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Sidiropoulos G, Karakasis P, Antoniadis A, Saplaouras A, Karamitsos T, Fragakis N. The Effect of Cardiac Resynchronization Therapy on Right Ventricular Function: A Systematic Review and Meta-Analysis. J Clin Med 2024; 13:4173. [PMID: 39064212 PMCID: PMC11277751 DOI: 10.3390/jcm13144173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2024] [Revised: 07/10/2024] [Accepted: 07/15/2024] [Indexed: 07/28/2024] Open
Abstract
Background: Right ventricular (RV) failure is an important predicting factor regarding overall and event-free survival regardless of baseline left ventricular (LV) function in patients with severe heart failure (HF). Previous studies have indicated that cardiac resynchronization therapy (CRT) improves LV and RV reverse remodeling in patients with systolic dyssynchrony within the left ventricle. However, there is conflicting evidence regarding the role of CRT in RV function. The aim of this systematic review and meta-analysis was to examine the implications of CRT on RV function indices. Methods: A systematic literature search was conducted using the MedLine and EMBASE databases and the Cochrane Library from their inception until 18 March 2024. Eligible were studies providing information on RV function indices, both at baseline and after CRT. Evidence was summarized using random-effects meta-analytic models. Results: In total, 30 studies were deemed eligible. CRT resulted in a significant improvement in right ventricular fractional area change (mean difference (MD) 5.11%, 95% confidence interval (CI) 2.83 to 7.39), tricuspid annular plane systolic excursion (TAPSE, MD 1.63 mm, 95% CI 1.10 to 2.16), and myocardial systolic excursion velocity (MD 1.85 cm/s, 95% CI 1.24 to 2.47) as well as a significant decrease in pulmonary artery systolic pressure (MD -6.24 mmHg, 95% CI -8.32 to -4.16). A non-significant effect was observed on TAPSE to PASP ratio and right ventricular global longitudinal strain. Conclusions: Our meta-analysis demonstrates that CRT is associated with a significant improvement in echocardiographic parameters of RV function. Further investigation is necessary to elucidate how these changes, both independently and in conjunction with LV improvement, impact patients' long-term prognosis, and to identify the specific patient populations expected to derive the greatest benefit.
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Affiliation(s)
- Georgios Sidiropoulos
- Department of Cardiology, Georgios Papanikolaou General Hospital, Leoforos Papanikolaou, PK 57010 Thessaloniki, Greece;
| | - Paschalis Karakasis
- 2nd Cardiology Department, Hippokration General Hospital, Aristotle University Medical School, Κonstantinoupoleos 49, PK 54642 Thessaloniki, Greece;
| | - Antonios Antoniadis
- 3rd Cardiology Department, Hippokration General Hospital, Aristotle University Medical School, Κonstantinoupoleos 49, PK 54642 Thessaloniki, Greece;
| | - Athanasios Saplaouras
- Onassis Cardiac Surgery Center, Electrophysiology Department, Leoforos Andrea Syggrou 356, PK 17674 Athens, Greece;
| | - Theodoros Karamitsos
- 1st Cardiology Department, AHEPA University Hospital, Aristotle University Medical School, Kiriakidi 1, PK 54636 Thessaloniki, Greece;
| | - Nikolaos Fragakis
- 2nd Cardiology Department, Hippokration General Hospital, Aristotle University Medical School, Κonstantinoupoleos 49, PK 54642 Thessaloniki, Greece;
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2
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Yuyun MF, Joseph J, Erqou SA, Kinlay S, Echouffo-Tcheugui JB, Peralta AO, Hoffmeister PS, Boden WE, Yarmohammadi H, Martin DT, Singh JP. Evolution and prognosis of tricuspid and mitral regurgitation following cardiac implantable electronic devices: a systematic review and meta-analysis. Europace 2024; 26:euae143. [PMID: 38812433 PMCID: PMC11259857 DOI: 10.1093/europace/euae143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Accepted: 05/23/2024] [Indexed: 05/31/2024] Open
Abstract
AIMS Significant changes in tricuspid regurgitation (TR) and mitral regurgitation (MR) post-cardiac implantable electronic devices (CIEDs) are increasingly recognized. However, uncertainty remains as to whether the risk of CIED-associated TR and MR differs with right ventricular pacing (RVP) via CIED with trans-tricuspid RV leads, compared with cardiac resynchronization therapy (CRT), conduction system pacing (CSP), and leadless pacing (LP). The study aims to synthesize extant data on risk and prognosis of significant post-CIED TR and MR across pacing strategies. METHODS AND RESULTS We searched PubMed, EMBASE, and Cochrane Library databases published until 31 October 2023. Significant post-CIED TR and MR were defined as ≥ moderate. Fifty-seven TR studies (n = 13 723 patients) and 90 MR studies (n = 14 387 patients) were included. For all CIED, the risk of post-CIED TR increased [pooled odds ratio (OR) = 2.46 and 95% CI = 1.88-3.22], while the risk of post-CIED MR reduced (OR = 0.74, 95% CI = 0.58-0.94) after 12 and 6 months of median follow-up, respectively. Right ventricular pacing via CIED with trans-tricuspid RV leads was associated with increased risk of post-CIED TR (OR = 4.54, 95% CI = 3.14-6.57) and post-CIED MR (OR = 2.24, 95% CI = 1.18-4.26). Binarily, CSP did not alter TR risk (OR = 0.37, 95% CI = 0.13-1.02), but significantly reduced MR (OR = 0.15, 95% CI = 0.03-0.62). Cardiac resynchronization therapy did not significantly change TR risk (OR = 1.09, 95% CI = 0.55-2.17), but significantly reduced MR with prevalence pre-CRT of 43%, decreasing post-CRT to 22% (OR = 0.49, 95% CI = 0.40-0.61). There was no significant association of LP with post-CIED TR (OR = 1.15, 95% CI = 0.83-1.59) or MR (OR = 1.31, 95% CI = 0.72-2.39). Cardiac implantable electronic device-associated TR was independently predictive of all-cause mortality [pooled hazard ratio (HR) = 1.64, 95% CI = 1.40-1.90] after median of 53 months. Mitral regurgitation persisting post-CRT independently predicted all-cause mortality (HR = 2.00, 95% CI = 1.57-2.55) after 38 months. CONCLUSION Our findings suggest that, when possible, adoption of pacing strategies that avoid isolated trans-tricuspid RV leads may be beneficial in preventing incident or deteriorating atrioventricular valvular regurgitation and might reduce mortality.
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Affiliation(s)
- Matthew F Yuyun
- Department of Medicine, VA Boston Healthcare System, 1400 VFW Parkway, West Roxbury, MA 02132, USA
- Department of Medicine, Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA
- Department of Medicine, Boston University Chobanian and Avedisian School of Medicine, 72 E Concord St, Boston, MA 02118, USA
| | - Jacob Joseph
- Department of Medicine, VA Boston Healthcare System, 1400 VFW Parkway, West Roxbury, MA 02132, USA
- Department of Medicine, VA Providence Healthcare System, 830 Chalkstone Ave, Providence, RI 02908, USA
- Department of Medicine, Brown University, 1 Prospect Street, Providence, RI 02912, USA
| | - Sebhat A Erqou
- Department of Medicine, VA Providence Healthcare System, 830 Chalkstone Ave, Providence, RI 02908, USA
- Department of Medicine, Brown University, 1 Prospect Street, Providence, RI 02912, USA
| | - Scott Kinlay
- Department of Medicine, VA Boston Healthcare System, 1400 VFW Parkway, West Roxbury, MA 02132, USA
- Department of Medicine, Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA
- Department of Medicine, Boston University Chobanian and Avedisian School of Medicine, 72 E Concord St, Boston, MA 02118, USA
- Department of Medicine, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115, USA
| | - Justin B Echouffo-Tcheugui
- Department of Medicine, Johns Hopkins University School of Medicine, 733 N Broadway, Baltimore, MD 21205, USA
| | - Adelqui O Peralta
- Department of Medicine, VA Boston Healthcare System, 1400 VFW Parkway, West Roxbury, MA 02132, USA
- Department of Medicine, Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA
- Department of Medicine, Boston University Chobanian and Avedisian School of Medicine, 72 E Concord St, Boston, MA 02118, USA
| | - Peter S Hoffmeister
- Department of Medicine, VA Boston Healthcare System, 1400 VFW Parkway, West Roxbury, MA 02132, USA
- Department of Medicine, Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA
- Department of Medicine, Boston University Chobanian and Avedisian School of Medicine, 72 E Concord St, Boston, MA 02118, USA
| | - William E Boden
- Department of Medicine, VA Boston Healthcare System, 1400 VFW Parkway, West Roxbury, MA 02132, USA
- Department of Medicine, Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA
- Department of Medicine, Boston University Chobanian and Avedisian School of Medicine, 72 E Concord St, Boston, MA 02118, USA
| | - Hirad Yarmohammadi
- Department of Medicine, Columbia University Irving Medical Center, 177 Fort Washington Avenue, New York, NY 10032, USA
| | - David T Martin
- Department of Medicine, Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA
- Department of Medicine, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115, USA
| | - Jagmeet P Singh
- Department of Medicine, Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA
- Department of Medicine, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, USA
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3
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Chen X, Zhang P, Lou J, Zhao R, Zhang S, Xie M, Lv Q. Application of an echocardiographic index to characterize right ventricular-pulmonary arterial coupling in heart failure. ESC Heart Fail 2024; 11:1290-1304. [PMID: 38229524 PMCID: PMC11098638 DOI: 10.1002/ehf2.14663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Revised: 11/29/2023] [Accepted: 12/19/2023] [Indexed: 01/18/2024] Open
Abstract
Heart failure (HF), with its high morbidity and mortality, remains a global public health issue. Right ventricular (RV) dysfunction is a sign of deterioration in the natural history of HF, and a thorough evaluation of the relationship between RV contractility and its afterload through RV-pulmonary arterial (RV-PA) coupling can aid in accurately assessing overall RV function. The ratio of RV end-systolic elastance (Ees) to pulmonary arterial elastance (Ea) invasively measured by right heart catheterization served as the gold standard for evaluating RV-PA coupling. An echocardiographic index termed tricuspid annular plane systolic excursion/pulmonary artery systolic pressure (TAPSE/PASP) has been shown to correlate well with Ees/Ea. TAPSE/PASP is recognized as a non-invasive surrogate of RV-PA coupling and has been extensively studied in patients with HF. This review briefly describes the methods of assessing RV-PA coupling, mainly discussing echocardiography, summarizes the clinical utility of TAPSE/PASP in patients with different HF types, and provides an overview of the available literature.
