Echocardiographic Advances in Dilated Cardiomyopathy

Association between the number of acute episodes and increased cardiac left ventricular mass index in patients diagnosed with schizophrenia

Patients with schizophrenia have a high risk of cardiovascular death. Increased cardiac left ventricular (LV) mass has been reported to be associated with heart failure and cardiac mortality. However, few studies have used echocardiographic imaging to evaluate the associations between cardiac LV mass and the clinical characteristics of schizophrenia. We recruited 121 adults to undergo standard and two-dimensional speckle-tracking echocardiography. Cardiac LV mass was determined using the Devereux formula and indexed with reference to the body surface area to obtain the cardiac LV mass index (LVMI). Clinical and demographic data were obtained through interviews and chart review. The results showed that relative to the mentally healthy controls (n = 55), individuals with schizophrenia (n = 66) had significantly higher mean values of cardiac LVMI as well as lower mitral valve E/A ratio, LV ejection fraction, and LV global longitudinal strain. Among the individuals with schizophrenia, cardiac LVMI was positively correlated with the number of acute episodes, and this association remained significant after adjustment for age, age at onset, and body mass index. On the contrary, there were no significant associations between cardiac LVMI and traditional cardiovascular risk factors. Taken together, this study suggests that the burden of psychotic symptoms may contribute to the increased risk of cardiac hypertrophy in individuals with schizophrenia independent of traditional cardiovascular risk factors. Because cardiac hypertrophy is among the major risk factors of heart failure and cardiac mortality, future research must investigate the mechanisms underlying the association between psychosis and increased cardiac LV mass.

Cardiomyopathy characterizing and heart failure risk predicting by echocardiography and pathoanatomy in aged male mice

Correlation between echocardiographic and pathoanatomic variables and their prognostic value in murine cardiomyopathy models remain unknown. Using echocardiography, morphometrics, and survival monitoring, we characterized transgenic (TG) mice with dilated cardiomyopathy due to cardiac overexpression of β2-adrenoceptors focusing on predicting heart failure (HF) risk and HF mortality. In 12-month-old non-TG and TG mice, echocardiography was performed to determine left ventricular (LV) dimensions (d), wall thickness (h), and fractional shortening (FS). Animals were monitored for 3 months for survival. Organ weights and pathological events indicating left HF were determined. TG mice (n = 76) had reduced FS and enlarged LV, and 79% died of HF or likely arrhythmias during the follow-up period while all non-TG mice (n = 26) survived. These mice with left HF also had pulmonary congestion and hypertrophy/dilatation of the right ventricle (RV). Weights of lungs, RV, and atria were intercorrelated (r = 0.79-0.83) and also negatively correlated with FS × (h/d) index (r = -0.502 to -0.609). By FS × (h/d) tertiles, TG mice of low tertiles were identified with the highest mortality (96%) largely due to HF (76%). In conclusion, in aged cardiomyopathy mice a good correlation existed between echocardiographic and pathoanatomic variables. Echocardiography-derived LV function and remodeling were useful in identifying a subgroup of TG mice with a high risk of HF and HF fatality.

Homozygous TNNI3 frameshift variant in a consanguineous family with lethal infantile dilated cardiomyopathy

BACKGROUND

Dilated cardiomyopathy (DCM) is characterized by dilatation of the left ventricle, systolic dysfunction, and normal or reduced thickness of the left ventricular wall. It is a leading cause of heart failure and cardiac death at a young age. Cases with neonatal onset DCM were correlated with severe clinical presentation and poor prognosis. A monogenic molecular etiology accounts for nearly half of cases.

FAMILY DESCRIPTION

Here, we report a family with three deceased offspring at the age of 1 year old. The autopsy of the first deceased infant revealed a DCM. The second infant presented a DCM phenotype with a severely reduced Left Ventricular Ejection Fraction (LVEF) of 10%. Similarly, the third infant showed a severe DCM phenotype with LVEF of 30% as well, in addition to eccentric mitral insufficiency.

RESULTS

Exome sequencing was performed for the trio (the second deceased infant and her parents). Data analysis following the autosomal dominant and recessive patterns of inheritance was carried out along with a mitochondrial pathways-based analysis. We identified a homozygous frameshift variant in the TNNI3 gene (c.204delG; p.(Arg69AlafsTer8)). This variant has been recently reported in the ClinVar database in association with cardiac phenotypes as pathogenic or likely pathogenic and classified as pathogenic according to ACMG.

CONCLUSION

Genetic counseling was provided for the family and a prenatal diagnosis of choronic villus was proposed in the absence of pre-implantation genetic diagnosis possibilities. Our study expands the case series of early-onset DCM patients with a protein-truncating variant in the TNNI3 gene by reporting three affected infant siblings.

