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Fumagalli C, Zocchi C, Ciabatti M, Milazzo A, Cappelli F, Fumagalli S, Pieroni M, Olivotto I. From Atrial Fibrillation Management to Atrial Myopathy Assessment: The Evolving Concept of Left Atrium Disease in Hypertrophic Cardiomyopathy. Can J Cardiol 2024; 40:876-886. [PMID: 38286174 DOI: 10.1016/j.cjca.2024.01.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 01/21/2024] [Accepted: 01/23/2024] [Indexed: 01/31/2024] Open
Abstract
Hypertrophic cardiomyopathy (HCM) is the most prevalent genetically inherited cardiovascular disorder in adults and a significant cause of heart failure and sudden cardiac death. Historically, atrial fibrillation (AF) has been considered as a critical aspect in HCM patients as it is considered to be a marker of disease progression, escalates the frequency of heart failure hospitalisations, increases the risk of thromboembolic events, and worsens quality of life and outcome. Increasing evidence suggests that AF is the result of a subtle long-standing process that starts early in the history of HCM. The process of left atrial dilation accompanied by morphologic and functional remodelling is the quintessential prerequisite for the onset of AF. This review aims to describe the current understanding of AF pathophysiology in HCM, emphasising the role of left atrial myopathy in its development. In addition, we discuss risk factors and management strategies specific to AF in the context of HCM, providing insights into the complexities and challenges of treating this specific patient population.
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Affiliation(s)
- Carlo Fumagalli
- Cardiomyopathy Unit, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy; Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli," Naples, Italy.
| | - Chiara Zocchi
- Cardiomyopathy Unit, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy; Cardiovascular Department, San Donato Hospital, Arezzo, Italy
| | | | - Alessandra Milazzo
- Cardiomyopathy Unit, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Francesco Cappelli
- Cardiomyopathy Unit, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Stefano Fumagalli
- Geriatric Intensive Care Unit and Geriatric Arrhythmia Unit, Department of Experimental and Clinical Medicine, University of Florence and AOU Careggi, Florence, Italy
| | | | - Iacopo Olivotto
- Cardiomyopathy Unit, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy; Meyer Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Florence, Italy
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2
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Baswaraj D, Flaker G. Syncope in Athletes: A Prelude to Sudden Cardiac Death? MISSOURI MEDICINE 2024; 121:52-59. [PMID: 38404441 PMCID: PMC10887456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Abstract
Athletes are generally healthy but might have certain cardiac disorders which might, during athletic participation or training, result in cardiac symptoms including syncope. Vasovagal syncope is probably the most common cause of syncope in athletes, but syncope in the context of these cardiac disorders might be a warning of sudden death.
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Affiliation(s)
- Deepa Baswaraj
- Chief Fellow in Cardiovascular Disease, Department of Medicine, University of Missouri - Columbia School of Medicine, Columbia, Missouri
| | - Greg Flaker
- Division of Cardiolog, Department of Medicine, University of Missouri - Columbia School of Medicine, Columbia, Missouri
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3
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Goette A, Kalman JM, Aguinaga L, Akar J, Cabrera JA, Chen SA, Chugh SS, Corradi D, D'Avila A, Dobrev D, Fenelon G, Gonzalez M, Hatem SN, Helm R, Hindricks G, Ho SY, Hoit B, Jalife J, Kim YH, Lip GYH, Ma CS, Marcus GM, Murray K, Nogami A, Sanders P, Uribe W, Van Wagoner DR, Nattel S. EHRA/HRS/APHRS/SOLAECE expert consensus on Atrial cardiomyopathies: Definition, characterisation, and clinical implication. J Arrhythm 2016; 32:247-78. [PMID: 27588148 PMCID: PMC4996910 DOI: 10.1016/j.joa.2016.05.002] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Affiliation(s)
- Andreas Goette
- Departement of Cardiology and Intensive Care Medicine, St. Vincenz-Hospital Paderborn, Working Group: Molecular Electrophysiology, University Hospital Magdeburg, Germany
| | - Jonathan M Kalman
- University of Melbourne, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | | | | | | | | | - Sumeet S Chugh
- The Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | | | | | - Dobromir Dobrev
- Institute of Pharmacology, West German Heart and Vascular Center, University Duisburg-Essen, Essen, Germany
| | | | - Mario Gonzalez
- Penn State Heart and Vascular Institute, Penn State University, Hershey, PA, USA
| | - Stephane N Hatem
- Department of Cardiology, Assistance Publique - Hô pitaux de Paris, Pitié-Salpêtrière Hospital, Sorbonne University, INSERM UMR_S1166, Institute of Cardiometabolism and Nutrition-ICAN, Paris, France
| | - Robert Helm
- Boston University School of Medicine, Boston Medical Center, Boston, MA, USA
| | | | - Siew Yen Ho
- Royal Brompton Hospital and Imperial College London, London, UK
| | - Brian Hoit
- UH Case Medical Center, Cleveland, OH, USA
| | | | | | | | | | | | | | | | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - William Uribe
- Electrophysiology Deparment at Centros Especializados de San Vicente Fundació n and Clínica CES. Universidad CES, Universidad Pontificia Bolivariana (UPB), Medellin, Colombia
| | | | - Stanley Nattel
- Université de Montréal, Montreal Heart Institute Research Center and McGill University, Montreal, Quebec, Canada; Institute of Pharmacology, West German Heart and Vascular Center, Faculty of Medicine, University Duisburg-Essen, Essen, Germany
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4
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Goette A, Kalman JM, Aguinaga L, Akar J, Cabrera JA, Chen SA, Chugh SS, Corradi D, D'Avila A, Dobrev D, Fenelon G, Gonzalez M, Hatem SN, Helm R, Hindricks G, Ho SY, Hoit B, Jalife J, Kim YH, Lip GYH, Ma CS, Marcus GM, Murray K, Nogami A, Sanders P, Uribe W, Van Wagoner DR, Nattel S. EHRA/HRS/APHRS/SOLAECE expert consensus on atrial cardiomyopathies: definition, characterization, and clinical implication. Europace 2016; 18:1455-1490. [PMID: 27402624 DOI: 10.1093/europace/euw161] [Citation(s) in RCA: 429] [Impact Index Per Article: 53.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Andreas Goette
- Departement of Cardiology and Intensive Care Medicine, St. Vincenz-Hospital Paderborn, Working Group: Molecular Electrophysiology, University Hospital Magdeburg, Germany
| | - Jonathan M Kalman
- University of Melbourne, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | | | | | | | | | - Sumeet S Chugh
- The Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | | | | | - Dobromir Dobrev
- Institute of Pharmacology, West German Heart and Vascular Center, University Duisburg-Essen, Essen, Germany
| | | | - Mario Gonzalez
- Penn State Heart and Vascular Institute, Penn State University, Hershey, PA, USA
| | - Stephane N Hatem
- Department of Cardiology, Assistance Publique - Hôpitaux de Paris, Pitié-Salpêtrière Hospital; Sorbonne University; INSERM UMR_S1166; Institute of Cardiometabolism and Nutrition-ICAN, Paris, France
| | - Robert Helm
- Boston University School of Medicine, Boston Medical Center, Boston, MA, USA
| | | | - Siew Yen Ho
- Royal Brompton Hospital and Imperial College London, London, UK
| | - Brian Hoit
- UH Case Medical Center, Cleveland, OH, USA
| | | | | | | | | | | | | | | | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - William Uribe
- Electrophysiology Deparment at Centros Especializados de San Vicente Fundación and Clínica CES. Universidad CES, Universidad Pontificia Bolivariana (UPB), Medellin, Colombia
| | | | - Stanley Nattel
- Université de Montréal, Montreal Heart Institute Research Center and McGill University, Montreal, Quebec, Canada .,Institute of Pharmacology, West German Heart and Vascular Center, Faculty of Medicine, University Duisburg-Essen, Essen, Germany
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WINTERFIELD JEFFREYR, VOSS JAMIE. Silent AF and Hypertrophic Stroke Risk: More Data, More Monitoring. J Cardiovasc Electrophysiol 2016; 27:785-7. [DOI: 10.1111/jce.13012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Revised: 05/10/2016] [Accepted: 05/11/2016] [Indexed: 11/26/2022]
Affiliation(s)
| | - JAMIE VOSS
- Loyola University Medical Center; Cardiovascular Institute; Maywood Illinois USA
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EHRA/HRS/APHRS/SOLAECE expert consensus on atrial cardiomyopathies: Definition, characterization, and clinical implication. Heart Rhythm 2016; 14:e3-e40. [PMID: 27320515 DOI: 10.1016/j.hrthm.2016.05.028] [Citation(s) in RCA: 214] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Indexed: 12/21/2022]
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7
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Oliphant CS, McCullough J, Hashim T, Khouzam RN. Vitamin K antagonist use for all patients with hypertrophic cardiomyopathy and atrial fibrillation: analysis of the literature and guideline review. Future Cardiol 2014; 10:229-33. [PMID: 24762250 DOI: 10.2217/fca.13.109] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Hypertrophic cardiomyopathy (HCM), which was first described in 1958, occurs in approximately one in 500 people. Patients with HCM are at an increased risk of atrial fibrillation, which is not only poorly tolerated in this population, but also increases their risk of an embolic event. The incidence of stroke in HCM patients with atrial fibrillation is approximately 21-23%. Given the high risk of stroke, antithrombotic therapy with warfarin is recommended in national guidelines. This therapy should be used without regard to other risk factors for stroke that may be present. Anticoagulation with the new oral anticoagulants may be considered as an alternative; although, specific data for patients with HCM is not available. The purpose of this review is to remind practitioners of the importance of stroke prophylaxis with oral anticoagulants in this population.
