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Narayanan CA, Bokhari N, Rowin EJ, Maron MS, Maron BJ, Link MS, Madias C. Maintenance of Subcutaneous Implantable Cardioverter Defibrillators in Hypertrophic Cardiomyopathy Patients With Iatrogenic Left Bundle-Branch Block After Septal Myectomy. J Am Heart Assoc 2024; 13:e033728. [PMID: 38563365 DOI: 10.1161/jaha.123.033728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 02/05/2024] [Indexed: 04/04/2024]
Affiliation(s)
| | | | | | | | | | - Mark S Link
- University of Texas Southwestern Medical Center Dallas TX USA
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Maron BA, Wang RS, Shevtsov S, Drakos SG, Arons E, Wever-Pinzon O, Huggins GS, Samokhin AO, Oldham WM, Aguib Y, Yacoub MH, Rowin EJ, Maron BJ, Maron MS, Loscalzo J. Author Correction: Individualized interactomes for network-based precision medicine in hypertrophic cardiomyopathy with implications for other clinical pathophenotypes. Nat Commun 2024; 15:3038. [PMID: 38589351 PMCID: PMC11002015 DOI: 10.1038/s41467-024-45814-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/10/2024] Open
Affiliation(s)
- Bradley A Maron
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.
| | - Rui-Sheng Wang
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Sergei Shevtsov
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Stavros G Drakos
- Division of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
- Nora Eccles Harrison Cardiovascular Research and Training Institute (CVRTI), University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Elena Arons
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Omar Wever-Pinzon
- Division of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Gordon S Huggins
- Hypertrophic Cardiomyopathy Center, Cardiology Division, Tufts Medical Center, Boston, MA, USA
| | - Andriy O Samokhin
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - William M Oldham
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Yasmine Aguib
- Department of Cardiac Surgery, Imperial College of London, London, UK
- The Magdi Yacoub Heart Center, Aswan, Egypt
| | - Magdi H Yacoub
- Department of Cardiac Surgery, Imperial College of London, London, UK
- The Magdi Yacoub Heart Center, Aswan, Egypt
| | - Ethan J Rowin
- Hypertrophic Cardiomyopathy Center, Cardiology Division, Tufts Medical Center, Boston, MA, USA
| | - Barry J Maron
- Hypertrophic Cardiomyopathy Center, Cardiology Division, Tufts Medical Center, Boston, MA, USA
| | - Martin S Maron
- Hypertrophic Cardiomyopathy Center, Cardiology Division, Tufts Medical Center, Boston, MA, USA
| | - Joseph Loscalzo
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
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Rowin EJ, Wadid M, Maron MS, White M, Hook BG, Harnish P, Silver JS, Reynolds MR, Maron BJ. Assessing the impact of atrial fibrillation on symptoms and quality of life in hypertrophic cardiomyopathy. J Cardiovasc Electrophysiol 2024; 35:654-663. [PMID: 38288888 DOI: 10.1111/jce.16192] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 01/08/2024] [Accepted: 01/14/2024] [Indexed: 04/10/2024]
Abstract
INTRODUCTION In hypertrophic cardiomyopathy (HCM), atrial fibrillation (AF) has historically been regarded to have a deleterious impact on clinical course, strongly associated with progressive heart failure (HF) symptoms. However, there is a paucity of information regarding the impact of AF on HCM employing validated quality of life (QoL) surveys. Therefore, we evaluated the impact of AF on QoL utilizing patient reported outcome measures (PROMs). METHODS 218 consecutive HCM patients with or without AF at the Lahey HCM center in 2022 completed PROMs at their most recent visit evaluating HF (Kansas City Cardiomyopathy Questionnaire [KCCQ]) and AF symptoms (AF Effect on QoL [AFEQT]). RESULTS Among the 218 patients, 50 (23%) had a history of AF and comprise the primary study cohort. AF was diagnosed at 55 ± 10 years of age, median of 5.5 years before PROM, with 66% of patients treated with a rhythm control strategy with antiarrhythmic drug and/or AF ablation. AFEQT indicated that 52% of patients experienced no or minimal AF-related disability, mild to moderate in 22%, and severe in 26%. There was no substantial difference in HCM phenotype in patients with no or minimal AF disability compared to those with severe disability. HF symptoms for most HCM patients with prior AF history was consistent with no or minimal (59%) or only mild (27%) disability as measured by KCCQ overall summary scores. In addition, with multivariate analysis, AF history was associated with less HF symptoms and improved QoL (OR 0.4, p = 0.02). CONCLUSION In contrast to prior perceptions, HCM patients with prior AF history were less likely to incur HF symptoms impairing QoL compared to HCM patients without AF. After treatment, prior history of AF did not substantially impact current QoL. These data provide a realistic appraisal for the impact that AF has on HCM patients and also offers a measure of reassurance for this patient subgroup.
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Affiliation(s)
- Ethan J Rowin
- Hypertrophic Cardiomyopathy Center, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
| | - Mark Wadid
- Hypertrophic Cardiomyopathy Center, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
| | - Martin S Maron
- Hypertrophic Cardiomyopathy Center, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
| | - Maggie White
- Hypertrophic Cardiomyopathy Center, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
| | - Bruce G Hook
- Hypertrophic Cardiomyopathy Center, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
| | - Paul Harnish
- Hypertrophic Cardiomyopathy Center, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
| | - Jonathan S Silver
- Hypertrophic Cardiomyopathy Center, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
| | - Matthew R Reynolds
- Hypertrophic Cardiomyopathy Center, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
| | - Barry J Maron
- Hypertrophic Cardiomyopathy Center, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
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Maron BJ. How Investigative Reporting and the "Fourth Estate" Saved Hypertrophic Cardiomyopathy…Twice. Am J Med 2024:S0002-9343(24)00139-6. [PMID: 38490306 DOI: 10.1016/j.amjmed.2024.02.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Accepted: 02/21/2024] [Indexed: 03/17/2024]
Affiliation(s)
- Barry J Maron
- HCM Center, Lahey Hospital and Medical Center, Burlington, Mass.
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Maron BJ, Rowin EJ, Maron MS. Advances in the Management of Hypertrophic Cardiomyopathy Leading to Low Disease-Related Mortality in 2023. Am J Cardiol 2024; 212S:S77-S82. [PMID: 38368039 DOI: 10.1016/j.amjcard.2023.10.073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 10/26/2023] [Indexed: 02/19/2024]
Abstract
Hypertrophic cardiomyopathy (HCM) is a relatively common often inherited heart disease encumbered throughout much of its almost 60-year history by the expectation of an unfavorable outcome with shortened longevity. However, it is notable that in 2023, most patients affected with HCM can now achieve normal or extended life expectancy without major disability because of a comprehensive constellation of management strategies that have evolved largely over the last 20 years. Distinct adverse disease pathways dictate high-benefit low-risk personalized treatments, without reliance on genomics and sarcomere mutations, including: primary prevention implantable defibrillators for sudden cardiac death prevention, surgical myectomy and percutaneous alcohol septal ablation to reverse heart failure symptoms, anticoagulation to prevent embolic stroke associated with concomitant atrial fibrillation, external defibrillation and hypothermia for out-of-hospital cardiac arrest, and heart transplant in a small patient subgroup with end-stage disease. Large cohort studies using these contemporary management strategies achieved remarkably low HCM-related mortality (0.5%/year) across all age groups, which is lower than in the other cardiac or noncardiac risks of living, and largely confined to nonobstructive patients with progressive heart failure, including those awaiting heart transplant.
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Affiliation(s)
- Barry J Maron
- HCM Center, Lahey Hospital and Medical Center, Burlington, Massachusetts.
| | - Ethan J Rowin
- HCM Center, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Martin S Maron
- HCM Center, Lahey Hospital and Medical Center, Burlington, Massachusetts
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Maron MS, Rowin EJ, Maron BJ. The Paradigm of Sudden Death Prevention in Hypertrophic Cardiomyopathy. Am J Cardiol 2024; 212S:S64-S76. [PMID: 38368038 DOI: 10.1016/j.amjcard.2023.10.076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 10/26/2023] [Indexed: 02/19/2024]
Abstract
Hypertrophic cardiomyopathy (HCM) is a relatively common and, often, inherited cardiac disease, once regarded as largely untreatable with ominous prognosis and, perhaps, most visibly as a common cause of sudden cardiac death (SCD) in the young. However, HCM is now more accurately considered a treatable disease with management options that significantly alter its clinical course. This is particularly true for SCD because the penetration of implantable cardioverter-defibrillators into HCM practice enables primary prevention device therapy that reliably terminates potentially lethal ventricular tachyarrhythmias (3% to 4%/year). This therapeutic advance is largely responsible for >10-fold decrease in the overall disease-related mortality to 0.5%/year, independent of patient age. A guideline-based clinical risk stratification algorithm has evolved, which included variables identifiable with cardiac magnetic resonance: ≥1 risk markers judged major within the clinical profile of an individual patient, associated with a measure of physician judgment and shared decision-making, can be sufficient to consider the recommendation of a prophylactic defibrillator implant. Implantable cardioverter-defibrillator decisions using the American College of Cardiology and the American Heart Association traditional major risk marker strategy are associated with a 95% sensitivity for identifying those patients who subsequently experience appropriate therapy, albeit often 5 to 10+ years after implant but without heart failure deterioration or death after a device intervention. A mathematical SCD risk score proposed by European Society of Cardiology is associated with a relatively low sensitivity (33%) for predicting and preventing SCD events but with potential for less device overtreatment.
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Affiliation(s)
- Martin S Maron
- Lahey Hospital and Medical Center, HCM Center, Burlington, Massachusetts.
| | - Ethan J Rowin
- Lahey Hospital and Medical Center, HCM Center, Burlington, Massachusetts
| | - Barry J Maron
- Lahey Hospital and Medical Center, HCM Center, Burlington, Massachusetts
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Carrick RT, Ahamed H, Sung E, Maron MS, Madias C, Avula V, Studley R, Bao C, Bokhari N, Quintana E, Rajesh-Kannan R, Maron BJ, Wu KC, Rowin EJ. Identification of high-risk imaging features in hypertrophic cardiomyopathy using electrocardiography: A deep-learning approach. Heart Rhythm 2024:S1547-5271(24)00085-7. [PMID: 38280624 DOI: 10.1016/j.hrthm.2024.01.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 01/05/2024] [Accepted: 01/21/2024] [Indexed: 01/29/2024]
Abstract
BACKGROUND Patients with hypertrophic cardiomyopathy (HCM) are at risk of sudden death, and individuals with ≥1 major risk markers are considered for primary prevention implantable cardioverter-defibrillators. Guidelines recommend cardiac magnetic resonance (CMR) imaging to identify high-risk imaging features. However, CMR imaging is resource intensive and is not widely accessible worldwide. OBJECTIVE The purpose of this study was to develop electrocardiogram (ECG) deep-learning (DL) models for the identification of patients with HCM and high-risk imaging features. METHODS Patients with HCM evaluated at Tufts Medical Center (N = 1930; Boston, MA) were used to develop ECG-DL models for the prediction of high-risk imaging features: systolic dysfunction, massive hypertrophy (≥30 mm), apical aneurysm, and extensive late gadolinium enhancement. ECG-DL models were externally validated in a cohort of patients with HCM from the Amrita Hospital HCM Center (N = 233; Kochi, India). RESULTS ECG-DL models reliably identified high-risk features (systolic dysfunction, massive hypertrophy, apical aneurysm, and extensive late gadolinium enhancement) during holdout testing (c-statistic 0.72, 0.83, 0.93, and 0.76) and external validation (c-statistic 0.71, 0.76, 0.91, and 0.68). A hypothetical screening strategy using echocardiography combined with ECG-DL-guided selective CMR use demonstrated a sensitivity of 97% for identifying patients with high-risk features while reducing the number of recommended CMRs by 61%. The negative predictive value with this screening strategy for the absence of high-risk features in patients without ECG-DL recommendation for CMR was 99.5%. CONCLUSION In HCM, novel ECG-DL models reliably identified patients with high-risk imaging features while offering the potential to reduce CMR testing requirements in underresourced areas.
