Restrictive cardiomyopathy caused by adipositas cordis

Causative Mechanisms of Childhood and Adolescent Obesity Leading to Adult Cardiometabolic Disease: A Literature Review

The past few decades have shown a worrisome increase in the prevalence of obesity and its related illnesses. This increasing burden has a noteworthy impact on overall worldwide mortality and morbidity, with significant economic implications as well. The same trend is apparent regarding pediatric obesity. This is a particularly concerning aspect when considering the well-established link between cardiovascular disease and obesity, and the fact that childhood obesity frequently leads to adult obesity. Moreover, most obese adults have a history of excess weight starting in childhood. In addition, given the cumulative character of both time and severity of exposure to obesity as a risk factor for associated diseases, the repercussions of obesity prevalence and related morbidity could be exponential in time. The purpose of this review is to outline key aspects regarding the current knowledge on childhood and adolescent obesity as a cardiometabolic risk factor, as well as the most common etiological pathways involved in the development of weight excess and associated cardiovascular and metabolic diseases.

Obesity and cardiovascular disease: revisiting an old relationship

A wealth of clinical and epidemiological evidence has linked obesity to a broad spectrum of cardiovascular diseases (CVD) including coronary heart disease, heart failure, hypertension, stroke, atrial fibrillation and sudden cardiac death. Obesity can increase CVD morbidity and mortality directly and indirectly. Direct effects are mediated by obesity-induced structural and functional adaptations of the cardiovascular system to accommodate excess body weight, as well as by adipokine effects on inflammation and vascular homeostasis. Indirect effects are mediated by co-existing CVD risk factors such as insulin resistance, hyperglycemia, hypertension and dyslipidemia. Adipose tissue (AT) quality and functionality are more relevant aspects for cardiometabolic risk than its total amount. The consequences of maladaptive AT expansion in obesity are local and systemic: the local include inflammation, hypoxia, dysregulated adipokine secretion and impaired mitochondrial function; the systemic comprise insulin resistance, abnormal glucose/lipid metabolism, hypertension, a pro-inflammatory and pro-thrombotic state and endothelial dysfunction, all of which provide linking mechanisms for the association between obesity and CVD. The present narrative review summarizes the major pathophysiological links between obesity and CVD (traditional and novel concepts), analyses the heterogeneity of obesity-related cardiometabolic consequences, and provides an overview of the cardiovascular impact of weight loss interventions.

Adipositas Cordis: A Rare and Poorly Understood Cardiomyopathy

Adipositas cordis is a rare cardiomyopathy characterized by diffuse fatty infiltration of the ventricular myocardium or interventricular septum. This occurs without myocardial cell destruction, unlike arrhythmogenic right ventricular cardiomyopathy. A 40-year-old obese woman was found to have a II/VI systolic murmur that worsened with standing. A transthoracic echocardiogram showed interventricular septal hypertrophy with a preserved left ventricular ejection fraction. Cardiac magnetic resonance imaging revealed a fatty mass in the interventricular septum. An endomyocardial biopsy revealed structurally normal myocytes with diffuse adipose cell infiltration and no evidence of malignant cells. Left and right cardiac catheterizations and stress echocardiography showed no abnormalities. This case shows the importance of considering a broad differential when approaching rare diseases. It also demonstrates the utility of noninvasive imaging and its impact on clinical decision making.

Adiposity, body composition and ventricular-arterial stiffness in the elderly: the Atherosclerosis Risk in Communities Study

AIM

Weight gain appears to accelerate age-related ventricular-arterial stiffening, which has been implicated in the development of heart failure (HF), but it is unclear whether body fat accumulation underpins this association. We evaluated the relationship of adiposity, using measures of body composition, with ventricular-arterial stiffness among the elderly in the community.

METHODS AND RESULTS

Adiposity was accessed through body mass index (BMI), waist circumference, and body fat percentage. We studied the association of these measures with carotid-femoral pulse wave velocity (cfPWV), arterial elastance index (EaI), left ventricular (LV) end-systolic elastance index (EesI) and LV end-diastolic elastance index (EedI) in 5520 community-based, elderly Atherosclerosis Risk in Communities (ARIC) Study participants, who underwent echocardiography between 2011 and 2013. BMI and waist circumference were directly associated with EaI, EedI and EesI even after adjusting for age, sex, race, hypertension, diabetes mellitus, heart rate, prevalent coronary heart disease and HF. After further adjustment for BMI, body fat percentage demonstrated significant independent linear relationships with EaI [standardized beta coefficient (β)=0.17, P<0.001], EesI (β=0.08, P=0.003) and EedI (β=0.20, P<0.001), and significant non-linear relationships with cfPWV (P=0.033).