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Affiliation(s)
- Carrie S Oliphant
- Methodist University Hospital, Department of Pharmacy, 1265 Union Avenue, Memphis, TN 38104, USA
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8
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Di Donna P, Olivotto I, Delcre SDL, Caponi D, Scaglione M, Nault I, Montefusco A, Girolami F, Cecchi F, Haissaguerre M, Gaita F. Efficacy of catheter ablation for atrial fibrillation in hypertrophic cardiomyopathy: impact of age, atrial remodelling, and disease progression. Europace 2010; 12:347-55. [DOI: 10.1093/europace/euq013] [Citation(s) in RCA: 105] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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9
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Papavassiliu T, Germans T, Flüchter S, Doesch C, Suriyakamar A, Haghi D, Süselbeck T, Wolpert C, Dinter D, Schoenberg SO, van Rossum AC, Borggrefe M. CMR findings in patients with hypertrophic cardiomyopathy and atrial fibrillation. J Cardiovasc Magn Reson 2009; 11:34. [PMID: 19740409 PMCID: PMC2749835 DOI: 10.1186/1532-429x-11-34] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2009] [Accepted: 09/09/2009] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES We sought to evaluate the relation between atrial fibrillation (AF) and the extent of myocardial scarring together with left ventricular (LV) and atrial parameters assessed by late gadolinium-enhancement (LGE) cardiovascular magnetic resonance (CMR) in patients with hypertrophic cardiomyopathy (HCM). BACKGROUND AF is the most common arrhythmia in HCM. Myocardial scarring is also identified frequently in HCM. However, the impact of myocardial scarring assessed by LGE CMR on the presence of AF has not been evaluated yet. METHODS 87 HCM patients underwent LGE CMR, echocardiography and regular ECG recordings. LV function, volumes, myocardial thickness, left atrial (LA) volume and the extent of LGE, were assessed using CMR and correlated to AF. Additionally, the presence of diastolic dysfunction and mitral regurgitation were obtained by echocardiography and also correlated to AF. RESULTS Episodes of AF were documented in 37 patients (42%). Indexed LV volumes and mass were comparable between HCM patients with and without AF. However, indexed LA volume was significantly higher in HCM patients with AF than in HCM patients without AF (68 +/- 24 ml.m-2 versus 46 +/- 18 ml.m-2, p = 0.0002, respectively). The mean extent of LGE was higher in HCM patients with AF than those without AF (12.4 +/- 14.5% versus 6.0 +/- 8.6%, p = 0.02). When adjusting for age, gender and LV mass, LGE and indexed LA volume significantly correlated to AF (r = 0.34, p = 0.02 and r = 0.42, p < 0.001 respectively). By echocardiographic examination, LV diastolic dysfunction was evident in 35 (40%) patients. Mitral regurgitation greater than II was observed in 12 patients (14%). Multivariate analysis demonstrated that LA volume and presence of diastolic dysfunction were the only independent determinant of AF in HCM patients (p = 0.006, p = 0.01 respectively). Receiver operating characteristic curve analysis indicated good predictive performance of LA volume and LGE (AUC = 0.74 and 0.64 respectively) with respect to AF. CONCLUSION HCM patients with AF display significantly more LGE than HCM patients without AF. However, the extent of LGE is inferior to the LA size for predicting AF prevalence. LA dilation is the strongest determinant of AF in HCM patients, and is related to the extent of LGE in the LV, irrespective of LV mass.
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Affiliation(s)
- Theano Papavassiliu
- 1st Department of Medicine-Cardiology, University Hospital of Mannheim, Mannheim, Germany
| | - Tjeerd Germans
- Department of Cardiology, VU University Medical Center, Amsterdam, the Netherlands
| | - Stephan Flüchter
- 1st Department of Medicine-Cardiology, University Hospital of Mannheim, Mannheim, Germany
| | - Christina Doesch
- 1st Department of Medicine-Cardiology, University Hospital of Mannheim, Mannheim, Germany
| | - Anton Suriyakamar
- 1st Department of Medicine-Cardiology, University Hospital of Mannheim, Mannheim, Germany
| | - Dariusch Haghi
- 1st Department of Medicine-Cardiology, University Hospital of Mannheim, Mannheim, Germany
| | - Tim Süselbeck
- 1st Department of Medicine-Cardiology, University Hospital of Mannheim, Mannheim, Germany
| | - Christian Wolpert
- 1st Department of Medicine-Cardiology, University Hospital of Mannheim, Mannheim, Germany
| | - Dietmar Dinter
- Department of Cardiology, VU University Medical Center, Amsterdam, the Netherlands
| | | | - Albert C van Rossum
- Department of Cardiology, VU University Medical Center, Amsterdam, the Netherlands
| | - Martin Borggrefe
- 1st Department of Medicine-Cardiology, University Hospital of Mannheim, Mannheim, Germany
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10
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Kubo T, Kitaoka H, Okawa M, Hirota T, Hayato K, Yamasaki N, Matsumura Y, Yabe T, Takata J, Doi YL. Clinical impact of atrial fibrillation in patients with hypertrophic cardiomyopathy. Results from Kochi RYOMA Study. Circ J 2009; 73:1599-605. [PMID: 19590139 DOI: 10.1253/circj.cj-09-0140] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND There have been few studies of the clinical features of hypertrophic cardiomyopathy (HCM) in a community-based patient cohort in Japan. METHODS AND RESULTS Cardiomyopathy registration was established in Kochi Prefecture and named the Kochi RYOMA (registry of myocardial diseases) study, consisting of 9 hospitals that registered 261 patients with a diagnosis of HCM. At registration, 74 patients (28%) had documented paroxysmal or chronic atrial fibrillation (AF). Although most patients (93%) were in New York Heart Association (NYHA) class I or II, 17 of the 18 patients in NYHA III had AF; 37 of the 74 patients with AF suffered from morbid events (embolism and/or heart failure (HF) admission), and 15 of 19 patients with embolic events had AF prior to or at the time of embolism. Of the 29 patients who had a history of HF admission, 8 had left ventricular systolic dysfunction, and the other 21 patients were hospitalized because of diastolic HF. AF occurred prior to HF in 20 of those 21 patients. Furthermore, 19 of those 20 patients with AF and diastolic HF were hospitalized within 1 year after detection of AF. CONCLUSIONS In an unselected regional registry, AF was the major determinant of clinical deteriorations in patients with HCM.
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Affiliation(s)
- Toru Kubo
- Department of Medicine and Geriatrics, Kochi Medical School, Nankoku, Japan
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11
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Oki T, Tabata T, Yamada H, Wakatsuki T, Fukuda K, Abe M, Onose Y, Iuchi A, Fukuda N, Ito S. Evaluation of left atrial filling using systolic pulmonary venous flow velocity measurements in patients with atrial fibrillation. Clin Cardiol 2009; 21:169-74. [PMID: 9541760 PMCID: PMC6655777 DOI: 10.1002/clc.4960210306] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND The pattern of pulmonary venous flow velocity is useful for understanding the hemodynamic relationship between the left atrium and left ventricle in patients with a variety of diseases, and the systolic flow wave, in particular, is considered a clinically important parameter that reflects left atrial filling. HYPOTHESIS The study was undertaken to determine whether systolic pulmonary venous flow velocity patterns can be used to evaluate left atrial filling in patients with atrial fibrillation. METHODS We performed transesophageal pulsed Doppler echocardiography and cardiac catheterization in 34 patients with chronic atrial fibrillation (10 with hypertrophic cardiomyopathy, 5 with dilated cardiomyopathy, 7 with previous myocardial infarction, and 12 with isolated atrial fibrillation) and 15 normal controls in sinus rhythm. RESULTS Mean pulmonary capillary wedge pressure, V-wave height in the pulmonary capillary wedge pressure curve, and left ventricular end-diastolic pressure were significantly higher in the hypertrophic cardiomyopathy and dilated failing heart (previous myocardial infarction and dilated cardiomyopathy) groups than in the isolated atrial fibrillation and normal groups. The peak velocity and time-velocity integral of the systolic pulmonary venous flow velocity, and percent left atrial emptying fraction were significantly lower in the dilated failing heart group than in the isolated atrial fibrillation, hypertrophic cardiomyopathy, and normal groups. The peak velocity and time-velocity integral of the systolic pulmonary venous flow velocity, percent left atrial emptying fraction, and V-wave height were comparatively constant when the preceding R-R intervals were relatively stable in the isolated atrial fibrillation group and in 4 of the 10 patients with hypertrophic cardiomyopathy. However, changes in these variables correlated with the preceding R-R interval in all patients with dilated failing hearts and in 6 of the 10 patients with hypertrophic cardiomyopathy. CONCLUSION Transesophageal pulsed Doppler echocardiographic measurements of systolic pulmonary venous flow velocity are valid indicators of left atrial filling in patients with atrial fibrillation.