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Affiliation(s)
- Xin Chen
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
- Clinical Research Centre for Medical Imaging in Hubei ProvinceWuhanChina
- Hubei Province Key Laboratory of Molecular ImagingWuhanChina
| | - Peige Zhang
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
- Clinical Research Centre for Medical Imaging in Hubei ProvinceWuhanChina
- Hubei Province Key Laboratory of Molecular ImagingWuhanChina
| | - Jie Lou
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
- Clinical Research Centre for Medical Imaging in Hubei ProvinceWuhanChina
- Hubei Province Key Laboratory of Molecular ImagingWuhanChina
| | - Ruohan Zhao
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
- Clinical Research Centre for Medical Imaging in Hubei ProvinceWuhanChina
- Hubei Province Key Laboratory of Molecular ImagingWuhanChina
| | - Siyi Zhang
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
- Clinical Research Centre for Medical Imaging in Hubei ProvinceWuhanChina
- Hubei Province Key Laboratory of Molecular ImagingWuhanChina
| | - Mingxing Xie
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
- Clinical Research Centre for Medical Imaging in Hubei ProvinceWuhanChina
- Hubei Province Key Laboratory of Molecular ImagingWuhanChina
- Shenzhen Huazhong University of Science and Technology Research InstituteShenzhenChina
- Tongji Medical College and Wuhan National Laboratory for OptoelectronicsHuazhong University of Science and TechnologyWuhanChina
| | - Qing Lv
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
- Clinical Research Centre for Medical Imaging in Hubei ProvinceWuhanChina
- Hubei Province Key Laboratory of Molecular ImagingWuhanChina
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4
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Tello K, Naeije R, de Man F, Guazzi M. Pathophysiology of the right ventricle in health and disease: an update. Cardiovasc Res 2023; 119:1891-1904. [PMID: 37463510 DOI: 10.1093/cvr/cvad108] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 04/14/2023] [Accepted: 05/02/2023] [Indexed: 07/20/2023] Open
Abstract
The contribution of the right ventricle (RV) to cardiac output is negligible in normal resting conditions when pressures in the pulmonary circulation are low. However, the RV becomes relevant in healthy subjects during exercise and definitely so in patients with increased pulmonary artery pressures both at rest and during exercise. The adaptation of RV function to loading rests basically on an increased contractility. This is assessed by RV end-systolic elastance (Ees) to match afterload assessed by arterial elastance (Ea). The system has reserve as the Ees/Ea ratio or its imaging surrogate ejection fraction has to decrease by more than half, before the RV undergoes an increase in dimensions with eventual increase in filling pressures and systemic congestion. RV-arterial uncoupling is accompanied by an increase in diastolic elastance. Measurements of RV systolic function but also of diastolic function predict outcome in any cause pulmonary hypertension and heart failure with or without preserved left ventricular ejection fraction. Pathobiological changes in the overloaded RV include a combination of myocardial fibre hypertrophy, fibrosis and capillary rarefaction, a titin phosphorylation-related displacement of myofibril tension-length relationships to higher pressures, a metabolic shift from mitochondrial free fatty acid oxidation to cytoplasmic glycolysis, toxic lipid accumulation, and activation of apoptotic and inflammatory signalling pathways. Treatment of RV failure rests on the relief of excessive loading.
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Affiliation(s)
- Khodr Tello
- Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Klinikstrasse 36, 35392 Giessen, Germany
| | - Robert Naeije
- Pathophysiology, Faculty of Medicine, Free University of Brussels, Brussels, Belgium
| | - Frances de Man
- Pulmonary Medicine, Amsterdam Medical Center, Amsterdam, The Netherlands
| | - Marco Guazzi
- Cardiology Division, San Paolo University Hospital, University of Milano, Milano, Italy
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5
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Ünlü S, Bézy S, Cvijic M, Duchenne J, Delcroix M, Voigt JU. Right ventricular strain related to pulmonary artery pressure predicts clinical outcome in patients with pulmonary arterial hypertension. Eur Heart J Cardiovasc Imaging 2022; 24:635-642. [PMID: 35852912 DOI: 10.1093/ehjci/jeac136] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 06/29/2022] [Indexed: 12/18/2022] Open
Abstract
Abstract
Aims
In pulmonary arterial hypertension (PAH), the right ventricle (RV) is exposed to an increased afterload. In response, RV mechanics are altered. Markers which would relate RV function and afterload could therefore aid to understand this complex response system and could be of prognostic value. The aim of our study was to (i) assess the RV-arterial coupling using ratio between RV strain and systolic pulmonary artery pressure (sPAP), in patients with PAH, and (ii) investigate the prognostic value of this new parameter over other echocardiographic parameters.
Methods and results
Echocardiograms of 65 pre-capillary PAH patients (45 females, age 61 ± 15 years) were retrospectively analysed. Fractional area change (FAC), sPAP, tricuspid annular plane systolic excursion, and RV free-wall (FW) longitudinal strain (LS) were measured. A primary endpoint of death or heart/lung transplantation described clinical endpoint. Patients who reached a clinical endpoint had worse functional capacity (New York Heart Association), reduced RV function, and higher sPAP. Left ventricle function was similar in both groups. Only RVFW LS/sPAP ratio was found as an independent predictor of clinical endpoint in multivariable analysis (hazard ratio 8.3, 95% confidence interval 3.2–21.6, P < 0.001). The RWFW LS/sPAP (cut-off 0.19) demonstrated a good accuracy for the prediction of reaching the clinical endpoint, with a sensitivity of 92% and specificity of 82.5%.
Conclusion
RVFW LS/sPAP ratio significantly predicts all-cause mortality and heart–lung transplantation, and was superior to other well-established parameters, in patients with pre-capillary PAH. We therefore propose RVFW LS/sPAP as a new prognostic echocardiographic marker.
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Affiliation(s)
- Serkan Ünlü
- Department of Cardiovascular Diseases, University Hospitals Leuven , Herestraat 49, 3000 Leuven , Belgium
- Department of Cardiology, Gazi University Faculty of Medicine , Ankara , Turkey
| | - Stéphanie Bézy
- Department of Cardiovascular Diseases, University Hospitals Leuven , Herestraat 49, 3000 Leuven , Belgium
| | - Marta Cvijic
- Department of Cardiovascular Diseases, University Hospitals Leuven , Herestraat 49, 3000 Leuven , Belgium
- Department of Cardiology, University Medical Centre Ljubljana, Slovenia Faculty of Medicine, University of Ljubljana , Ljubljana , Slovenia
| | - Jürgen Duchenne
- Department of Cardiovascular Diseases, University Hospitals Leuven , Herestraat 49, 3000 Leuven , Belgium
| | - Marion Delcroix
- Department of Pulmonology, University Hospitals Leuven , Leuven , Belgium
| | - Jens Uwe Voigt
- Department of Cardiovascular Diseases, University Hospitals Leuven , Herestraat 49, 3000 Leuven , Belgium
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6
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Martens P, Mathieu C, Vanassche T. The use of glucagon-like-peptide-1 receptor agonist in the cardiology practice. Acta Cardiol 2022:1-13. [PMID: 35575294 DOI: 10.1080/00015385.2022.2076307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
The presence of type 2 diabetes confronts the patient with an elevated risk to develop atherosclerotic cardiovascular disease (ASCVD), heart failure (HF), or chronic kidney disease (CKD). Glucose control in itself does not prevent these complications in their entirety. More recently several agents within the class of Sodium-Glucose cotransporter 2 inhibitors (SGLT2-I) and Glucagon-like-peptide-1 receptor agonists (GLP-1RA) have emerged as preferred agents to tackle the residual risk of ASCVD, HF, and CKD in patients with type 2 diabetes. Despite compelling trial data and professional society endorsement, the uptake of these agents in clinical practice is low. Especially GLP-1RA is only used in 8% of eligible candidates with type 2 diabetes and <5% of these prescriptions are attributed to cardiologists. This low uptake amongst cardiologists is related to the unfamiliarity with this class, its initiation, and titration, hesitation regarding simultaneous adjustment of other glucose-lowering agents, the unaccustomedness to prescribing injectable agents, and differential medical priorities. This review aims to offer cardiologists a practical tool for the optimal use of a GLP-1RA in their suitable patients and is focussed on the Belgian field of practice.