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Affiliation(s)
- Richard T Carrick
- Johns Hopkins University School of Medicine, Heart and Vascular Institute, Baltimore, Maryland.
| | - Hisham Ahamed
- Amrita Institute of Medical Sciences and Research Centre, Amrita Hypertrophic Cardiomyopathy Center, Kochi, Kerala, India
| | - Eric Sung
- Johns Hopkins University School of Medicine, Heart and Vascular Institute, Baltimore, Maryland
| | - Martin S Maron
- Lahey Hospital and Medical Center, Hypertrophic Cardiomyopathy Center, Burlington, Massachusetts
| | | | - Vennela Avula
- Johns Hopkins University School of Medicine, Heart and Vascular Institute, Baltimore, Maryland
| | - Rachael Studley
- Tufts Medical Center, Cardiac Arrhythmia Center, Boston, Massachusetts
| | - Chen Bao
- Tufts Medical Center, Cardiac Arrhythmia Center, Boston, Massachusetts
| | - Nadia Bokhari
- Tufts Medical Center, Cardiac Arrhythmia Center, Boston, Massachusetts
| | - Erick Quintana
- Tufts Medical Center, Cardiac Arrhythmia Center, Boston, Massachusetts
| | - Ramiah Rajesh-Kannan
- Amrita Institute of Medical Sciences and Research Centre, Amrita Hypertrophic Cardiomyopathy Center, Kochi, Kerala, India
| | - Barry J Maron
- Lahey Hospital and Medical Center, Hypertrophic Cardiomyopathy Center, Burlington, Massachusetts
| | - Katherine C Wu
- Johns Hopkins University School of Medicine, Heart and Vascular Institute, Baltimore, Maryland
| | - Ethan J Rowin
- Lahey Hospital and Medical Center, Hypertrophic Cardiomyopathy Center, Burlington, Massachusetts
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Bataiosu R, Hoss S, Scolari FL, Cooper C, Tsoi M, Brahmbhatt DH, Billia F, Lee DZJ, Chan R, Ha ACT, Maron BJ, Rowin E, Maron MS, Ralph-Edwards A, Rakowski H, Adler A. Clinical Significance of Postoperative Atrial Fibrillation in Hypertrophic Cardiomyopathy Patients Undergoing Septal Myectomy. Can J Cardiol 2023; 39:1931-1937. [PMID: 37355230 DOI: 10.1016/j.cjca.2023.06.415] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 06/16/2023] [Accepted: 06/16/2023] [Indexed: 06/26/2023] Open
Abstract
BACKGROUND The optimal management of hypertrophic cardiomyopathy (HCM) patients with postoperative atrial fibrillation (POAF) after surgical myectomy remains unknown. We sought to investigate the association between POAF and atrial fibrillation (AF) or cardioembolic events during follow-up to bridge this gap. METHODS Patients undergoing surgical myectomy at 2 HCM referral centres in North America from 2002 to 2020 were included in this study. Patients with preoperative AF were excluded. POAF was defined as any episode of AF within 30 days after surgery. RESULTS Of 1176 patients, 375 (31.9%) had POAF. Age (adjusted hazard ratio [HR] 1.05, 95% confidence interval [CI] 1.03-1.06; P < 0.001), premyectomy left atrial diameter (LAD; adjusted HR 1.6, 95% CI 1.32-2.02; P < 0.001), and smoking (adjusted HR 1.60, 95% CI 1.17-2.20; P = 0.001) were associated with POAF on multivariable analysis. Of 934 patients with follow-up data, of duration 4.3 ± 4.1 years, AF was detected in 86 (9.2%). Only POAF (HR 4.20, 95% CI 2.44-7.23; P < 0.001), previous history of stroke (HR 4.81, 95% CI 1.63-14.17; P = 0.01), and postmyectomy LAD (HR 1.80, 95% CI 1.21-2.70; P = 0.004) were associated with AF incidence during follow-up. Cardioembolic events occurred in only 15 patients (1.6%). POAF was not associated with increased cardioembolic risk, with only 3 patients with POAF suffering such an event, all more than 4 years after surgery. CONCLUSIONS POAF is common in HCM patients undergoing myectomy and is a predictor of AF during follow-up. Over long-term follow-up, cardioembolic events are uncommon. These findings suggest that routine long-term anticoagulation for all HCM patients with postmyectomy AF is not justified after the initial postoperative period.
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Affiliation(s)
- Roxana Bataiosu
- Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada
| | - Sara Hoss
- Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada
| | - Fernando L Scolari
- Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada
| | - Craig Cooper
- Division of Cardiology, Tufts Medical Center, Boston, Massachusetts, USA
| | - Melissa Tsoi
- Division of Cardiology, Tufts Medical Center, Boston, Massachusetts, USA
| | - Darshan H Brahmbhatt
- Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada
| | - Filio Billia
- Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada
| | - Deacon Z J Lee
- Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada
| | - Raymond Chan
- Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada
| | - Andrew C T Ha
- Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada
| | - Barry J Maron
- Hypertrophic Cardiomyopathy Center, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
| | - Ethan Rowin
- Hypertrophic Cardiomyopathy Center, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
| | - Martin S Maron
- Hypertrophic Cardiomyopathy Center, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
| | - Anthony Ralph-Edwards
- University of Toronto, Toronto, Ontario, Canada; Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Harry Rakowski
- Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada
| | - Arnon Adler
- Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada.
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Maron BJ, Rowin EJ, Maron MS. Commotio cordis…once again: Unusual occurrence in a noncontact sport. HeartRhythm Case Rep 2023; 9:855-857. [PMID: 38204836 PMCID: PMC10774598 DOI: 10.1016/j.hrcr.2023.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2024] Open
Affiliation(s)
- Barry J. Maron
- HCM Center, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Ethan J. Rowin
- HCM Center, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Martin S. Maron
- HCM Center, Lahey Hospital and Medical Center, Burlington, Massachusetts
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Rowin EJ, Link MS, Maron MS, Maron BJ. Evolving Contemporary Management of Atrial Fibrillation in Hypertrophic Cardiomyopathy. Circulation 2023; 148:1797-1811. [PMID: 38011245 DOI: 10.1161/circulationaha.123.065037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
Atrial fibrillation (AF) is the most common sustained arrhythmia in hypertrophic cardiomyopathy (HCM) with clinical and subclinical episodes occurring in nearly one-half of patients. AF in HCM historically has been characterized as a decisive disease complication associated with substantial risk for thromboembolic stroke and increased morbidity and mortality. However, there have been many advances in treatment strategy resulting in improved outcomes for this patient group. For example, stroke risk in HCM has been greatly reduced by using systemic oral anticoagulation initiated after the first clinical (symptomatic) AF episode, usually with preference given to direct anticoagulants over warfarin. In contrast, stroke risk scoring systems (such as CHA2DS2-VASc score) are not informative in HCM given the substantial potential for stroke events in patients with low scores, and therefore should not be used for anticoagulation decisions in this disease. A novel risk score specifically designed for HCM (HCM-AF score) can reliably identify most patients with HCM at risk for future AF. Although a strategy focused on controlling ventricular rate is effective in asymptomatic (or minimally symptomatic) patients with AF, restoring and maintaining sinus rhythm is required for most patients with marked AF symptom burden and impaired quality of life. Several antiarrhythmic drugs such as sotalol, disopyramide, and amiodarone, can be effective in suppressing AF episodes; albeit safe, long-term efficacy is supported by only limited data. Catheter AF ablation has emerged as an important treatment option for some patients, although freedom from AF after a single ablation is relatively low (35% at 3 years), multiple ablations and the concomitant use of antiarrhythmic drugs can control AF with more than two-thirds of patients maintaining sinus rhythm at 5 years. Surgical AF ablation with biatrial Cox-Maze IV performed as an adjunctive procedure during myectomy can reduce symptomatic AF episodes (70% of patients free from AF at 5 years). For the vast majority of patients who have HCM with AF, the implementation of contemporary therapies has allowed for improved quality of life and low HCM-related mortality.
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Affiliation(s)
- Ethan J Rowin
- Lahey Hospital and Medical Center, Burlington, MA (E.J.R., M.S.M., B.J.M.)
| | - Mark S Link
- University of Texas Southwestern Medical Center, Dallas (M.S.L.)
| | - Martin S Maron
- Lahey Hospital and Medical Center, Burlington, MA (E.J.R., M.S.M., B.J.M.)
| | - Barry J Maron
- Lahey Hospital and Medical Center, Burlington, MA (E.J.R., M.S.M., B.J.M.)
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Studley R, Madias C, Bokhari N, Carrick RT, Quintana E, Bao C, Maron BJ, Maron MS, Rowin EJ. QRS Fragmentation as a Risk Marker for Sudden Death in Hypertrophic Cardiomyopathy. JACC Clin Electrophysiol 2023; 9:2353-2355. [PMID: 37632508 DOI: 10.1016/j.jacep.2023.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 07/05/2023] [Accepted: 07/10/2023] [Indexed: 08/28/2023]
Affiliation(s)
- Rachael Studley
- CardioVascular Center, Tufts Medical Center, Boston, Massachusetts, USA
| | | | - Nadia Bokhari
- CardioVascular Center, Tufts Medical Center, Boston, Massachusetts, USA
| | - Richard T Carrick
- Johns Hopkins University School of Medicine, Heart and Vascular Institute, Baltimore, Maryland, USA
| | - Erick Quintana
- CardioVascular Center, Tufts Medical Center, Boston, Massachusetts, USA
| | - Chen Bao
- CardioVascular Center, Tufts Medical Center, Boston, Massachusetts, USA
| | - Barry J Maron
- Hypertrophic Cardiomyopathy Center, Lahey Hospital and Medical Center, Burlington Massachusetts, USA
| | - Martin S Maron
- Hypertrophic Cardiomyopathy Center, Lahey Hospital and Medical Center, Burlington Massachusetts, USA
| | - Ethan J Rowin
- Hypertrophic Cardiomyopathy Center, Lahey Hospital and Medical Center, Burlington Massachusetts, USA.
