demonstrate that SMR, even when mild, correlates with adverse outcomes in patients with ischemic or idiopathic cardiomyopathies. Because SMR is an intrinsic consequence of LV dysfunction, causality between SMR and mortality should not be implied.

A Test in Context: E/A and E/e' to Assess Diastolic Dysfunction and LV Filling Pressure

Diastolic dysfunction represents a combination of impaired left ventricular (LV) relaxation, restoration forces, myocyte lengthening load, and atrial function, culminating in increased LV filling pressures. Current Doppler echocardiography guidelines recommend using early to late diastolic transmitral flow velocity (E/A) to assess diastolic function, and E to early diastolic mitral annular tissue velocity (E/e') to estimate LV filling pressures. Although both parameters have important diagnostic and prognostic implications, they should be interpreted in the context of a patient's age and the rest of the echocardiogram to describe diastolic function and guide patient management. This review discusses: 1) the physiological basis for the E/A and E/e' ratios; 2) their roles in diagnosing diastolic dysfunction; 3) prognostic implications of abnormalities in E/A and E/e'; 4) special scenarios of the E/A and E/e' ratios that are either useful or challenging when evaluating diastolic function clinically; and 5) their usefulness in guiding therapeutic decision making.

Left ventricular diastolic function in hypertension: methodological considerations and clinical implications

The assessment of left ventricular (LV) diastolic function should be an integral part of a routine examination of hypertensive patient; indeed when LV diastolic function is impaired, it is possible to have heart failure even with preserved LV ejection fraction. Left ventricular diastolic dysfunction (LVDD) occurs frequently and is associated to heart disease. Doppler echocardiography is the best tool for early LVDD diagnosis. Hypertension affects LV relaxation and when left ventricular hypertrophy (LVH) occurs, it decreases compliance too, so it is important to calculate Doppler echocardiography parameters, for diastolic function evaluation, in all hypertensive patients. The purpose of our review was to discuss about the strong relationship between LVDD and hypertension, and their relationship with LV systolic function. Furthermore, we aimed to assess the relationship between the arterial stiffness and LV structure and function in hypertensive patients.

Role of echocardiography in the contemporary management of chronic heart failure

Echocardiography is an excellent noninvasive tool for the assessment of ventricular size and both systolic and diastolic function, and it is routinely used in patients with heart failure. This review will discuss the role of echocardiography in heart failure diagnosis, prognostic assessment and in the management of heart failure patients.

Valve replacement for aortic stenosis normalizes subendocardial function in patients with normal ejection fraction

AIMS

Long-standing aortic stenosis (AS) causes various degrees of left ventricular (LV) dysfunction, which may improve after valve replacement. The aim of this study was to assess the nature of LV subendocardial abnormalities in AS and their response to valve replacement (AVR).

METHODS AND RESULTS

We studied 41 consecutive symptomatic patients (age 64 +/- 13 years) with severe AS, normal LV ejection fraction (EF), but no obstructive coronary artery disease before, a week after AVR, and 6 months after AVR. LV subendocardial function was studied from recordings of long-axis M-mode (amplitude), tissue-Doppler (myocardial velocities) and speckle tracking (myocardial strain) echocardiographic techniques. Results were compared with those from 20 age- and gender-matched controls. In patients, LV dimensions and markers of asynchrony, total isovolumic time (t-IVT), and Tei index were not different from controls before AVR and remained unchanged afterwards. LV lateral long-axis amplitude, as well as lateral and septal systolic velocities and strain, were reduced (P < 0.001 for all) and E/E' was modestly raised. Lateral long-axis amplitude, systolic and diastolic velocities normalized within a week of AVR but strain lagged behind until 6 months later. The reduced septal long-axis amplitude remained permanently unchanged (NS) despite the early normalization of its systolic velocities (P < 0.001) and strain (P < 0.001). LV mass normalized at 6 months after AVR (P < 0.005).

CONCLUSIONS

In patients with severe AS and maintained LV ejection fraction, subendocardial function is globally abnormal showing reduced amplitude of motion, velocities, and strain. The different response of its components suggests an evidence for differential reverse remodelling, irrespective of myocardial mass regression.

Transthoracic bioimpedance and brain natriuretic peptide levels accurately indicate additional diastolic dysfunction in patients with chronic advanced systolic heart failure

AIMS

Diastolic dysfunction in patients with heart failure has prognostic relevance, possibly because of its relationship with worsening haemodynamic status. In the quest for simpler indexes of haemodynamic status in patients, brain natriuretic peptide (BNP) levels have been proposed as a surrogate of diastolic function. To date, the value of combining BNP levels with non-invasive haemodynamic monitoring by transthoracic electric bioimpedance (TEB) for the prediction of diastolic function has not been evaluated.