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Affiliation(s)
- T Oki
- Second Department of Internal Medicine, School of Medicine, University of Tokushima, Japan
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12
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BUNCH TJARED, MUNGER THOMASM, FRIEDMAN PAULA, ASIRVATHAM SAMUELJ, BRADY PETERA, CHA YONGMEI, REA ROBERTF, SHEN WINKUANG, POWELL BRIAND, OMMEN STEVER, MONAHAN KRISTIH, HAROLDSON JANISM, PACKER DOUGLASL. Substrate and Procedural Predictors of Outcomes After Catheter Ablation for Atrial Fibrillation in Patients with Hypertrophic Cardiomyopathy. J Cardiovasc Electrophysiol 2008; 19:1009-14. [DOI: 10.1111/j.1540-8167.2008.01192.x] [Citation(s) in RCA: 86] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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13
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Matsuura H, Murakami T, Hina K, Yamamoto K, Kawamura H, Sogo T, Shinohata R, Usui S, Ninomiya Y, Kusachi S. Association of elevated plasma B-type natriuretic peptide levels with paroxysmal atrial fibrillation in patients with nonobstructive hypertrophic cardiomyopathy. Clin Biochem 2008; 41:134-9. [DOI: 10.1016/j.clinbiochem.2007.10.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2007] [Revised: 10/02/2007] [Accepted: 10/30/2007] [Indexed: 10/22/2022]
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14
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Gaita F, Di Donna P, Olivotto I, Scaglione M, Ferrero I, Montefusco A, Caponi D, Conte MR, Nistri S, Cecchi F. Usefulness and safety of transcatheter ablation of atrial fibrillation in patients with hypertrophic cardiomyopathy. Am J Cardiol 2007; 99:1575-81. [PMID: 17531584 DOI: 10.1016/j.amjcard.2006.12.087] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2006] [Revised: 12/28/2006] [Accepted: 12/28/2006] [Indexed: 11/20/2022]
Abstract
Atrial fibrillation (AF) is common in patients with hypertrophic cardiomyopathy (HC) and predicts adverse outcome. Radiofrequency catheter ablation (RFCA) represents a potentially advantageous alternative to lifelong pharmacologic treatment. However, its efficacy in patients with HC is not established. In the present study, the feasibility, safety, and efficacy of RFCA of AF in patients with HC were evaluated. Twenty-six patients with HC with paroxysmal (n = 13) or permanent (n = 13) AF refractory to antiarrhythmic therapy (age 58 +/- 11 years, time from AF onset 7.3 +/- 6.2 years, left atrial volume 170 +/- 48 ml) underwent RFCA. A schema with pulmonary vein isolation plus linear lesions was used. No major periprocedural complication occurred. One patient died from a hemorrhagic stroke 4 weeks after RFCA while in sinus rhythm. During a 19 +/- 10-month follow-up, 9 of the remaining 25 patients (36%) experienced recurrence of AF (despite repeated RFCA in 3) and were considered failures, whereas 16 remained in sinus rhythm (i.e., 64% overall success rate). Ten of these 16 patients were off antiarrhythmic drug therapy at final evaluation. RFCA was highly successful in patients with paroxysmal AF (77% success rate compared with 50% in the subgroup with permanent AF). Patients with restoration of sinus rhythm showed marked symptomatic improvement (final New York Heart Association functional class 1.2 +/- 0.5 vs 1.7 +/- 0.7 before the procedure, p = 0.003). Conversely, patients for whom RFCA failed showed no change (final functional class 1.9 +/- 0.8 vs 1.7 +/- 0.9 before the procedure, p = 0.59). In conclusion, in most studied patients with HC, RFCA proved a safe and effective therapeutic option for AF, improved functional status, and was able to reduce or postpone the need for long-term pharmacologic treatment.
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15
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Woo A, Williams WG, Choi R, Wigle ED, Rozenblyum E, Fedwick K, Siu S, Ralph-Edwards A, Rakowski H. Clinical and Echocardiographic Determinants of Long-Term Survival After Surgical Myectomy in Obstructive Hypertrophic Cardiomyopathy. Circulation 2005; 111:2033-41. [PMID: 15824202 DOI: 10.1161/01.cir.0000162460.36735.71] [Citation(s) in RCA: 227] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Surgical myectomy has been the standard treatment for patients with drug-refractory obstructive hypertrophic cardiomyopathy. The clinical and echocardiographic predictors of long-term survival and freedom from cardiovascular morbidity after myectomy have been unclear.
Methods and Results—
We studied a consecutive cohort of 338 adult patients (age at operation 47±14 [range 18 to 77] years, 60% male) who underwent myectomy at our institution. Preoperative resting left ventricular outflow tract (LVOT) gradient was 66±32 mm Hg (range 5 to 158 mm Hg). Early postoperative mortality was 1.5% (5 deaths): 4 deaths occurred between 1978 and 1992, and 1 death occurred between 1993 and 2002. During long-term follow-up, 83% of patients reported an improvement to functional class I or II. The majority of patients (98%) had no resting LVOT gradient. Long-term survival was excellent, with 98±1% survival at 1 year, 95±1% at 5 years, and 83±3% at 10 years after myectomy. Multivariable Cox regression analysis identified 5 predictors of overall mortality: (1) age ≥50 years at surgery (hazard ratio [HR] 2.8, 95% CI 1.5 to 5.1,
P
=0.001), (2) female gender (HR 2.5, 95% CI 1.5 to 4.3,
P
=0.0009), (3) history of preoperative atrial fibrillation (HR 2.2, 95% CI 1.2 to 4.0,
P
=0.008), (4) concomitant CABG (HR 3.7, 95% CI 1.7 to 8.2,
P
=0.001), and (5) preoperative left atrial diameter ≥46 mm (HR 2.9, 95% CI 1.6 to 5.4,
P
=0.0008). Significant predictors of late major cardiovascular events found on multivariable analysis were (1) female gender (HR 3.3, 95% CI 2.0 to 5.4,
P
<0.0001), (2) history of preoperative atrial fibrillation (HR 1.9, 95% CI 1.1 to 3.3,
P
=0.02), and (3) preoperative left atrial diameter ≥46 mm (HR 2.5, 95% CI 1.5 to 4.3,
P
=0.0008).
Conclusions—
Myectomy provides excellent relief for LVOT obstruction in patients with hypertrophic cardiomyopathy. Preoperative clinical and echocardiographic variables can predict long-term outcome after myectomy.
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Affiliation(s)
- Anna Woo
- Division of Cardiology, Toronto General Hospital, 4N-506, 200 Elizabeth St, Toronto, Ontario, Canada M5G 2C4.
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16
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Ozdemir O, Soylu M, Demir AD, Topaloglu S, Alyan O, Turhan H, Bicer A, Kutuk E. P-wave durations as a predictor for atrial fibrillation development in patients with hypertrophic cardiomyopathy. Int J Cardiol 2004; 94:163-6. [PMID: 15093974 DOI: 10.1016/j.ijcard.2003.01.001] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2002] [Revised: 11/08/2002] [Accepted: 01/29/2003] [Indexed: 11/23/2022]
Abstract
Atrial fibrillation (AF) is the most common arrhythmia observed in hypertropic cardiomyopathy (HCM) and is associated with an acute deterioration. Recently, P wave dispersion (PWD) reflecting inhomogeneous atrial conduction has been proposed as being useful for the estimation of paroxysmal AF. In this study, we aimed to define the clinical, echocardiographic and electrocardiographic predictors for AF occurrence in patients with HCM. Twenty-seven patients diagnosed with HCM and having a history of documented AF attack were compared with 53 age- and gender-matched patients who had no such history. LA diameter was significantly greater and gradient in the left ventricle outflow tract was lower in patients with AF than those without AF. Maximum P-wave duration (Pmax), PWD and PTF1 values were significantly higher in patients with AF. A Pmax>134.5 ms separated the patients with AF from controls with a sensitivity of 92%, specificity of 89% and a positive predictive value of 80%. APWD value>52.5 ms separated patients from controls with a sensitivity of 96%, a specificity of 91% and a positive predictive accuracy of 84%. An LA diameter>4.2 cm separated patients from controls with a sensitivity of 96% and a specificity of 81%. We concluded that LA diameter and PWD values are the most significant predictors for AF occurrence in patients with HCM, and simply by measuring Pmax and PWD values, we could easily identify the patients with high risk, and prescribe the necessary treatment and follow-up protocols for such patients.
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Affiliation(s)
- Ozcan Ozdemir
- Cardiology Department, Turkey Yuksek Yhtisas Hospital, 06200 Ankara, Turkey.
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17
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Tekten T, Onbaşili OA, Ceylan C, Ercan E. Left atrial free floating ball thrombus in hypertrophic cardiomyopathy: a case report. J Am Soc Echocardiogr 2002; 15:1018-20. [PMID: 12221426 DOI: 10.1067/mje.2002.120980] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
In this article we reported a 33-year-old female patient who was referred to our emergency department with atrial fibrillation, congestive heart failure, and cardiogenic shock. In her transthoracic echocardiography, a free-floating ball-type mass was seen in the left atrial cavity with a hypertrophic cardiomyopathy. An emergency open-heart surgery was performed. The mass was removed, and pathologic examination confirmed the thrombotic material.
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Affiliation(s)
- Tarkan Tekten
- Adnan Menderes University, Faculty of Medicine, Department of Cardiology, Aydin, Turkey.