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Maron BJ, Estes NAM. Commotio Cordis Returns…When We Least Expected It: Cardiac Arrest in A Professional Football Player. Am J Cardiol 2023; 202:229-232. [PMID: 37495440 DOI: 10.1016/j.amjcard.2023.06.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 06/01/2023] [Accepted: 06/06/2023] [Indexed: 07/28/2023]
Abstract
For the first time in 52 years, an American professional football player (Damar Hamlin) collapsed in cardiac arrest during a game, viewed in real-time on national television. The cause of this profound event was commotio cordis, that is, blunt non-penetrating chest blow-initiated ventricular fibrillation triggered by physical contact not considered unusual for football. The athlete survived because of timely cardiopulmonary resuscitation and defibrillation provided by first responders organized by the National Football League. Commotio cordis, albeit rare, was most prominently identified initially in competitive and also recreational sports participants. More recently it became apparent that similar events could occur in almost any circumstance involving a chest blow, such as during everyday activities around the home and with innocent play. The determinant of a commotio cordis event is a blow over the heart in a narrow vulnerable electrical window during dispersion of repolarization. Survival from these events has increased substantially to >60% due to enhanced recognition and prompt resuscitation/defibrillation. In conclusion, in this commentary, we take a timely opportunity to describe in detail the relevant demographics, mechanism/pathophysiology, and clinical course of commotio cordis.
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Affiliation(s)
- Barry J Maron
- Hypertrophic Cardiomyopathy Center, Lahey Hospital and Medical Center, Burlington, Massachusetts.
| | - N A Mark Estes
- Heart and Vascular Institute, University of Pittsburgh Medical Center Presbyterian, Pittsburgh, Pennsylvania
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Maron BJ. In Memoriam: WCR: The Remarkable Life and Works of Dr. Bill Roberts. J Am Coll Cardiol 2023; 82:964-968. [PMID: 37516945 DOI: 10.1016/j.jacc.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/31/2023]
Affiliation(s)
- Barry J Maron
- HCM Center, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA.
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Maron MS, Mitten M, Borchers J, Rowin EJ, Maron BJ. Medical and Legal Determinants of Sports Eligibility for Young Competitive Athletes With Cardiovascular Disease. J Am Coll Cardiol 2023; 82:828-832. [PMID: 37542484 DOI: 10.1016/j.jacc.2023.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 06/01/2023] [Accepted: 06/05/2023] [Indexed: 08/07/2023]
Affiliation(s)
- Martin S Maron
- Hypertrophic Cardiomyopathy Center at Lahey Medical Center and Hospital, Burlington, Massachusetts, USA.
| | - Matthew Mitten
- National Sports Law Institute, Marquette University Law School, Milwaukee, Wisconsin, USA
| | - James Borchers
- Division of Family Medicine-Sports Medicine, Ohio State Wexner Medical Center, Columbus, Ohio, USA
| | - Ethan J Rowin
- Hypertrophic Cardiomyopathy Center at Lahey Medical Center and Hospital, Burlington, Massachusetts, USA
| | - Barry J Maron
- Hypertrophic Cardiomyopathy Center at Lahey Medical Center and Hospital, Burlington, Massachusetts, USA
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15
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Bonaventura J, Maron BJ, Berul CI, Rowin EJ, Maron MS. Analysis of risk stratification and prevention of sudden death in pediatric patients with hypertrophic cardiomyopathy: Dilemmas and clarity. Heart Rhythm O2 2023; 4:506-516. [PMID: 37645261 PMCID: PMC10461211 DOI: 10.1016/j.hroo.2023.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023] Open
Abstract
Hypertrophic cardiomyopathy (HCM) has been considered the most common cause of sudden death (SD) in the young. However, introduction of implantable cardioverter-defibrillators (ICDs) in HCM has proved highly effective and the mainstay of preventing SD in children, adolescents, and adults by terminating malignant ventricular tachyarrhythmias. Nevertheless, ICD decision making is generally regarded as more difficult in pediatrics, and the strategy for selecting ICD patients from this population remains without consensus. Prospective studies in HCM children and adolescents have shown the American Heart Association/American College of Cardiology traditional major risk marker strategy to be reliable with >90% sensitivity in selecting patients for SD prevention. International data in >2000 young HCM patients assembled over 20 years who were stratified by major risk markers showed ICDs effectively prevented SD in 20%. Alternatively, novel quantitative risk scoring initiatives provide 5-year risk estimates that are potentially useful as adjunctive tools to facilitate discussion of prophylactic ICD risks vs benefit but are as yet unsupported by prospective outcome studies. Risk scoring strategies are characterized by reasonable discriminatory statistical power (C-statistic 0.69-0.76) for identifying patients with SD events but with relatively low sensitivity, albeit with specificity comparable with the risk marker strategy. While some reticence for obligating healthy-appearing young patients to lifelong device implants is understandable, underutilization of the ICD in high-risk children and adolescents can represent a lost opportunity for fulfilling the long-standing aspiration of SD prevention. This review provides a critical assessment of the current strengths and weaknesses of SD risk stratification strategies in young HCM patients in an effort to clarify clinical decision making in this challenging subpopulation.
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Affiliation(s)
- Jiri Bonaventura
- Department of Cardiology, 2nd Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
- Hypertrophic Cardiomyopathy Center, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Barry J. Maron
- Hypertrophic Cardiomyopathy Center, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Charles I. Berul
- Division of Cardiology, Children’s National Hospital, Department of Pediatrics, George Washington University School of Medicine, Washington, DC
| | - Ethan J. Rowin
- Hypertrophic Cardiomyopathy Center, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Martin S. Maron
- Hypertrophic Cardiomyopathy Center, Lahey Hospital and Medical Center, Burlington, Massachusetts
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Maron BJ, Estes NAM, Rowin EJ, Maron MS, Reynolds MR. Development of the Implantable Cardioverter-Defibrillator: JACC Historical Breakthroughs in Perspective. J Am Coll Cardiol 2023; 82:353-373. [PMID: 37468191 DOI: 10.1016/j.jacc.2023.04.056] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 04/13/2023] [Accepted: 04/28/2023] [Indexed: 07/21/2023]
Abstract
Implantable cardioverter-defibrillators (ICDs) represent transformational technology, arguably the most significant advance in cardiovascular medicine in 50 years. The vision and determination of pioneers Mirowski and Mower was fundamental to this monumental achievement, working with limited resources and confronted by skepticism/criticism from medical establishment. The inventors were followed >35 years in which a multitude of innovative clinical scientists and engineers introduced technological advances leading to the sophisticated devices in practice today. A pivotal patient experiment with automated termination of ventricular fibrillation (1980) led to U.S. Food and Drug Administration approval. Transvenous lead systems converted ICDs from thoracotomy-based secondary prevention to primary prevention of sudden death devices in countless patients worldwide. ICD acceptance was solidified by prospective randomized controlled trials showing reduced mortality superior to antiarrhythmic drugs. ICDs eventually expanded from coronary disease to inherited arrhythmia conditions (eg, hypertrophic cardiomyopathy). The ICD breakthrough story demonstrates how significant progress is possible in medicine against all odds, given fearless imagination to pursue novel ideas that conflict with accepted wisdom.
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Affiliation(s)
- Barry J Maron
- Lahey Hospital and Medical Center, Burlington, Massachusetts, USA.
| | - N A Mark Estes
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ethan J Rowin
- Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
| | - Martin S Maron
- Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
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Maron MS, Rowin EJ, Bonaventura J, Maron BJ. Do Implantable Cardioverter-Defibrillators Really Belong on the Athlete Field? Am J Cardiol 2023:S0002-9149(23)00343-0. [PMID: 37393157 DOI: 10.1016/j.amjcard.2023.05.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 05/10/2023] [Accepted: 05/29/2023] [Indexed: 07/03/2023]
Abstract
High-risk athletes with implanted cardioverter-defibrillators who are competing in intense sports represent a controversial issue in cardiovascular medicine. Such devices have the capability to protect patients with a variety of cardiovascular diseases from sudden death and have aborted potentially lethal events during competitive sports but they can also lead to adverse clinical consequences for athletes with implants and other participants. In conclusion, clinicians and athletes should consider the data presented here in making prudent and informed recommendations regarding the eligibility of this patient group with implanted cardioverter-defibrillators for intense competitive sports.
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Affiliation(s)
- Martin S Maron
- HCM Center, Lahey Hospital and Medical Center, Burlington, Massachusetts..
| | - Ethan J Rowin
- HCM Center, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Jiri Bonaventura
- HCM Center, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Barry J Maron
- HCM Center, Lahey Hospital and Medical Center, Burlington, Massachusetts
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18
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Bonaventura J, Rowin EJ, Maron MS, Maron BJ. Is Hypertrophic Cardiomyopathy Always a Familial and Inherited Disease? J Am Heart Assoc 2023:e028974. [PMID: 37301765 DOI: 10.1161/jaha.122.028974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Accepted: 05/15/2023] [Indexed: 06/12/2023]
Affiliation(s)
- Jiri Bonaventura
- Hypertrophic Cardiomyopathy Center Lahey Hospital and Medical Center Burlington MA USA
- Department of Cardiology, 2nd Faculty of Medicine Charles University and Motol University Hospital Prague Czech Republic
| | - Ethan J Rowin
- Hypertrophic Cardiomyopathy Center Lahey Hospital and Medical Center Burlington MA USA
| | - Martin S Maron
- Hypertrophic Cardiomyopathy Center Lahey Hospital and Medical Center Burlington MA USA
| | - Barry J Maron
- Hypertrophic Cardiomyopathy Center Lahey Hospital and Medical Center Burlington MA USA
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19
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Wang RS, Rowin EJ, Maron BJ, Maron MS, Maron BA. A novel patient-patient network medicine approach to refine hypertrophic cardiomyopathy subgrouping: implications for risk stratification. Cardiovasc Res 2023; 119:e125-e127. [PMID: 37129987 PMCID: PMC10409890 DOI: 10.1093/cvr/cvad036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/03/2023] Open
Affiliation(s)
- Rui-Sheng Wang
- Division of Cardiovascular Medicine, Department of Medicine, 77 Ave Louis Pasteur, NRB 0630-N, Boston, MA 02115, USA
- Channing Division of Network Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Ethan J Rowin
- HCM Center, Lahey Hospital and Medical Center, Burlington, MA 01805, USA
| | - Barry J Maron
- HCM Center, Lahey Hospital and Medical Center, Burlington, MA 01805, USA
| | - Martin S Maron
- HCM Center, Lahey Hospital and Medical Center, Burlington, MA 01805, USA
| | - Bradley A Maron
- Division of Cardiovascular Medicine, Department of Medicine, 77 Ave Louis Pasteur, NRB 0630-N, Boston, MA 02115, USA
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Shaw KE, Lund PG, Witt D, Okeson BK, Lohese O, Schmitz K, Saxena R, Maron BJ, Sharkey SW. Super Recurrence of Takotsubo Syndrome: Clinical Characteristics and Late Cardiac Outcomes. J Am Heart Assoc 2023; 12:e029144. [PMID: 37119086 PMCID: PMC10227233 DOI: 10.1161/jaha.122.029144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 04/04/2023] [Indexed: 04/30/2023]
Affiliation(s)
- Kirsten E. Shaw
- Department of Cardiovascular Disease, Hennepin HealthcareMinneapolisMNUSA
- Minneapolis Heart Institute FoundationMinneapolisMNUSA
| | - Peter G. Lund
- Department of Graduate Medical Education, Abbott Northwestern HospitalMinneapolisMNUSA
| | - Dawn Witt
- Minneapolis Heart Institute FoundationMinneapolisMNUSA
| | | | - Opema Lohese
- Minneapolis Heart Institute FoundationMinneapolisMNUSA
| | - Katlin Schmitz
- Department of Internal Medicine, Mayo ClinicRochesterMNUSA
| | - Retu Saxena
- Minneapolis Heart Institute FoundationMinneapolisMNUSA
| | - Barry J. Maron
- Hypertrophic Cardiomyopathy Center, Lahey Hospital and Medical CenterBurlingtonMAUSA
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21
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Maron BJ, Cooper S, Sheppard MN. Erratum to 'Defining Commotio Cordis': The American Journal of Cardiology Volume 124, Issue 10, 15 November 2019, Pages 1649-1650. Am J Cardiol 2023; 193:133. [PMID: 37003669 DOI: 10.1016/j.amjcard.2023.03.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/03/2023]
Affiliation(s)
- Barry J Maron
- Hypertrophic Cardiomyopathy Institute, Tufts Medical Center, Boston, Massachusetts.