Echocardiographic quantification of mitral apparatus morphology and dynamics in patients with dilated cardiomyopathy

Mitral regurgitation is among the most common valvular heart diseases. Mitral regurgitation in patients with dilated cardiomyopathy is a complex pathology involving annular dilatation, papillary muscle displacement, systolic leaflet tethering, and left ventricular remodeling. Quantification of mitral apparatus damage in these patients is essential for successful interventional and surgical therapy. Mitral regurgitation in the presence of dilated cardiomyopathy is classified as Carpentier type IIIB, with restricted leaflet mobility as a standard feature. Echocardiography allows accurate evaluation of the complex anatomy and function of the mitral apparatus. Updated guidelines recommend two-dimensional followed by systematic three-dimensional echocardiographic evaluation in patients with mitral regurgitation. New three-dimensional echocardiographic software packages provide many parameters that help identify the precise morphology and function of the various components of the mitral apparatus, helping to determine the etiology of mitral regurgitation and evaluate disease severity. This review provides the first point-by-point approach to the assessment of all old and new echocardiographic methods, from the simplest to the most complex, used to examine the components of the mitral valve apparatus in patients with dilated cardiomyopathy. Although these parameters are still under research, this information will be helpful for establishing therapeutic procedures in a disease with a poor prognosis.

Evaluating Goldberger's triad as a marker of congestive heart failure: A systematic review and retrospective study

BACKGROUND

In 1982, Drs. Barold and Goldberger described an ECG triad associated with left ventricular dysfunction (LVD) consisting of high precordial QRS voltage, low limb lead voltage, and poor precordial R wave progression. Studies have since attempted to replicate the originally reported sensitivity (70%), specificity (>99%), and positive predictive value (PPV, 100%) of Goldberger's triad (GT) with variable results.

PURPOSE

To assess sensitivity, specificity and PPV of GT as a screening tool for LVD in the current era.

METHODS

We performed: (1) A systematic review of the published studies; (2) Searched our hospital ECG database (GE MUSE) for diagnoses of "low limb-voltage" and "left ventricular hypertrophy" from 2017 to 2022; identified ECGs were analyzed for GT criteria and their medical records were screened for LVD. (3) ECG analysis of patients with known idiopathic LVD for the GT.

RESULTS

A total of 11,115 patients from 8 studies were included in the systematic review of published studies and showed widely varying sensitivity, specificity and PPV. A total of 4576 ECGs (in GE MUSE) from 372 patients met initial screening criteria of low limb lead voltage and LVH; only 12 patients had ECGs that satisfied GT. Of these 12, only 1 patient had evidence of LVD, yielding a PPV of 8%. Finally, of the 40 patients with known LVD, only 1 met the ECG criteria for GT, resulting in a sensitivity of 2.5%.

CONCLUSION

Our literature review does not support the original results of GT. ECGs from our database that met GT (searched by low limb-voltage and left ventricular hypertrophy) over a span of 5 years were rare. When present, the PPV of GT was 8%. In patients with established LVD, the sensitivity was 2.5%. These data do not validate GT as tool to identify LVD in the current era.

Development and validation of nomogram for unplanned ICU admission in patients with dilated cardiomyopathy

Objective

Unplanned admission to the intensive care unit (ICU) is the major in-hospital adverse event for patients with dilated cardiomyopathy (DCM). We aimed to establish a nomogram of individualized risk prediction for unplanned ICU admission in DCM patients.

Methods

A total of 2,214 patients diagnosed with DCM from the First Affiliated Hospital of Xinjiang Medical University from January 01, 2010, to December 31, 2020, were retrospectively analyzed. Patients were randomly divided into training and validation groups at a 7:3 ratio. The least absolute shrinkage and selection operator and multivariable logistic regression analysis were used for nomogram model development. The area under the receiver operating characteristic curve, calibration curves, and decision curve analysis (DCA) were used to evaluate the model. The primary outcome was defined as unplanned ICU admission.

Results

A total of 209 (9.44%) patients experienced unplanned ICU admission. The variables in our final nomogram included emergency admission, previous stroke, New York Heart Association Class, heart rate, neutrophil count, and levels of N-terminal pro b-type natriuretic peptide. In the training group, the nomogram showed good calibration (Hosmer-Lemeshow χ 2 = 14.40, P = 0.07) and good discrimination, with an optimal-corrected C-index of 0.76 (95% confidence interval: 0.72-0.80). DCA confirmed the clinical net benefit of the nomogram model, and the nomogram maintained excellent performances in the validation group.

Conclusion

This is the first risk prediction model for predicting unplanned ICU admission in patients with DCM by simply collecting clinical information. This model may assist physicians in identifying individuals at a high risk of unplanned ICU admission for DCM inpatients.