METHODS AND RESULTS

We compared left ventricular diastolic function measured by tissue Doppler imaging (TDI) with TEB results and BNP levels in 120 patients with chronic advanced systolic heart failure on optimal treatment (70 +/- 9 years, NYHA 2.4 +/- 0.8, ejection fraction 31 +/- 5%). Of the TEB variables measured, we only considered thoracic fluid content (TFC). To describe diastolic function, we used the TDI of the velocity of displacement of the mitral annulus (E') and the ratio E/E'. In all patients, E/E' was significantly related to TFC and to BNP levels (P < 0.001). Moreover, the combination of BNP > or = 350 pg/mL and TFC > or = 35/kOmega identified patients with diastolic dysfunction (defined as E/E' > or = 15) with high sensitivity and specificity (95 and 94%, respectively).

CONCLUSION

The combination of transthoracic bioimpedance monitoring and BNP measurement accurately indicated the presence of diastolic dysfunction in most patients. These user-friendly and operator-independent tools may be useful as a screening assessment for diastolic dysfunction, and consequently abnormal central haemodynamic status, either in ambulatory patients or when an adequate echocardiographic evaluation is not readily available.

Predictors of mortality in medically treated patients with congestive heart failure of nonrheumatic etiology and reduced systolic function

OBJECTIVE

We investigated the prognostic value of various parameters on the mortality of patients with nonrheumatic chronic heart failure and left ventricular (LV) systolic dysfunction.

METHODS

This study included 132 consecutive patients with congestive heart failure and reduced LV systolic function without rheumatic valve disease. The primary outcome was mortality. Mean follow-up was 38+/-6 months.

RESULTS

During the follow-up period there were 47 deaths (35.6%). The age (64.1+/-13.5 vs. 58.7+/-11.8 years, P=0.019), left bundle branch block (44.7% vs. 18.8%, P=0.002), urea concentration (11.4+/-5.3 vs. 8.9+/-4.6 mmol/L, P=0.006), LV end-diastolic and end-systolic dimensions (6.7+/-0.8 vs. 6.4+/-0.8 cm, P=0.025 and 5.5+/-0.8 vs. 4.9+/-0.8 cm, P<0.001, respectively), grade 3-4 mitral regurgitation (40.4 vs. 22.4%, P<0.001), fractional shortening (16.7+/-5.3% vs. 19.8+/-5.7%, P=0.002) and LV ejection fraction (32.9+/-8.5% vs. 38.7+/-11.3%, P=0.003) were different between non-survivors and survivors. Multivariate analysis identified severity of mitral regurgitation (OR=1.99, 95% CI 1.18-3.34; P=0.009), age (OR=1.07, 95% CI 1.02-1.12; P=0.01) and LV end-systolic dimension (OR=1.09, 95% CI 1.02-1.16; P=0.014) as independent correlates of mortality.

CONCLUSIONS

In medically treated patients with nonrheumatic chronic heart failure and left ventricular systolic dysfunction, severity of mitral regurgitation, age and enlarged LV end-systolic dimension were independently associated with increased risk of death.

Over-time mitral regurgitation changes following cardiac resynchronization therapy

PURPOSE

Mitral regurgitation (MR) is a leading cause of mortality in patients with heart failure (HF). Cardiac resynchronization therapy (CRT) has been shown to improve MR in these patients, but maintenance of MR improvement after CRT implantation has not yet been evaluated. We aimed to evaluate the post-CRT improvement pattern of MR in a 6-month follow-up period.

MATERIALS AND METHODS

65 consecutive patients scheduled for CRT implantation with inclusion criteria of moderate to severe heart failure, left ventricular ejection fraction (LVEF) <or=35%, and QRS duration >120 ms with left bundle branch block configuration were invited to participate. 60 patients with MR were registered. Clinical, electrocardiographic and echocardiographic evaluations were recorded before CRT implantation and 3 and 6 months after.

RESULTS

We found significant improvement in MR score, NYHA class, QRS duration, LVEF and left ventricular end diastolic diameter (LVEDD) at the 3-month follow-up (p<0.001). These parameters also improved significantly (p<0.0001) between the 3 and 6-month follow-ups except for the MR score, which did not show any significant improvement.

CONCLUSION

MR improvement was sustained after CRT implantation between the 3 and 6-month follow-ups.

