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Lund LH, Crespo-Leiro MG, Laroche C, Garcia-Pinilla JM, Bennis A, Vataman EB, Polovina M, Radovanovic S, Apostolovic SR, Ašanin M, Gackowski A, Kaplon-Cieslicka A, Cabac-Pogorevici I, Anker SD, Chioncel O, Coats AJS, Filippatos G, Lainscak M, Mcdonagh T, Mebazaa A, Metra M, Piepoli M, Rosano GM, Ruschitzka F, Savarese G, Seferović PM, Iung B, Popescu BA, Maggioni AP. Rationale and design of the ESC Heart Failure III Registry - Implementation and discovery. Eur J Heart Fail 2023; 25:2316-2330. [PMID: 37990135 DOI: 10.1002/ejhf.3087] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 10/31/2023] [Accepted: 11/04/2023] [Indexed: 11/23/2023] Open
Abstract
AIMS Heart failure outcomes remain poor despite advances in therapy. The European Society of Cardiology Heart Failure III Registry (ESC HF III Registry) aims to characterize HF clinical features and outcomes and to assess implementation of guideline-recommended therapy in Europe and other ESC affiliated countries. METHODS Between 1 November 2018 and 31 December 2020, 10 162 patients with chronic or acute/worsening HF with reduced, mildly reduced, or preserved ejection fraction were enrolled from 220 centres in 41 European or ESC affiliated countries. The ESC HF III Registry collected data on baseline characteristics (hospital or clinic presentation), hospital course, diagnostic and therapeutic decisions in hospital and at the clinic visit; and on outcomes at 12-month follow-up. These data include demographics, medical history, physical examination, biomarkers and imaging, quality of life, treatments, and interventions - including drug doses and reasons for non-use, and cause-specific outcomes. CONCLUSION The ESC HF III Registry will provide comprehensive and unique insight into contemporary HF characteristics, treatment implementation, and outcomes, and may impact implementation strategies, clinical discovery, trial design, and public policy.
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Affiliation(s)
- Lars H Lund
- Unit of Cardiology, Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Maria Generosa Crespo-Leiro
- Department of Cardiology, Hospital Universitario A Coruña (CHUAC), A Coruña, Spain
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain
- Fisioterapia, Medicina y Ciencias Biomédicas, Universidad de A Coruña (UDC), A Coruña, Spain
- Instituto Investigación Biomedica A Coruña (INIBIC), A Coruña, Spain
| | - Cecile Laroche
- EURObservational Research Programme, European Society of Cardiology, Sophia Antipolis, France
| | - Jose M Garcia-Pinilla
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain
- Servicio de Cardiología, Hospital Universitario Virgen de la Victoria, Málaga Biomedical Research Institute (IBIMA), Málaga, Spain
- Departamento de Medicina y Dermatología, Universidad de Málaga, Málaga, Spain
| | - Ahmed Bennis
- Department of Cardiology, Ibn Rochd University Center, Casablanca, Morocco
| | - Eleonora B Vataman
- Heart Failure Department, Institute of Cardiology, Chișinău, Moldova
- Cardiac Rehabilitation Department, Institute of Cardiology, Chișinău, Moldova
| | - Marija Polovina
- Department of Cardiology, University Clinical Centre of Serbia, Belgrade, Serbia
- Faculty of Medicine, Belgrade University, Belgrade, Serbia
| | - Slavica Radovanovic
- Department of Cardiology, Heart Failure Center, University Hospital Center 'Dr Dragisa Misovic-Dedinje', Belgrade, Serbia
| | - Svetlana R Apostolovic
- Department of Cardiology, University Clinical Centre of Serbia, Nis, Serbia
- Medical School, University Clinical Centre of Serbia, Nis, Serbia
| | - Milika Ašanin
- Department of Cardiology, University Clinical Centre of Serbia, Belgrade, Serbia
- Faculty of Medicine, Belgrade University, Belgrade, Serbia
| | - Andrzej Gackowski
- Department of Coronary Disease and Heart Failure, Jagiellonian University, Medical College, John Paul II Hospital, Krakow, Poland