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Affiliation(s)
- Pieter Martens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- Department of Cardiology, Universitair Ziekenhuis Leuven, Leuven, Belgium
| | - Chantal Mathieu
- Department of Endocrinology, Universitair Ziekenhuis Leuven, Leuven, Belgium
| | - Thomas Vanassche
- Department of Cardiology, Universitair Ziekenhuis Leuven, Leuven, Belgium
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7
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Stassen J, Galloo X, Hirasawa K, Chimed S, Marsan NA, Delgado V, van der Bijl P, Bax JJ. Right ventricular-pulmonary artery coupling in cardiac resynchronization therapy: evolution and prognosis. ESC Heart Fail 2022; 9:1597-1607. [PMID: 35266319 PMCID: PMC9065855 DOI: 10.1002/ehf2.13857] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 01/20/2022] [Accepted: 02/06/2022] [Indexed: 11/06/2022] Open
Abstract
AIMS Chronic pressure overload and right ventricular (RV) dysfunction can lead to RV-pulmonary artery (PA) uncoupling in patients with heart failure. The evolution and prognostic values of RV-PA coupling assessed by echocardiography in patients undergoing cardiac resynchronization therapy (CRT) have not been thoroughly investigated. The aim of this study was to evaluate the evolution and prognostic value of tricuspid annular plane systolic excursion (TAPSE)/pulmonary artery systolic pressure (PASP) ratio in CRT recipients. METHODS AND RESULTS The RV-PA coupling was measured non-invasively with echocardiography using the TAPSE/PASP ratio at baseline and 6 month follow-up in CRT recipients. The cut-off value for TAPSE/PASP uncoupling was derived from spline curve analysis (i.e. <0.45 mm/mmHg). The primary endpoint was all-cause mortality. A total of 807 patients (age 66 ± 11 years, 76% men) were analysed. During a median follow-up of 97 (54-143) months, 483 (60%) patients died. Survival rates at 3 and 5 year follow-up were significantly lower for patients with a TAPSE/PASP ratio <0.45 mm/mmHg (76% and 58%, respectively), compared with those with a TAPSE/PASP ratio ≥0.45 mm/mmHg (91% and 82%, respectively) (P < 0.001). On multivariable analysis, TAPSE/PASP ratio <0.45 mm/mmHg (hazard ratio 1.437; 95% confidence interval: 1.145-1.805; P = 0.002) was independently associated with all-cause mortality, whereas TAPSE <17 mm (hazard ratio 1.237; 95% confidence interval: 0.990-1.546; P = 0.061) was not. In addition, no improvement of the TAPSE/PASP ratio after CRT implantation was independently associated with worse survival. CONCLUSIONS The TAPSE/PASP ratio at baseline is independently associated with long-term outcomes in CRT recipients. The baseline TAPSE/PASP ratio has incremental value over TAPSE, which does not take account of RV afterload. A lack of improvement in the TAPSE/PASP ratio after CRT implantation is associated with worse survival.
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Affiliation(s)
- Jan Stassen
- Department of Cardiology, Heart and Lung Center, Leiden University Medical Center, Albinusdreef 2, Leiden, 2300 RC, The Netherlands.,Department of Cardiology, Jessa Hospital Hasselt, Hasselt, Belgium
| | - Xavier Galloo
- Department of Cardiology, Heart and Lung Center, Leiden University Medical Center, Albinusdreef 2, Leiden, 2300 RC, The Netherlands.,Department of Cardiology, Vrije Universiteit Brussel (VUB) and Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
| | - Kensuke Hirasawa
- Department of Cardiology, Heart and Lung Center, Leiden University Medical Center, Albinusdreef 2, Leiden, 2300 RC, The Netherlands
| | - Surenjav Chimed
- Department of Cardiology, Heart and Lung Center, Leiden University Medical Center, Albinusdreef 2, Leiden, 2300 RC, The Netherlands
| | - Nina Ajmone Marsan
- Department of Cardiology, Heart and Lung Center, Leiden University Medical Center, Albinusdreef 2, Leiden, 2300 RC, The Netherlands
| | - Victoria Delgado
- Department of Cardiology, Heart and Lung Center, Leiden University Medical Center, Albinusdreef 2, Leiden, 2300 RC, The Netherlands
| | - Pieter van der Bijl
- Department of Cardiology, Heart and Lung Center, Leiden University Medical Center, Albinusdreef 2, Leiden, 2300 RC, The Netherlands
| | - Jeroen J Bax
- Department of Cardiology, Heart and Lung Center, Leiden University Medical Center, Albinusdreef 2, Leiden, 2300 RC, The Netherlands.,Turku Heart Center, University of Turku and Turku University Hospital, Turku, Finland
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8
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Lunardi M, Wu S, Serruys PW, Onuma Y, Soliman O, Wijns W, Mullens W, Sharif F. Acute and chronic exercise training in patients with Class II pulmonary hypertension: effects on haemodynamics and symptoms. ESC Heart Fail 2022; 9:791-799. [PMID: 35132779 PMCID: PMC8934934 DOI: 10.1002/ehf2.13819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 12/10/2021] [Accepted: 01/17/2022] [Indexed: 11/24/2022] Open
Abstract
More than half of heart failure (HF) patients have concomitant pulmonary hypertension, impacting symptoms and prognosis. The role of exercise in this category of patients is still unclear, probably because of the lack of a clear relationship between exercise and acute and chronic pulmonary artery pressure variations and related changes in symptoms. The limited evidence on this topic is contradictory and hardly comparable due to use of different exercise programmes and pulmonary artery pressure assessment techniques. This is further compounded by different functional and structural classes of HF making definite assessments and interpretations of exercise effect on outcomes difficult. Exercise training programmes were proven beneficial in HF patients; however, the lack of data about their pulmonary haemodynamic effects prevents clear indications on the best exercise types for patients presenting secondary pulmonary hypertension and different HF categories. Indeed, some data suggest that not all HF patients have similar responses to training, leading to either beneficial or detrimental effects, depending on the HF type. Future studies, involving modern technologies such as continuous pulmonary artery pressure monitoring implantable devices, may clarify the current gaps in this field, aiming at patient‐tailored exercise training rehabilitation programmes, in order to improve clinical outcomes, quality of life, and hopefully prognosis.