Exercise does not enhance the prognostic value of Doppler echocardiography in patients with left ventricular systolic dysfunction and functional mitral regurgitation at rest

BACKGROUND

Functional mitral regurgitation (MR) is a powerful predictor of poor prognosis in patients with chronic heart failure (CHF) due to left ventricular systolic dysfunction (LVSD). However, severity of MR varies with dynamic exercise. Accordingly, we sought to assess the prognostic value of exercise-induced changes in functional MR in patients with LVSD and functional MR at rest.

METHODS

One hundred four patients with chronic heart failure due to LVSD (ejection fraction [EF] < 45%) and functional MR at rest underwent conventional continuous 2-dimensional Doppler echocardiography at rest and during maximal symptom-limited exercise. The primary end point of the study was all-cause mortality. The median follow-up period was 20 months.

RESULTS

Fifty-six patients (54%) had ischemic cardiomyopathy. When feasible, all 56 patients with ischemic cardiomyopathy had undergone revascularization procedures before enrollment into the study. In the whole patient cohort, resting LV end-diastolic volume was 205 +/- 76 mL and EF was 26% +/- 9%. Univariate predictors of death were functional class (New York Heart Association), LV EF, LV end-diastolic volume, resting mitral effective regurgitant orifice, mitral E deceleration time, tricuspid annular plane systolic excursion < or = 14 mm, systolic blood pressure, LV EF, and trans-tricuspid pressure gradient response to exercise. Exercise-induced change in mitral effective regurgitant orifice did not predict survival (HR 0.99, 95% CI 0.94-1.04, P = .63). By Cox multivariate analysis, resting LV end-diastolic volume and tricuspid annular plane systolic excursion < or = 14 mm were the independent predictors of death.

CONCLUSIONS

Exercise Doppler echocardiography does not refine the predictive value of resting Doppler echocardiography in patients with LVSD and functional MR at rest.

Myocardial Doppler velocities as a marker of prognosis in the ICU

Relatively simple measures of echocardiography and Doppler, as left ventricular end-systolic area and volume, should be taken in consideration when performing a Doppler echocardiographic examination, as they could have both clinical and prognostic value.

The prognostic significance of restrictive diastolic filling associated with heart failure: A meta-analysis

BACKGROUND

Several studies have reported that the presence of a restrictive filling pattern (RFP) is associated with poor outcome in patients with heart failure (HF). These studies, of variable sample size, have involved different HF patient groups with variable associated mortality rates and follow-up times, and while powered for effects on combined end-points such as death or hospital admission, many were underpowered to reliably determine the overall effect of the RFP on total mortality. Consequently, we performed a meta-analysis to determine the mortality associated with RFP in patients with HF.

METHODS

We searched several online medical databases for prospective studies of patients with HF. All authors were requested to confirm their data. All-cause mortality was compared between RFP and non-restrictive filling patterns (Non-RFP). Review Manager version 4.2.7 software was used for the analysis.

RESULTS

3024 patients in 27 studies were identified (379 idiopathic cardiomyopathy, 2645 mixed aetiology HF). Average follow-up was between 3 months and 5 years. 1284 (42%) patients had RFP at baseline. 688 deaths occurred and the overall odds ratio for death was 4.36 (CI 3.60, 5.04); idiopathic group: 6.65 (CI 3.86, 11.47); mixed aetiology group: 4.10 (CI 3.34, 5.04). The overall odds ratio for death/transplantation was 4.87 (CI 4.04, 5.86); idiopathic group: 7.62 (CI 4.50, 12.92); mixed aetiology group: 4.56 (CI 3.74, 5.56).

CONCLUSIONS

Restrictive filling pattern is associated with a four-fold increase in mortality in patients with HF and thus should be an important part of the echocardiographic assessment of such patients.

Left ventricular geometric patterns in the Jackson cohort of the Atherosclerotic Risk in Communities (ARIC) Study: clinical correlates and influences on systolic and diastolic dysfunction

BACKGROUND

The distribution and determinants of left ventricular (LV) geometric patterns and their relation to LV function in African Americans is not well described despite higher rates of LV hypertrophy and cardiovascular mortality reported in this group.

PURPOSE

This study investigates the distribution and clinical correlates of LV geometric patterns and how these patterns relate to function in a population-based African American cohort.