- Noninvasive Cardiovascular Laboratory, John Paul II Hospital, Krakow, Poland
| | | | - Irina Cabac-Pogorevici
- Department of Cardiology, State University of Medicine and Pharmacy 'Nicolae Testemitanu', Chișinău, Moldova
| | - Stefan D Anker
- Department of Cardiology (CVK) of German Heart Center Charité, Institute of Health Center for Regenerative Therapies (BCRT), German Centre for Cardiovascular Research (DZHK) partner site Berlin, Charité Universitätsmedizin, Berlin, Germany
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Ovidiu Chioncel
- 1st Cardiology Department, Emergency Institute for Cardiovascular Diseases 'Prof. Dr. C.C. Iliescu', Bucharest, Romania
- University of Medicine and Pharmacy 'Carol Davila', Bucharest, Romania
| | - Andrew J S Coats
- Office of the CEO, Heart Research Institute, Sydney, NSW, Australia
| | - Gerasimos Filippatos
- Department of Cardiology, National and Kapodistrian, University of Athens, Athens, Greece
| | - Mitja Lainscak
- Division of Cardiology, General Hospital Murska Sobota, Murska Sobota, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Theresa Mcdonagh
- Cardiovascular Science, Faculty of Life Science and Medicine, King's College London, London, UK
| | - Alexandre Mebazaa
- Anaethesia and Critical Care, APHP, Hôpital Lariboisière, Paris, France
- Burn and the multi-organ retrieval, APHP, Hôpital Saint Louis, Paris, France
- Cardiovascular MArkers in Stressed COndiTions, UMRS INSERM 942, Université Paris-Cité, Paris, France
| | - Marco Metra
- Department of Cardiology, Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
- Department of Cardiology, ASST Spedali Civili, Brescia, Italy
| | - Massimo Piepoli
- Clinical Cardiology, IRCCS Policlinico San Donato, San Donato Milanese, Italy
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | - Giuseppe M Rosano
- Department of Medical Sciences, IRCCS Ospedale San Raffaele, Rome, Italy
| | - Frank Ruschitzka
- Department of Cardiology, University Heart Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
- Department of Cardiology, Center for Translational and Experimental Cardiology (CTEC), University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Gianluigi Savarese
- Unit of Cardiology, Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
- Heart and Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Petar M Seferović
- Faculty of Medicine, Belgrade University, Belgrade, Serbia
- Serbian Academy of Sciences and Arts, Belgrade, Serbia
| | - Bernard Iung
- Department of Cardiology, APHP, Hôpital Bichat Claude-Bernard, Paris, France
- LVTS INSERM 1148, Université Paris-Cité, Paris, France
| | - Bogdan A Popescu
- Department of Cardiology, University of Medicine and Pharmacy 'Carol Davila', Bucharest, Romania
- Department of Cardiology, Emergency Institute for Cardiovascular Diseases 'Prof. Dr. C.C. Iliescu', Bucharest, Romania
| | - Aldo P Maggioni
- ANMCO Research Center, Heart Care Foundation, Florence, Italy
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Protonotarios A, Barriales-Villa R, Antoniades L, Mogensen J, Garcia-Pavia P, Wahbi K, Biagini E, Anastasakis A, Tsatsopoulou A, Zorio E, Gimeno JR, Garcia-Pinilla JM, Sinagra G, Bauce B, Elliott PM. Risk stratification in Arrhythmogenic Right Ventricular Cardiomyopathy: the impact of genotype on the 2019 ARVC risk calculator. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1752] [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] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC) is associated with sudden cardiac death (SCD). The 2019 ARVC risk model has been proposed as a method to quantify arrhythmic risk, but the impact of genotype its performance has not been addressed.
Purpose
To study arrhythmic outcomes in patients with ARVC and the performance of the 2019 ARVC risk model in predefined genetic subgroups.