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Affiliation(s)
- Mattia Lunardi
- Department of Cardiology, Saolta Group, Galway University Hospital, Health Service Executive and National University of Ireland Galway (NUIG), Galway, Ireland.,Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Sijing Wu
- Department of Cardiology, Saolta Group, Galway University Hospital, Health Service Executive and National University of Ireland Galway (NUIG), Galway, Ireland.,Department of Cardiology, Anzhen Hospital, Capital Medical University, Beijing, China
| | - Patrick W Serruys
- Department of Cardiology, Saolta Group, Galway University Hospital, Health Service Executive and National University of Ireland Galway (NUIG), Galway, Ireland.,International Centre for Circulatory Health, NHLI, Imperial College, London, UK
| | - Yoshinobu Onuma
- Department of Cardiology, Saolta Group, Galway University Hospital, Health Service Executive and National University of Ireland Galway (NUIG), Galway, Ireland
| | - Osama Soliman
- Department of Cardiology, Saolta Group, Galway University Hospital, Health Service Executive and National University of Ireland Galway (NUIG), Galway, Ireland
| | - William Wijns
- Department of Cardiology, Saolta Group, Galway University Hospital, Health Service Executive and National University of Ireland Galway (NUIG), Galway, Ireland.,The Lambe Institute for Translational Medicine and CURAM, National University of Ireland Galway (NUIG), Galway, Ireland
| | - Wilfried Mullens
- Department of Cardiovascular Medicine, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Faisal Sharif
- Department of Cardiology, Saolta Group, Galway University Hospital, Health Service Executive and National University of Ireland Galway (NUIG), Galway, Ireland
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9
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Legris V, Thibault B, Dupuis J, White M, Asgar AW, Fortier A, Pitre C, Bouabdallaoui N, Henri C, O'Meara E, Ducharme A. Right ventricular function and its coupling to pulmonary circulation predicts exercise tolerance in systolic heart failure. ESC Heart Fail 2021; 9:450-464. [PMID: 34953062 PMCID: PMC8788036 DOI: 10.1002/ehf2.13726] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 10/31/2021] [Accepted: 11/11/2021] [Indexed: 12/05/2022] Open
Abstract
Aims Right ventricular (RV) dysfunction, pulmonary hypertension, and exercise intolerance have prognostic values, but their interrelation is not fully understood. We investigated how RV function alone and its coupling with pulmonary circulation (RV‐PA) predict cardio‐respiratory fitness in patients with heart failure and reduced ejection fraction (HFrEF). Methods and results The Evaluation of Resynchronization Therapy for Heart Failure (EARTH) study included 205 HFrEF patients with narrow (n = 85) and prolonged (n = 120) QRS duration undergoing implantable cardioverter defibrillator implantation. All patients underwent a comprehensive evaluation with exercise tolerance tests and echocardiography. We investigated the correlations at baseline between RV parameters {size, function [tricuspid annular plane systolic excursion (TAPSE), RV fractional area change (RV‐FAC), and RV myocardial performance index (RV‐MPI)], pulmonary artery systolic pressure (PASP), and tricuspid regurgitation}; left ventricular ejection fraction (LVEF), left ventricular end‐diastolic volume index (LVEDVi), and left atrial volume index (LAVi); and cardiopulmonary exercise test (CPET) [peak VO2, minute ventilation/carbon dioxide production (VE/VCO2), 6 min walk distance (6MWD), and submaximal exercise duration (SED)]. We also studied the relationship between RV‐PA coupling (TAPSE/PASP ratio) and echocardiographic parameters in patients with both data available. Univariate and multivariate linear regression models were used. Patients enrolled in EARTH (overall population) were mostly male (73.2%), mean age 61.0 ± 9.8 years, New York Heart Association class II–III (87.8%), mean LVEF of 26.6 ± 7.7%, and reduced peak VO2 (15.1 ± 4.6 mL/kg/min). Of these, 100 had both TAPSE and PASP available (TAPSE/PASP population): they exhibited higher BNP, wider QRS duration, larger LVEDVi, with more having tricuspid regurgitation compared with the 105 patients for whom these values were not available (all P < 0.05). RV‐FAC (β = 7.5), LAVi (β = −0.1), and sex (female, β = −1.9) predicted peak VO2 in the overall population (all P = 0.01). When available, TAPSE/PASP ratio was the only echocardiographic parameter associated with peak VO2 (β = 6.8; P < 0.01), a threshold ≤0.45 predicting a peak VO2 ≤ 14 mL/kg/min (0.39 for VO2 ≤ 12). RV‐MPI was the only echocardiographic parameter associated with ventilatory inefficiency (VE/VCO2) and 6MWD (β = 21.9 and β = −69.3, respectively, both P ≤ 0.01) in the overall population. In presence of TAPSE/PASP, it became an important predictor for those two CPET (β = −18.0 and β = 72.4, respectively, both P < 0.01), together with RV‐MPI (β = 18.5, P < 0.01) for VE/VCO2. Tricuspid regurgitation predicted SED (β = −3.2, P = 0.03). Conclusions Right ventricular function assessed by echocardiography (RV‐MPI and RV‐FAC) is closely associated with exercise tolerance in patients with HFrEF. When the TAPSE/PASP ratio is available, this marker of RV‐PA coupling becomes the stronger echocardiographic predictor of exercise capacity in this population, highlighting its potential role as a screening tool to identify patients with reduced exercise capacity and potentially triage them to formal peak VO2 and/or evaluation for advanced HF therapies.
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Affiliation(s)
- Valéry Legris
- Department of Medicine, Montreal Heart Institute and University of Montreal, Montreal, Quebec, Canada
| | - Bernard Thibault
- Department of Medicine, Montreal Heart Institute and University of Montreal, Montreal, Quebec, Canada
| | - Jocelyn Dupuis
- Department of Medicine, Montreal Heart Institute and University of Montreal, Montreal, Quebec, Canada
| | - Michel White
- Department of Medicine, Montreal Heart Institute and University of Montreal, Montreal, Quebec, Canada
| | - Anita W Asgar
- Department of Medicine, Montreal Heart Institute and University of Montreal, Montreal, Quebec, Canada
| | - Annik Fortier
- Montreal Health Institute Coordinating Center (MHICC), Montreal, Quebec, Canada
| | - Céline Pitre
- Department of Medicine, Montreal Heart Institute and University of Montreal, Montreal, Quebec, Canada
| | - Nadia Bouabdallaoui
- Department of Medicine, Montreal Heart Institute and University of Montreal, Montreal, Quebec, Canada
| | - Christine Henri
- Department of Medicine, Montreal Heart Institute and University of Montreal, Montreal, Quebec, Canada
| | - Eileen O'Meara
- Department of Medicine, Montreal Heart Institute and University of Montreal, Montreal, Quebec, Canada
| | - Anique Ducharme
- Department of Medicine, Montreal Heart Institute and University of Montreal, Montreal, Quebec, Canada
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Brener MI, Grayburn P, Lindenfeld J, Burkhoff D, Liu M, Zhou Z, Alu MC, Medvedofsky DA, Asch FM, Weissman NJ, Bax J, Abraham W, Mack MJ, Stone GW, Hahn RT. Right Ventricular-Pulmonary Arterial Coupling in Patients With HF Secondary MR: Analysis From the COAPT Trial. JACC Cardiovasc Interv 2021; 14:2231-2242. [PMID: 34674862 DOI: 10.1016/j.jcin.2021.07.047] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 07/23/2021] [Accepted: 07/27/2021] [Indexed: 12/30/2022]
Abstract
OBJECTIVES The aim of this study was to determine the prognostic impact of right ventricular (RV)-pulmonary arterial (PA) coupling in patients with heart failure (HF) with severe secondary mitral regurgitation (SMR) enrolled in the COAPT (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients With Functional Mitral Regurgitation) trial. BACKGROUND RV contractile function and PA pressures influence outcomes in patients with SMR, but the impact of RV-PA coupling in patients randomized to transcatheter edge-to-edge repair (TEER) vs guideline-directed medical therapy (GDMT) is unknown. METHODS RV-PA coupling was assessed by the ratio of RV free wall longitudinal strain derived from speckle-tracking echocardiography and noninvasively measured RV systolic pressure. Advanced RV-PA uncoupling was defined as RV free wall longitudinal strain/RV systolic pressure ≤0.5%/mm Hg. The primary endpoint was a composite of all-cause mortality or HF hospitalization at 24-month follow-up. RESULTS A total of 372 patients underwent speckle-tracking echocardiography, and 70.2% had advanced RV-PA uncoupling. By multivariable analysis, advanced RV-PA uncoupling was strongly associated with an increased risk for the primary 24-month endpoint of death or HF hospitalization (HR: 1.87; 95% CI: 1.31-2.66; P = 0.0005). A similar association was present for all-cause mortality alone (HR: 2.57; 95% CI: 1.54-4.29; P = 0.0003). The impact of RV-PA uncoupling was consistent in patients randomized to TEER and GDMT alone. Compared with GDMT alone, the addition of TEER improved 2-year outcomes in patients with (48.0% vs 74.8%; HR: 0.51; 95% CI: 0.37-0.71) and those without (28.8% vs 47.8%; HR: 0.51; 95% CI: 0.27-0.97) advanced RV-PA uncoupling (Pinteraction = 0.98). CONCLUSIONS In the COAPT trial, advanced RV dysfunction assessed by RV-PA uncoupling was a powerful predictor of 2-year adverse outcomes in patients with HF and SMR. (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients With Functional Mitral Regurgitation [The COAPT Trial]; NCT01626079).
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Affiliation(s)
- Michael I Brener
- Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Paul Grayburn
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, Texas, USA
| | - JoAnn Lindenfeld
- Vanderbilt Heart and Vascular Institute, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Daniel Burkhoff
- Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA; Cardiovascular Research Foundation, New York, New York, USA
| | - Mengdan Liu
- Cardiovascular Research Foundation, New York, New York, USA
| | - Zhipeng Zhou
- Cardiovascular Research Foundation, New York, New York, USA
| | - Maria C Alu
- Cardiovascular Research Foundation, New York, New York, USA
| | - Diego A Medvedofsky
- Cardiovascular Core Laboratory, MedStar Health Research Institute, Washington, District of Columbia, USA
| | - Federico M Asch
- Cardiovascular Core Laboratory, MedStar Health Research Institute, Washington, District of Columbia, USA
| | - Neil J Weissman
- Cardiovascular Core Laboratory, MedStar Health Research Institute, Washington, District of Columbia, USA
| | - Jeroen Bax
- Heart Lung Center, Leiden University Medical Center, Leiden, the Netherlands
| | - William Abraham
- Davis Heart and Lung Research Institute, The Ohio State University Medical Center, Columbus, Ohio, USA
| | - Michael J Mack
- Baylor Scott & White Heart and Vascular Hospital, Plano, Texas, USA
| | - Gregg W Stone
- Cardiovascular Research Foundation, New York, New York, USA; The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Rebecca T Hahn
- Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA.