| | - Ste Cooper
- CRY Cardiovascular Pathology Department, St George's University, London, United Kingdom
| | - M N Sheppard
- CRY Cardiovascular Pathology Department, St George's University, London, United Kingdom
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22
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Massera D, Sherrid MV, Maron MS, Rowin EJ, Maron BJ. How common is hypertrophic cardiomyopathy… really?: Disease prevalence revisited 27 years after CARDIA. Int J Cardiol 2023; 382:64-67. [PMID: 37028711 DOI: 10.1016/j.ijcard.2023.04.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 03/01/2023] [Accepted: 04/03/2023] [Indexed: 04/09/2023]
Abstract
Hypertrophic cardiomyopathy (HCM) is a heterogeneous albeit treatable cardiac disease of variable severity, with the potential for heart failure, atrial fibrillation and arrhythmic sudden death, characterized by otherwise unexplained left ventricular (LV) hypertrophy and affecting all ages and races. Over the last 30 years, several studies have estimated the prevalence of HCM in the general population, employing echocardiography and cardiac magnetic resonance imaging (CMR), as well electronic health records and billing databases for clinical diagnosis. The estimated prevalence in the general population based on the disease phenotype of LV hypertrophy by imaging is 1:500 (0.2%). This prevalence was initially proposed in 1995 in the population-based CARDIA study employing echocardiography, and more recently confirmed by automated CMR analysis in the large UK Biobank cohort. The 1:500 prevalence appears most relevant to clinical assessment and management of HCM. These available data suggest that HCM is not a rare condition but likely underdiagnosed clinically and by extrapolation potentially affects about 700,000 Americans and possibly 15 million people worldwide.
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Affiliation(s)
- Daniele Massera
- Hypertrophic Cardiomyopathy Program, Leon H. Charney Division of Cardiology, NYU Langone Health, New York, NY, United States of America.
| | - Mark V Sherrid
- Hypertrophic Cardiomyopathy Program, Leon H. Charney Division of Cardiology, NYU Langone Health, New York, NY, United States of America
| | - Martin S Maron
- Hypertrophic Cardiomyopathy Center, Lahey Hospital and Medical Center, Burlington, MA, United States of America
| | - Ethan J Rowin
- Hypertrophic Cardiomyopathy Center, Lahey Hospital and Medical Center, Burlington, MA, United States of America
| | - Barry J Maron
- Hypertrophic Cardiomyopathy Center, Lahey Hospital and Medical Center, Burlington, MA, United States of America
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23
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Maron MS, Rowin E, Spirito P, Maron BJ. Differing strategies for sudden death prevention in hypertrophic cardiomyopathy. Heart 2023; 109:589-594. [PMID: 36270782 PMCID: PMC10086464 DOI: 10.1136/heartjnl-2020-316693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 06/01/2022] [Indexed: 11/04/2022] Open
Abstract
Sudden death (SD) has traditionally been the most visible and feared complication of hypertrophic cardiomyopathy (HCM). Substantial progress in reducing the occurrence of these catastrophic events represents a new paradigm in disease management. Prevention of SD in HCM has resulted from introduction of primary prevention ICDs that reliably terminate life-threatening ventricular tachyarrhythmias, as well as a matured risk stratification algorithm capable of reliably identifying those patients at highest risk. This initiative has been a major determinant of reducing HCM-related mortality to a low rate of 0.5%/year. In such a heterogeneous heart disease as HCM, no perfect risk stratification strategy is possible, and available approaches differ in terms of sensitivity and specificity for identifying patients with SD risk. Major cardiovascular societies, American Heart Association/American College of Cardiology in the USA and European Society of Cardiology in Europe have promoted different risk stratification guidelines creating the potential for judging SD risk in a given HCM patient differently based on commitment to a particular societal guideline or country of residence. In this review, we provide a critical but balanced assessment of these two divergent SD prevention strategies with regard to their respective strengths and weaknesses, as a guide to clinicians directly engaged in this important management issue.
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MESH Headings
- Humans
- Risk Assessment
- Death, Sudden, Cardiac/etiology
- Death, Sudden, Cardiac/prevention & control
- Death, Sudden, Cardiac/epidemiology
- Defibrillators, Implantable/adverse effects
- Tachycardia, Ventricular/etiology
- Cardiomyopathy, Hypertrophic/complications
- Cardiomyopathy, Hypertrophic/diagnosis
- Cardiomyopathy, Hypertrophic/therapy
- Risk Factors
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Affiliation(s)
- Martin S Maron
- Hypertrophic Cardiomyopathy Center, Lahey Medical Center, Burlington, Massachusetts, USA
| | - Ethan Rowin
- Hypertrophic Cardiomyopathy Center, Lahey Medical Center, Burlington, Massachusetts, USA
| | - Paolo Spirito
- Divisione di Cardiologia, Ospedali Galliera, Genoa, Italy
| | - Barry J Maron
- Hypertrophic Cardiomyopathy Center, Lahey Medical Center, Burlington, Massachusetts, USA
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Maron BA, Kleiner DE, Arons E, Wertheim BM, Sharma NS, Haley KJ, Samokhin AO, Rowin EJ, Maron MS, Rosing DR, Maron BJ. Evidence of Advanced Pulmonary Vascular Remodeling in Obstructive Hypertrophic Cardiomyopathy With Pulmonary Hypertension. Chest 2023; 163:678-686. [PMID: 36243062 PMCID: PMC9993337 DOI: 10.1016/j.chest.2022.09.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 09/28/2022] [Accepted: 09/29/2022] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Elevated mean pulmonary artery pressure (mPAP) is common in patients with hypertrophic cardiomyopathy (HCM) and heart failure symptoms. However, dynamic left ventricular (LV) outflow tract obstruction may confound interpretation of pulmonary hypertension (PH) pathophysiologic features in HCM when relying on resting invasive hemodynamic data alone. RESEARCH QUESTION Do structural changes to the lung vasculature clarify PH pathophysiologic features in patients with HCM with progressive heart failure? STUDY DESIGN AND METHODS Clinical data and ultrarare lung autopsy specimens were acquired retrospectively from the National Institutes of Health (1975-1992). Patients were included based on the availability of lung tissue and recorded mPAP. Discarded tissue from rejected lung donors served as control specimens. Histomorphology was performed on pulmonary arterioles and veins. Comparisons were calculated using the Student t test and Mann-Whitney U test; Pearson correlation was used to assess association between morphometric measurements and HCM cardiac and hemodynamic measurements. RESULTS The HCM cohort (n = 7; mean ± SD age, 43 ± 18 years; 71% men) showed maximum mean ± SD LV wall thickness of 25 ± 2.8 mm, mean ± SD outflow tract gradient of 90 ± 30 mm Hg, median mPAP of 25 mm Hg (interquartile range [IQR], 6 mm Hg), median pulmonary artery wedge pressure (PAWP) of 16 mm Hg (IQR, 4 mm Hg), and median pulmonary vascular resistance of 1.8 Wood units (WU; IQR, 2.4 WU). Compared with control samples (n = 5), patients with HCM showed greater indexed pulmonary arterial hypertrophy (20.7 ± 7.2% vs 49.7 ± 12%; P < .001) and arterial wall fibrosis (11.5 ± 3.4 mm vs 21.0 ± 4.7 mm; P < .0001), which correlated with mPAP (r = 0.84; P = .018), PAWP (r = 0.74; P = .05), and LV outflow tract gradient (r = 0.78; P = .035). Compared with control samples, pulmonary vein thickness was increased by 2.9-fold (P = .008) in the HCM group, which correlated with mPAP (r = 0.81; P = .03) and LV outflow tract gradient (r = 0.83; P = .02). INTERPRETATION To the best of our knowledge, these data demonstrate for the first time that in patients with obstructive HCM, heart failure is associated with pathogenic pulmonary vascular remodeling even when mPAP is elevated only mildly. These observations clarify PH pathophysiologic features in HCM, with future implications for clinical strategies that mitigate outflow tract obstruction.
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Affiliation(s)
- Bradley A Maron
- Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA.
| | - David E Kleiner
- Laboratory of Pathology, National Cancer Institute, Bethesda, MD
| | - Elena Arons
- Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Bradley M Wertheim
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Nirmal S Sharma
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Kathleen J Haley
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Andriy O Samokhin
- Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Ethan J Rowin
- HCM Center, Lahey Hospital and Medical Center, Burlington, MA
| | - Martin S Maron
- HCM Center, Lahey Hospital and Medical Center, Burlington, MA
| | - Douglas R Rosing
- Cardiovascular Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Barry J Maron
- HCM Center, Lahey Hospital and Medical Center, Burlington, MA
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Bokhari N, Madias C, Studley R, Quintana E, Bao C, Maron BJ, Maron MS, Rowin E. IS IDIOPATHIC LEFT BUNDLE BRANCH BLOCK IN HYPERTROPHIC CARDIOMYOPATHY A MARKER FOR ADVERSE OUTCOMES? J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)01091-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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26
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Maron BJ, Rowin EJ, Ambe SP, Maron MS. The Reply. Am J Med 2023; 136:e50. [PMID: 36796956 DOI: 10.1016/j.amjmed.2022.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 09/02/2022] [Indexed: 02/16/2023]
Affiliation(s)
- Barry J Maron
- HCM Center at Lahey Hospital and Medical Center, Burlington, Mass.
| | - Ethan J Rowin
- HCM Center at Lahey Hospital and Medical Center, Burlington, Mass
| | - Shray P Ambe
- HCM Center at Lahey Hospital and Medical Center, Burlington, Mass
| | - Martin S Maron
- HCM Center at Lahey Hospital and Medical Center, Burlington, Mass
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Carrick R, Maron MS, Maron BJ, Madias C, Wu KC, Rowin E. USE OF ECG DEEP-LEARNING TO IDENTIFY HYPERTROPHIC CARDIOMYOPATHY PATIENTS WITH HIGH-RISK FEATURES. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)04462-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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28
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Bonaventura J, Rowin EJ, Maron MS, Maron BJ. Risks of the Athletic Field Revisited: Report of Unusual Occurrences of Cardiac Arrest and Sudden Death in Professional Soccer Players. Am J Med 2023; 136:315-321. [PMID: 36495934 DOI: 10.1016/j.amjmed.2022.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 11/22/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Sudden deaths in competitive athletes are highly visible but potentially preventable events that generate great interest amongst the cardiovascular community and general public. METHODS Internet searches were performed using a combination of keywords and operators to produce search results for sudden death or cardiac arrest on the field in professional soccer players. RESULTS We identified 35 male professional soccer players (mean age 26 ± 5 years) who experienced collapse and cardiac arrest on the field (most during matches) in Europe from December 2002 to February 2022 with 63% in the last 6 years. Twenty-five have died on the field or later in a hospital despite cardiopulmonary resuscitation. Of the 10 survivors, eight were implanted with cardioverter-defibrillators for secondary (n = 6) or primary (n = 2) prevention and returned to full competition; five of the 8 required successful device therapy during matches or training. CONCLUSIONS Cardiac arrest and sudden death can occur not uncommonly in professional athletes highly trained over decades and participating at an elite sports level. Our observations also underscore the importance of targeted preparticipation cardiovascular screening, and availability of external defibrillators on the playing field.
