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Pan JA. Late Gadolinium Enhancement in Hypertrophic Cardiomyopathy: Is There More to it Than Size? JACC Cardiovasc Imaging 2024; 17:498-500. [PMID: 38180415 PMCID: PMC11227108 DOI: 10.1016/j.jcmg.2023.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 11/29/2023] [Indexed: 01/06/2024]
Affiliation(s)
- Jonathan A Pan
- Cardiovascular Division, Department of Medicine, University of Virginia Health System, Charlottesville, Virginia, USA.
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Maron MS, Rowin EJ, Maron BJ. The Paradigm of Sudden Death Prevention in Hypertrophic Cardiomyopathy. Am J Cardiol 2024; 212S:S64-S76. [PMID: 38368038 DOI: 10.1016/j.amjcard.2023.10.076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 10/26/2023] [Indexed: 02/19/2024]
Abstract
Hypertrophic cardiomyopathy (HCM) is a relatively common and, often, inherited cardiac disease, once regarded as largely untreatable with ominous prognosis and, perhaps, most visibly as a common cause of sudden cardiac death (SCD) in the young. However, HCM is now more accurately considered a treatable disease with management options that significantly alter its clinical course. This is particularly true for SCD because the penetration of implantable cardioverter-defibrillators into HCM practice enables primary prevention device therapy that reliably terminates potentially lethal ventricular tachyarrhythmias (3% to 4%/year). This therapeutic advance is largely responsible for >10-fold decrease in the overall disease-related mortality to 0.5%/year, independent of patient age. A guideline-based clinical risk stratification algorithm has evolved, which included variables identifiable with cardiac magnetic resonance: ≥1 risk markers judged major within the clinical profile of an individual patient, associated with a measure of physician judgment and shared decision-making, can be sufficient to consider the recommendation of a prophylactic defibrillator implant. Implantable cardioverter-defibrillator decisions using the American College of Cardiology and the American Heart Association traditional major risk marker strategy are associated with a 95% sensitivity for identifying those patients who subsequently experience appropriate therapy, albeit often 5 to 10+ years after implant but without heart failure deterioration or death after a device intervention. A mathematical SCD risk score proposed by European Society of Cardiology is associated with a relatively low sensitivity (33%) for predicting and preventing SCD events but with potential for less device overtreatment.
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Affiliation(s)
- Martin S Maron
- Lahey Hospital and Medical Center, HCM Center, Burlington, Massachusetts.
| | - Ethan J Rowin
- Lahey Hospital and Medical Center, HCM Center, Burlington, Massachusetts
| | - Barry J Maron
- Lahey Hospital and Medical Center, HCM Center, Burlington, Massachusetts
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Franceschi P, Balducci A, Nardi E, Niro F, Attinà D, Russo V, Donti A, Angeli E, Gargiulo GD, Lovato L. Predictive value of Cardiac Magnetic Resonance: new and old parameters in the natural history of repaired Tetralogy of Fallot. BMC Cardiovasc Disord 2024; 24:15. [PMID: 38172687 PMCID: PMC10765701 DOI: 10.1186/s12872-023-03671-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Accepted: 12/13/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Patients with repaired Tetralogy of Fallot (rTOF) often develop pulmonary regurgitation (PR) and right ventricle (RV) dysfunction, experiencing increased mortality and morbidity rates in adulthood. Pulmonary valve replacement (PVR) timing to address PR is controversial. Cardiac Magnetic Resonance (CMR) is the gold standard for morpho-functional evaluation of complex cardiopathies. This study aims to identify CMR parameters predictive of adverse outcomes to help defining the best therapeutic management of rTOF patients. METHODS 130 rTOF patients who underwent CMR (2006-2019) were enrolled in this retrospective single-center study. CMR, clinical, ECG and exercise data were analyzed. Univariate and multivariate analyses identified clinical and CMR parameters predictive of adverse outcomes both individually (e.g., death, arrhythmias, heart failure (HF), pharmacological therapy, QRS ≥ 160ms) and as composite outcome. RESULTS Univariate analysis confirmed RV volumes and RV ejection fraction corrected for PR as adverse outcome predictors and identified interesting correlations: pulmonary artery bifurcation geometry and abnormal interventricular septum (IVS) motion with arrhythmias (p < .001; p = .037), HF (p = .049; p = .005), composite outcome (p = .039; p = .009); right atrium (RA) dimensions with the composite outcome and the outcomes individually (p < .001). The best predictive models by multivariate analysis included sex (male), RV and RA dilation for QRS ≥ 160ms, time form repair to CMR, age at TOF repair and IVS fibrosis for pharmacological therapy. CONCLUSIONS Besides RV volumes, new adverse prognostic factors could guide rTOF therapeutic management: pulmonary arteries morphology, abnormal IVS motion, RV dysfunction, RA dilation. Perspective multicentric evaluation is needed to specify their effective role.