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11
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Park SJ, Kwon DH, Rickard JW, Varma N. Right ventricular dilatation and systolic dysfunction and relationship to QRS duration in patients with left bundle branch block and cardiomyopathy. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2021; 44:1890-1896. [PMID: 34499749 DOI: 10.1111/pace.14357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 08/02/2021] [Accepted: 09/05/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Marked QRS widening in patients with left bundle branch block (LBBB) may reduce efficacy of cardiac resynchronization therapy (CRT). We hypothesized that extreme QRS prolongation may accompany right ventricular (RV) dilatation/systolic dysfunction (RVD/RVsD) as well as left ventricular dilatation/systolic dysfunction (LVD/LVsD). METHODS We assessed rates of both ventricular dilatation and systolic dysfunction according to widening of QRS duration (QRSd) in 100 consecutive cardiomyopathy patients with true LBBB (QRSd ≥ 130 ms in female or ≥140 ms in male, QS or rS in leads V1/V2, and mid-QRS notching/slurring in ≥2 contiguous leads of I, aVL, and V1/V2/V5/V6). Ventricular dimensions and function were measured by cardiac magnetic resonance imaging. RESULTS There was a trend toward an increase in the prevalence of LVD (13%, 20%, and 90%), LVsD (67%, 77%, and 90%), RVD (23%, 27%, and 50%), RVsD (27%, 27%, and 40%), RVD plus RVsD (13%, 17%, and 40%), or RVD/RVsD (37%, 37%, and 50%) according to the degree of QRS prolongation (<150 ms, n = 30; 150-180 ms, n = 60; and ≥180 ms, n = 10). Similarly, patients in the highest quartile of QRSd (QRSd ≥ 168 ms, n = 26) showed greater rates of RVD (23% vs. 44%, p = .069), RVsD (22% vs. 48%, p = .032), RVD plus RVsD (10% vs. 30%, p = .040), or RVD/RVsD (33% vs. 57%, p = .050) compared to those in the remaining quartiles (n = 74). QRSd ≥ 180 ms was identified as an independent predictor for the presence of RVD plus RVsD. CONCLUSION The rates of RVD and/or RVsD increased with QRS widening, particularly when QRSd exceeded 180 ms. This may diminish anticipated CRT response rates in cardiomyopathy patients with LBBB.
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Affiliation(s)
- Seung-Jung Park
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA.,Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Deborah H Kwon
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | - John W Rickard
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Niraj Varma
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
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12
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The physiological effects of cardiac resynchronization therapy on aortic and pulmonary flow and dynamic and static components of systemic impedance. Heart Rhythm O2 2021; 2:365-373. [PMID: 34430942 PMCID: PMC8369303 DOI: 10.1016/j.hroo.2021.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background Patients who improve following cardiac resynchronization therapy (CRT) have left ventricular (LV) remodeling and improved cardiac output (CO). Effects on the systemic circulation are unknown. Objective To explore the effects of CRT on aortic and pulmonary blood flow and systemic afterload. Methods At CRT implant patients underwent a noninvasive assessment of central hemodynamics, including wave intensity analysis (n = 28). This was repeated at 6 months after CRT. A subsample (n = 11) underwent an invasive electrophysiological and hemodynamic assessment immediately following CRT. CRT response was defined as reduction in LV end-systolic volume ≥15% at 6 months. Results In CRT responders (75% of those in the noninvasive arm), there was a significant increase in CO (from 3 ± 2 L/min to 4 ± 2 L/min, P = .002) and LV dP/dtmax (from 846 ± 162 mm Hg/s to 958 ± 194 mm Hg/s, P = .001), immediately after CRT in those in the invasive arm. They demonstrated a significant increase in aortic forward compression wave (FCW) both acutely and at follow-up. The relative change in LV dP/dtmax strongly correlated with changes in the aortic FCW (R s 0.733, P = .025). CRT responders displayed a significant reduction in afterload, and a decrease in systemic vascular resistance and pulse wave velocity acutely; there was a significant decrease in acute pulmonary afterload measured by the pulmonary FCW and forward expansion wave. Conclusion Improved cardiac function following CRT is attributable to a combination of changes in the cardiac and cardiovascular system. The relative importance of these 2 mechanisms may then be important for optimizing CRT.
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13
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Mullens W, Auricchio A, Martens P, Witte K, Cowie MR, Delgado V, Dickstein K, Linde C, Vernooy K, Leyva F, Bauersachs J, Israel CW, Lund LH, Donal E, Boriani G, Jaarsma T, Berruezo A, Traykov V, Yousef Z, Kalarus Z, Nielsen JC, Steffel J, Vardas P, Coats A, Seferovic P, Edvardsen T, Heidbuchel H, Ruschitzka F, Leclercq C. Optimized implementation of cardiac resynchronization therapy: a call for action for referral and optimization of care. Europace 2021; 23:1324-1342. [PMID: 34037728 DOI: 10.1093/europace/euaa411] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 10/28/2020] [Accepted: 10/29/2020] [Indexed: 12/28/2022] Open
Abstract
Cardiac resynchronization therapy (CRT) is one of the most effective therapies for heart failure with reduced ejection fraction and leads to improved quality of life, reductions in heart failure hospitalization rates and all-cause mortality. Nevertheless, up to two-thirds of eligible patients are not referred for CRT. Furthermore, post-implantation follow-up is often fragmented and suboptimal, hampering the potential maximal treatment effect. This joint position statement from three European Society of Cardiology Associations, Heart Failure Association (HFA), European Heart Rhythm Association (EHRA) and European Association of Cardiovascular Imaging (EACVI), focuses on optimized implementation of CRT. We offer theoretical and practical strategies to achieve more comprehensive CRT referral and post-procedural care by focusing on four actionable domains: (i) overcoming CRT under-utilization, (ii) better understanding of pre-implant characteristics, (iii) abandoning the term 'non-response' and replacing this by the concept of disease modification, and (iv) implementing a dedicated post-implant CRT care pathway.
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Affiliation(s)
- Wilfried Mullens
- Ziekenhuis Oost Limburg, Genk, Belgium
- University Hasselt, Hasselt, Belgium
| | - Angelo Auricchio
- Division of Cardiology, Cardiocentro Ticino, Lugano, Switzerland
| | - Pieter Martens
- Ziekenhuis Oost Limburg, Genk, Belgium
- University Hasselt, Hasselt, Belgium
| | - Klaus Witte
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Martin R Cowie
- Imperial College London (Royal Brompton Hospital), London, UK
| | - Victoria Delgado
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Cecilia Linde
- Heart and Vascular Theme, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
| | - Kevin Vernooy
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
- Department of Cardiology, Radboud University Medical Center (Radboudumc), Nijmegen, The Netherlands
| | | | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Carsten W Israel
- Department of Medicine - Cardiology, Diabetology and Nephrology, Bethel-Clinic, Bielefeld, Germany
| | - Lars H Lund
- Department of Medicine Karolinska Institutet, and Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Erwan Donal
- Cardiologie, CHU Rennes - LTSI Inserm UMR 1099, Université Rennes-1, Rennes, France
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Tiny Jaarsma
- Julius Center, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Health, Medicine and Caring Science, Linköping University, Linköping, Sweden
| | | | - Vassil Traykov
- Department of Cardiology, Acibadem City Clinic Tokuda Hospital, Sofia, Bulgaria
| | - Zaheer Yousef
- Department of Cardiology, University Hospital of Wales & Cardiff University, Cardiff, UK
| | - Zbigniew Kalarus
- Department of Cardiology, Medical University of Silesia, Katowice, Poland
| | | | - Jan Steffel
- UniversitätsSpital Zürich, Zürich, Switzerland
| | - Panos Vardas
- Heart Sector, Hygeia Hospitals Group, Athens, Greece
| | | | - Petar Seferovic
- Faculty of Medicine, Serbian Academy of Science and Arts, Belgrade University, Belgrade, Serbia
| | - Thor Edvardsen
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, and University of Oslo, Oslo, Norway
| | - Hein Heidbuchel
- Antwerp University and Antwerp University Hospital, Antwerp, Belgium
| | - Frank Ruschitzka
- Department of Cardiology, University Hospital, University Heart Center, Zurich, Switzerland
| | - Christophe Leclercq
- Cardiologie, CHU Rennes - LTSI Inserm UMR 1099, Université Rennes-1, Rennes, France
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14
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Lyhne MD, Kabrhel C, Giordano N, Andersen A, Nielsen-Kudsk JE, Zheng H, Dudzinski DM. The echocardiographic ratio tricuspid annular plane systolic excursion/pulmonary arterial systolic pressure predicts short-term adverse outcomes in acute pulmonary embolism. Eur Heart J Cardiovasc Imaging 2021; 22:285-294. [PMID: 33026070 DOI: 10.1093/ehjci/jeaa243] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Accepted: 08/07/2020] [Indexed: 12/22/2022] Open
Abstract
AIMS Right ventricular (RV) failure causes death from acute pulmonary embolism (PE), due to a mismatch between RV systolic function and increased RV afterload. We hypothesized that an echocardiographic ratio of this mismatch [RV systolic function by tricuspid annular plane systolic excursion (TAPSE) divided by pulmonary arterial systolic pressure (PASP)] would predict adverse outcomes better than each measurement individually, and would be useful for risk stratification in intermediate-risk PE. METHODS AND RESULTS This was a retrospective analysis of a single academic centre Pulmonary Embolism Response Team registry from 2012 to 2019. All patients with confirmed PE and a formal transthoracic echocardiogram performed within 2 days were included. All echocardiograms were analysed by an observer blinded to the outcome. The primary endpoint was a 7-day composite outcome of death or haemodynamic deterioration. Secondary outcomes were 7- and 30-day all-cause mortality. A total of 627 patients were included; 135 met the primary composite outcome. In univariate analysis, the TAPSE/PASP was associated with our primary outcome [odds ratio = 0.028, 95% confidence interval (CI) 0.010-0.087; P < 0.0001], which was significantly better than either TAPSE or PASP alone (P = 0.017 and P < 0.0001, respectively). A TAPSE/PASP cut-off value of 0.4 was identified as the optimal value for predicting adverse outcome in PE. TAPSE/PASP predicted both 7- and 30-day all-cause mortality, while TAPSE and PASP did not. CONCLUSION A combined echocardiographic ratio of RV function to afterload is superior in prediction of adverse outcome in acute intermediate-risk PE. This ratio may improve risk stratification and identification of the patients that will suffer short-term deterioration after intermediate-risk PE.