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Affiliation(s)
- Jiri Bonaventura
- Department of Cardiology, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic; Hypertrophic Cardiomyopathy Center, Lahey Hospital and Medical Center, Burlington, Mass
| | - Ethan J Rowin
- Hypertrophic Cardiomyopathy Center, Lahey Hospital and Medical Center, Burlington, Mass
| | - Martin S Maron
- Hypertrophic Cardiomyopathy Center, Lahey Hospital and Medical Center, Burlington, Mass
| | - Barry J Maron
- Hypertrophic Cardiomyopathy Center, Lahey Hospital and Medical Center, Burlington, Mass
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29
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Rowin EJ, Ruberg FL, Das G, Higgins D, Lipe WC, Bokhari N, Dehn M, Maron BJ, Maron MS. Identification of Transthyretin Cardiac Amyloidosis Among Patients Previously Diagnosed With Hypertrophic Cardiomyopathy. Circ Cardiovasc Imaging 2022; 15:e014938. [PMID: 36448453 DOI: 10.1161/circimaging.122.014938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Affiliation(s)
- Ethan J Rowin
- Hypertrophic Cardiomyopathy Center at Lahey Hospital and Medical Center, Burlington MA (E.J.R., B.J.M., M.S.M.)
| | - Frederick L Ruberg
- Section of Cardiovascular Medicine, Amyloidosis Center, Boston University School of Medicine, Boston Medical Center, Boston, MA (F.L.R.)
| | - Gaurav Das
- CardioVascular Center, Tufts Medical Center, Boston MA (G.D., D.H., W.C.L., N.B., M.D.)
| | - Daniel Higgins
- CardioVascular Center, Tufts Medical Center, Boston MA (G.D., D.H., W.C.L., N.B., M.D.)
| | - Willard C Lipe
- CardioVascular Center, Tufts Medical Center, Boston MA (G.D., D.H., W.C.L., N.B., M.D.)
| | - Nadia Bokhari
- CardioVascular Center, Tufts Medical Center, Boston MA (G.D., D.H., W.C.L., N.B., M.D.)
| | - Monica Dehn
- CardioVascular Center, Tufts Medical Center, Boston MA (G.D., D.H., W.C.L., N.B., M.D.)
| | - Barry J Maron
- Hypertrophic Cardiomyopathy Center at Lahey Hospital and Medical Center, Burlington MA (E.J.R., B.J.M., M.S.M.).,CardioVascular Center, Tufts Medical Center, Boston MA (G.D., D.H., W.C.L., N.B., M.D.)
| | - Martin S Maron
- Hypertrophic Cardiomyopathy Center at Lahey Hospital and Medical Center, Burlington MA (E.J.R., B.J.M., M.S.M.)
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Maron BA, Wang RS, Shevtsov S, Drakos SG, Arons E, Wever-Pinzon O, Huggins GS, Samokhin AO, Oldham WM, Aguib Y, Yacoub MH, Rowin EJ, Maron BJ, Maron MS, Loscalzo J. Author Correction: Individualized interactomes for network-based precision medicine in hypertrophic cardiomyopathy with implications for other clinical pathophenotypes. Nat Commun 2022; 13:7026. [PMID: 36396654 PMCID: PMC9672304 DOI: 10.1038/s41467-022-34834-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Abdelfattah OM, Martinez M, Sayed A, ElRefaei M, Abushouk AI, Hassan A, Masri A, Winters SL, Kapadia SR, Maron BJ, Rowin E, Maron MS. Temporal and Global Trends of the Incidence of Sudden Cardiac Death in Hypertrophic Cardiomyopathy. JACC Clin Electrophysiol 2022; 8:1417-1427. [PMID: 36424010 DOI: 10.1016/j.jacep.2022.07.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 07/11/2022] [Accepted: 07/18/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Since the initial clinical description of hypertrophic cardiomyopathy (HCM) over 60 years ago, sudden cardiac death (SCD) has been the most visible and feared complication of HCM. OBJECTIVES This study sought to characterize the temporal, geographic, and age-related trends of reported SCD rates in adult HCM patients. METHODS Electronic databases were systematically searched up to November 2021 for studies reporting on SCD event rates in HCM patients. Patients with SCD equivalents (appropriate implantable cardioverter-defibrillator [ICD] shocks and nonfatal cardiac arrests) were not included. A random-effects model was used to pool study estimates calculating the overall incidence rates (IR) for each time-era, geographic region, and age group. We analyzed 2 periods (before vs after 2000, following clinical implementation of ICD in HCM). Following 2000, 5-year intervals were used to demonstrate the temporal change in SCD rates. RESULTS A total of 98 studies (N = 70,510 patients and 431,407 patient-years) met our inclusion criteria. The overall rate of HCM SCD was 0.43%/y (95% CI: 0.37-0.50%/y; I2 = 75%; SCD events: 1,938; person-years of follow-up: 408,715), with young patients (<18 years of age) demonstrating a >2-fold-risk for sudden death vs adult patients 18-60 years of age (IR: 1.09%; 95% CI: 0.69%-1.73% vs IR: 0.43%; 95% CI: 0.37%-0.50%) (P value for subgroup differences <0.01). Contemporary SCD rates from 2015 to present were 0.32%/y and significantly lower compared with 2000 or earlier (IR: 0.32%; 95% CI: 0.20%-0.52% vs IR: 0.73%; 95% CI: 0.53%-1.02%, respectively). Reported SCD rates for HCM were lowest in North America (IR: 0.28%; 95% CI: 0.18%-0.43%,) and highest in Asia (IR: 0.67%; 95% CI: 0.54%-0.84%). CONCLUSIONS Contemporary HCM-related SCD rates are low (0.32%/y) representing a 2-fold decrease compared with prior treatment eras. Young HCM patients are at the highest risk. The maturation of SCD risk stratification strategies and the application of primary prevention ICD to HCM are likely responsible for the notable decline over time in SCD events. In addition, worldwide geographic disparities in SCD rates were evident, underscoring the need to increase access to SCD prevention treatment for all HCM patients.
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Affiliation(s)
- Omar M Abdelfattah
- Department of Internal Medicine, Morristown Medical Center, Atlantic Health System, Morristown, New Jersey, USA
| | - Matthew Martinez
- Shannon T. Mast Center for Hypertrophic Cardiomyopathy, Department of Cardiovascular Medicine, Morristown Medical Center, Atlantic Health System, Morristown, New Jersey, USA
| | - Ahmed Sayed
- Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | | | - Abdelrahman I Abushouk
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Ahmed Hassan
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Ahmad Masri
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - Stephen L Winters
- Section of Electrophysiology, Department of Cardiovascular Medicine, Gagnon Cardiovascular Institute, Morristown Medical Center, Atlantic Health System, Morristown, New Jersey, USA
| | - Samir R Kapadia
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Barry J Maron
- Hypertrophic Cardiomyopathy Center, Department of Cardiology, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
| | - Ethan Rowin
- Hypertrophic Cardiomyopathy Center, Department of Cardiology, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
| | - Martin S Maron
- Hypertrophic Cardiomyopathy Center, Department of Cardiology, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA.
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Maron BA, Wang RS, Carnethon MR, Rowin EJ, Loscalzo J, Maron BJ, Maron MS. What Causes Hypertrophic Cardiomyopathy? Am J Cardiol 2022; 179:74-82. [PMID: 35843734 DOI: 10.1016/j.amjcard.2022.06.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 05/31/2022] [Accepted: 06/15/2022] [Indexed: 01/11/2023]
Abstract
Hypertrophic cardiomyopathy (HCM) is a global and relatively common cause of patient morbidity and mortality and is among the first reported monogenic cardiac diseases. For 30 years, the basic etiology of HCM has been attributed largely to variants in individual genes encoding cardiac sarcomere proteins, with the implication that HCM is fundamentally a genetic disease. However, data from clinical and network medicine analyses, as well as contemporary genetic studies show that single gene variants do not fully explain the broad and diverse HCM clinical spectrum. These transformative advances place a new focus on possible novel interactions between acquired disease determinants and genetic context to produce complex HCM phenotypes, also offering a measure of caution against overemphasizing monogenics as the principal cause of this disease. These new perspectives in which HCM is not a uniformly genetic disease but likely explained by multifactorial etiology will also unavoidably impact how HCM is viewed by patients and families in the clinical practicing community going forward, including relevance to genetic counseling and access to healthcare insurance and psychosocial wellness.