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Affiliation(s)
- Paola Franceschi
- Pediatric and Adult CardioThoracic and Vascular, Oncohematologic and Emergency Radiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via G. Massarenti, 9, Bologna, 40138, Italy.
| | - A Balducci
- Pediatric Cardiology, Pediatric Cardiac Surgery and Adult Congenital Heart Disease Program, Department of Cardio-Thoracic and Vascular Medicine, IRCCS Azienda Ospedaliero- Universitaria di Bologna, Via G. Massarenti, 9, Bologna, 40138, Italy
| | - E Nardi
- Cardiology Unit, Cardiac Thoracic and Vascular Department, IRCCS Azienda Ospedaliero- Universitaria di Bologna, Via G. Massarenti, 9, Bologna, 40138, Italy
- Department of Surgical and Medical Sciences, University of Bologna, Bologna, Italy
| | - F Niro
- Pediatric and Adult CardioThoracic and Vascular, Oncohematologic and Emergency Radiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via G. Massarenti, 9, Bologna, 40138, Italy
| | - D Attinà
- Pediatric and Adult CardioThoracic and Vascular, Oncohematologic and Emergency Radiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via G. Massarenti, 9, Bologna, 40138, Italy
| | - V Russo
- Pediatric and Adult CardioThoracic and Vascular, Oncohematologic and Emergency Radiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via G. Massarenti, 9, Bologna, 40138, Italy
| | - A Donti
- Pediatric Cardiology, Pediatric Cardiac Surgery and Adult Congenital Heart Disease Program, Department of Cardio-Thoracic and Vascular Medicine, IRCCS Azienda Ospedaliero- Universitaria di Bologna, Via G. Massarenti, 9, Bologna, 40138, Italy
| | - E Angeli
- Pediatric Cardiology, Pediatric Cardiac Surgery and Adult Congenital Heart Disease Program, Department of Cardio-Thoracic and Vascular Medicine, IRCCS Azienda Ospedaliero- Universitaria di Bologna, Via G. Massarenti, 9, Bologna, 40138, Italy
| | - G D Gargiulo
- Pediatric Cardiology, Pediatric Cardiac Surgery and Adult Congenital Heart Disease Program, Department of Cardio-Thoracic and Vascular Medicine, IRCCS Azienda Ospedaliero- Universitaria di Bologna, Via G. Massarenti, 9, Bologna, 40138, Italy
- Department of Surgical and Medical Sciences, University of Bologna, Bologna, Italy
| | - L Lovato
- Pediatric and Adult CardioThoracic and Vascular, Oncohematologic and Emergency Radiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via G. Massarenti, 9, Bologna, 40138, Italy
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Left Ventricular Hypertrophy and Ventricular Tachyarrhythmia: The Role of Biomarkers. Int J Mol Sci 2023; 24:ijms24043881. [PMID: 36835293 PMCID: PMC9958550 DOI: 10.3390/ijms24043881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 02/08/2023] [Accepted: 02/14/2023] [Indexed: 02/17/2023] Open
Abstract
Left ventricular hypertrophy (LVH) refers to a complex rebuilding of the left ventricle that can gradually lead to serious complications-heart failure and life-threatening ventricular arrhythmias. LVH is defined as an increase in the size of the left ventricle (i.e., anatomically), therefore the basic diagnosis detecting the increase in the LV size is the domain of imaging methods such as echocardiography and cardiac magnetic resonance. However, to evaluate the functional status indicating the gradual deterioration of the left ventricular myocardium, additional methods are available approaching the complex process of hypertrophic remodeling. The novel molecular and genetic biomarkers provide insights on the underlying processes, representing a potential basis for targeted therapy. This review summarizes the spectrum of the main biomarkers employed in the LVH valuation.
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Chen Y, Zhao X, Yuan J, Zhang Y, Liu W, Qiao S. Preoperative myocardial fibrosis is associated with worse survival after alcohol septal ablation in patients with hypertrophic obstructive cardiomyopathy: A delayed enhanced cardiac magnetic resonance study. Front Cardiovasc Med 2022; 9:924804. [PMID: 36035960 PMCID: PMC9403173 DOI: 10.3389/fcvm.2022.924804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 07/20/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundPrior studies have shown that myocardial fibrosis can be detected by late gadolinium enhancement (LGE) of cardiac magnetic resonance (CMR) and might be associated with higher mortality risk in hypertrophic cardiomyopathy (HCM). The objective of this study was to examine the prognostic utility of CMR in patients with hypertrophic obstructive cardiomyopathy (HOCM) undergoing alcohol septal ablation (ASA).Materials and methodsWe conducted a retrospective study which consisted of 183 consecutive patients with symptomatic drug-refractory HOCM who underwent CMR for assessment of myocardial fibrosis before ASA. The cardiovascular disease related survival was evaluated according to LGE-CMR status.ResultsThe cohort comprised 74 (40.4%) women with a mean age of 51 ± 8 years. Preoperative myocardial fibrosis was detected in 148 (80.9%) patients. After a median of 6 years (range 2–11 years) follow-up, adverse clinical events occurred in 14 (7.7%) patients. Multivariate-adjusted Cox regression analyses revealed that age [hazard ratio (HR) 1.142 (1.059–1.230), p = 0.001] and LGE [HR 1.170 (1.074–1.275), p < 0.001] were independent predictors of cardiovascular mortality during follow-up.ConclusionPreoperative myocardial fibrosis measured by LGE-CMR was an independent predictor of increased adverse clinical outcomes in patients with HOCM undergoing ASA and could be used for the pre-operative evaluation of risk stratification and long-term prognosis after ASA in these patients.