Relationships of Whole-Heart Myocardial Mechanics and Cardiac Morphometrics by Transthoracic Echocardiography with Main Prognostic Factors of Heart Failure in Non-Ischemic Dilated Cardiomyopathy

BACKGROUND

there are many prognostic factors of heart failure (HF) based on their evaluation from imaging, to laboratory tests. In clinical practice, it is crucial to use widely available, cheap, and easy-to-use prognostic factors, such as left ventricular ejection fraction (LVEF), New York Heart Association (NYHA) functional class, 6 min walk test (6MWT), B-type natriuretic peptide (BNP), etc. We sought to evaluate the relationships between whole-heart myocardial mechanics and cardiac morphometrics with the main commonly used prognostic factors of HF in patients with non-ischemic dilated cardiomyopathy (NIDCM).

METHODS AND RESULTS

two-dimensional (2D) echocardiography for myocardial mechanics (global longitudinal, radial, and circumferential strains of the left ventricle; right ventricular longitudinal strain; strain values of reservoir, conduit, and contraction function of both atria) and cardiac morphometric (diameters and volumes of both atria and ventricles) parameters were performed, and the HF main traditional prognostic factors were identified. We assessed 109 patients (68.8% male; 49.7 ± 10.5 years) with newly diagnosed NIDCM. Myocardial mechanics and morphometrics were weakly correlated with the patient's age, gender, and smoking (R = 0.2, p < 0.05). Stronger relationships were observed with NYHA class, 6MWT, and BNP (the strongest correlations were with LVEF: R = -0.499, R 0.462, R = -0.461, p < 0.001, respectively). There were moderately strong correlations with LVEF and other whole-heart myocardial mechanics or morphometrics. Moreover, LVEF with global regurgitation volume (GRV) and right ventricle free wall longitudinal strain (RVFWLS) were the most usually detected parameters in multivariate analysis to be associated with changes in HF prognostic factors.

CONCLUSIONS

in NIDCM patients, the main prognostic factors of HF are correlated with whole-heart myocardial mechanics and morphometrics. However, LVEF, GRV, and RVFWLS are the most usually found 2D echocardiographic factors associated with changes in HF prognostic factors.

Rodent Models of Dilated Cardiomyopathy and Heart Failure for Translational Investigations and Therapeutic Discovery

Even with modern therapy, patients with heart failure only have a 50% five-year survival rate. To improve the development of new therapeutic strategies, preclinical models of disease are needed to properly emulate the human condition. Determining the most appropriate model represents the first key step for reliable and translatable experimental research. Rodent models of heart failure provide a strategic compromise between human in vivo similarity and the ability to perform a larger number of experiments and explore many therapeutic candidates. We herein review the currently available rodent models of heart failure, summarizing their physiopathological basis, the timeline of the development of ventricular failure, and their specific clinical features. In order to facilitate the future planning of investigations in the field of heart failure, a detailed overview of the advantages and possible drawbacks of each model is provided.

Effects of Hypertrophic and Dilated Cardiac Geometric Remodeling on Ejection Fraction

Background: Both heart failure (HF) with preserved ejection fraction (HFpEF) and heart failure with reduced ejection fraction (HFrEF) can present a wide variety of cardiac morphologies consequent to cardiac remodeling. We sought to study if geometric changes to the heart during such remodeling will adversely affect the ejection fraction (EF) parameter’s ability to serve as an indicator of heart function, and to identify the mechanism for it.

Methods and Results: A numerical model that simulated the conversion of myocardial strain to stroke volume was developed from two porcine animal models of heart failure. Hypertrophic wall thickening was found to elevate EF, while left ventricle (LV) dilation was found to depress EF when myocardial strain was kept constant, causing EF to inaccurately represent the overall strain function. This was caused by EF being calculated using the endocardial boundary rather than the mid-wall layer. Radial displacement of the endocardial boundary resulted in endocardial strain deviating from the overall LV strain, and this deviation varied with LV geometric changes. This suggested that using the epi- or endo-boundaries to calculate functional parameters was not effective, and explained why EF could be adversely affected by geometric changes. Further, when EF was modified by calculating it at the mid-wall layer instead of at the endocardium, this shortcoming was resolved, and the mid-wall EF could differentiate between healthy and HFpEF subjects in our animal models, while the traditional EF could not.

Conclusion: We presented the mechanism to explain why EF can no longer effectively indicate cardiac function during cardiac geometric changes relevant to HF remodeling, losing the ability to distinguish between hypertrophic diseased hearts from healthy hearts. Measuring EF at the mid-wall location rather than endocardium can avoid the shortcoming and better represent the cardiac strain function.