METHODS

The study population included participants in the Jackson cohort of ARIC, who underwent echocardiograms between 1993 and 1995. We defined 4 geometric patterns (normal geometry, concentric remodeling [CR], eccentric hypertrophy [EH], and concentric hypertrophy [CH]) according to LV mass index and relative wall thickness. Multiple logistic regression was used to assess the association of geometric patterns to systolic dysfunction and diastolic dysfunction, adjusting for traditional coronary risk factors.

RESULTS

There were 1849 participants in the study population (mean age 59 years, 65% women). Concentric remodeling and CH were highly prevalent. Concentric hypertrophy and EH groups had the highest rates of hypertension, obesity, and diabetes mellitus. Compared to the normal geometric pattern, EH was related to systolic dysfunction (OR 24.27, CI 6.71-87.80), and CH was related to diastolic dysfunction 1.58 (1.04-2.39). Concentric remodeling was not related to systolic or diastolic dysfunction.

CONCLUSION

In this large middle-aged African American cohort, CR and CH are prevalent. Hypertension, diabetes mellitus, and obesity are associated with both CH and EH. Concentric hypertrophy is strongly associated with diastolic dysfunction; EH is strongly associated with systolic dysfunction. Concentric remodeling, however, is not related to either systolic or diastolic dysfunction.

The prognostic value of the mitral diastolic filling velocity ratio for all-cause mortality and cardiovascular morbidity in African Americans: the Atherosclerotic Risks in Communities (ARIC) study

BACKGROUND

Although recent data suggest that the mitral diastolic early-to-late (E/A) ratio may be prognostic in selected population-based cohorts, its predictive value for morbidity and mortality in African Americans has not yet been well studied.

METHODS

The study population consisted of African American participants from the Jackson cohort of the Atherosclerotic Risks in Community Study. Three subgroups of E/A ratios were defined: E/A <0.7, E/A 0.7-1.5, and E/A >1.5, using the middle group as reference. Cox proportional hazard models were used to assess the association between the E/A ratio and both all-cause mortality and incident cardiovascular disease (CVD). The mean follow-up period was 6.8 +/- 1.3 years.

RESULTS

Of the 2211 participants in the study population (mean age 62 years, 65.1% women), 8.2% had an E/A ratio <0.7, 84.7% had an E/A 0.7-1.5, and 7.1% had an E/A >1.5. An E/A >1.5 was independently associated with all-cause mortality (hazard ratio [HR] 2.18, 95% confidence interval [CI] 1.20-4.03) in the multivariable model. An E/A <0.7 was associated with higher all-cause mortality (HR 1.79, 95% CI 1.17-2.73) and incident CVD (HR 1.91, 95% CI 1.29-2.83) compared with a normal E/A in the age and sex adjusted model but was not independently predictive in the multivariable model (P > .05).

CONCLUSIONS

In a population-based cohort of middle-aged African Americans, an E/A >1.5 independently predicts all-cause mortality. An E/A >1.5 and an E/A <0.7 were both associated with incident CVD when adjusted for age and sex alone but were not independently predictive in the multivariable analysis.

Functional mitral regurgitation predicts 1-year mortality in elderly patients with systolic chronic heart failure

BACKGROUND AND AIM

Mitral regurgitation (MR) has been demonstrated to be a powerful predictor of adverse outcome in middle-aged patients with chronic heart failure (CHF). In this study, we sought to define the prognostic impact of functional mitral regurgitation in a population of elderly patients with systolic CHF.

METHODS

One hundred seventy-five outpatients aged >70 years with validated CHF and left ventricular ejection fraction <40% underwent clinical and echocardiographic evaluations at baseline. Mitral regurgitation was diagnosed by Color Doppler and quantified in 5 categorical values using a 0-4+ grading system. Outcome measures included 1-year mortality and hospitalization for worsening CHF.

RESULTS

The distribution of patients according to the 5 different degrees of MR detected at baseline was: absent=11%, 1+=31%, 2+=38%, 3+=16%, 4+=4%. The relationship between MR and mortality was direct and approximately linear (r=0.39, p=0.00001). The prevalence of death in the 5 subgroups was 0%, 7%, 15%, 45%, 57%, respectively. Multivariate logistic regression analysis showed that MR was the strongest predictor of death (OR 4.47, 95% CI 1.50-13.0), independently of the presence of diabetes mellitus, older age and larger left ventricular end-diastolic volume. No association was found between MR and hospitalization for worsening CHF (r=0.08, p=0.41).

CONCLUSIONS

This study establishes the direct and independent relationship between MR severity and one-year mortality among elders with systolic CHF. Conversely, MR does not provide useful information regarding the risk of subsequent hospitalization for worsening CHF.