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Affiliation(s)
- Youzhou Chen
- Department of Cardiology, Beijing Jishuitan Hospital, Beijing, China
- *Correspondence: Youzhou Chen,
| | - Xingshan Zhao
- Department of Cardiology, Beijing Jishuitan Hospital, Beijing, China
| | - Jiansong Yuan
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yan Zhang
- Department of Magnetic Resonance Imaging, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wei Liu
- Department of Cardiology, Beijing Jishuitan Hospital, Beijing, China
- Wei Liu,
| | - Shubin Qiao
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Shubin Qiao,
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Karabinowska-Małocha A, Dziewięcka E, Banyś P, Urbańczyk-Zawadzka M, Krupiński M, Mielnik M, Łach J, Budkiewicz A, Podolec P, Żydzik Ł, Wiśniowska-Śmiałek S, Holcman K, Kostkiewicz M, Rubiś P. The Relationship between Cardiac Magnetic Resonance-Assessed Replacement and Interstitial Fibrosis and Ventricular Arrhythmias in Hypertrophic Cardiomyopathy. J Pers Med 2022; 12:jpm12020294. [PMID: 35207782 PMCID: PMC8876292 DOI: 10.3390/jpm12020294] [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: 12/06/2021] [Revised: 02/07/2022] [Accepted: 02/10/2022] [Indexed: 02/04/2023] Open
Abstract
Non-sustained ventricular tachycardia (nsVT) creates the electrical basis for sudden cardiac death (SCD) in hypertrophic cardiomyopathy (HCM). We aimed to evaluate the relationship between interstitial fibrosis on cardiac magnetic resonance (CMR) and nsVT in HCM. A total of 50 HCM patients underwent CMR with a 3 T scanner to determine the presence of replacement fibrosis expressed by late gadolinium enhancement (LGE), and interstitial fibrosis expressed by native T₁, post-contrast T₁, and extracellular volume (ECV). The incidence of nsVT was assessed by Holter monitoring. We detected nsVT in 14 (28%) out of 50 HCM patients. Replacement fibrosis expressed by LGE was present in 37 (74%) patients and only showed a trend towards a differentiation between the groups with and without nsVT (p = 0.07). However, the extent of LGE was clearly higher in the nsVT group (3.8 ± 4.9% vs. 7.94 ± 4.5%, p = 0.002) and was an independent predictor of nsVT in a multivariable regression analysis (OR 1.2; 95%CI 1.02–1.4; p = 0.02). No relationship was observed between interstitial fibrosis and nsVT. To conclude, it was found that it is not the mere presence but the actual extent of LGE that determines the occurrence of nsVT in HCM patients; the role of interstitial fibrosis remains unclear.
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Affiliation(s)
- Aleksandra Karabinowska-Małocha
- Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, John Paul II Hospital, Prądnicka Street 80, 31-202 Krakow, Poland; (E.D.); (J.Ł.); (P.P.); (S.W.-Ś.); (K.H.); (M.K.); (P.R.)
- Correspondence: ; Tel.: +48-12-614-22-87
| | - Ewa Dziewięcka
- Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, John Paul II Hospital, Prądnicka Street 80, 31-202 Krakow, Poland; (E.D.); (J.Ł.); (P.P.); (S.W.-Ś.); (K.H.); (M.K.); (P.R.)
| | - Paweł Banyś
- Department of Radiology, John Paul II Hospital, Prądnicka Street 80, 31-202 Krakow, Poland; (P.B.); (M.U.-Z.); (M.K.); (M.M.)
| | - Małgorzata Urbańczyk-Zawadzka
- Department of Radiology, John Paul II Hospital, Prądnicka Street 80, 31-202 Krakow, Poland; (P.B.); (M.U.-Z.); (M.K.); (M.M.)
| | - Maciej Krupiński
- Department of Radiology, John Paul II Hospital, Prądnicka Street 80, 31-202 Krakow, Poland; (P.B.); (M.U.-Z.); (M.K.); (M.M.)
| | - Małgorzata Mielnik
- Department of Radiology, John Paul II Hospital, Prądnicka Street 80, 31-202 Krakow, Poland; (P.B.); (M.U.-Z.); (M.K.); (M.M.)
| | - Jacek Łach
- Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, John Paul II Hospital, Prądnicka Street 80, 31-202 Krakow, Poland; (E.D.); (J.Ł.); (P.P.); (S.W.-Ś.); (K.H.); (M.K.); (P.R.)
| | - Aleksandra Budkiewicz
- Students’ Scientific Group on Heart Failure, at the Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, John Paul II Hospital, Prądnicka Street 80, 31-202 Krakow, Poland; (A.B.); (Ł.Ż.)
| | - Piotr Podolec
- Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, John Paul II Hospital, Prądnicka Street 80, 31-202 Krakow, Poland; (E.D.); (J.Ł.); (P.P.); (S.W.-Ś.); (K.H.); (M.K.); (P.R.)
| | - Łukasz Żydzik
- Students’ Scientific Group on Heart Failure, at the Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, John Paul II Hospital, Prądnicka Street 80, 31-202 Krakow, Poland; (A.B.); (Ł.Ż.)
| | - Sylwia Wiśniowska-Śmiałek
- Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, John Paul II Hospital, Prądnicka Street 80, 31-202 Krakow, Poland; (E.D.); (J.Ł.); (P.P.); (S.W.-Ś.); (K.H.); (M.K.); (P.R.)
| | - Katarzyna Holcman
- Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, John Paul II Hospital, Prądnicka Street 80, 31-202 Krakow, Poland; (E.D.); (J.Ł.); (P.P.); (S.W.-Ś.); (K.H.); (M.K.); (P.R.)
| | - Magdalena Kostkiewicz
- Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, John Paul II Hospital, Prądnicka Street 80, 31-202 Krakow, Poland; (E.D.); (J.Ł.); (P.P.); (S.W.-Ś.); (K.H.); (M.K.); (P.R.)
| | - Paweł Rubiś
- Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, John Paul II Hospital, Prądnicka Street 80, 31-202 Krakow, Poland; (E.D.); (J.Ł.); (P.P.); (S.W.-Ś.); (K.H.); (M.K.); (P.R.)