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Affiliation(s)
- Mads D Lyhne
- Department of Emergency Medicine, Center for Vascular Emergencies, Massachusetts General Hospital, 0 Emerson Place, MA 02114, USA.,Department of Cardiology, Aarhus University Hospital, Palle Juul Jensens Boulevard 99, 8200, Aarhus N, Denmark.,Department of Cardiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Christopher Kabrhel
- Department of Emergency Medicine, Center for Vascular Emergencies, Massachusetts General Hospital, 0 Emerson Place, MA 02114, USA
| | - Nicholas Giordano
- Department of Emergency Medicine, Center for Vascular Emergencies, Massachusetts General Hospital, 0 Emerson Place, MA 02114, USA
| | - Asger Andersen
- Department of Cardiology, Aarhus University Hospital, Palle Juul Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Jens Erik Nielsen-Kudsk
- Department of Cardiology, Aarhus University Hospital, Palle Juul Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Hui Zheng
- Biostatistics Center, Massachusetts General Hospital, 50 Staniford Street, Boston, MA 02114, USA
| | - David M Dudzinski
- Department of Emergency Medicine, Center for Vascular Emergencies, Massachusetts General Hospital, 0 Emerson Place, MA 02114, USA.,Department of Cardiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
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15
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Izumo M, Kuwata S, Ishibashi Y, Suzuki T, Ohara H, Watanabe M, Sato Y, Nishikawa H, Okuyama K, Kamijima R, Takai M, Kou S, Harada T, Akashi YJ. Prognostic impact of transcatheter mitral valve repair in patients with exercise-induced secondary mitral regurgitation. Eur Heart J Cardiovasc Imaging 2021; 22:530-538. [PMID: 32856088 DOI: 10.1093/ehjci/jeaa200] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Accepted: 06/20/2020] [Indexed: 11/12/2022] Open
Abstract
AIMS Although exercise-induced secondary mitral regurgitation (MR) is known to have a poor prognosis, the therapeutic strategy towards this condition remains to be investigated. In the present study, we aimed to investigate the prognostic impact of transcatheter mitral valve repair (TMVr) using the MitraClip in patients with exercise-induced secondary MR. METHODS AND RESULTS Of the 200 consecutive patients with secondary MR who underwent exercise stress echocardiography, 46 (23%) that presented with exercise-induced secondary MR [i.e. increase in effective regurgitant orifice area (EROA) of ≥ 0.13 cm2] were enrolled in the present investigation. The composite endpoints of all-cause mortality and hospitalization for heart failure were evaluated. Of the 46 patients included in the current cohort, 19 (41%) underwent TMVr and 27 (59%) were medically managed (control group). Although the TMVr group tended to present with a greater EROA at rest (0.26 ± 0.10 vs. 0.20 ± 0.08 cm2, P = 0.047), there were no differences in the EROA changes during exercise between the two groups (0.18 ± 0.10 vs. 0.18 ± 0.04 cm2, P = 0.940). While the TMVr group reported a higher event-free survival rate after the 13-month follow-up period (log-rank P = 0.017), the Cox proportional-hazard analysis suggested the TMVr to be associated with clinical outcomes (hazard ratio: 0.419, P = 0.044). CONCLUSION As opposed to the medical management, TMVr treatment was associated with a lower risk of composite endpoints in patients with exercise-induced secondary MR. Exercise stress echocardiography is considered to have played an important role in decision-making for secondary MR.
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Affiliation(s)
- Masaki Izumo
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan
| | - Shingo Kuwata
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan
| | - Yuki Ishibashi
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan
| | - Tomomi Suzuki
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan
| | - Hiroshi Ohara
- Division of Cardiovascular Medicine, Department of Internal Medicine, Toho University Faculty of Medicine, Tokyo, Japan
| | - Mika Watanabe
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan
| | - Yukio Sato
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan
| | - Haruka Nishikawa
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan
| | - Kazuaki Okuyama
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan
| | - Ryo Kamijima
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan
| | - Manabu Takai
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan
| | - Seisyo Kou
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan
| | - Tomoo Harada
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan
| | - Yoshihiro J Akashi
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan
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Cardiopulmonary Exercise Testing with Echocardiography to Identify Mechanisms of Unexplained Dyspnea. J Cardiovasc Transl Res 2021; 15:116-130. [PMID: 34110608 DOI: 10.1007/s12265-021-10142-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 05/31/2021] [Indexed: 12/28/2022]
Abstract
Little data is available about the pathophysiological mechanisms of unexplained dyspnea and their clinical meaning. Consecutive patients with unexplained dyspnea underwent prospective standardized cardiopulmonary exercise testing with echocardiography (CPETecho). Patients were grouped as having normal exercise capacity (peak VO2 > 80% with respiratory exchange [RER] > 1.05), reduced exercise capacity (peak VO2 ≤ 80% with RER > 1.05), or a submaximal exercise test (RER ≤ 1.05). From 307 patients, 144 (47%) had normal and 116 (38%) reduced exercise capacity, and 47 (15%) had a submaximal exercise test. Patients with reduced versus normal exercise capacity had significantly more mechanisms for unexplained dyspnea (2.3±1.0 vs 1.5±1.0, respectively; p<0.001). Exercise PH (42%), low heart rate reserve (51%), low stroke volume reserve (38%), low diastolic reserve (18%), and peripheral muscle limitation (17%) were most common. Patients with more mechanisms for dyspnea displayed poorer peak VO2 and had an increased risk for cardiovascular hospitalization (p=0.002). Patients with unexplained dyspnea display multiple coexisting mechanisms for exercise intolerance, which relate to the severity of exercise limitation and risk of subsequent cardiovascular hospitalizations.
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17
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Deaconu S, Deaconu A, Scarlatescu A, Petre I, Onciul S, Vijiac A, Onut R, Zamfir D, Marascu G, Iorgulescu C, Radu DA, Bogdan S, Vatasescu R, Dorobantu M. Right ventricular-arterial coupling - A new perspective for right ventricle evaluation in heart failure patients undergoing cardiac resynchronization therapy. Echocardiography 2021; 38:1157-1164. [PMID: 34028880 DOI: 10.1111/echo.15096] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 05/03/2021] [Accepted: 05/06/2021] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Right ventricular - arterial (RV-PA) coupling can be estimated by echocardiography using the ratio between (TAPSE) and pulmonary arterial systolic pressure (PASP). TAPSE/PASP ratio proved to be a prognostic parameter in patients with heart failure and reduced ejection fraction (HFrEF). OBJECTIVE To evaluate the significance of RV-PA coupling in patients with HFrEF undergoing cardiac resynchronization therapy (CRT). METHODS Patients undergoing CRT in our center between January 2017 and November 2019 were eligible. Response to CRT was defined by a reduction of more than 15% of left ventricle systolic volume (LVESV) one year after CRT. Primary endpoint was a composite of HF hospitalizations and death during follow-up. RESULTS 54 patients (Age 64.0 ± 13.8 years; 58% male; left ventricular ejection fraction (LVEF) 28.4 ± 1.3%) were prospectively included. After a mean follow-up of 31 ± 12.9months, the primary endpoint had occurred in 18 (33.3%) patients. A lower TAPSE/PASP ratio was associated with baseline worse HF symptoms, lower LVEF and long-term less LV reverse remodeling (P < .05). After one year CRT improved RV systolic function (TAPSE, RV global longitudinal strain, P < .05), but not TAPSE/PASP ratio (P = .4). The ratio TAPSE/PASP (AUC=0.834) ≥ 0.58 mm/mm Hg showed good sensitivity (90%) and specificity (81.8%) for predicting response to CRT while a ratio <0.58 mm/mm Hg was associated with a higher risk of death and HF hospitalizations during the follow-up (HR 5.37 95%CI [1.6-18], P < .001). CONCLUSION RV-PA coupling evaluation using TAPSE/PASP ratio predicts CRT response. A lower TAPSE/PASP ratio is associated with a higher risk of adverse cardiovascular events.