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Affiliation(s)
- Bradley A Maron
- Division of Cardiovascular Medicine, Department of Medicine and Harvard Medical School, Boston, Massachusetts.
| | - Rui-Sheng Wang
- Channing Division of Network Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mercedes R Carnethon
- Division of Pulmonology and Critical Care, Feinberg School of Medicine, Chicago, Illinois
| | - Ethan J Rowin
- HCM Center, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Joseph Loscalzo
- Division of Cardiovascular Medicine, Department of Medicine and Harvard Medical School, Boston, Massachusetts
| | - Barry J Maron
- HCM Center, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Martin S Maron
- HCM Center, Lahey Hospital and Medical Center, Burlington, Massachusetts
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Rowin EJ, Cooper C, Carrick RT, Tsoi M, Maron BJ, Maron MS. Ventricular Septal Myectomy Decreases Long-Term Risk for Atrial Fibrillation in Patients With Hypertrophic Cardiomyopathy. Am J Cardiol 2022; 179:70-73. [PMID: 35835601 PMCID: PMC10028409 DOI: 10.1016/j.amjcard.2022.05.032] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 05/21/2022] [Accepted: 05/25/2022] [Indexed: 11/01/2022]
Abstract
Atrial fibrillation (AF) is the most common sustained arrhythmia in hypertrophic cardiomyopathy (HCM) and is an important cause of morbidity and embolic stroke. The impact of outflow obstruction and the influence of surgical septal myectomy on the development of new-onset AF has not been well described. Consecutive patients with HCM without previous AF were followed for 5.0 ± 3.6 years for new-onset AF, including 717 with obstruction who did not undergo surgical myectomy (outflow gradients ≥30 mm Hg at rest or after provocation), 555 with nonobstructive HCM (outflow gradients <30 mm Hg), and 503 who underwent surgical myectomy. Patients with obstructive HCM who did not undergo myectomy had a 1.5-fold increased risk for new-onset AF compared with nonobstructive HCM (26% vs 16% at 10 years, hazard ratio = 0.69, p = 0.02). Patients who underwent myectomy had more advanced heart failure (95% vs 18% New York Heart Association class III, p <0.001) and had larger left atrium dimension (42 ± 7 vs 41 ± 7 mm; p <0.01) as compared with patients with obstructive HCM who did not undergo myectomy. However, after myectomy, the risk of new-onset AF was significantly lower than nonoperated obstructive (17% vs 26% at 10 years, p = 0.04) and no different from the risk of AF in patients with nonobstructive HC (hazard ratio 0.95, p = 0.81). In conclusion, patients with HCM with outflow obstruction are at a higher risk for AF compared with patients with nonobstructive HCM. However, after surgical myectomy, the risk for new-onset AF is substantially reduced. In addition to the known benefits of myectomy to permanently relieve outflow tract obstruction and mitral regurgitation, reverse heart failure symptoms, and increase longevity, myectomy is now shown to decrease susceptibility to AF in HCM.
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Affiliation(s)
- Ethan J Rowin
- Hypertrophic Cardiomyopathy Center at Lahey Hospital and Medical Center, Burlington, Massachusetts.
| | - Craig Cooper
- Department of Internal Medicine, Tufts Medical Center, Boston, Massachusetts
| | - Richard T Carrick
- Department of Internal Medicine, Tufts Medical Center, Boston, Massachusetts
| | - Melissa Tsoi
- Department of Internal Medicine, Tufts Medical Center, Boston, Massachusetts
| | - Barry J Maron
- Hypertrophic Cardiomyopathy Center at Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Martin S Maron
- Hypertrophic Cardiomyopathy Center at Lahey Hospital and Medical Center, Burlington, Massachusetts
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Maron BJ, Maron MS, Sherrid MV, Ommen SR, Rowin EJ. Personalized Treatment Strategies Effective in Hypertrophic Cardiomyopathy Do Not Rely on Genomics in 2022: A Different Tale of Precision Medicine. Am J Cardiol 2022; 183:150-152. [PMID: 36114018 DOI: 10.1016/j.amjcard.2022.07.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 07/14/2022] [Accepted: 07/18/2022] [Indexed: 11/01/2022]
Affiliation(s)
- Barry J Maron
- HCM Center, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Martin S Maron
- HCM Center, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Mark V Sherrid
- Hypertrophic Cardiomyopathy Program, Division of Cardiology. New York University Langone Health, New York, New York
| | - Steve R Ommen
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Ethan J Rowin
- HCM Center, Lahey Hospital and Medical Center, Burlington, Massachusetts.
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Maron BJ, Dearani JA, Smedira NG, Schaff HV, Wang S, Rastegar H, Ralph-Edwards A, Ferrazzi P, Swistel D, Shemin RJ, Quintana E, Bannon PG, Shekar PS, Desai M, Roberts WC, Lever HM, Adler A, Rakowski H, Spirito P, Nishimura RA, Ommen SR, Sherrid MV, Rowin EJ, Maron MS. Ventricular Septal Myectomy for Obstructive Hypertrophic Cardiomyopathy (Analysis Spanning 60 Years Of Practice): AJC Expert Panel. Am J Cardiol 2022; 180:124-139. [PMID: 35965115 DOI: 10.1016/j.amjcard.2022.06.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 05/23/2022] [Accepted: 06/06/2022] [Indexed: 12/15/2022]
Abstract
Surgical myectomy remains the time-honored primary treatment for hypertrophic cardiomyopathy patients with drug refractory limiting symptoms due to LV outflow obstruction. Based on >50 years experience, surgery reliably reverses disabling heart failure by permanently abolishing mechanical outflow impedance and mitral regurgitation, with normalization of LV pressures and preserved systolic function. A consortium of 10 international currently active myectomy centers report about 11,000 operations, increasing significantly in number over the most recent 15 years. Performed in experienced multidisciplinary institutions, perioperative mortality for myectomy has declined to 0.6%, becoming one of the safest currently performed open-heart procedures. Extended myectomy relieves symptoms in >90% of patients by ≥ 1 NYHA functional class, returning most to normal daily activity, and also with a long-term survival benefit; concomitant Cox-Maze procedure can reduce the number of atrial fibrillation episodes. Surgery, preferably performed in high volume clinical environments, continues to flourish as a guideline-based and preferred high benefit: low treatment risk option for adults and children with drug refractory disabling symptoms from obstruction, despite prior challenges: higher operative mortality/skepticism in 1960s/1970s; dual-chamber pacing in 1990s, alcohol ablation in 2000s, and now introduction of strong negative inotropic drugs potentially useful for symptom management.
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Affiliation(s)
- Barry J Maron
- Hypertrophic Cardiomyopathy Center, Lahey Hospital and Medical Center, Burlington, MA.
| | | | | | | | | | | | | | | | | | | | | | | | - Prem S Shekar
- Hypertrophic Cardiomyopathy Center, Lahey Hospital and Medical Center, Burlington, MA
| | | | - William C Roberts
- Department of Pathology and Medicine; Baylor UniversityMedical Center, Dallas Texas
| | | | - Arnon Adler
- Toronto General Hospital, Toronto Ontario, Canada
| | | | | | | | | | | | - Ethan J Rowin
- Hypertrophic Cardiomyopathy Center, Lahey Hospital and Medical Center, Burlington, MA
| | - Martin S Maron
- Hypertrophic Cardiomyopathy Center, Lahey Hospital and Medical Center, Burlington, MA
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Maron MS, Lanuario EL, Rowin EJ, Maron BJ. Global Dissemination and Implementation of Contemporary Management Principles for Hypertrophic Cardiomyopathy and Role of the International HCM Summit. Am J Cardiol 2022; 172:146-149. [PMID: 35569881 DOI: 10.1016/j.amjcard.2022.01.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 01/25/2022] [Indexed: 11/15/2022]
Affiliation(s)
- Martin S Maron
- HCM Center, Lahey Hospital & Medical Center, Burlington, Massachusetts
| | | | - Ethan J Rowin
- HCM Center, Lahey Hospital & Medical Center, Burlington, Massachusetts
| | - Barry J Maron
- HCM Center, Lahey Hospital & Medical Center, Burlington, Massachusetts..
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Maron BJ, Maron MS. Reflections on Six Decades of Hypertrophic Cardiomyopathy From Eugene Braunwald. Am J Cardiol 2022; 172:150-153. [PMID: 35569882 DOI: 10.1016/j.amjcard.2022.01.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 01/25/2022] [Indexed: 11/01/2022]
Abstract
On October 16 to 18, 2021, the 3-day 7th International Summit of Hypertrophic Cardiomyopathy was held virtually with almost 700 registrants and faculty from 40 countries and 42 states (Drs. Martin and Barry Maron, Directors). This meeting, the largest for this disease, was an opportunity to engage on a wide variety of topics with insights relevant to hypertrophic cardiomyopathy provided by 47 lectures, debates, and comprehensive discussions from 36 distinguished international speakers, including Dr. Eugene Braunwald.
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Maron MS, Rosing DR, Braunwald E, Rastegar H, Koethe B, Roberts WC, Maron BJ, Rowin EJ. Sixty-Year Evolution of Surgical Myectomy for Symptomatic Obstructive Hypertrophic Cardiomyopathy with Insights From the Historic NIH Surgical Experience to Present. Am J Cardiol 2022; 172:107-108. [PMID: 35361474 PMCID: PMC10858732 DOI: 10.1016/j.amjcard.2022.02.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 02/15/2022] [Indexed: 12/20/2022]
Affiliation(s)
- Martin S Maron
- Hypertrophic Cardiomyopathy Center at Lahey Hospital, Burlington, MA.
| | - Douglas R Rosing
- Cardiovascular Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Eugene Braunwald
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Hassan Rastegar
- Hypertrophic Cardiomyopathy Center and Research Institute, Division of Cardiology, Tufts Medical Center, Boston, MA
| | - Benjamin Koethe
- Hypertrophic Cardiomyopathy Center and Research Institute, Division of Cardiology, Tufts Medical Center, Boston, MA
| | - William C Roberts
- Cardiovascular Institute, Baylor University Medical Center, Dallas, Texas
| | - Barry J Maron
- Hypertrophic Cardiomyopathy Center at Lahey Hospital, Burlington, MA
| | - Ethan J Rowin
- Hypertrophic Cardiomyopathy Center at Lahey Hospital, Burlington, MA
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Cui H, Schaff HV, Wang S, Lahr BD, Rowin EJ, Rastegar H, Hu S, Eleid MF, Dearani JA, Kimmelstiel C, Maron BJ, Nishimura RA, Ommen SR, Maron MS. Survival Following Alcohol Septal Ablation or Septal Myectomy for Patients With Obstructive Hypertrophic Cardiomyopathy. J Am Coll Cardiol 2022; 79:1647-1655. [PMID: 35483751 DOI: 10.1016/j.jacc.2022.02.032] [Citation(s) in RCA: 41] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 02/14/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND There is little information regarding long-term mortality comparing the 2 most common procedures for septal reduction for obstructive hypertrophic cardiomyopathy (HCM), alcohol septal ablation (ASA), and septal myectomy. OBJECTIVES This study sought to compare the long-term mortality of patients with obstructive HCM following septal myectomy or ASA. METHODS We evaluated outcomes of 3,859 patients who underwent ASA or septal myectomy in 3 specialized HCM centers. All-cause mortality was the primary endpoint of the study. RESULTS In the study cohort, 585 (15.2%) patients underwent ASA, and 3,274 (84.8%) underwent septal myectomy. Patients undergoing ASA were significantly older (median age: 63.0 years [IQR: 52.7-72.8 years] vs 53.7 years [IQR: 44.9-62.8 years]; P < 0.001) and had smaller septal thickness (19.0 mm [IQR: 17.0-22.0 mm] vs 20.0 mm [IQR: 17.0-23.0 mm]; P = 0.007). Patients undergoing ASA also had more comorbidities, including renal failure, diabetes, hypertension, and coronary artery disease. There were 4 (0.7%) early deaths in the ASA group and 9 (0.3%) in the myectomy group. Over a median follow-up of 6.4 years (IQR: 3.6-10.2 years), the 10-year all-cause mortality rate was 26.1% in the ASA group and 8.2% in the myectomy group. After adjustment for age, sex, and comorbidities, the mortality remained greater in patients having septal reduction by ASA (HR: 1.68; 95% CI: 1.29-2.19; P < 0.001). CONCLUSIONS In patients with obstructive hypertrophic cardiomyopathy, ASA is associated with increased long-term all-cause mortality compared with septal myectomy. This impact on survival is independent of other known factors but may be influenced by unmeasured confounding patient characteristics.