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18
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Olivotto I, Cecchi F, Casey SA, Dolara A, Traverse JH, Maron BJ. Impact of atrial fibrillation on the clinical course of hypertrophic cardiomyopathy. Circulation 2001; 104:2517-24. [PMID: 11714644 DOI: 10.1161/hc4601.097997] [Citation(s) in RCA: 533] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Clinical impact of atrial fibrillation (AF) in hypertrophic cardiomyopathy (HCM) is largely unresolved. Thus, we analyzed the prognostic implications of AF in a large, community-based HCM population assembled from Italian and US cohorts. METHODS AND RESULTS Occurrence of AF and outcome were assessed in 480 consecutive HCM patients (age at diagnosis, 45+/-20 years; 61% male) who were followed up for 9.1+/-6.4 years. AF occurred in 107 patients (22%; incidence, 2%/y) and was independently predicted by advancing age, congestive symptoms, and increased LA size at diagnosis. Patients with AF had increased risk for HCM-related death (OR, 3.7; P<0.002) because of excess heart failure-related mortality but not sudden, unexpected death. This risk associated with AF was substantially greater in patients with outflow obstruction or with earlier development of AF (</=50 years of age). AF patients were also at increased risk for stroke (OR, 17.7; P=0.0001) and severe functional limitation (OR for NYHA class III or IV, 2.8; P<0.0001). Compared with those with exclusively paroxysmal AF, patients developing chronic AF showed higher combined probability of HCM-related death, functional impairment, and stroke (P<0.0001). In a subgroup of 37 patients with AF (35%), the clinical course was largely benign in the absence of stroke and severe symptoms. CONCLUSIONS In a community-based HCM population, AF (1) was common, with 22% prevalence over 9 years; (2) was associated with substantial risk for heart failure-related mortality, stroke, and severe functional disability, particularly in patients with outflow obstruction, those </=50 years of age, or those developing chronic AF; and (3) was nevertheless compatible with benign outcome in 35% of patients.
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Affiliation(s)
- I Olivotto
- Cardiologia S. Luca, Azienda Ospedaliera Careggi, Florence, Italy.
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19
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Huang X, Song L, Ma AQ, Gao J, Zheng W, Zhou X, Zhang Q, Lu H, Li Y, Liu Y, Hui R. A malignant phenotype of hypertrophic cardiomyopathy caused by Arg719Gln cardiac beta-myosin heavy-chain mutation in a Chinese family. Clin Chim Acta 2001; 310:131-9. [PMID: 11498078 DOI: 10.1016/s0009-8981(01)00538-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Mutations of the cardiac beta-myosin heavy-chain (beta-MHC) gene cause hypertrophic cardiomyopathy (HCM). Recent genotype-phenotype correlation studies have shown that mutations carry prognostic significance. We studied five unrelated Chinese families with hypertrophic cardiomyopathy. Exons 3-27 and 40 of the beta-MHC gene were screened with both the polymerase chain reaction-single-strand conformation polymorphism (PCR-SSCP) method and the cycle sequencing of the PCR products. A previously reported heterozygous mutation Arg719Gln (arginine-->glutamine in codon 719) in exon 19 was found in one family. The proband is a 30-year-old female diagnosed at age of 25 years when she presented with symptoms of chest pain, palpitations, and frequent incidents of dizziness and syncope. A two-dimensional echocardiogram showed moderate asymmetrical septal hypertrophy with left atrial enlargement. There was no obstruction of the left ventricular outflow tract (LVOT). The patient also developed atrial fibrillation. The proband's mother and one of her sisters had similar clinical manifestations and both died suddenly at the age of 38 years. In addition, two silent nucleotide substitutions (ACT63ACC, TTT244TTC) in the cardiac beta-MHC gene were identified in the other four families. These synonymous mutations did not cosegregate with the disease in the families and they were also present in the 60 healthy and age-matched control subjects. Of the five families studied, we did not find any missense mutation in the remaining four families. The missense mutation Arg719Gln found in the Chinese family is associated with a malignant phenotype of severe clinical symptoms and poor survival prognosis. This mutation also causes atrial enlargement and atrial fibrillation. Our study provides further evidence that the mutation, which alters the charge of the myosin heavy chain, is associated with a serious clinical outcome.
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Affiliation(s)
- X Huang
- Sino-German Laboratory for Molecular Medicine, Fu Wai Cardiovascular Hospital and Cardiovascular Institute, Chinese Academy of Medical Sciences, 167 Beilishilu Beijing, 100037 China
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20
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Abstract
Atrial fibrillation (AF) is the most common sustained arrhythmia in patients with hypertrophic cardiomyopathy (HCM), and it bears numerous pathophysiologic consequences that potentially affect patient outcome and symptoms. However, studies regarding the impact of AF on the long-term prognosis of HCM patients have been limited in number, with sometimes conflicting results. Recently, studies on community-based patient populations showed that AF is associated with long-term clinical deterioration, embolic complications, and increased cardiovascular mortality due to heart failure and stroke. The consequences of AF on the long-term prognosis of HCM patients are not uniformly unfavorable, however, and in about one third of patients the arrhythmia is compatible with an uneventful course.
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Affiliation(s)
- I Olivotto
- Cardiologia S. Luca, Azienda Ospedaliera Careggi, Via Jacopo Nardi 30, Florence, 50132, Italy.
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21
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Savelieva I, Camm AJ. Clinical relevance of silent atrial fibrillation: prevalence, prognosis, quality of life, and management. J Interv Card Electrophysiol 2000; 4:369-82. [PMID: 10936003 DOI: 10.1023/a:1009823001707] [Citation(s) in RCA: 225] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Although first described about 100yr ago, atrial fibrillation (AF) is now recognized as the most common of all arrhythmias. It has a substantial morbidity and presents a considerable health care burden. Improved diagnosis and an ageing population with an increased likelihood of underlying cardiac disease results in AF in more than 1% of population. AF is associated with an approximately two-fold increase in mortality, largely due to stroke which occurs at an annual rate of 5-7%. Another risk to survival is heart failure, which is aggravated by poor control of the ventricular rate during AF. Usually AF is associated with a variety of symptoms: palpitations, dyspnea, chest discomfort, fatigue, dizziness, and syncope. Paroxysmal AF is likely to be symptomatic and frequently presents with specific symptoms, while permanent AF is usually associated with less specific symptoms. However, in at least one third of patients, no obvious symptoms or noticeable degradation of quality of life are observed. This asymptomatic, or silent, AF is diagnosed incidentally during routine physical examinations, pre-operative assessments or population surveys. Recently, a very large incidence of generally short paroxysms of AF has been seen in patients with implantable pacemakers or defibrillators and these arrhythmias are often silent. Pharmacological suppression of arrhythmia may be associated with a conversion from a symptomatic to an asymptomatic form of AF. Holter monitoring and transtelephonic monitoring studies have demonstrated that asymptomatic episodes of AF exceed symptomatic paroxysms by twelve-fold or more. Although symptoms may not stem directly from AF, the risk of complications is probably the same for symptomatic and asymptomatic patients. AF is found incidentally in about 25% of admissions for a stroke. Studies in patients with little or no awareness of their arrhythmia condition indicate that unrecognized and untreated AF may cause congestive heart failure. In patients with coronary bypass, AF may not only represent risk for immediate postoperative morbidity and increase hospital resource utilization, but being unrecognized, may produce a significant impact on long-term survival and quality of life. Although silent AF merits consideration for anticoagulation and rate control therapy according to standard criteria, whether antiarrhythmic therapy is relevant in this condition remains unclear.
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Affiliation(s)
- I Savelieva
- St George's Hospital Medical School, Cranmer Terrace, London, SW17 0RE
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22
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Berger M, Schweitzer P. Timing of thromboembolic events after electrical cardioversion of atrial fibrillation or flutter: a retrospective analysis. Am J Cardiol 1998; 82:1545-7, A8. [PMID: 9874066 DOI: 10.1016/s0002-9149(98)00704-8] [Citation(s) in RCA: 136] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Pooled data from 32 studies were reviewed to assess the timing of thrombolic complications after cardioversion of atrial fibrillation or flutter. We found that 98% of embolic episodes occurred within 10 days of cardioversion.
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Affiliation(s)
- M Berger
- Heart Institute, Beth Israel Medical Center, New York, New York 10003, USA
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23
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Abstract
Atrial fibrillation (AF) is in most patients (approximately 70%) associated with organic heart disease including valvular heart disease, coronary artery disease, hypertension, hypertrophic cardiomyopathy, dilated cardiomyopathy, and congenital heart disease, mostly atrial septal defect in adults. In many chronic conditions, determining whether AF is the result or is unrelated to the underlying heart disease, remains unclear. The list of possible etiologies also include cardiac amyloidosis, hemochromatosis and endomyocardial fibrosis. Other heart diseases, such as mitral valve prolapse (without mitral regurgitation), calcifications of the mitral annulus, atrial myxoma, pheochomocytoma, and idiopathic dilated right atrium may present with AF. Atrial fibrillation may occur in the absence of detectable organic heart disease, the so-called "lone AF", in about 30% of cases. The term "idiopathic AF" implies the absence of any detectable etiology including hyperthyroidism, chronic obstructive lung disease, overt sinus node dysfunction, and overt or concealed preexcitation (Wolff-Parkinson-White syndrome), only to mention a few of other uncommon causes of AF. The autonomous nervous system may contribute to the occurrence of AF in some patients. AF occurs commonly. In patients with valvular heart disease, AF is common, particularly when the mitral valve is involved. The occurrence of AF is unrelated to the severity of mitral stenosis or mitral regurgitation but is more common in patients with enlarged left atrium and congestive heart failure. In patients with coronary artery disease, AF occurs predominantly in older patients, males, and patients with left ventricular dysfunction, Important predictive factors of AF include hypertension, left ventricular hypertrophy and diabetes. The risk of the development of AF, in an individual patient, is often difficult to assess. Increasing age, presence of valvular heart disease, and congestive heart failure increase the risk of atrial fibrillation.