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Affiliation(s)
- Silvia Deaconu
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania.,Cardiology Department, Emergency Hospital of Bucharest, Bucharest, Romania
| | - Alexandru Deaconu
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania.,Cardiology Department, Emergency Hospital of Bucharest, Bucharest, Romania
| | - Alina Scarlatescu
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania.,Cardiology Department, Emergency Hospital of Bucharest, Bucharest, Romania
| | - Ioana Petre
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania.,Cardiology Department, Emergency Hospital of Bucharest, Bucharest, Romania
| | - Sebastian Onciul
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania.,Cardiology Department, Emergency Hospital of Bucharest, Bucharest, Romania
| | - Aura Vijiac
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania.,Cardiology Department, Emergency Hospital of Bucharest, Bucharest, Romania
| | - Roxana Onut
- Cardiology Department, Emergency Hospital of Bucharest, Bucharest, Romania
| | - Diana Zamfir
- Cardiology Department, Emergency Hospital of Bucharest, Bucharest, Romania
| | - Gabriela Marascu
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | | | - Dan Andrei Radu
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania.,Cardiology Department, Emergency Hospital of Bucharest, Bucharest, Romania
| | - Stefan Bogdan
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania.,Cardiology Department, Emergency Hospital of Bucharest, Bucharest, Romania
| | - Radu Vatasescu
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania.,Cardiology Department, Emergency Hospital of Bucharest, Bucharest, Romania
| | - Maria Dorobantu
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania.,Cardiology Department, Emergency Hospital of Bucharest, Bucharest, Romania
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18
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Mullens W, Auricchio A, Martens P, Witte K, Cowie MR, Delgado V, Dickstein K, Linde C, Vernooy K, Leyva F, Bauersachs J, Israel CW, Lund LH, Donal E, Boriani G, Jaarsma T, Berruezo A, Traykov V, Yousef Z, Kalarus Z, Cosedis Nielsen J, Steffel J, Vardas P, Coats A, Seferovic P, Edvardsen T, Heidbuchel H, Ruschitzka F, Leclercq C. Optimized implementation of cardiac resynchronization therapy: a call for action for referral and optimization of care: A joint position statement from the Heart Failure Association (HFA), European Heart Rhythm Association (EHRA), and European Association of Cardiovascular Imaging (EACVI) of the European Society of Cardiology. Eur J Heart Fail 2021; 22:2349-2369. [PMID: 33136300 DOI: 10.1002/ejhf.2046] [Citation(s) in RCA: 100] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 10/28/2020] [Accepted: 10/29/2020] [Indexed: 12/28/2022] Open
Abstract
Cardiac resynchronization therapy (CRT) is one of the most effective therapies for heart failure with reduced ejection fraction and leads to improved quality of life, reductions in heart failure hospitalization rates and all-cause mortality. Nevertheless, up to two-thirds of eligible patients are not referred for CRT. Furthermore, post-implantation follow-up is often fragmented and suboptimal, hampering the potential maximal treatment effect. This joint position statement from three European Society of Cardiology Associations, Heart Failure Association (HFA), European Heart Rhythm Association (EHRA) and European Association of Cardiovascular Imaging (EACVI), focuses on optimized implementation of CRT. We offer theoretical and practical strategies to achieve more comprehensive CRT referral and post-procedural care by focusing on four actionable domains: (i) overcoming CRT under-utilization, (ii) better understanding of pre-implant characteristics, (iii) abandoning the term 'non-response' and replacing this by the concept of disease modification, and (iv) implementing a dedicated post-implant CRT care pathway.
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Affiliation(s)
- Wilfried Mullens
- Ziekenhuis Oost Limburg, Genk, Belgium.,University Hasselt, Hasselt, Belgium
| | - Angelo Auricchio
- Division of Cardiology, Cardiocentro Ticino, Lugano, Switzerland
| | - Pieter Martens
- Ziekenhuis Oost Limburg, Genk, Belgium.,University Hasselt, Hasselt, Belgium
| | - Klaus Witte
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Martin R Cowie
- Imperial College London (Royal Brompton Hospital), London, UK
| | - Victoria Delgado
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Cecilia Linde
- Heart and Vascular Theme, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
| | - Kevin Vernooy
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands.,Department of Cardiology, Radboud University Medical Center (Radboudumc), Nijmegen, The Netherlands
| | | | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Carsten W Israel
- Department of Medicine - Cardiology, Diabetology and Nephrology, Bethel-Clinic, Bielefeld, Germany
| | - Lars H Lund
- Department of Medicine Karolinska Institutet, and Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Erwan Donal
- Cardiologie, CHU Rennes - LTSI Inserm UMR 1099, Université Rennes-1, Rennes, France
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Tiny Jaarsma
- Julius Center, University Medical Center Utrecht, Utrecht, The Netherlands.,Department of Health, Medicine and Caring Science, Linköping University, Linköping, Sweden
| | | | - Vassil Traykov
- Department of Cardiology, Acibadem City Clinic Tokuda Hospital, Sofia, Bulgaria
| | - Zaheer Yousef
- Department of Cardiology, University Hospital of Wales & Cardiff University, Cardiff, UK
| | - Zbigniew Kalarus
- Department of Cardiology, Medical University of Silesia, Katowice, Poland
| | | | - Jan Steffel
- UniversitätsSpital Zürich, Zürich, Switzerland
| | - Panos Vardas
- Heart Sector, Hygeia Hospitals Group, Athens, Greece
| | | | - Petar Seferovic
- Faculty of Medicine, Serbian Academy of Science and Arts, Belgrade University, Belgrade, Serbia
| | - Thor Edvardsen
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, and University of Oslo, Oslo, Norway
| | - Hein Heidbuchel
- Antwerp University and Antwerp University Hospital, Antwerp, Belgium
| | - Frank Ruschitzka
- Department of Cardiology, University Hospital, University Heart Center, Zurich, Switzerland
| | - Christophe Leclercq
- Cardiologie, CHU Rennes - LTSI Inserm UMR 1099, Université Rennes-1, Rennes, France
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19
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Hirasawa K, Izumo M, Mizukoshi K, Nishikawa H, Sato Y, Watanabe M, Kamijima R, Akashi YJ. Prognostic significance of right ventricular function during exercise in asymptomatic/minimally symptomatic patients with nonobstructive hypertrophic cardiomyopathy. Echocardiography 2021; 38:916-923. [PMID: 33971038 DOI: 10.1111/echo.15075] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 04/22/2021] [Accepted: 04/24/2021] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND The risk stratification of hypertrophic cardiomyopathy (HCM) without left ventricular outflow tract (LVOT) obstruction and the utility of exercise stress echocardiography (ESE) remains unclear. We investigated the value of right ventricular (RV) function and RV-pulmonary artery (PA) coupling during exercise in asymptomatic/minimally symptomatic patients with nonobstructive HCM (nHCM). METHOD AND RESULTS This retrospective study evaluated 74 HCM patients (age 63 ± 13 years, 65% men) without LVOT obstruction (≥30 mmHg) who underwent ESE. Eight patients (11%) suffered from HCM-related cardiac events during a median 2.5 years follow-up. During exercise, tricuspid annular plane systolic excursion (Ex-TAPSE) and Ex-TAPSE/systolic pulmonary artery pressure [SPAP] ratio were more impaired in patients with than in those without events (22 ± 4 vs 26 ± 4 mm, P = .005; and 0.45 [0.41, 0.47] vs 0.56 [0.47, 0.82] mm/mmHg, P = .002). In Cox regression analysis, Ex-TAPSE (HR: 1.397, P = .002) and the Ex-TAPSE/SPAP ratio (HR: 2.737, P = .006) were associated with cardiac events. In Kaplan-Meier analysis, patients with a low Ex-TAPSE (<24 mm) and Ex-TAPSE/SPAP ratio (<0.50 mm/mmHg) had a higher incidence of adverse outcomes than those with high Ex-TAPSE (Log rank, P < .001 and =.001, respectively). CONCLUSIONS A low Ex-TAPSE and Ex-TAPSE/SPAP ratio were associated with adverse outcomes in nHCM. Evaluation of RV functional performance during exercise may play a crucial role in the risk stratification of nHCM.