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Song C, Zhang Y, Zheng X, Lu J, Fang X, Wang S, Huang X. Relation of Mitral Leaflet Elongation to Nonsustained Ventricular Tachycardia in Patients with Obstructive Hypertrophic Cardiomyopathy. Am J Cardiol 2021; 158:112-117. [PMID: 34465462 DOI: 10.1016/j.amjcard.2021.07.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 07/01/2021] [Accepted: 07/01/2021] [Indexed: 12/07/2022]
Abstract
The impact of mitral valve abnormality on the occurrence of non-sustained ventricular tachycardia (NSVT) in patients with hypertrophic cardiomyopathy (HC) has not been well determined. We sought to demonstrate the relation of mitral valve abnormalities with NSVT in patients with obstructive HC. Three hundred and sixteen adult patients with obstructive HC with at least 1 Holter electrocardiographic monitoring and cardiac magnetic resonance (CMR) from 2014 to 2018 were enrolled. CMR images and Holter electrocardiography were analyzed in all patients. NSVT occurred in 50 patients (16%). Compared with those without NSVT, anterior mitral leaflet and posterior mitral leaflet lengths was significantly increased in patients with NSVT (AML 32.0 ± 5.0mm vs. 26.1±4.8mm, p<0.001; PML 17.7±3.7mm vs. 15.2±2.7mm, p<0.001, respectively). Multivariate logistic regression analysis indicated that elongated AML and PML were significantly independent predictors of NSVT (AML: OR 1.261, 95%CI 1.156-1.375, p<0.001; PML: OR 1.126, 95%CI 1.001-1.265, p=0.047). Furthermore, the area under the receiver operating characteristic curve for AML was 0.812. At a cutoff valve of 27.5mm, AML length had a sensitivity of 86% and specificity of 65%. Elongated mitral leaflets independently correlated with NSVT in patients with obstructive HC. Furthermore, the morphological abnormalities of mitral valve could serve as a useful marker for improving risk stratification of SCD and may play a role in optimizing surgical strategy for patients with obstructive HC.
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Safabakhsh S, Du D, Liew J, Parker J, McIlroy C, Khasanova E, Indraratna P, Blanke P, Leipsic J, Andrade JG, Bennett MT, Hawkins NM, Chakrabarti S, Yeung J, Deyell MW, Krahn AD, Moss R, Ong K, Laksman Z. Bluetooth-enabled implantable cardiac monitors and two-way smartphone communication for patients with hypertrophic cardiomyopathy. CJC Open 2021; 4:305-314. [PMID: 35386128 PMCID: PMC8978112 DOI: 10.1016/j.cjco.2021.10.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 10/28/2021] [Indexed: 01/10/2023] Open
Abstract
Background Sudden cardiac death (SCD) risk stratification in hypertrophic cardiomyopathy (HCM) currently relies on arrhythmic burden quantification by 24 or 48-hour Holter monitoring. Whether this approach adequately captures arrhythmic burden, compared with longer-term continuous monitoring, is unclear. We sought to assess the long-term incidence of nonsustained ventricular tachycardia (NSVT) in HCM patients at low or moderate SCD risk, using implantable cardiac monitors (ICMs) paired with a novel Bluetooth-enabled 2-way communication platform. Methods This prospective, single-arm, observational study enrolled 33 HCM patients. Patients were implanted with an Abbott (Chicago, IL) Confirm Rx ICM and monitored using a protocolized care pathway. Results A total of 20 patients (60.6%) had ≥ 1 episode of NSVT recorded on the ICM, the majority of whom had previous Holter monitors that did not identify NSVT (60%, n = 12). A total of 71 episodes of NSVT were detected. Median time to first NSVT detection was 76.5 days (range: 0-553 days). A total of 19 patients underwent primary prevention implantable cardioverter defibrillator implantation during an average follow-up of 544 days (range: 42-925 days). A total of 172,112 automatic transmissions were received, and 65 (0.04%) required clinical follow-up. A total of 325 manual transmissions were received and managed. A total of 14 manual transmissions (4.3%) required follow-up, whereas 311 (95.7%) were managed solely with a text message. Conclusions Surveillance and reporting systems utilizing 2-way communication enabled by novel ICMs are feasible and allow remote management of patients with HCM. Prolonged monitoring with ICMs identified more patients with nonsustained arrythmias than did standard Holter monitoring. In many cases, this information impacted both SCD risk stratification and patient management.