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Affiliation(s)
- S Lévy
- University of Marseille, School of Medicine, Chief Cardiology Division, Hôpital Nord, France
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24
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Abstract
Supraventricular and ventricular arrhythmias, particularly nonsustained ventricular tachycardia, and ventricular premature beats are a common finding in patients with hypertrophic cardiomyopathy. Several investigations have demonstrated that nonsustained ventricular tachycardia on Holter monitoring is associated with an increased risk of sudden cardiac death. It has been a long lasting controversial discussion whether suppression of these arrhythmias with drugs, such as amiodarone is capable to reduce the incidence of sudden cardiac death. While recent studies have indicated that nonsustained ventricular tachycardia in asymptomatic patients without additional risk factors, such as a positive family history of sudden cardiac death or syncope should not be treated prophylactically with amiodarone. Symptomatic patients with sustained ventricular tachycardias and/or syncope related to ventricular arrhythmias should undergo ICD implantation. The implantation of an ICD in asymptomatic patients should be limited to those who have several risk factors for sudden cardiac death. It is questionable whether other risk stratifiers, such as programmed electrical stimulation may be helpful to identify asymptomatic patients who are at risk to die suddenly. Moreover, whether the demonstration of electrocardiogram fractionation during electrophysiological study is superior to the induction of sustained ventricular arrhythmias for risk stratification, needs further investigation.
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MESH Headings
- Anti-Arrhythmia Agents/adverse effects
- Anti-Arrhythmia Agents/therapeutic use
- Arrhythmias, Cardiac/diagnosis
- Arrhythmias, Cardiac/etiology
- Arrhythmias, Cardiac/therapy
- Cardiac Pacing, Artificial
- Cardiomyopathy, Hypertrophic/complications
- Death, Sudden, Cardiac/etiology
- Defibrillators, Implantable
- Electrocardiography, Ambulatory
- Humans
- Risk Assessment
- Risk Factors
- Tachycardia, Ventricular/complications
- Tachycardia, Ventricular/diagnosis
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25
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Higashikawa M, Nakamura Y, Yoshida M, Kinoshita M. Incidence of ischemic strokes in hypertrophic cardiomyopathy is markedly increased if complicated by atrial fibrillation. JAPANESE CIRCULATION JOURNAL 1997; 61:673-81. [PMID: 9276772 DOI: 10.1253/jcj.61.673] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The clinical outcome and the incidence of ischemic strokes in patients with hypertrophic cardiomyopathy (HCM) with and without atrial fibrillation (AF) were examined. Eighty-three patients with HCM, complicated by AF in 19 patients, and 131 patients with AF but without HCM were studied retrospectively. Primary endpoints (ischemic strokes or cardiac death, whichever occurred first) and ischemic strokes were examined by Kaplan-Meier curves. In the patients with HCM, the primary endpoints occurred more frequently in those with AF than in those without AF (event rate at 5 year 23.0% vs 12.3%, p < 0.01). Similarly, the frequency of ischemic strokes in HCM was also much higher with AF than without AF (23.0% vs 5.9% at 5 years, p < 0.01). According to multivariate Cox analysis, the strong independent risk factor for ischemic strokes in HCM was AF (p < 0.01), whereas in patients with AF they were HCM (p < 0.01) and age (p < 0.01). These results suggest that incidence of ischemic strokes in HCM is markedly increased if complicated by AF as compared with that in patients with AF alone.
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Affiliation(s)
- M Higashikawa
- First Department of Internal Medicine, Shiga University of Medical Science, Ohtsu, Japan
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26
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Cecchi F, Montereggi A, Olivotto I, Marconi P, Dolara A, Maron BJ. Risk for atrial fibrillation in patients with hypertrophic cardiomyopathy assessed by signal averaged P wave duration. Heart 1997; 78:44-9. [PMID: 9290401 PMCID: PMC484863 DOI: 10.1136/hrt.78.1.44] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE To assess the relation between P wave duration and the occurrence of atrial fibrillation in hypertrophic cardiomyopathy (HCM). DESIGN High resolution signal averaged electrocardiography was used in 110 patients with HCM to determine whether patients at risk for paroxysmal atrial fibrillation could be detected during sinus rhythm by measuring P wave duration. Filtered P wave duration was measured manually, over an average of 300 beats per patient. RESULTS During follow up, 18 patients (16%) had at least one one clinical episode of paroxysmal atrial fibrillation, including four patients whose initial episode followed the signal averaged electrocardiogram. The 18 patients with overt atrial fibrillation had greater P wave duration than the 69 patients who did not develop atrial fibrillation: 150 (SD 20) v 126 (14) ms; P < 0.001. Another 23 patients without clinically evident atrial fibrillation had prolonged bursts of the arrhythmia on Holter recording, and showed a P wave duration (138 (15) ms) intermediate between patients with and without clinical atrial fibrillation. In assessing risk for atrial fibrillation, P wave duration > or = 140 ms was associated with sensitivity, specificity, and positive predictive accuracy values of 56%, 83%, and 66%. Multivariate analysis showed that duration of the P wave was the only independent variable associated with occurrence of atrial fibrillation; if P wave duration > or = 140 ms was combined with left atrial enlargement > 40 mm, the specificity and positive predictive accuracy for atrial fibrillation increased to 93% and 78%. CONCLUSIONS Measurement of P wave duration in sinus rhythm by high resolution signal averaged electrocardiography may be a useful non-invasive clinical tool for identifying patients with HCM likely to develop electrical instability and atrial fibrillation.
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Affiliation(s)
- F Cecchi
- Cardiologia di S Luca, Ospedale di Careggi, Florence, Italy
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27
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Brembilla-Perrot B, Jacquot A, Beurrier D, Jacquemin L. Hypertrophic cardiomyopathy: value of atrial programmed electrical stimulation in patients with or without syncope with special reference to the role of atrial arrhythmias. Int J Cardiol 1997; 59:47-56. [PMID: 9080025 DOI: 10.1016/s0167-5273(96)02900-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Hypertrophic cardiomyopathy may be associated with both supraventricular and ventricular arrhythmias, which may play a role in the genesis of syncope. The aim of this study was to assess the findings of electrophysiological study and programmed atrial and ventricular stimulation and their possible role in syncope. Programmed atrial and ventricular stimulation using up to two extrastimuli in right atrium and three in right ventricle at three cycle lengths (600, 400 ms and spontaneous) was systematically performed in 56 patients with hypertrophic cardiomyopathy. Thirty seven had unexplained dizzinesses or syncopes (group I) and 19 did not present loss of consciousness (group II). Patients with syncopes had a higher prevalence of induced sustained supraventricular tachyarrhythmia (73%) than those of group II (16%) (P<0.05). Inducible supraventricular tachycardia was the only finding in 16 patients with syncopes. During the follow-up (3 years+/-6 months), empirical antiarrhythmic therapy suppressed the symptoms, except in two patients who developed atrial fibrillation despite therapy. The high incidence of inducible atrial tachycardia of these patients was not correlated with particular Holter findings or echocardiographic data. However, their mean age was rather high (58+/-12 years). In conclusion, atrial tachyarrhythmias may play a role in syncopes of middle-aged patients with hypertrophic cardiomyopathy. Moreover programmed atrial stimulation is an useful means to identify this syncope mechanism.
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28
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Fananapazir L, McAreavey D. Hypertrophic cardiomyopathy: evaluation and treatment of patients at high risk for sudden death. Pacing Clin Electrophysiol 1997; 20:478-501. [PMID: 9058851 DOI: 10.1111/j.1540-8159.1997.tb06206.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Hypertrophic cardiomyopathy (HCM) is a heritable disease characterized by LV hypertrophy with markedly variable clinical, morphological, and genetic manifestations. It is the most common cause of sudden death in otherwise healthy young individuals. HCM patients often have disabling symptoms and are prone to arrhythmias. Frequently, there is associated LV systolic and diastolic dysfunction, LV outflow obstruction, and myocardial ischemia. Over the past decade, progress has been made in identifying patients who are at high risk for sudden death, in elucidating potential mechanisms of sudden death, and in defining therapeutic algorithms that may improve prognosis. It has also been possible to determine the genetic defect in some of the patients and to correlate clinical findings with the molecular defects. An exciting development has been the use of dual chamber pacemaker as an alternative to cardiac surgery to improve symptoms and relieve LV outflow obstruction.
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MESH Headings
- Age Factors
- Cardiomyopathy, Hypertrophic/diagnosis
- Cardiomyopathy, Hypertrophic/etiology
- Cardiomyopathy, Hypertrophic/genetics
- Cardiomyopathy, Hypertrophic/therapy
- Death, Sudden, Cardiac/etiology
- Death, Sudden, Cardiac/prevention & control
- Electrophysiology/methods
- Humans
- Risk Assessment
- Syncope/diagnosis
- Syncope/etiology
- Tachycardia, Ventricular/diagnosis
- Tachycardia, Ventricular/etiology
- Tachycardia, Ventricular/therapy
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Affiliation(s)
- L Fananapazir
- Cardiology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland 20892-1650 USA.