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Affiliation(s)
- Hao Cui
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Hartzell V Schaff
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA.
| | - Shuiyun Wang
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Brian D Lahr
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | - Ethan J Rowin
- Division of Cardiology, Hypertrophic Cardiomyopathy Center, Tufts Medical Center, Boston, Massachusetts, USA
| | - Hassan Rastegar
- Division of Cardiothoracic Surgery, Hypertrophic Cardiomyopathy Center, Tufts Medical Center, Boston, Massachusetts, USA
| | - Shengshou Hu
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Mackram F Eleid
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Carey Kimmelstiel
- Division of Cardiology, Hypertrophic Cardiomyopathy Center, Tufts Medical Center, Boston, Massachusetts, USA
| | - Barry J Maron
- Division of Cardiology, Hypertrophic Cardiomyopathy Center, Tufts Medical Center, Boston, Massachusetts, USA
| | - Rick A Nishimura
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Steve R Ommen
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Martin S Maron
- Division of Cardiology, Hypertrophic Cardiomyopathy Center, Tufts Medical Center, Boston, Massachusetts, USA
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Maron BJ, Maron MS, Sherrid MV, Rowin EJ. Future Role of New Negative Inotropic Agents in the Era of Established Surgical Myectomy for Symptomatic Obstructive Hypertrophic Cardiomyopathy. J Am Heart Assoc 2022; 11:e024566. [PMID: 35502772 PMCID: PMC9238594 DOI: 10.1161/jaha.121.024566] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Affiliation(s)
- Barry J Maron
- Tufts Medical Center Hypertrophic Cardiomyopathy Center Boston MA
| | - Martin S Maron
- Tufts Medical Center Hypertrophic Cardiomyopathy Center Boston MA
| | - Mark V Sherrid
- NYU Grossman School of MedicineNYU Langone Health New York NY
| | - Ethan J Rowin
- Tufts Medical Center Hypertrophic Cardiomyopathy Center Boston MA
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Larson A, Codden CJ, Huggins GS, Rastegar H, Chen FY, Maron BJ, Rowin EJ, Maron MS, Chin MT. Altered intercellular communication and extracellular matrix signaling as a potential disease mechanism in human hypertrophic cardiomyopathy. Sci Rep 2022; 12:5211. [PMID: 35338173 PMCID: PMC8956620 DOI: 10.1038/s41598-022-08561-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 03/08/2022] [Indexed: 11/17/2022] Open
Abstract
Hypertrophic cardiomyopathy (HCM) is considered a primary disorder of the sarcomere resulting in unexplained left ventricular hypertrophy but the paradoxical association of nonmyocyte phenotypes such as fibrosis, mitral valve anomalies and microvascular occlusion is unexplained. To understand the interplay between cardiomyocyte and nonmyocyte cell types in human HCM, single nuclei RNA-sequencing was performed on myectomy specimens from HCM patients with left ventricular outflow tract obstruction and control samples from donor hearts free of cardiovascular disease. Clustering analysis based on gene expression patterns identified a total of 34 distinct cell populations, which were classified into 10 different cell types based on marker gene expression. Differential gene expression analysis comparing HCM to Normal datasets revealed differences in sarcomere and extracellular matrix gene expression. Analysis of expressed ligand-receptor pairs across multiple cell types indicated profound alteration in HCM intercellular communication, particularly between cardiomyocytes and fibroblasts, fibroblasts and lymphocytes and involving integrin β1 and its multiple extracellular matrix (ECM) cognate ligands. These findings provide a paradigm for how sarcomere dysfunction is associated with reduced cardiomyocyte secretion of ECM ligands, altered fibroblast ligand-receptor interactions with other cell types and increased fibroblast to lymphocyte signaling, which can further alter the ECM composition and promote nonmyocyte phenotypes.
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Affiliation(s)
- Amy Larson
- Molecular Cardiology Research Institute, Tufts Medical Center, 800 Washington Street, Box 80, Boston, MA, 02111, USA
| | - Christina J Codden
- Molecular Cardiology Research Institute, Tufts Medical Center, 800 Washington Street, Box 80, Boston, MA, 02111, USA
| | - Gordon S Huggins
- Molecular Cardiology Research Institute, Tufts Medical Center, 800 Washington Street, Box 80, Boston, MA, 02111, USA.,CardioVascular Center, Tufts Medical Center, Boston, MA, USA
| | - Hassan Rastegar
- CardioVascular Center, Tufts Medical Center, Boston, MA, USA.,Hypertrophic Cardiomyopathy Center, Tufts Medical Center, Boston, MA, USA
| | | | - Barry J Maron
- CardioVascular Center, Tufts Medical Center, Boston, MA, USA.,Hypertrophic Cardiomyopathy Center, Tufts Medical Center, Boston, MA, USA
| | - Ethan J Rowin
- CardioVascular Center, Tufts Medical Center, Boston, MA, USA.,Hypertrophic Cardiomyopathy Center, Tufts Medical Center, Boston, MA, USA
| | - Martin S Maron
- CardioVascular Center, Tufts Medical Center, Boston, MA, USA.,Hypertrophic Cardiomyopathy Center, Tufts Medical Center, Boston, MA, USA
| | - Michael T Chin
- Molecular Cardiology Research Institute, Tufts Medical Center, 800 Washington Street, Box 80, Boston, MA, 02111, USA. .,CardioVascular Center, Tufts Medical Center, Boston, MA, USA. .,Hypertrophic Cardiomyopathy Center, Tufts Medical Center, Boston, MA, USA.
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Maron BJ, Desai MY, Nishimura RA, Spirito P, Rakowski H, Towbin JA, Rowin EJ, Maron MS, Sherrid MV. Diagnosis and Evaluation of Hypertrophic Cardiomyopathy. J Am Coll Cardiol 2022; 79:372-389. [DOI: 10.1016/j.jacc.2021.12.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 10/27/2021] [Accepted: 11/02/2021] [Indexed: 12/20/2022]
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Maron BJ, Desai MY, Nishimura RA, Spirito P, Rakowski H, Towbin JA, Dearani JA, Rowin EJ, Maron MS, Sherrid MV. Management of Hypertrophic Cardiomyopathy. J Am Coll Cardiol 2022; 79:390-414. [DOI: 10.1016/j.jacc.2021.11.021] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 10/28/2021] [Accepted: 11/02/2021] [Indexed: 01/14/2023]
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Abstract
Hypertrophic cardiomyopathy (HCM), a relatively common, globally distributed, and often inherited myocardial disorder, transformed over the last several years into a treatable condition with the emergence of effective management options that alter natural history at all ages. Now available are a matured risk stratification algorithm selecting patients for prophylactic implantable defibrillators that prevent arrhythmic sudden death; low-risk, high-benefit surgical myectomy to reverse progressive heart failure symptoms due to left ventricular outflow obstruction; anticoagulation prophylaxis to prevent atrial fibrillation-mediated embolic stroke; and heart transplant for refractory end-stage disease in the absence of obstruction. Those strategies have resulted in reduction of HCM-related morbidity and reduction of mortality to 0.5% per year.
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Affiliation(s)
- Barry J Maron
- Division of Cardiology, Hypertrophic Cardiomyopathy Institute, Tufts Medical Center, Boston, Massachusetts 02111;
| | - Ethan J Rowin
- Division of Cardiology, Hypertrophic Cardiomyopathy Institute, Tufts Medical Center, Boston, Massachusetts 02111;
| | - Martin S Maron
- Division of Cardiology, Hypertrophic Cardiomyopathy Institute, Tufts Medical Center, Boston, Massachusetts 02111;
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Maron MS, Rowin EJ, Maron BJ. Is surgical myectomy challenged by emergence of novel drug therapy with mavacamten? Asian Cardiovasc Thorac Ann 2022; 30:11-18. [PMID: 35068194 DOI: 10.1177/02184923221074414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
For 60 years, surgical myectomy has been the definitive treatment for symptomatic obstructive hypertrophic cardiomyopathy (HCM). Myectomy provides the opportunity to reverse heart failure symptoms in the vast majority of patient with low risk when performed in experienced centers and associated with extended longevity. More recently, a novel class of negative inotropic drug therapy with mavacamten has emerged offering expanded treatment options for obstructive HCM. In the recently completed phase III clinical trial, the EXPLORER-HCM about one-third of patients on mavacamten achieved the primary end-point of subjective symptomatic improvement and increased functional capacity assessed by peak VO2. Of note, outflow gradients persistent in 43% of patients on mavacamten and 50% with symptoms consistent with NYHA class II or greater. A subset of patients also experienced significant reversible systolic dysfunction. Therefore, it is timely to place into perspective the potential role of mavacamten in context of the established low risk: high benefit of surgical myectomy for treatment of heart failure.
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Affiliation(s)
- Martin S Maron
- HCM Institute, Tufts Medical Center, Hypertrophic Cardiomyopathy Program, Boston, MA, USA
| | - Ethan J Rowin
- HCM Institute, Tufts Medical Center, Hypertrophic Cardiomyopathy Program, Boston, MA, USA
| | - Barry J Maron
- HCM Institute, Tufts Medical Center, Hypertrophic Cardiomyopathy Program, Boston, MA, USA
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Maron MS, Rastegar H, Dolan N, Carpino P, Koethe B, Maron BJ, Rowin EJ. Outcomes Over Follow-up ≥10 Years After Surgical Myectomy for Symptomatic Obstructive Hypertrophic Cardiomyopathy. Am J Cardiol 2022; 163:91-97. [PMID: 34785034 DOI: 10.1016/j.amjcard.2021.09.040] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Revised: 09/17/2021] [Accepted: 09/21/2021] [Indexed: 01/23/2023]
Abstract
For over 50 years, surgical septal myectomy has been the preferred treatment for drug-refractory heart failure symptoms in obstructive hypertrophic cardiomyopathy (HCM). However, given the relatively youthful adult ages at which HCM surgery is usually performed, it is informative to evaluate longer-term results of myectomy after ≥10 years. We identified 139 consecutive obstructive HCM patients (50 ± 15 years of age; 55% men) who underwent surgical myectomy, 2003 to 2010 at Tufts HCM Center and followed 11.3 ± 2.7 years (range to 17). Operative mortality was low (0.6%) and left ventricular (LV) outflow gradients at rest were reduced from 56 ± 40 mm Hg preoperatively to 1 ± 7 mm Hg postoperatively, durable over the study period, with no patient requiring reoperation for the residual gradient. Over follow-up, 129 of 139 patients (93%) were alive ≥10 years after myectomy, including 17 patients ≥15 years. Of 118 patients with complete long-term clinical follow-up data, 109 (92%) experienced clinical improvement to New York Heart Association classes I or II. In 9 patients (8%) refractory class III/IV symptoms reoccurred 6.6 ± 3.9 years postoperatively, including 4 who ultimately underwent a heart transplant. After myectomy, there were 2 late HCM-related deaths, but none suddenly; notably 6 patients (12%) with prophylactic implantable cardioverter-defibrillators experienced appropriate therapy terminating ventricular tachycardia/ventricular fibrillation after myectomy. Survival following myectomy was 91% at 10 years (95% confidence interval: 85, 96%) not different from the age- and gender-matched general United States population (log-rank p = 0.64). In conclusion, myectomy provides permanent abolition of outflow gradients with reversal of heart failure and highly favorable long-term survival, representing a low-risk:high-benefit option when performed in experienced HCM centers. Myectomy did not protect absolutely against arrhythmic sudden death events, underscoring the importance of risk stratification in operative patients.