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Affiliation(s)
- Sina Safabakhsh
- Centre for Cardiovascular Innovation, Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Darson Du
- Centre for Cardiovascular Innovation, Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Janet Liew
- Centre for Cardiovascular Innovation, Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jeremy Parker
- Centre for Cardiovascular Innovation, Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Cheryl McIlroy
- Centre for Cardiovascular Innovation, Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Elina Khasanova
- Division of Radiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Praveen Indraratna
- Division of Radiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Philipp Blanke
- Division of Radiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jonathon Leipsic
- Division of Radiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jason G. Andrade
- Centre for Cardiovascular Innovation, Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Matthew T. Bennett
- Centre for Cardiovascular Innovation, Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Nathaniel M. Hawkins
- Centre for Cardiovascular Innovation, Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Shantabanu Chakrabarti
- Centre for Cardiovascular Innovation, Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - John Yeung
- Centre for Cardiovascular Innovation, Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Marc W. Deyell
- Centre for Cardiovascular Innovation, Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Andrew D. Krahn
- Centre for Cardiovascular Innovation, Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Robert Moss
- Centre for Cardiovascular Innovation, Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Kevin Ong
- Centre for Cardiovascular Innovation, Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Zachary Laksman
- Centre for Cardiovascular Innovation, Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
- Corresponding author: Dr Zachary Laksman, 211-1033 Davie St, Vancouver, British Columbia V6E 1M7, Canada. Tel.: +1-604-608-8256; fax: +1-604-706-8723.
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Schleihauf J, Cleuziou J, Meierhofer C, Klingel K, Jesinghaus M, Kaltenecker E, Ewert P, Wolf CM. No increased extracellular volume fraction or conduction time after childhood septal myectomy. Eur J Cardiothorac Surg 2021; 57:958-964. [PMID: 31951249 DOI: 10.1093/ejcts/ezz356] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 11/14/2019] [Accepted: 11/29/2019] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES The aim of this study was to assess the effect of surgical septal myectomy performed during early childhood for severe, drug-refractory hypertrophic cardiomyopathy with left ventricular outflow tract obstruction on the extent of septal myocardial extracellular volume fraction and the potential risk of developing atrioventricular cardiac conduction system disease. METHODS In this retrospective study, data from 30 patients with a confirmed diagnosis of childhood-onset hypertrophic cardiomyopathy were reviewed including cardiovascular magnetic resonance (CMR) with myocardial T1 mapping and late gadolinium enhancement, histopathology of myocardial specimens, transthoracic echocardiography, electrocardiography, 24-h Holter and cardiopulmonary exercise testing. Eighteen patients without were compared to 12 patients with prior septal myectomy performed during childhood (non-operated versus myectomy patients). RESULTS Late gadolinium enhancement on CMR as a correlate for focal myocardial fibrosis was found in 53% of patients, predominantly located in the septal region, with no difference between groups. As compared to non-operated patients, those after myectomy showed a similar amount of total and septal extracellular volume fraction, as calculated from pre- and post-contrast CMR T1 mapping, which is a correlate for diffuse interstitial myocardial fibrosis. PQ-intervals or the occurrence of higher degree conduction system disease were equal between the 2 groups. CONCLUSIONS Data from CMR and electrocardiography suggest that surgical septal myectomy performed during early childhood for severe obstructive hypertrophic cardiomyopathy does not cause an increased septal extracellular volume fraction or delayed atrioventricular conduction time on long-term follow-up.
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Affiliation(s)
- Julia Schleihauf
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Julie Cleuziou
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Christian Meierhofer
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Karin Klingel
- Department of Cardiopathology, Institute for Pathology and Neuropathology, University Hospital Tuebingen, Tuebingen, Germany
| | - Moritz Jesinghaus
- Institute of Pathology, TUM School of Medicine, Technical University Munich, Munich, Germany
| | - Emanuel Kaltenecker
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Peter Ewert
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Cordula M Wolf
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technical University of Munich, Munich, Germany
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Qin L, Chen C, Gu S, Zhou M, Xu Z, Ge Y, Yan F, Yang W. A radiomic approach to predict myocardial fibrosis on coronary CT angiography in hypertrophic cardiomyopathy. Int J Cardiol 2021; 337:113-118. [PMID: 33961944 DOI: 10.1016/j.ijcard.2021.04.060] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 04/21/2021] [Accepted: 04/28/2021] [Indexed: 01/14/2023]
Abstract
BACKGROUND Late gadolinium enhancement (LGE) derived from cardiac magnetic resonance (CMR) represents myocardial fibrosis (MF) and is associated with prognosis in hypertrophic cardiomyopathy (HCM). However, it cannot be evaluated when CMR is unavailable. Hence, we aimed to investigate the ability of radiomic features derived from coronary computed tomography angiography (CCTA) to detect the presence and extent of MF in HCM, with LGE as references. METHODS 161 patients with HCM who underwent CCTA and CMR were retrospectively enrolled and randomly divided into training (107 patients, 1712 segments) and testing cohorts (54 patients, 864 segments). Segments were obtained according to AHA 17-segment method. Radiomic features were extracted from per-segment and entire myocardium regions, and multiple machine-learning algorithms were used for radiomic signatures (Rad-sig) generation and model building. Four models were established by multivariable logistic regression using Rad-sig (R-model), clinical characteristic (C-model), echocardiography parameters (E-model), and all features integrated (Integ-model) to identify LGE/left ventricular mass ≥ 15%. RESULTS The model achieved good diagnostic accuracy in both training (area under the curve [AUC]:0.81, 95% confidence interval [CI]: 0.78-0.83) and testing cohort (AUC: 0.78, 95%CI: 0.75-0.81) on a per-segment basis for the presence of MF. The Integ-model owned the highest discriminative ability for patients with LGE/left ventricular mass ≥ 15% in both training and testing cohorts with AUC of 0.94 (95%CI: 0.89-0.98) and 0.92 (95%CI: 0.85-0.99), respectively. CONCLUSIONS Our radiomic models were considered as useful and complementary biomarkers for the evaluation of the presence and extent of MF on CCTA, facilitating clinical decision-making and risk stratification in HCM patients.