Methods
This is an international, retrospective observational cohort study on consecutively evaluated patients with ARVC recruited from 17 centres in 7 countries. Inclusion criteria were: (i) a definite diagnosis of ARVC according to the 2010 Task Force Criteria; (ii) no history of sustained ventricular arrhythmia (VA) prior to first assessment at the participating centre; (iii) a follow up period of ≥1 month; (iv) age of diagnosis ≥14 years. Sustained ventricular arrhythmia (sustained ventricular tachycardia, appropriate implantable cardioverter defibrillator intervention, aborted SCD, or SCD) comprised the primary outcome (VA). Discriminative ability was assessed by Uno's concordance index (c-statistic) and calibration with the calibration plot slope. Fine-Gray regression was used to model the impact of clinical predictors on the arrhythmic outcome, in the context of competing risks (heart transplantation and non-arrhythmic death). The cumulative probability and 95% confidence intervals (95% CI) for the occurrence of an outcome were estimated using the Aalen-Johansen estimate in order to take into account competing risks.
Results
The study cohort comprised 554 ARVC patients. During a median follow-up of 6.0 [3.1,12.5] years, 100 patients (18%) experienced VA (Figure). Risk estimates for VA using the 2019 ARVC risk model showed good discriminative ability (c-statistic 0.75 (95% CI 0.70–0.81)) but with overestimation of risk (slope 0.46 (95% CI 0.33–0.63)). The ARVC risk model was compared in 4 gene groups: PKP2 (n=118, 21%); DSP (n=79, 14%); other desmosomal (n=59, 11%); and gene elusive (n=160, 29%). Discrimination and calibration were highest for PKP2 [c-statistic 0.83 (95% CI 0.75–0.91); calibration slope 0.67 (95% CI 0.40–1.04)] and lowest for the gene elusive group [c-statistic 0.65 (95% CI 0.57–0.74); calibration slope 0.26 (95% CI 0.06–0.49)]. Univariable analyses revealed variable performance of individual clinical risk markers in the different gene groups (see heatmap of hazard ratios and statistical significance in Figure). For example, RV dimensions and systolic function are significant risk markers in PKP2 but not in DSP patients and the opposite is true of LV systolic function (Figure).
Conclusion
The 2019 ARVC risk model performs reasonably well in gene positive ARVC, (particularly for PKP2) but is more limited in gene elusive patients. Genotype specific risk factors should be considered in ARVC patients.
Funding Acknowledgement
Type of funding sources: Foundation. Main funding source(s): British Heart Foundation
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Affiliation(s)
| | - R Barriales-Villa
- Institute of Biomedical Research of La Coruna (INIBIC) , A Coruna , Spain
| | | | - J Mogensen
- Aalborg University Hospital , Aalborg , Denmark
| | - P Garcia-Pavia
- Puerta de Hierro Majadahonda University Hospital, Majadahonda , Madrid , Spain
| | - K Wahbi
- Cochin APHP Site of Paris Centre University Hospital , Paris , France
| | - E Biagini
- University Hospital of Bologna S. Orsola-Malpighi Polyclinic , Bologna , Italy
| | | | - A Tsatsopoulou
- Yannis Protonotarios Medical Center of Naxos , Naxos , Greece
| | - E Zorio
- University Hospital y Politecnico La Fe , Valencia , Spain
| | - J R Gimeno
- Virgin of the Arrixaca University Clinical Hospital , Murcia , Spain
| | | | - G Sinagra
- University of Trieste , Trieste , Italy
| | - B Bauce
- University of Padova , Padua , Italy
| | - P M Elliott
- University College London , London , United Kingdom
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3
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Frutos Seminario F, Ochoa JP, Navarro-Penalver M, Baas A, Bjerre JV, Zorio E, Mendez I, Lorca R, Verdonschot JAJ, Garcia-Granja PE, Bilinska Z, Fatkin D, Fuentes-Canamero ME, Garcia-Pinilla JM, Garcia-Pavia P. Natural history of MYH7-related dilated cardiomyopathy. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1745] [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] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Variants in MYH7 are responsible for disease in 1–5% of patients with dilated cardiomyopathy (DCM); however, the clinical characteristics and natural history of MYH7-related DCM are poorly described.
Objectives
We sought to determine the phenotype and prognosis of MYH7-related DCM. We also evaluated the influence of variant location on phenotypic expression.