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29
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DAUBERT JCLAUDE, PAVIN DOMINIQUE, GRAS DANIEL, PLACE CHRISTIANDE, LECLERCQ CHRISTOPHE, LE BRETON HERVÉ, MABO PHILIPPE. Importance of Atrial Contraction in Hypertrophic Obstructive Cardiomyopathy: Implications for Pacing Therapy. J Interv Cardiol 1996. [DOI: 10.1111/j.1540-8183.1996.tb00639.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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30
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Cecchi F, Olivotto I, Montereggi A, Santoro G, Dolara A, Maron BJ. Hypertrophic cardiomyopathy in Tuscany: clinical course and outcome in an unselected regional population. J Am Coll Cardiol 1995; 26:1529-36. [PMID: 7594081 DOI: 10.1016/0735-1097(95)00353-3] [Citation(s) in RCA: 215] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVES Our aim was to study a population of patients with hypertrophic cardiomyopathy from the well defined geographic region of Tuscany in central Italy, a group virtually free of selective referral bias and therefore probably closely representative of the true patient population with this disease. BACKGROUND Most available information on clinical course, natural history and prognosis of hypertrophic cardiomyopathy is based on data generated from tertiary referral centers and therefore constitutes a potentially biased perspective of the disease process in this complex and diverse condition. METHODS The study group comprised 202 patients aged 1 to 74 years (mean +/- SD 41 +/- 17) at initial diagnosis and followed up for 1 to 30 years (mean 10 +/- 5). RESULTS Largely with the use of single or multiple drug therapy, the vast majority of patients (n = 154 [76%]) were asymptomatic or mildly symptomatic and in stable or improved condition over the period of follow-up, whereas the remaining patients (n = 48 [24%]) experienced deterioration, had substantial functional impairment or died. Of the 13 patients (6%) who died of cardiovascular causes related to hypertrophic cardiomyopathy, 11 had progressive congestive heart failure (including 6 in the end-stage phase) and only 2 died suddenly. The annual mortality rate for cardiovascular disease was 0.6% and that due to sudden cardiac death was only 0.1%; the cumulative survival rate was 97%, 95% and 92%, respectively, at 5, 10 and 15 years of follow-up. Atrial fibrillation proved to be a relatively common (n = 57 [28%]) and particularly unfavorable clinical feature, with premature death occurring in 9 of the 57 patients. The cumulative survival rate after 15 years was 76% for patients with atrial fibrillation versus 97% for patients with sinus rhythm. Syncope occurred in 33 patients (16%) but did not appear to be of prognostic significance. CONCLUSIONS In an unselected regional population, hypertrophic cardiomyopathy had a relatively benign prognosis inconsistent with its prior characterization as a generally progressive disorder, based primarily on the experience of selected referral institutions. Sudden unexpected cardiac death was distinctly uncommon, although a sizable proportion of patients (particularly the subset prone to atrial fibrillation), did experience clinical deterioration.
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Affiliation(s)
- F Cecchi
- Cardiologia di San Luca, Ospedale di Careggi, Florence, Italy
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31
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Abstract
HCM is a heterogeneous disease genotypically, phenotypically, pathophysiologically, clinically, and therapeutically. In decisions on the management of these patients, it is important to recognize this heterogeneity and to direct therapy at the predominant abnormalities.
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Affiliation(s)
- E D Wigle
- Division of Cardiology, Toronto Hospital, Ontario, Canada
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32
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Yamamoto K, Ikeda U, Furuhashi K, Irokawa M, Nakayama T, Shimada K. The coagulation system is activated in idiopathic cardiomyopathy. J Am Coll Cardiol 1995; 25:1634-40. [PMID: 7539015 DOI: 10.1016/0735-1097(95)00049-a] [Citation(s) in RCA: 117] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVES We investigated the plasma levels of molecular markers for platelet activity and the thrombotic and fibrinolytic status in patients with hypertrophic cardiomyopathy and dilated cardiomyopathy to determine the activating site of coagulation in these disorders. BACKGROUND A thromboembolic event is a serious complication in patients with idiopathic cardiomyopathy. However, the activating site of the coagulation system in idiopathic cardiomyopathy has not been fully investigated. METHODS We determined the plasma levels of molecular markers for platelet activity (platelet factor 4 and beta-thromboglobulin), thrombotic status (fibrinopeptide A and thrombin-antithrombin III complex) and fibrinolytic status (D-dimer and plasmin-alpha 2-plasmin inhibitor complex) in 13 patients with hypertrophic cardiomyopathy, 17 patients with dilated cardiomyopathy and 20 normal subjects. RESULTS Plasma levels of platelet factor 4, beta-thromboglobulin and plasmin-alpha 2-plasmin inhibitor complex did not differ significantly among the three groups, whereas plasma levels of fibrinopeptide A and thrombin-antithrombin III complex in both patient groups were significantly higher than those in normal subjects. Plasma levels of D-dimer in patients with dilated cardiomyopathy were significantly higher than those in patients with hypertrophic cardiomyopathy and normal groups. In patients with hypertrophic cardiomyopathy, both fibrinopeptide A and thrombin-antithrombin III complex levels were significantly correlated with left atrial diameter. In patients with dilated cardiomyopathy, fibrinopeptide A and thrombin-antithrombin III complex levels showed a positive correlation with left ventricular end-diastolic volume and a negative correlation with fractional shortening of the left ventricle. CONCLUSIONS The activated coagulation system in patients with hypertrophic and dilated cardiomyopathy may be triggered by left atrial dilation in hypertrophic cardiomyopathy and left ventricular enlargement and dysfunction in dilated cardiomyopathy.
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Affiliation(s)
- K Yamamoto
- Department of Cardiology, Jichi Medical School, Tochigi, Japan
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33
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Marian AJ. Sudden cardiac death in patients with hypertrophic cardiomyopathy: from bench to bedside with an emphasis on genetic markers. Clin Cardiol 1995; 18:189-98. [PMID: 7788945 DOI: 10.1002/clc.4960180403] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Hypertrophic cardiomyopathy (HCM) is the most common cause of death in the young, particularly in young competitive athletes. Death often occurs suddenly in asymptomatic, apparently healthy individuals. Several clinical parameters as well as genetic factors have been characterized that can identify those HCM patients who are at high risk for sudden cardiac death (SCD). The clinical parameters that have some predictive values for SCD in HCM patients are the following: a prior history of SCD, a family history of SCD, history of syncope, symptomatic ventricular tachycardia on Holter monitoring, inducible ventricular tachycardia during electrophysiologic studies, and myocardial ischemia in children with HCM. Recent identification of mutations in the beta myosin heavy chain gene and genotype-phenotype correlation in HCM patients have shown that the beta myosin heavy chain mutations are also prognosticators in HCM families. Several mutations such as Arg403Gln and Arg719Gln are associated with a high incidence of SCD, while Leu908Val mutation is associated with a benign course and a low incidence of SCD in HCM families. Additional genetic factors such as a polymorphism in angiotensin-converting enzyme I gene may also contribute to a high incidence of SCD in HCM families. Identification and characterization of HCM patients at high risk for SCD provide the opportunity to render prophylactic therapeutic interventions, such as implantation of defibrillators, in these individuals.
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Affiliation(s)
- A J Marian
- Baylor College of Medicine, Houston, TX 77030, USA
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34
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Abstract
Atrial fibrillation is the most common atrial tachyarrhythmia. Consideration for the potential conversion of atrial fibrillation and the subsequent maintenance of sinus rhythm may be related to underlying pathology. Typically, extra cardiac factors such as thyroid hyperactivity help to determine initial therapy. Intrinsic cardiac factors may also influence the clinician's decision regarding potential cardioversion and maintenance of sinus rhythm. Some acute events such as pericarditis and the effects of cardiac trauma may resolve and result in spontaneous restoration of sinus rhythm. Other cardiac events such as acute myocardial infarction with or without atrial ischemia, valvular disease, and others may result in the precipitation of atrial fibrillation. The major reasons to consider cardioversion, either medically or electrically, are ventricular rate control, hemodynamic improvement, sense of well being, and the avoidance of embolism. Certain clinical situations (e.g., Wolff-Parkinson-White syndrome) require urgent restoration of sinus rhythm in light of the potential for extremely rapid ventricular rates. It has been suggested that all antiarrhythmic drug administration should be initiated in the hospital setting, but the brief period of drug administration in an inpatient setting does not protect the patient from potential, late-onset proarrhythmic events. Both antiarrhythmic drug therapy and electric cardioversion are useful for restoration of sinus rhythm in both acute and chronic atrial fibrillation. The most important negative aspect of drug conversion of atrial fibrillation may be the potential development of a proarrhythmic drug effect. Although controversial, conversion (medical or electrical) is probably indicated in every patient with the first episode of persistent atrial fibrillation, even if the patient is asymptomatic.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- W J Mandel
- Cardiology Division, Cedars-Sinai Medical Center, Los Angeles, California
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35
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Abstract
Concerns about proarrhythmia risk and inefficacy associated with class I antiarrhythmic drugs have revived interest in low-dose amiodarone (maintenance dose 200-400 mg/day) for suppression of atrial fibrillation. In nonrandomized trials of amiodarone for atrial fibrillation refractory to conventional agents, amiodarone has been successful in maintaining sinus rhythm in 53-79% of patients during a mean follow-up of 15-27 months. Intolerable side effects, including pulmonary toxicity, are in the range of 1-12% per year and resolve following amiodarone withdrawal in the majority of cases. Proarrhythmia risk associated with amiodarone, even in the setting of left ventricular dysfunction, is extremely low. In patients with congestive heart failure, in whom other pharmacologic options are limited by proarrhythmia risk and negative inotropism, preliminary experience with amiodarone is especially promising. Randomized trials are needed, directly comparing amiodarone to conventional antiarrhythmic therapy for atrial fibrillation suppression and comparing amiodarone to warfarin for thromboembolism prevention in patients with atrial fibrillation refractory to conventional antiarrhythmic drugs.