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Affiliation(s)
- Le Qin
- Department of Radiology, Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine, No. 197 Ruijin 2nd Rd, Shanghai 200025, China
| | - Chihua Chen
- Department of Radiology, Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine, No. 197 Ruijin 2nd Rd, Shanghai 200025, China
| | - Shengjia Gu
- Department of Radiology, Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine, No. 197 Ruijin 2nd Rd, Shanghai 200025, China
| | - Mi Zhou
- Department of Cardiovascular Surgery, Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine, No. 197 Ruijin 2nd Rd, Shanghai 200025, China
| | - Zhihan Xu
- Siemens Healthcare Ltd., No. 278 Zhouzhu Road, Shanghai 201318, China
| | - Yingqian Ge
- Siemens Healthcare Ltd., No. 278 Zhouzhu Road, Shanghai 201318, China
| | - Fuhua Yan
- Department of Radiology, Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine, No. 197 Ruijin 2nd Rd, Shanghai 200025, China
| | - Wenjie Yang
- Department of Radiology, Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine, No. 197 Ruijin 2nd Rd, Shanghai 200025, China.
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Evolution of risk stratification and sudden death prevention in hypertrophic cardiomyopathy: Twenty years with the implantable cardioverter-defibrillator. Heart Rhythm 2021; 18:1012-1023. [PMID: 33508516 DOI: 10.1016/j.hrthm.2021.01.019] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 01/14/2021] [Accepted: 01/20/2021] [Indexed: 11/21/2022]
Abstract
Hypertrophic cardiomyopathy (HCM) is a relatively common inherited myocardial disorder, once regarded as largely untreatable with ominous prognosis and most visibly as a common cause of sudden death (SD) in the young. Over the last several years, HCM has been transformed into a contemporary treatable disease with management options that significantly alter clinical course. With the use of implantable cardioverter-defibrillators (ICDs) in the HCM patient population, a new paradigm has emerged, with primary prevention device therapy reliably terminating potentially lethal ventricular tachyarrhythmias (3%-4% per year) and being largely responsible for a >10-fold decrease in disease-related mortality (to 0.5% per year), independent of age. An evidenced-based and guideline directed clinical risk stratification algorithm has evolved, including variables identified with cardiac magnetic resonance. One or more risk markers judged major and relevant within a patient's clinical profile can be considered sufficient to recommend a primary prevention implant (associated with a measure of physician judgment and shared decision-making). ICD decisions using the prospective individual risk marker strategy have been associated with 95% sensitivity for identifying patients who subsequently experienced appropriate ICD therapy, (albeit often delayed substantially for >5 or >10 years after implant), but without heart failure deterioration or HCM death following device intervention. A rigid mathematically derived statistical risk model proposed by the European Society of Cardiology is associated with low sensitivity (ie, 33%) for predicting SD events. Introduction of prophylactically inserted ICDs to HCM 20 years ago has significantly altered the clinical course and landscape of this disease. SD prevention has reduced HCM mortality significantly, making preservation of life and the potential for normal longevity a reality for most patients.
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Progression of Myocardial Fibrosis in Hypertrophic Cardiomyopathy: A Cardiac Magnetic Resonance Study. JACC Cardiovasc Imaging 2020; 14:947-958. [PMID: 33248971 DOI: 10.1016/j.jcmg.2020.09.037] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 09/04/2020] [Accepted: 09/21/2020] [Indexed: 11/21/2022]
Abstract
OBJECTIVES This study examined fibrosis progression in hypertrophic cardiomyopathy (HCM) patients, as well as its relationship to patient characteristics, clinical outcomes, and its effect on clinical decision making. BACKGROUND Myocardial fibrosis, as quantified by late gadolinium enhancement (LGE) in cardiac magnetic resonance (CMR), provides valuable prognostic information in patients with HCM. METHODS A total of 157 patients with HCM were enrolled in this study, with 2 sequential CMR scans separated by an interval of 4.7 ± 1.9 years. RESULTS At the first CMR session (CMR-1), 70% of patients had LGE compared with 85% at CMR-2 (p = 0.001). The extent of LGE extent increased between the 2 CMR procedures, from 4.0 ± 5.6% to 6.3 ± 7.4% (p < 0.0001), with an average LGE progression rate of 0.5 ± 1.0%/year. LGE mass progression was correlated with higher LGE mass and extent on CMR-1 (p = 0.0017 and p = 0.007, respectively), greater indexed left ventricular (LV) mass (p < 0.0001), greater LV maximal wall thickness (p < 0.0001), apical aneurysm at CMR-1 (p < 0.0001), and lower LV ejection fraction (EF) (p = 0.029). Patients who were more likely to have a higher rate of LGE progression presented with more severe disease at baseline, characterized by LGE extent >8% of LV mass, indexed LV mass >100 g/m2, maximal wall thickness ≥20 mm, LVEF ≤60%, and apical aneurysm. There was a significant correlation between the magnitude of LGE progression and future implantation of insertable cardioverter-defibrillators (p = 0.004), EF deterioration to ≤50% (p < 0.0001), and admission for heart failure (p = 0.0006). CONCLUSIONS Myocardial fibrosis in patients with HCM is a slowly progressive process. Progression of LGE is significantly correlated with a number of clinical outcomes such as progression to EF ≤50% and heart failure admission. Judicious use of serial CMR with LGE can provide valuable information to help patient management.