CONCLUSION

In this biracial community-based cohort, increased adiposity was associated with increased ventricular-arterial stiffness among the elderly and suggests a potential mechanism by which obesity might contribute to the development of HF.

Fat infiltration of left ventricle - a rare cause of sudden cardiac death

Cor adiposum is a rare disorder of the heart, where the normal heart tissue is replaced by fibro-fatty infiltrates. We report one such case of a middle-aged female who was declared dead shortly after a syncopal episode. At autopsy, the pericardium was intact and firmly adhered to the heart. Histopathology revealed fatty infiltrates extending into the left ventricle of the heart. A post-mortem diagnosis of Cor adiposum was made which is an uncommonly reported cause of sudden cardiac death.

Impact of bariatric surgery on cardiac structure, function and clinical manifestations in morbid obesity

Obesity results from the excessive accumulation of fat. Risk of premature death is doubled compared to nonobese individuals, and risk of death from cardiovascular disease is increased fivefold. In patients with morbid obesity, a variety of adaptations and alterations in cardiac structure and function occur in the individual, as an excess amount of adipose tissue accumulates. The high long-term failure rate of diet intervention is well acknowledged by the clinician. Surgery for severe obesity has evolved during the last 40 years. Many surgical techniques have been described and abandoned. Nevertheless, numerous different techniques are still in use today. Weight loss has beneficial impacts on functional and structural cardiac status and will be reviewed in this report.

Effect of obesity and overweight on left ventricular diastolic function: a community-based study in an elderly cohort

OBJECTIVES

The purpose of this study was to assess the independent effect of increased body size on left ventricular (LV) diastolic function.

BACKGROUND

Obese and overweight persons are at increased risk of heart failure. Left ventricular diastolic dysfunction is an asymptomatic condition associated with future heart failure. It is unclear whether obesity and overweight are independently associated with LV diastolic dysfunction.

METHODS

The LV diastolic function was evaluated in 950 participants from the CABL (Cardiovascular Abnormalities and Brain Lesions) study by traditional and tissue Doppler imaging. Peak early transmitral diastolic flow velocity (E), late transmitral diastolic flow velocity (A), and early diastolic mitral annulus velocity (E') were measured, and E/A and E/E' were calculated. The study sample was divided into 3 groups: normal weight (body mass index [BMI] <25.0 kg/m(2)), overweight (BMI 25.0 to 29.9 kg/m(2)), and obese (BMI ≥30 kg/m(2)).

RESULTS

In multivariate analyses, BMI was independently associated with higher E, A, and E/E', an indicator of LV filling pressure (all p ≤ 0.01). Overweight and obese had lower E' (both p < 0.01) and higher E/E' (both p < 0.01) than normal weight participants. The E/A was lower in obese subjects than in normal weight subjects (p < 0.01). The risk of diastolic dysfunction was significantly higher in overweight subjects (adjusted odds ratio: 1.52, 95% confidence interval: 1.04 to 2.22) and obese subjects (adjusted odds ratio: 1.60, 95% confidence interval: 1.06 to 2.41) compared to normal weight subjects.

CONCLUSIONS

Increased BMI was associated with worse LV diastolic function independent of LV mass and associated risk factors. The increased risk of LV diastolic dysfunction in both overweight and obese persons may partially account for the increased risk of heart failure associated with both conditions.

Effects of obesity and subsequent weight reduction on left ventricular function

Obesity is reaching epidemic proportions in the United States. Obesity adversely affects the circulatory system with resultant endothelial dysfunction, which promotes systemic hypertension, coronary artery disease, and vascular calcification. It is believed that the release of adipokines is responsible for this effect. In addition, obesity causes intrinsic changes in the heart including an increase in left ventricular (LV) mass, LV hypertrophy, LV dilatation, left atrial dilatation, and diastolic, as well as systolic dysfunction in some cases. The combination of increased adipose cells and an increase lean muscle mass in obese patients results in high cardiac output and an accompanying increased circulating volume leading to these adaptive changes. Weight loss by means of caloric restriction or surgery results in favorable hemodynamic changes referred to as "reverse remodeling." Regression of LV mass and chamber size has been shown universally. However, some studies have failed to reveal improvement in diastolic function possibly because of confounders such as nutritional deficiency that may occur after weight loss surgery. Some evidence seems to suggest that the greatest regression of LV mass and LV hypertrophy may occur when weight loss is combined with beta-adrenergic blocker therapy (in those who have an indication for the drug) when compared with other antihypertensive drugs versus weight loss alone.