Methods
We studied clinical data from 147 individuals with DCM-causing MYH7 variants (47.6% females, 35.6±19.2 years) recruited from 29 international centers.
Results
At initial evaluation, 106 patients (72.1%) had DCM (LVEF 34.5±11.7%). Median follow-up was 4.5 years (interquartile range: 1.7–8.0). 23.7% carriers who were initially phenotype-negative developed DCM. Disease penetrance by 40 and 60 years was 46% and 88%, respectively, with 18 patients (16%) first diagnosed at <18 years. Thirty-six percent of patients with DCM met imaging criteria for LV non-compaction. During follow-up, 28% showed left ventricular reverse remodeling (LVRR). Overall incidence of end-stage heart failure (heart transplantation or heart failure related death) was 11.6% at 5 years. Overall major ventricular arrhythmia rate was low (1.0% at 5 years) even among patients with LVEF ≤35% (2.1% at 5 years). LV non-compaction was more prevalent in patients with variants in head domain (S1) (44.2%) compared with other domains (P<0.001). No differences among domain groups were found regarding LVRR, major ventricular arrhythmias or end-stage heart failure.
Conclusions
MYH7-related DCM is characterized by early age of onset, high penetrance, low rate of LVRR, and frequent progression to ESHF. Heart failure complications predominate over ventricular arrhythmias, even among patients with severe systolic disfunction.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- F Frutos Seminario
- Puerta de Hierro Majadahonda University Hospital, Majadahonda , Madrid , Spain
| | - J P Ochoa
- Puerta de Hierro Majadahonda University Hospital, Majadahonda , Madrid , Spain
| | | | - A Baas
- University Medical Center Utrecht , Utrecht , The Netherlands
| | - J V Bjerre
- Aarhus University Hospital , Aarhus , Denmark
| | - E Zorio
- University Hospital La Fe , Valencia , Spain
| | - I Mendez
- Gregorio Maranon University General Hospital - Madrid Health Service , Madrid , Spain
| | - R Lorca
- Asturias Central University Hospital , Oviedo , Spain
| | - J A J Verdonschot
- Maastricht University Medical Centre (MUMC) , Maastricht , The Netherlands
| | | | - Z Bilinska
- National Institute of Cardiology , Warsaw , Poland
| | - D Fatkin
- Victor Chang Cardiac Research Institute , Sydney , Australia
| | | | | | - P Garcia-Pavia
- Puerta de Hierro Majadahonda University Hospital, Majadahonda , Madrid , Spain
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4
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Escobar-Lopez L, Ochoa JP, Royuela A, Verdonschot JAJ, Dal Ferro M, Espinosa MA, Sabater-Molina M, Gallego-Delgado M, Larrañaga-Moreira JM, Garcia-Pinilla JM, Basurte-Elorz MT, Rodríguez-Palomares JF, Climent V, Bermudez-Jimenez FJ, Mogollón-Jiménez MV, Lopez J, Peña-Peña ML, Garcia-Alvarez A, López-Abel B, Ripoll-Vera T, Palomino-Doza J, Bayes-Genis A, Brugada R, Idiazabal U, Mirelis JG, Dominguez F, Henkens MTHM, Krapels IPC, Brunner HG, Paldino A, Zaffalon D, Mestroni L, Sinagra G, Heymans SRB, Merlo M, Garcia-Pavia P. Clinical Risk Score to Predict Pathogenic Genotypes in Patients With Dilated Cardiomyopathy. J Am Coll Cardiol 2022; 80:1115-1126. [PMID: 36109106 PMCID: PMC10804447 DOI: 10.1016/j.jacc.2022.06.040] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 06/22/2022] [Accepted: 06/23/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Although genotyping allows family screening and influences risk-stratification in patients with nonischemic dilated cardiomyopathy (DCM) or isolated left ventricular systolic dysfunction (LVSD), its result is negative in a significant number of patients, limiting its widespread adoption. OBJECTIVES This study sought to develop and externally validate a score that predicts the probability for a positive genetic test result (G+) in DCM/LVSD. METHODS Clinical, electrocardiogram, and echocardiographic variables were collected in 1,015 genotyped patients from Spain with DCM/LVSD. Multivariable logistic regression analysis was used to identify variables