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Rrapo Kaso E, Kramer CM. Multimodality Imaging for Hypertrophic Cardiomyopathy. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2020. [DOI: 10.1007/s11936-020-00827-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Liu L, Liu S, Shen L, Tu B, Hu Z, Hu F, Zheng L, Ding L, Fan X, Yao Y. Correlations between cardiac troponin I and nonsustained ventricular tachycardia in hypertrophic obstructive cardiomyopathy. Clin Cardiol 2020; 43:1150-1159. [PMID: 32810305 PMCID: PMC7534013 DOI: 10.1002/clc.23425] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 06/22/2020] [Accepted: 07/10/2020] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Nonsustained ventricular tachycardia (NSVT) is an independent risk factor for sudden cardiac death (SCD) in patients with hypertrophic obstructive cardiomyopathy (HOCM). However, data concerning the correlations of cardiac biomarkers and NSVT in HOCM are rather limited. HYPOTHESIS Our study aimed to investigate the associations between the occurrence of NSVT and circulating biomarkers representing myocardial injury (cardiac troponin I, cTnI), cardiac function (N-terminal pro-brain natriuretic peptide, NT-pro BNP), and inflammation (high-sensitivity C-reactive protein) in a large Chinese HOCM cohort. METHODS A total of 755 consecutive HOCM patients were recruited. Systematic cardiac evaluations and circulating biomarkers were examined routinely in all subjects under the clinically stable status. According to the results of 24-hour Holter monitoring, patients were divided into the NSVT group (n = 138) and the nonventricular tachycardia (non-VT) group (n = 617). RESULTS Compared with the non-VT group, circulating levels of both cTnI and NT-pro BNP elevated significantly in patients with positive NSVT episodes (P < .001). Multivariable analyses demonstrated that cTnI was independently associated with the presence of NSVT (OR = 1.675, 95% CI: 1.406-1.994, P < .001). Concentrations of cTnI increased progressively not only with the aggravation of ventricular arrhythmic events (P < .001), but also with the growing risk of SCD in HOCM patients (P < .001). Serum cTnI ≥ 0.0265 ng/mL indicated predictive value for the occurrence of NSVT in the HOCM cohort (area under the curve = 0.707, 95% CI: 0.660-0.754, P < .001). CONCLUSIONS Elevated cTnI was an independent determinant of NSVT, and it seemed to be valuable for assessing the clinical status of ventricular arrhythmias and the risk of SCD in patients with HOCM.
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Affiliation(s)
- Limin Liu
- Clinical EP Lab & Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shangyu Liu
- Clinical EP Lab & Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lishui Shen
- Clinical EP Lab & Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bin Tu
- Clinical EP Lab & Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhicheng Hu
- Clinical EP Lab & Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Feng Hu
- Clinical EP Lab & Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lihui Zheng
- Clinical EP Lab & Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ligang Ding
- Clinical EP Lab & Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaohan Fan
- Clinical EP Lab & Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yan Yao
- Clinical EP Lab & Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Vajapey R, Eck B, Tang W, Kwon DH. Advances in MRI Applications to Diagnose and Manage Cardiomyopathies. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2019; 21:74. [PMID: 31773390 DOI: 10.1007/s11936-019-0762-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW The prevalence of heart failure continues to rise, and imaging characterization of the cardiomyopathic process is important for identifying myocardial disease, initiating appropriate treatment, and improving outcomes. We aimed to summarize recent advances in cardiac magnetic resonance imaging (CMR) applications for the diagnosis, characterization, and implications on management of various cardiomyopathies. RECENT FINDINGS Parametric mapping by CMR has emerged as an important advancement in quantification of myocardial fibrosis, increased extracellular space, and myocardial edema. In addition, improved assessment of myocardial function with myocardial strain assessment may provide early identification of patients at risk and determining responsiveness to therapeutic interventions. Novel MRI techniques and the advent of artificial intelligence may help to uncover important mechanistic insights into the cardiomyopathic process. Innovative CMR techniques continue to evolve, and it will be of interest to determine how these advances can be incorporated into clinical practice to improve diagnosis, treatment, and management of patients with cardiomyopathies.
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Affiliation(s)
- Ramya Vajapey
- Cleveland Clinic, Heart and Vascular Institute, Cleveland, OH, USA
| | - Brendan Eck
- Cleveland Clinic, Heart and Vascular Institute, Cleveland, OH, USA
| | - Wilson Tang
- Cleveland Clinic, Heart and Vascular Institute, Cleveland, OH, USA
| | - Deborah H Kwon
- Cleveland Clinic, Heart and Vascular Institute, Cleveland, OH, USA. .,Department of Cardiovascular Medicine, Cleveland Clinic, Imaging Institute, 9500 Euclid Avenue, Desk J1-5, Cleveland, OH, 44195, USA.