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Affiliation(s)
- Martin S Maron
- Hypertrophic Cardiomyopathy Institute, Division of Cardiology, Tufts Medical Center, Boston, Massachusetts.
| | - Hassan Rastegar
- Hypertrophic Cardiomyopathy Institute, Division of Cardiology, Tufts Medical Center, Boston, Massachusetts
| | - Noreen Dolan
- Hypertrophic Cardiomyopathy Institute, Division of Cardiology, Tufts Medical Center, Boston, Massachusetts
| | - Philip Carpino
- Hypertrophic Cardiomyopathy Institute, Division of Cardiology, Tufts Medical Center, Boston, Massachusetts
| | - Benjamin Koethe
- Hypertrophic Cardiomyopathy Institute, Division of Cardiology, Tufts Medical Center, Boston, Massachusetts
| | - Barry J Maron
- Hypertrophic Cardiomyopathy Institute, Division of Cardiology, Tufts Medical Center, Boston, Massachusetts
| | - Ethan J Rowin
- Hypertrophic Cardiomyopathy Institute, Division of Cardiology, Tufts Medical Center, Boston, Massachusetts
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Sridharan A, Maron MS, Carrick RT, Madias CA, Huang D, Cooper C, Drummond J, Maron BJ, Rowin EJ. Impact of comorbidities on atrial fibrillation and sudden cardiac death in hypertrophic cardiomyopathy. J Cardiovasc Electrophysiol 2022; 33:20-29. [PMID: 34845799 PMCID: PMC10092906 DOI: 10.1111/jce.15304] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 09/25/2021] [Accepted: 10/03/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND The impact of comorbid disease states on the development of atrial and ventricular arrhythmias in patients with hypertrophic cardiomyopathy (HCM) remains unresolved. OBJECTIVE Evaluate the association of comorbidities linked to arrhythmias in other cardiovascular diseases (e.g., obesity, systemic hypertension, diabetes, obstructive sleep apnea, renal disorders, tobacco, and alcohol use) to atrial fibrillation (AF) and sudden cardiac death (SCD) events in a large cohort of HCM patients. METHODS A total of 2269 patients, 54 ± 15 years of age, 1392 males, were evaluated at the Tufts HCM Institute between 2004 and 2018 and followed for an average of 4 ± 3 years for new-onset clinical AF and SCD events (appropriate defibrillation for ventricular tachyarrhythmias, resuscitated cardiac arrest, or SCD). RESULTS One or more comorbidity was present in 75% of HCM patients, including 50% with ≥2 comorbidities, most commonly obesity (body mass index [BMI] ≥ 30 kg/m2 ) in 43%. New-onset atrial fibrillation developed in 11% of our cohort (2.6%/year). On univariate analysis, obesity was associated with a 1.7-fold increased risk for AF (p = .03) with 12% of obese patients developing AF (3.3%/year) as compared to 7% of patients with BMI < 25 kg/m2 (1.6%/year; p = .006). On multivariate analysis, age and LA transverse dimension emerged as the only variables predictive of AF. Comorbidities, including obesity, were not independently associated with AF development (p > .10 for each). SCD events occurred in 3.3% of patients (0.8%/year) and neither obesity nor other comorbidities were associated with increased risk for SCD (p > .10 for each). CONCLUSIONS In adult HCM patients comorbidities do not appear to impact AF or SCD risk. Therefore, for most patients with HCM, adverse disease related events of AF and SCD appear to be primarily driven by underlying left ventricular and atrial myopathy as opposed to comorbidities.
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Affiliation(s)
- Aadhavi Sridharan
- Division of Cardiology, HCM Institute, Tufts Medical Center, Boston, Massachusetts, USA
| | - Martin S Maron
- Division of Cardiology, HCM Institute, Tufts Medical Center, Boston, Massachusetts, USA
| | - Richard T Carrick
- Division of Cardiology, HCM Institute, Tufts Medical Center, Boston, Massachusetts, USA
| | - Christopher A Madias
- Division of Cardiology, HCM Institute, Tufts Medical Center, Boston, Massachusetts, USA
| | - Dou Huang
- Division of Cardiology, HCM Institute, Tufts Medical Center, Boston, Massachusetts, USA
| | - Craig Cooper
- Division of Cardiology, HCM Institute, Tufts Medical Center, Boston, Massachusetts, USA
| | - Jennifer Drummond
- Division of Cardiology, HCM Institute, Tufts Medical Center, Boston, Massachusetts, USA
| | - Barry J Maron
- Division of Cardiology, HCM Institute, Tufts Medical Center, Boston, Massachusetts, USA
| | - Ethan J Rowin
- Division of Cardiology, HCM Institute, Tufts Medical Center, Boston, Massachusetts, USA
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Abstract
It is important for both the patient and physician communities to have timely access to information recognizing rapid progress in the diagnosis and treatment of familiar but relatively uncommon cardiovascular diseases. Patients with 3 cardiovascular diseases (ie, hypertrophic cardiomyopathy, pulmonary arterial hypertension, and transthyretin (TTR) cardiac amyloidosis (ATTR)]), once considered rare without effective management options and associated with malignant prognosis, have now benefited substantially from the development of a variety of innovative therapeutic strategies. In addition, in each case, enhanced diagnostic testing has expanded the patient population and allowed for more widespread administration of contemporary treatments. In hypertrophic cardiomyopathy, introduction of implantable defibrillators to prevent sudden death as well as high-benefit:low-risk septal reduction therapies to reverse heart failure have substantially reduced morbidity and disease-related mortality (to 0.5% per year). For pulmonary arterial hypertension, a disease once characterized by a particularly grim prognosis, prospective randomized drug trials with aggressive single (or combined) pharmacotherapy have measurably improved survival and quality of life for many patients. In cardiac amyloidosis, development of disease-specific drugs can for the first time reduce morbidity and mortality, prominently with breakthrough ATTR-protein-stabilizing tafamidis. In conclusion, in less common and visible cardiovascular diseases, it is crucial to recognize substantial progress and achievement, given that penetration of such information into clinical practice and the patient community can be inconsistent. Diseases such as hypertrophic cardiomyopathy, pulmonary arterial hypertension, and ATTR cardiac amyloidosis, once linked to a uniformly adverse prognosis, are now associated with the opportunity for patients to experience satisfactory quality of life and extended longevity.
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Affiliation(s)
- Barry J Maron
- Division of Cardiology HCM Institute Tufts Medical Center Boston MA
| | - Martin S Maron
- Division of Cardiology HCM Institute Tufts Medical Center Boston MA
| | - Mathew S Maurer
- Cardiac Amyloidosis Center Columbia University Irving Medical CenterNew York-Presbyterian Hospital New York NY
| | - Ethan J Rowin
- Division of Cardiology HCM Institute Tufts Medical Center Boston MA
| | - Bradley A Maron
- Division of Cardiovascular Medicine Brigham & Women's Hospital and Harvard Medical School Boston MA
| | - Nazzareno Galiè
- Alma Mater Studiorum University of Bologna Bologna Italy.,S. Orsola University Hospital Bologna Italy
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Sherrid MV, Swistel DG, Olivotto I, Pieroni M, Wever-Pinzon O, Riedy K, Bach RG, Husaini M, Cresci S, Reyentovich A, Massera D, Maron MS, Maron BJ, Kim B. Syndrome of Reversible Cardiogenic Shock and Left Ventricular Ballooning in Obstructive Hypertrophic Cardiomyopathy. J Am Heart Assoc 2021; 10:e021141. [PMID: 34634917 PMCID: PMC8751867 DOI: 10.1161/jaha.121.021141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Cardiogenic shock from most causes has unfavorable prognosis. Hypertrophic cardiomyopathy (HCM) can uncommonly present with apical ballooning and shock in association with sudden development of severe and unrelenting left ventricular (LV) outflow obstruction. Typical HCM phenotypic features of mild septal thickening, outflow gradients, and distinctive mitral abnormalities differentiate these patients from others with Takotsubo syndrome, who have normal mitral valves and no outflow obstruction. Methods and Results We analyzed 8 patients from our 4 HCM centers with obstructive HCM and abrupt presentation of cardiogenic shock with LV ballooning, and 6 cases reported in literature. Of 14 patients, 10 (71%) were women, aged 66±9 years, presenting with acute symptoms: LV ballooning; depressed ejection fraction (25±5%); refractory systemic hypotension; marked LV outflow tract obstruction (peak gradient, 94±28 mm Hg); and elevated troponin, but absence of atherosclerotic coronary disease. Shock was managed with intravenous administration of phenylephrine (n=6), norepinephrine (n=6), β‐blocker (n=7), and vasopressin (n=1). Mechanical circulatory support was required in 8, including intra‐aortic balloon pump (n=4), venoarterial extracorporeal membrane oxygenation (n=3), and Impella and Tandem Heart in 1 each. In refractory shock, urgent relief of obstruction by myectomy was performed in 5, and alcohol ablation in 1. All patients survived their critical illness, with full recovery of systolic function. Conclusions When cardiogenic shock and LV ballooning occur in obstructive HCM, they are marked by distinctive anatomic and physiologic features. Relief of obstruction with targeted pharmacotherapy, mechanical circulatory support, and myectomy, when necessary for refractory shock, may lead to survival and normalization of systolic function.
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Affiliation(s)
- Mark V Sherrid
- Hypertrophic Cardiomyopathy Program NYU Langone Health New York NY
| | - Daniel G Swistel
- Department of Cardiothoracic Surgery NYU Langone Health New York NY
| | - Iacopo Olivotto
- Cardiomyopathy Unit Division of Cardiology Careggi University Hospital Florence Italy
| | | | | | - Katherine Riedy
- Hypertrophic Cardiomyopathy Program NYU Langone Health New York NY
| | | | | | | | - Alex Reyentovich
- Leon Charney Division of Cardiology Heart Failure Advanced Care Center NYU Langone Health New York NY
| | - Daniele Massera
- Hypertrophic Cardiomyopathy Program NYU Langone Health New York NY
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Abstract
Non-penetrating chest blows can occasionally trigger fatal ventricular tachyarrhythmias and sudden death (commotio cordis). Such events were initially reported in association with sporting activities and projectiles such as baseball/lacrosse balls. However, similar potentially fatal chest blows, seemingly incapable of causing death, can occur during a variety of other circumstances such as when delivered during a fight (by a fist) such as in the accompanying paper. Notably, commotio cordis events can be reversed by resuscitation and defibrillation.
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