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Affiliation(s)
- H R Middlekauff
- Division of Cardiology, University of California, Los Angeles School of Medicine 90024
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36
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Sanada H, Shimizu M, Sugihara N, Shimizu K, Ino H, Takeda R. Increased left atrial chamber stiffness in hypertrophic cardiomyopathy. BRITISH HEART JOURNAL 1993; 69:31-5. [PMID: 8457391 PMCID: PMC1024912 DOI: 10.1136/hrt.69.1.31] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVE To investigate left atrial chamber stiffness and its influence on left atrial and left ventricular functions in hypertrophic cardiomyopathy. DESIGN Prospective study. SETTING Department of internal medicine in a university teaching hospital. PATIENTS Five control subjects, six patients with essential hypertension, and 11 patients with hypertrophic cardiomyopathy. INTERVENTIONS Measurement of left atrial pressure by a tip micromanometer and of real-time left atrial volume from left atrial cineangiograms. MAIN OUTCOME MEASURE Left atrial stiffness constant determined by fitting the ascending limb of the v loop of the left atrial pressure-volume relation to an exponential curve. RESULTS The mean (SD) left atrial chamber stiffness constant was significantly larger in patients with hypertrophic cardiomyopathy than in controls (0.063 (0.018) v 0.041 (0.006), p < 0.05) and was correlated with left ventricular wall thickness (r = 0.560, p < 0.01). Left atrial reservoir volume (left atrial emptying volume before atrial contraction) was significantly smaller in patients with hypertrophic cardiomyopathy than in the controls (7.3 (2.1) v 12.5 (4.4) ml/m2, p < 0.01) and was inversely correlated with the left atrial chamber stiffness constant (r = -0.598, p < 0.01). The cardiac index was inversely correlated with the left atrial chamber stiffness constant (r = -0.542, p < 0.01). CONCLUSIONS Left atrial chamber stiffness was increased in patients with hypertrophic cardiomyopathy and this affected the left atrial reservoir function. This may in turn have affected cardiac output.
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Affiliation(s)
- H Sanada
- Second Department of Internal Medicine, School of Medicine, Kanazawa University, Japan
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37
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Fananapazir L, Chang AC, Epstein SE, McAreavey D. Prognostic determinants in hypertrophic cardiomyopathy. Prospective evaluation of a therapeutic strategy based on clinical, Holter, hemodynamic, and electrophysiological findings. Circulation 1992; 86:730-40. [PMID: 1516184 DOI: 10.1161/01.cir.86.3.730] [Citation(s) in RCA: 166] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Patients with hypertrophic cardiomyopathy (HCM) frequently have arrhythmias and hemodynamic abnormalities and are prone to sudden death and syncope. An important need exists for improved risk stratification and definition of appropriate investigation and therapy. METHODS AND RESULTS The relation of 31 clinical, Holter, cardiac catheterization, and electrophysiological (EP) variables to subsequent cardiac events in 230 HCM patients was examined by multivariate analysis. Studies were for cardiac arrest (n = 32), syncope (n = 80), presyncope (n = 52), ventricular tachycardia (VT) on Holter (n = 36), a strong family history of sudden death (n = 9), and palpitations (n = 21). Nonsustained VT on Holter was present in 115 patients (50%). Sustained ventricular arrhythmia was induced in 82 patients (36%). Seventeen cardiac events (eight sudden deaths, one cardiac arrest, and eight syncope with defibrillator discharges) occurred during a follow-up of 28 +/- 19 months. The 1-year and 5-year event-free rates were 99% and 79%, respectively. Two variables were significant independent predictors of subsequent events: sustained ventricular arrhythmia induced at EP study (beta, 3.5; p = 0.002) and a history of cardiac arrest or syncope (beta, 2.9; p less than 0.05). Only two of 66 patients without symptoms of impaired consciousness had a cardiac event (3-year event-free rate, 97%). In contrast, nonsustained VT on Holter was associated with a worse prognosis only in patients with symptoms of impaired consciousness: 11 of 79 symptomatic patients with VT on Holter (14%) had events versus only four of 85 symptomatic patients without VT on Holter (5%) (p = 0.057). Notably, none of 51 patients without symptoms of impaired consciousness in whom VT was not induced at EP study had a cardiac event. CONCLUSIONS In HCM, VT on Holter is of benign prognostic significance in the absence of symptoms of impaired consciousness and inducible VT, and sustained VT induced at EP study, especially when associated with cardiac arrest or syncope, identifies a subgroup at high risk for subsequent cardiac events.
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Affiliation(s)
- L Fananapazir
- Electrophysiology Section, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD 20892
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39
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Blitz A, McLoughlin D, Gross J, Schwartz DS, Fisher JD, Kim SG, Frame R, Brodman RF. Combined maze procedure and septal myectomy in a septuagenarian. Ann Thorac Surg 1992; 54:364-5. [PMID: 1637234 DOI: 10.1016/0003-4975(92)91404-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
A 75-year-old woman with refractory paroxysmal atrial fibrillation and hypertrophic obstructive cardiomyopathy underwent a successful combined maze procedure and septal myectomy. Postoperative episodes of atrial fibrillation and flutter occurred only during periods of bradyarrhythmia and did not recur with atrial inhibited pacing.
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Affiliation(s)
- A Blitz
- Department of Cardiothoracic Surgery, Montefiore Medical Center, Moses Division, Bronx, NY 10467
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41
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Petrone RK, Klues HG, Panza JA, Peterson EE, Maron BJ. Coexistence of mitral valve prolapse in a consecutive group of 528 patients with hypertrophic cardiomyopathy assessed with echocardiography. J Am Coll Cardiol 1992; 20:55-61. [PMID: 1607539 DOI: 10.1016/0735-1097(92)90137-c] [Citation(s) in RCA: 49] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Hypertrophic cardiomyopathy and mitral valve prolapse are both conditions that may be genetically transmitted and incur a risk for sudden cardiac death. Although the small left ventricular cavity and distorted geometry characteristic of hypertrophic cardiomyopathy might suggest a predisposition to mitral valve prolapse, the frequency with which these two entities coexist and the potential clinical significance of such an association are not known. To further define the relation of hypertrophic cardiomyopathy and mitral valve prolapse, 528 consecutive patients with hypertrophic cardiomyopathy were studied by echocardiography. Patients ranged in age from 1 to 86 years (mean 45); 335 (63%) were male. Unequivocal echocardiographic evidence of systolic mitral valve prolapse into the left atrium was identified in only 16 (3%) of the 528 patients. The mitral valve excised at operation from three of the patients had morphologic characteristics of a floppy mitral valve, which was judged to be responsible for the echocardiographic findings. Occurrence of clinically evident atrial fibrillation was common in patients with hypertrophic cardiomyopathy and mitral valve prolapse (9 [56%] of 16). Hence, in a large group of patients with hypertrophic cardiomyopathy, the association of echocardiographically documented mitral valve prolapse was uncommon. The coexistence of mitral valve prolapse in patients with hypertrophic cardiomyopathy appears to predispose such patients to atrial fibrillation.
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Affiliation(s)
- R K Petrone
- Cardiology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland 20892
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42
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Spirito P, Lakatos E, Maron BJ. Degree of left ventricular hypertrophy in patients with hypertrophic cardiomyopathy and chronic atrial fibrillation. Am J Cardiol 1992; 69:1217-22. [PMID: 1533490 DOI: 10.1016/0002-9149(92)90939-v] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
It has been generally assumed that most patients with hypertrophic cardiomyopathy (HC) who develop atrial fibrillation (AF) have marked left ventricular (LV) hypertrophy and subaortic obstruction. The morphologic and functional features of this subset of patients with HC have not been systematically investigated. The LV morphology and functional profile of 46 patients with HC and chronic AF were compared with those of 81 control patients with HC and normal sinus rhythm. Contrary to expectations, LV hypertrophy (assessed with 2-dimensional echocardiography) was substantially less marked in the patients with AF than in the control patients, and prevalence of subaortic obstruction was similar in the 2 groups. Maximal LV wall thickness and wall thickness index were lower in patients with AF (18 +/- 2 and 56 +/- 7 mm, respectively) than in control patients (22 +/- 6 and 67 +/- 16 mm, respectively; p less than 0.001). Furthermore, mild LV hypertrophy (maximal LV wall thickness less than or equal to 17 mm confined to 1 ventricular segment) was almost twice as frequent in patients with AF (63%) than in control patients (36%; p less than 0.005). Subaortic obstruction was present in 9 patients with AF (20%) and in 28 control patients (35%; p greater than 0.05). In a subgroup of 22 patients with AF who were followed for 4 to 10 years, 5 patients had marked LV wall thinning (greater than or equal to 5 mm, range 5 to 14). In conclusion, these results demonstrate that most patients with HC and chronic AF have the nonobstructive form of HC, and relatively mild LV hypertrophy.