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Eijgenraam TR, Silljé HHW, de Boer RA. Current understanding of fibrosis in genetic cardiomyopathies. Trends Cardiovasc Med 2019; 30:353-361. [PMID: 31585768 DOI: 10.1016/j.tcm.2019.09.003] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 09/13/2019] [Accepted: 09/17/2019] [Indexed: 12/13/2022]
Abstract
Myocardial fibrosis is the excessive deposition of extracellular matrix proteins, including collagens, in the heart. In cardiomyopathies, the formation of interstitial fibrosis and/or replacement fibrosis is almost always part of the pathological cardiac remodeling process. Different forms of cardiomyopathies show particular patterns of myocardial fibrosis that can be considered as distinctive hallmarks. Although formation of fibrosis is initially aimed to be a reparative mechanism, in the long term, on-going and excessive myocardial fibrosis may lead to arrhythmias and stiffening of the heart wall and subsequently to diastolic dysfunction. Ultimately, adverse remodeling with progressive myocardial fibrosis can lead to heart failure. Not surprisingly, the presence of fibrosis in cardiomyopathies, even when subtle, has consistently been associated with complications and adverse outcomes. In the last decade, non-invasive in vivo techniques for visualization of myocardial fibrosis have emerged, and have been increasingly used in research and in the clinic. In this review, we will describe the epidemiology, distribution, and role of myocardial fibrosis in genetic cardiomyopathies, including hypertrophic, dilated, arrhythmogenic, and non-compaction cardiomyopathy, and a few specific forms of genetic cardiomyopathies.
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Affiliation(s)
- Tim R Eijgenraam
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Antonius Deusinglaan 1, 9713 AV Groningen, the Netherlands
| | - Herman H W Silljé
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Antonius Deusinglaan 1, 9713 AV Groningen, the Netherlands
| | - Rudolf A de Boer
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Antonius Deusinglaan 1, 9713 AV Groningen, the Netherlands.
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Abstract
Hypertrophic cardiomyopathy (HCM) is a worldwide genetic heart disease and a common cause of sudden death in the young. Penetration of the implantable cardioverter-defibrillator (ICD) into this patient population over the past 20 years has made accurate selection of patients for primary prevention ICDs a priority. Consequently, a new paradigm has emerged in the management of this complex disease with ICD therapy responsible for a substantial decrease in overall HCM-related mortality (to 0.5%/y) and independent of patient age. Selection of candidates for ICDs has matured substantially with the formulation of an enhanced risk stratification algorithm. One or more contemporary risk markers judged major within a given patient’s clinical profile, in association with physician judgment and shared decision-making, is sufficient to consider a primary prevention ICD implant. An enhanced American College of Cardiology/American Heart Association risk factor model (including new contrast-magnetic resonance–based markers, such as left ventricular apical aneurysm) used prospectively to make ICD decisions proved to be 95% sensitive for identifying patients who would experience ≥1 appropriate device therapies terminating ventricular tachycardia/fibrillation. The number of HCM patients required to treat with ICDs to save 1 patient with abolition of lethal ventricular tachyarrhythmias was 6:1, similar to randomized defibrillator trials in other cardiomyopathies. In contrast to patients with ischemic heart disease, after ICD shock HCM patients rarely experience transformation to heart failure deterioration or sudden arrhythmic death. The mathematically derived risk score model proposed by the European Society of Cardiology was inferior for identifying high-risk patients susceptible to arrhythmic sudden death with a sensitivity of only 33%, leaving many patients exposed to the possibility of sudden death without ICDs. In conclusion, introduction of the ICD associated with a matured risk stratification algorithm has altered management strategy and clinical course of many HCM patients, making the likelihood of sudden death prevention a reality and fulfilling the aspiration of preservation of life and reduced mortality for this vulnerable patient population.
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Affiliation(s)
- Barry J. Maron
- From the HCM Institute, Division of Cardiology, Tufts Medical Center, Boston, MA
| | - Ethan J. Rowin
- From the HCM Institute, Division of Cardiology, Tufts Medical Center, Boston, MA
| | - Martin S. Maron
- From the HCM Institute, Division of Cardiology, Tufts Medical Center, Boston, MA
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Abstract
PURPOSE OF REVIEW This review discusses the basic and evolving echocardiographic and cardiac magnetic resonance (CMR) approaches in the diagnosis and management of patients with hypertrophic cardiomyopathy (HCM). RECENT FINDINGS Newer imaging technologies and techniques in both echocardiography and CMR have proved to add incremental value to our understanding of HCM. 3D reconstruction in echocardiography and CMR allows for more accurate morphological and volumetric assessment of the left ventricle. Echocardiographic and CMR-based left atrial assessment, including for its mechanical properties, has been shown to be correlated to outcomes and development of atrial fibrillation. Tissue characterization and scar burden quantification by late gadolinium enhancement on CMR has revolutionized our understanding of fibrotic processes in HCM and their contribution to disease severity and clinical outcomes. Cardiac imaging plays a crucial role in HCM patients. Using echocardiography and CMR as complementary modalities allows for improved diagnostics, optimization of treatment, and better prognostication.
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