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Affiliation(s)
- Kensuke Hirasawa
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Masaki Izumo
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Kei Mizukoshi
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Haruka Nishikawa
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Yukio Sato
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Mika Watanabe
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Ryo Kamijima
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Yoshihiro J Akashi
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
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20
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Yuan F, Liu C, Yu S, Bian S, Yang J, Ding X, Zhang J, Tan H, Ke J, Yang Y, He C, Zhang C, Rao R, Liu Z, Yang J, Huang L. The Association Between Notching of the Right Ventricular Outflow Tract Flow Velocity Doppler Envelope and Impaired Right Ventricular Function After Acute High-Altitude Exposure. Front Physiol 2021; 12:639761. [PMID: 33868004 PMCID: PMC8047424 DOI: 10.3389/fphys.2021.639761] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 02/26/2021] [Indexed: 01/25/2023] Open
Abstract
Introduction Pulmonary artery pressure (PAP) is increased and right ventricular (RV) function is well preserved in healthy subjects upon exposure to high altitude (HA). An increase in PAP may trigger notching of the right ventricular outflow tract Doppler flow velocity envelope (RVOT notch), which is associated with impaired RV function in patients with pulmonary hypertension. However, whether HA exposure can induce RVOT notch formation and the subsequent impact on cardiac function in healthy subjects remains unclear. Methods A total of 99 subjects (69 males and 30 females) with a median age of 25 years were enrolled in this study; they traveled from 500 to 4100 m by bus over a 2-day period. All subjects underwent a comprehensive physiological and echocardiographic examination 1 day before ascension at low altitude and 15 ± 3 h after arrival at HA. The RVOT notch was determined by the presence of a notched shape in the RVOT Doppler flow velocity envelope. The systolic PAP (SPAP) was calculated as Bernoulli equation SPAP = 4 × (maximum tricuspid regurgitation velocity)2+5 and mean PAP (mPAP) = 0.61 × SPAP+2. Cardiac output was calculated as stroke volume × heart rate. Pulmonary capillary wedge pressure (PCWP) was calculated as 1.9+1.24 × mitral E/e’. Pulmonary vascular resistance (PVR) was calculated as (mPAP-PCWP)/CO. Results After HA exposure, 20 (20.2%) subjects had an RVOT notch [notch (+)], and 79 (79.8%) subjects did not have an RVOT notch [notch (−)]. In the multivariate logistic regression analysis, the SPAP, right ventricular global longitude strain (RV GLS), and tricuspid E/A were independently associated with the RVOT notch. The SPAP, mPAP, PVR, standard deviations of the times to peak systolic strain in the four mid-basal RV segments (RVSD4), peak velocity of the isovolumic contraction period (ICV), and the peak systolic velocity (s’) at the mitral/tricuspid annulus were increased in all subjects. Conversely, the pulse oxygen saturation (SpO2), RV GLS, and tricuspid annulus plane systolic excursion (TAPSE)/SPAP were decreased. However, the increases of SPAP, mPAP, PVR, and RVSD4 and the decreases of SpO2, RV GLS, and TAPSE/SPAP were more pronounced in the notch (+) group than in the notch (−) group. Additionally, increased tricuspid ICV and mitral/tricuspid s’ were found only in the notch (−) group. Conclusion HA exposure-induced RVOT notch formation is associated with impaired RV function, including no increase in the tricuspid ICV or s’, reduction of RV deformation, deterioration in RV-pulmonary artery coupling, and RV intraventricular synchrony.
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Affiliation(s)
- Fangzhengyuan Yuan
- Institute of Cardiovascular Diseases of PLA, The Second Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing, China.,Department of Cardiology, The Second Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Chuan Liu
- Institute of Cardiovascular Diseases of PLA, The Second Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing, China.,Department of Cardiology, The Second Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Shiyong Yu
- Institute of Cardiovascular Diseases of PLA, The Second Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing, China.,Department of Cardiology, The Second Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Shizhu Bian
- Institute of Cardiovascular Diseases of PLA, The Second Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing, China.,Department of Cardiology, The Second Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Jie Yang
- Institute of Cardiovascular Diseases of PLA, The Second Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing, China.,Department of Cardiology, The Second Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Xiaohan Ding
- Department of Geriatric Cardiology, Chinese PLA General Hospital, Beijing, China
| | - Jihang Zhang
- Institute of Cardiovascular Diseases of PLA, The Second Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Hu Tan
- Institute of Cardiovascular Diseases of PLA, The Second Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing, China.,Department of Cardiology, The Second Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Jingbin Ke
- Institute of Cardiovascular Diseases of PLA, The Second Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing, China.,Department of Cardiology, The Second Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Yuanqi Yang
- Institute of Cardiovascular Diseases of PLA, The Second Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing, China.,Department of Cardiology, The Second Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Chunyan He
- Institute of Cardiovascular Diseases of PLA, The Second Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing, China.,Department of Cardiology, The Second Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Chen Zhang
- Institute of Cardiovascular Diseases of PLA, The Second Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing, China.,Department of Cardiology, The Second Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Rongsheng Rao
- Department of Medical Ultrasonics, The Second Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Zhaojun Liu
- Department of Medical Ultrasonics, The Second Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Jun Yang
- Department of Medical Ultrasonics, The Second Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Lan Huang
- Institute of Cardiovascular Diseases of PLA, The Second Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing, China.,Department of Cardiology, The Second Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing, China
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21
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Bragança B, Trêpa M, Santos R, Silveira I, Fontes-Oliveira M, Sousa MJ, Reis H, Torres S, Santos M. Echocardiographic Assessment of Right Ventriculo-arterial Coupling: Clinical Correlates and Prognostic Impact in Heart Failure Patients Undergoing Cardiac Resynchronization Therapy. J Cardiovasc Imaging 2020; 28:109-120. [PMID: 32052609 PMCID: PMC7114448 DOI: 10.4250/jcvi.2019.0094] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Revised: 11/30/2019] [Accepted: 12/17/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Right ventriculo-arterial coupling (RV-PA) can be estimated by echocardiography using the ratio between tricuspid annular plane systolic excursion (TAPSE) and pulmonary artery systolic pressure (PASP) and it has prognostic value in the general heart failure (HF) population. We aimed to study the clinical correlates and prognostic value of RV-PA in HF patients undergoing cardiac resynchronization therapy (CRT). METHODS We retrospectively studied 70 HF patients undergoing CRT implantation. RESULTS RV-PA coupling was estimated by TAPSE/PASP ratio using baseline echocardiography. Non-response to CRT was defined as improvement of left ventricular ejection fraction < 5% in a follow-up echo 6-12 months after CRT. Those with lower TAPSE/PASP ratios (worse RV-PA coupling) had higher NT-proBNP concentrations and increased E/e' ratio. TAPSE/PASP ratio and PASP, but not TAPSE, predicted nonresponse to CRT with TAPSE/PASP ratio showing the best discriminative ability with a sensitivity of 76% and specificity of 71%. Among these parameters, PASP independently predicted all-cause mortality. CONCLUSIONS RV-PA coupling estimated by TAPSE/PASP ratio was associated with established prognostic markers in HF. It numerically outperformed PASP and TAPSE in predicting the response to CRT. Our data suggest that this simple and widely available echocardiographic parameter conveys significant pathophysiological and prognostic meaning in HF patients undergoing CRT.
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Affiliation(s)
- Bruno Bragança
- Instituto de Ciências Biomédicas Abel Salazar, University of Porto, Porto, Portugal
| | - Maria Trêpa
- Centro Hospitalar Universitário do Porto, Porto, Portugal.
| | - Raquel Santos
- Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Inês Silveira
- Centro Hospitalar Universitário do Porto, Porto, Portugal
| | | | | | - Hipólito Reis
- Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Severo Torres
- Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Mário Santos
- Centro Hospitalar Universitário do Porto, Porto, Portugal
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22
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Affiliation(s)
- Wilfried Mullens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium (W.M., P.M.).,Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium (W.M.)
| | - Pieter Martens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium (W.M., P.M.).,Doctoral School for Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium (P.M.)
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23
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Katbeh A, Van Camp G, Barbato E, Galderisi M, Trimarco B, Bartunek J, Vanderheyden M, Penicka M. Cardiac Resynchronization Therapy Optimization: A Comprehensive Approach. Cardiology 2019; 142:116-128. [PMID: 31117077 DOI: 10.1159/000499192] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 02/26/2019] [Indexed: 11/19/2022]
Abstract
Since the first report on biventricular pacing in 1994, cardiac resynchronization therapy (CRT) has become standard for patients with advanced heart failure (HF) and ventricular conduction delay. CRT improves myocardial function by resynchronizing myocardial contraction, which results in reverse left ventricular remodeling and improves symptoms and clinical outcomes. Despite the accelerated development of CRT device technology and its increased application in treating HF patients, almost one-third of these patients do not respond to the therapy or gain any clinical benefit from device implantation. Over the last decade, multiple cardiac imaging modalities have provided a deeper understanding of myocardial pathophysiology, thereby improving HF treatment management. However, the optimal strategy for improving the CRT response remains debatable. This article provides an updated overview of the electropathophysiology of myocardial dysfunction in ventricular conduction delay and the diagnostic approaches involving the use of multiple modalities.
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Affiliation(s)
- Asim Katbeh
- Cardiovascular Center Aalst, OLV Clinic, Aalst, Belgium.,Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Guy Van Camp
- Cardiovascular Center Aalst, OLV Clinic, Aalst, Belgium
| | - Emanuele Barbato
- Cardiovascular Center Aalst, OLV Clinic, Aalst, Belgium.,Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Maurizio Galderisi
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Bruno Trimarco
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | | | | | - Martin Penicka
- Cardiovascular Center Aalst, OLV Clinic, Aalst, Belgium,
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24
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Nagueh SF. Cardiac Resynchronization Therapy and Dynamic Changes in Right Ventricular Function. Circ Cardiovasc Imaging 2018; 11:e008195. [DOI: 10.1161/circimaging.118.008195] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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