independently predicting G+, which were summed to create the Madrid Genotype Score. The external validation sample comprised 1,097 genotyped patients from the Maastricht and Trieste registries. RESULTS A G+ result was found in 377 (37%) and 289 (26%) patients from the derivation and validation cohorts, respectively. Independent predictors of a G+ result in the derivation cohort were: family history of DCM (OR: 2.29; 95% CI: 1.73-3.04; P < 0.001), low electrocardiogram voltage in peripheral leads (OR: 3.61; 95% CI: 2.38-5.49; P < 0.001), skeletal myopathy (OR: 3.42; 95% CI: 1.60-7.31; P = 0.001), absence of hypertension (OR: 2.28; 95% CI: 1.67-3.13; P < 0.001), and absence of left bundle branch block (OR: 3.58; 95% CI: 2.57-5.01; P < 0.001). A score containing these factors predicted a G+ result, ranging from 3% when all predictors were absent to 79% when ≥4 predictors were present. Internal validation provided a C-statistic of 0.74 (95% CI: 0.71-0.77) and a calibration slope of 0.94 (95% CI: 0.80-1.10). The C-statistic in the external validation cohort was 0.74 (95% CI: 0.71-0.78). CONCLUSIONS The Madrid Genotype Score is an accurate tool to predict a G+ result in DCM/LVSD.
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Affiliation(s)
- Luis Escobar-Lopez
- Heart Failure and Inherited Cardiac Diseases Unit, Department of Cardiology, Hospital Universitario Puerta de Hierro, IDIPHISA, Madrid, Spain; CIBER Cardiovascular, Instituto de Salud Carlos III, Madrid, Spain; European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart (ERN-GUARDHEART), Madrid, Spain
| | - Juan Pablo Ochoa
- Heart Failure and Inherited Cardiac Diseases Unit, Department of Cardiology, Hospital Universitario Puerta de Hierro, IDIPHISA, Madrid, Spain; European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart (ERN-GUARDHEART), Madrid, Spain
| | - Ana Royuela
- Biostatistics Unit, Puerta de Hierro Biomedical Research Institute (IDIPHISA), CIBERESP, Madrid, Spain
| | - Job A J Verdonschot
- Department of Clinical Genetics, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Matteo Dal Ferro
- European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart (ERN-GUARDHEART), Madrid, Spain; Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Maria Angeles Espinosa
- CIBER Cardiovascular, Instituto de Salud Carlos III, Madrid, Spain; Department of Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Maria Sabater-Molina
- CIBER Cardiovascular, Instituto de Salud Carlos III, Madrid, Spain; European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart (ERN-GUARDHEART), Madrid, Spain; Inherited Cardiac Disease Unit, University Hospital Virgen de la Arrixaca, Murcia, Spain
| | - Maria Gallego-Delgado
- CIBER Cardiovascular, Instituto de Salud Carlos III, Madrid, Spain; Inherited Cardiac Diseases Unit, Department of Cardiology, Instituto de Investigación Biomédica de Salamanca (IBSAL), Complejo Asistencial Universitario de Salamanca, Gerencia Regional de Salud de Castilla y León (SACYL), Salamanca, Spain
| | - Jose M Larrañaga-Moreira
- CIBER Cardiovascular, Instituto de Salud Carlos III, Madrid, Spain; Inherited Cardiac Diseases Unit, Instituto de Investigación Biomédica de A Coruña (INIBIC), Complexo Hospitalario Universitario de A Coruña, Servizo Galego de Saúde (SERGAS), Universidade da Coruña, A Coruña, Spain
| | - Jose M Garcia-Pinilla
- CIBER Cardiovascular, Instituto de Salud Carlos III, Madrid, Spain; Heart Failure and Familial Heart Diseases Unit, Cardiology Department, Hospital Universitario Virgen de la Victoria, IBIMA, Malaga, Spain
| | | | - José F Rodríguez-Palomares
- CIBER Cardiovascular, Instituto de Salud Carlos III, Madrid, Spain; Inherited Cardiovascular Diseases Unit, Department of Cardiology, Hospital Universitari Vall d´Hebron, Vall d'Hebron Institut de Recerca (VHIR), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Vicente Climent
- Inherited Cardiovascular Diseases Unit, Department of Cardiology, Hospital General Universitario de Alicante, Institute of Health and Biomedical Research, Alicante, Spain