Dilated versus nondilated cardiomyopathy in the elderly population treated with guideline-based medical therapy for systolic chronic heart failure

BACKGROUND

Although the process by which the left ventricular (LV) remodels in response to an injury generally leads to dilatation, in patients with heart failure (HF) the recognition of a small or mildly dilated left ventricle is not uncommon. We investigated the prevalence and the characteristics of elderly patients with traditional dilated and nondilated cardiomyopathy (CMP). We also assessed the response to the guideline-based medical therapy and the prognosis based on LV dilatation in this population.

METHODS AND RESULTS

We selected 243 patients >70 years of age with HF and LV ejection fraction <40% who underwent clinical and echocardiographic evaluations at baseline and after 12 months. They were subdivided into 2 groups according to baseline LV end-diastolic volume (LVEDV) (values < or =78 mL/m(2) identified nondilated CMP). Nondilated CMP was recognized in 64 patients (26%) who showed at baseline better clinical status, less severe mitral regurgitation, and higher LV ejection fraction than those with dilated CMP. At the final evaluation, favorable changes in clinical and echocardiographic parameters could be detected in both groups. The magnitude of these variations did not differ between the groups. The risk of hospitalization for worsening HF was 2.4-fold higher in patients with nondilated than dilated CMP. Mortality was 11% and 20%, respectively (P = .06). Statistical analysis revealed a direct, approximately linear relationship between LVEDV and outcomes in this population.

CONCLUSIONS

A total of 1 of 4 elderly patients with systolic HF had a nondilated left ventricle. These patients had a better clinical presentation than did counterparts with dilated left ventricles. After HF therapy is optimized, the likelihood of improvement is independent of LV size in this population, whereas the risk of death or worsening HF linearly increases with LV dilatation.

Genesis of the restrictive filling pattern: pericardial constraint or myocardial restraint

BACKGROUND

Restrictive filling pattern has been predictive of heart failure in patients with cardiomyopathy and after myocardial infarction, and is similar to the filling pattern in constrictive pericarditis and amyloid heart disease. The purpose of this study was to determine the role of both myocardial restraint and pericardial constraint in a chronic left ventricular dysfunction model with restrictive filling.

METHODS

After instrumentation, a flat balloon containing a high-fidelity pressure catheter was inserted through a pericardial incision in 12 dogs with chronic left ventricular dysfunction. Intracardiac volume (ICV) was manipulated by inferior venal caval balloon occlusion and volume loading while hemodynamics, echo-assessed chamber size, and transmitral Doppler were obtained at the same atrial paced rate with an intact pericardium and after pericardiectomy.

RESULTS

With an intact pericardium, deceleration time increased with reduced ICV (130 +/- 35 vs 153 +/- 47 milliseconds, P <.05) and shortened with increased ICV (107 +/- 45 milliseconds, P <.05). The filling fraction at one-third of diastole decreased with reduced ICV (45.6 +/- 29.3 vs 24.2 +/- 15.8%, P <.01) and increased with increased ICV (60.1 +/- 14.8%, P <.05). Deceleration time could be predicted from intrapericardial pressure, the transmural left ventricular chamber stiffness constant, and filling fraction at one-third of diastole. After pericardiectomy, deceleration time also shortened with increased ICV (141 +/- 26 vs 112 +/- 38 milliseconds, P <.01). However, filling fraction at one-third of diastole was markedly reduced at paced baseline (19.9 +/- 14.4%, P <.01) and with increased ICV (15.5 +/- 11.8%, P <.001) as compared with an intact pericardium.

CONCLUSIONS

Pericardial constraint and myocardial restraint play a role in restrictive filling pattern. Pericardial constraint becomes evident with redistribution of diastolic filling to later in diastole after pericardiectomy.

Role of echocardiography in the diagnosis and prognosis of patients with mitral regurgitation

The diagnosis of mitral regurgitation is often made from physical diagnosis, but quantitation of severity of valvular dysfunction and timing of intervention are often quite challenging. The purpose of this review is to examine the recent echocardiographic methods reported for quantitative assessment of mitral regurgitation, and the role of echocardiography in guiding medical and surgical management. Refinement of quantitative methods and development of newer technologies, including three-dimensional echocardiography, provide more accurate assessment of mitral anatomy and function. These methods for evaluation of the mitral valve to ascertain etiology or mechanism have important implications for medical or surgical management. This review summarizes the recent literature addressing the role of echocardiography in the diagnosis, management and prognosis of mitral regurgitation.