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Affiliation(s)
- P Spirito
- Echocardiography Laboratory, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland
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43
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44
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Affiliation(s)
- O Odemuyiwa
- Department of Cardiological Sciences, St George's Hospital Medical School, London, UK
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45
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Abstract
Over the past 30 years, knowledge of the natural history and effects of therapy in patients with hypertrophic cardiomyopathy has expanded greatly, but progress has been hampered by its variable patterns of expression. Many but not all patients show symptomatic improvement with medical treatment. Chronic beta blockage does not appear to affect long-term survival, whereas results with calcium channel blockade by verapamil have been encouraging; however, they await confirmation, and verapamil may be hazardous in some patients with severe left ventricular (LV) outflow tract obstruction and elevated LV end-diastolic pressure. Reported beneficial effects of amiodarone on survival also require further study. Surgical therapy has become the treatment of choice for medically refractory patients with proven outflow tract obstruction. In several centers, the operative risk is low, and long-term follow-up demonstrates prolonged symptomatic relief. It is hoped that work currently underway will provide more definitive information on the long-term effects of the role of calcium channel blockers, antiarrhythmic medications, and the long-term effects of surgical therapy on survival of patients with this disorder.
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Affiliation(s)
- D G Blanchard
- Department of Medicine, University of California, San Diego School of Medicine, La Jolla 92093
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46
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Pelliccia F, Cianfrocca C, Cristofani R, Romeo F, Reale A. Electrocardiographic findings in patients with hypertrophic cardiomyopathy. Relation to presenting features and prognosis. J Electrocardiol 1990; 23:213-22. [PMID: 2384727 DOI: 10.1016/0022-0736(90)90159-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The relation of ECG findings to presenting features and prognosis was evaluated in 125 consecutive patients with hypertrophic cardiomyopathy (HC). Seventy-nine men and 46 women (mean age, 34 +/- 7 years) were studied since 1970. Most ECG features were similar in patients with and without a left ventricular outflow tract gradient. Those with obstruction had a higher prevalence of left ventricular hypertrophy according to ECG voltage criteria (54% vs. 28%, p less than 0.01), whereas higher grade ventricular arrhythmias were more common in patients without an outflow gradient (20% vs. 7%, p less than 0.05). The prevalence of ECG abnormalities was also similar in younger (less than or equal to 14 years) and older patients (greater than 14 years), and only repolarization abnormalities were more frequently detected in the older age group (56% vs. 32%, p less than 0.025). Stratification of patients according to the clinical state revealed that those who had moderate to severe functional limitation had a higher prevalence of atrial fibrillation than asymptomatic or mildly symptomatic patients (24% vs. 1%, p less than 0.001). There were no significant differences in most hemodynamic variables among patients dichotomized according to any specific ECG abnormality. Only patients with atrial fibrillation had significantly higher right ventricular end-diastolic pressure (10 +/- 7 vs. 6 +/- 4 mmHg, p less than 0.01), lower systolic index (22 +/- 8 vs. 37 +/- 15 ml/m2; beat, p less than 0.02) and lower ejection fraction (53 +/- 8 vs. 64 +/- 10%, p less than 0.001) than those in sinus rhythm.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- F Pelliccia
- Department of Cardiology, University of Rome, La Sapienza, Italy
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47
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Robinson K, Frenneaux MP, Stockins B, Karatasakis G, Poloniecki JD, McKenna WJ. Atrial fibrillation in hypertrophic cardiomyopathy: a longitudinal study. J Am Coll Cardiol 1990; 15:1279-85. [PMID: 2329232 DOI: 10.1016/s0735-1097(10)80014-2] [Citation(s) in RCA: 216] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The clinical outcome of 52 consecutive patients with hypertrophic cardiomyopathy who developed paroxysmal (less than 1 week) or established (greater than or equal to 1 week) atrial fibrillation between 1960 and 1985 was examined retrospectively and compared with that of a matched group of patients with hypertrophic cardiomyopathy and sinus rhythm. Follow-up study until death or the present ranged from 6 months to 24 years (median 11 years) from diagnosis and from 6 months to 22 years (median 7 years) from the onset of atrial fibrillation. Atrial fibrillation was present in 6 patients at the time of diagnosis, whereas it developed subsequently in 46. The acute onset of arrhythmia was associated with a change in symptoms in 41 (89%) of the 46. After initial treatment of acute atrial fibrillation, sinus rhythm was restored in 29 (63%) of the 46 patients; 43 (93%) of the 46 returned to their original symptom class. Stepwise logistic regression revealed that shorter duration of arrhythmia and amiodarone therapy were the most powerful predictors of return to sinus rhythm. Sinus rhythm was maintained during a median follow-up period of 5.5 years in 22 of the 29 patients in whom it was restored after initial therapy. During follow-up study, 25 of the 52 patients were treated with conventional therapy alone and 7 with amiodarone alone. Amiodarone therapy was associated with maintenance of sinus rhythm, fewer alterations in drug therapy, fewer embolic episodes and fewer attempted direct current cardioversions (during a shorter follow-up period).(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- K Robinson
- Department of Cardiological Sciences, St. George's Hospital Medical School, London, England
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Affiliation(s)
- A M Greenspan
- Department of Medicine, Albert Einstein Medical Center, Philadelphia, Pennsylvania 19141
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49
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Fananapazir L, Tracy CM, Leon MB, Winkler JB, Cannon RO, Bonow RO, Maron BJ, Epstein SE. Electrophysiologic abnormalities in patients with hypertrophic cardiomyopathy. A consecutive analysis in 155 patients. Circulation 1989; 80:1259-68. [PMID: 2805263 DOI: 10.1161/01.cir.80.5.1259] [Citation(s) in RCA: 116] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Electrophysiologic studies (EPS) were performed in 155 patients with hypertrophic cardiomyopathy (HCM). Indications for EPS were cardiac arrest in 22 patients, syncope in 55 patients, presyncope in 37 patients, asymptomatic ventricular tachycardia (VT) in 24 patients, palpitations in 10 patients, and a strong family history of sudden cardiac death in seven patients. Thirty-five (23%) patients had significant resting left ventricular outflow tract obstruction. Electrophysiologic abnormalities were present in 126 (81%) patients. A high prevalence of abnormal sinus-node function (66%) and His-Purkinje (HV) conduction (30%) was noted. The most commonly induced supraventricular arrhythmias were atrial reentrant tachycardia and atrial fibrillation (10% and 11% of patients, respectively). Accessory atrioventricular pathways were present in seven (5%) patients. Programmed ventricular stimulation (PVS) induced nonsustained ventricular tachycardia in 22 (14%) patients and sustained ventricular arrhythmia in 66 (43%) patients. Sustained ventricular arrhythmia was polymorphic VT in 48 (73%) patients, monomorphic VT in 16 (24%) patients, and ventricular fibrillation in two (3%) patients. Induction was with two premature stimuli in 19 (29%) patients and three premature stimuli in 47 (71%) patients. Of 17 cardiac arrest survivors with sustained ventricular arrhythmia, 16 (94%) patients required three premature stimuli for arrhythmia induction. Sustained ventricular arrhythmia was induced at a right ventricular site in 51 (77%) patients and at a left ventricular site in 15 (23%) patients. Univariate analysis showed a significant (p less than 0.05) association between inducibility of sustained ventricular arrhythmia and VT on Holter in patients with a history of cardiac arrest or syncope but not in patients with presyncope or asymptomatic patients. Multivariate logistic regression analysis revealed that the following were significantly associated with inducibility of sustained ventricular arrhythmia: clinical presentation (cardiac arrest more than syncope more than presyncope more than asymptomatic patients, p = 0.0002; chronic or inducible atrial fibrillation, p = 0.002; and male gender, p = 0.04). In contrast, there was no clinical correlate of induced nonsustained VT.(ABSTRACT TRUNCATED AT 400 WORDS)
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Affiliation(s)
- L Fananapazir
- Cardiovascular Diagnostic Section, National Institutes of Health, Bethesda, Maryland 20892
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50
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Lazzeroni E, Domenicucci S, Finardi A, Zoni A, Dodi C, Francescon P, Botti G. Severity of arrhythmias and extent of hypertrophy in hypertrophic cardiomyopathy. Am Heart J 1989; 118:734-8. [PMID: 2529748 DOI: 10.1016/0002-8703(89)90586-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
To evaluate the relationship between the extent of left ventricular hypertrophy and ventricular or atrial arrhythmias, 77 patients with hypertrophic cardiomyopathy underwent two-dimensional echocardiography and 24-hour Holter monitoring. Antiarrhythmic treatment was discontinued before the study. Hypertrophy was septal in 33 patients, "extensive" (i.e., involving the septum and free wall) in 38 patients, and predominantly apical in six patients. Lown grade I and II ventricular arrhythmias were detected in 37% of patients, grade III in 21%, and grade IV in 29%. Atrial extrasystoles were seen in 52% of patients and chronic atrial fibrillation in 13%. More serious ventricular arrhythmias (Lown grades III and IV) occurred significantly more frequently in patients with extensive than in those with only septal hypertrophy (22/38 vs 11/33; p less than 0.001); similarly, chronic atrial fibrillation occurred more commonly in those with extensive hypertrophy (9/38 vs 1/33; p less than 0.01). During a mean follow-up period of 2.6 years, three patients died. All had a pattern of extensive hypertrophy. Two of them had ventricular tachycardia and the third had chronic atrial fibrillation. Results of this study suggest that an echocardiographic finding of extensive hypertrophy represents a useful marker for detecting patients at increased risk for serious ventricular and atrial arrhythmias.
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Affiliation(s)
- E Lazzeroni
- Divisione di Cardiologia, Ospedale Regionale, Italy
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