Metastatic uterine adenocarcinoma and hepatic lipomatosis in a llama (Lama glama)

A 6-year-old, female llama (Lama glama) presented with progressive anorexia and ascites. Postmortem examination revealed an infiltrative uterine adenocarcinoma with widespread metastases. The neoplasm completely replaced and infiltrated the myometrium of the uterine body and cervix and metastasized largely to the serosal surfaces of the peritoneal cavity. Histopathology identified a highly invasive growth of neoplastic cells in solid packets or tubular arrangements and marked fibroplasia. No bovine or llama papillomavirus DNA was detected intralesionally by polymerase chain reaction.

Obesity and cardiovascular disease: pathophysiology, evaluation, and effect of weight loss: an update of the 1997 American Heart Association Scientific Statement on Obesity and Heart Disease from the Obesity Committee of the Council on Nutrition, Physical Activity, and Metabolism

Obesity is becoming a global epidemic in both children and adults. It is associated with numerous comorbidities such as cardiovascular diseases (CVD), type 2 diabetes, hypertension, certain cancers, and sleep apnea/sleep-disordered breathing. In fact, obesity is an independent risk factor for CVD, and CVD risks have also been documented in obese children. Obesity is associated with an increased risk of morbidity and mortality as well as reduced life expectancy. Health service use and medical costs associated with obesity and related diseases have risen dramatically and are expected to continue to rise. Besides an altered metabolic profile, a variety of adaptations/alterations in cardiac structure and function occur in the individual as adipose tissue accumulates in excess amounts, even in the absence of comorbidities. Hence, obesity may affect the heart through its influence on known risk factors such as dyslipidemia, hypertension, glucose intolerance, inflammatory markers, obstructive sleep apnea/hypoventilation, and the prothrombotic state, in addition to as-yet-unrecognized mechanisms. On the whole, overweight and obesity predispose to or are associated with numerous cardiac complications such as coronary heart disease, heart failure, and sudden death because of their impact on the cardiovascular system. The pathophysiology of these entities that are linked to obesity will be discussed. However, the cardiovascular clinical evaluation of obese patients may be limited because of the morphology of the individual. In this statement, we review the available evidence of the impact of obesity on CVD with emphasis on the evaluation of cardiac structure and function in obese patients and the effect of weight loss on the cardiovascular system.

Fatty infiltration of right ventricle (adipositas cordis): an unrecognized cause of early graft failure after cardiac transplantation

Fatty infiltration of the right ventricle is usually an incidental finding at post-mortem, but may have clinical significance at times of physiologic stress. We report a case of fatal right ventricular dysfunction immediately after cardiac transplantation secondary to massive fatty infiltration of the donor right ventricle. Ante-mortem diagnosis of fatty infiltration may be difficult to determine despite non-invasive cardiac evaluation. If the diagnosis of fatty infiltration is suspected at time of donor harvest, the relative risks and benefits of proceeding with transplantation should be carefully assessed.

Improvement in hypertrophic cardiomyopathy after significant weight loss: case report

A 17-year-old obese boy found to have familial apical hypertrophic cardiomyopathy on routine screening was enrolled in a weight loss program on the basis of the hypothesis that significant weight loss would improve his cardiac status. He was followed with serial dual-energy x-ray absorptiometry, electrocardiography, echocardiography, and blood pressure and pulse rate measurements. Within 1 year, he lost 49 kg, with a body mass index reduction from 43.6 to 28.1 kg/m2 and associated reductions in systolic blood pressure, diastolic blood pressure, pulse pressure, mean heart rate, rate pressure product, and echocardiographic indices of left ventricular mass that resulted in a change from the initial geometric finding of eccentric left ventricular hypertrophy to a "normal" left ventricular mass with minimal asymmetric apical left ventricular thickening. Significant weight loss in an obese adolescent with presumed familial apical hypertrophic cardiomyopathy was associated with striking improvement in cardiac functional indices, which could have profound implications for long-term cardiovascular risk.

Quantitative measurement of normal and excessive (cor adiposum) subepicardial adipose tissue, its clinical significance, and its effect on electrocardiographic QRS voltage

In summary, adipose tissue in the heart may constitute up to 50% of the cardiac weight. The greater amounts of cardiac adipose tissue are associated with lower total 12-lead QRS voltages.