| | | | | | - Javier Lopez
- CIBER Cardiovascular, Instituto de Salud Carlos III, Madrid, Spain; Department of Cardiology, Instituto de Ciencias Del Corazón (ICICOR), Hospital Clínico Universitario Valladolid, Valladolid, Spain
| | - Maria Luisa Peña-Peña
- Inherited Cardiac Diseases Unit, Hospital Universitario Virgen Del Rocío, Seville, Spain
| | - Ana Garcia-Alvarez
- CIBER Cardiovascular, Instituto de Salud Carlos III, Madrid, Spain; IDIBAPS, Hospital Clínic, Department of Cardiology, Universitat de Barcelona, Barcelona, Spain; Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
| | - Bernardo López-Abel
- CIBER Cardiovascular, Instituto de Salud Carlos III, Madrid, Spain; Inherited Cardiac Diseases Unit, Department of Cardiology, Complexo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - Tomas Ripoll-Vera
- Inherited Cardiac Diseases Unit, Cardiology Department, Hospital Universitario Son Llatzer and IdISBa, Palma de Mallorca, Spain
| | - Julian Palomino-Doza
- CIBER Cardiovascular, Instituto de Salud Carlos III, Madrid, Spain; Inherited Cardiac Diseases Unit, Cardiology Department, Hospital Universitario 12 de Octubre, Instituto de Investigación i+12. Madrid, Spain
| | - Antoni Bayes-Genis
- CIBER Cardiovascular, Instituto de Salud Carlos III, Madrid, Spain; Heart Institute, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Ramon Brugada
- CIBER Cardiovascular, Instituto de Salud Carlos III, Madrid, Spain; Inherited Cardiac Diseases Unit, Department of Cardiology, Hospital Universitari Dr Josep Trueta, Girona, Spain
| | - Uxua Idiazabal
- Department of Cardiology, Clinica San Miguel, Pamplona, Spain
| | - Jesus G Mirelis
- Heart Failure and Inherited Cardiac Diseases Unit, Department of Cardiology, Hospital Universitario Puerta de Hierro, IDIPHISA, Madrid, Spain; CIBER Cardiovascular, Instituto de Salud Carlos III, Madrid, Spain; European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart (ERN-GUARDHEART), Madrid, Spain
| | - Fernando Dominguez
- Heart Failure and Inherited Cardiac Diseases Unit, Department of Cardiology, Hospital Universitario Puerta de Hierro, IDIPHISA, Madrid, Spain; CIBER Cardiovascular, Instituto de Salud Carlos III, Madrid, Spain; European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart (ERN-GUARDHEART), Madrid, Spain
| | - Michiel T H M Henkens
- Department of Cardiology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Ingrid P C Krapels
- Department of Clinical Genetics, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Han G Brunner
- Department of Clinical Genetics, Maastricht University Medical Center, Maastricht, the Netherlands; GROW Institute for Developmental Biology and Cancer, Maastricht University, Maastricht, the Netherlands; Department of Human Genetics, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Alessia Paldino
- European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart (ERN-GUARDHEART), Madrid, Spain; Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Denise Zaffalon
- European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart (ERN-GUARDHEART), Madrid, Spain; Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Luisa Mestroni
- CU Cardiovascular Institute, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Gianfranco Sinagra
- European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart (ERN-GUARDHEART), Madrid, Spain; Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Stephane R B Heymans
- Department of Cardiology, Maastricht University Medical Center, Maastricht, the Netherlands; Center for Molecular and Vascular Biology, Department of Cardiovascular Sciences, KU Leuven, Belgium
| | - Marco Merlo
- European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart (ERN-GUARDHEART), Madrid, Spain; Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Pablo Garcia-Pavia
- Heart Failure and Inherited Cardiac Diseases Unit, Department of Cardiology, Hospital Universitario Puerta de Hierro, IDIPHISA, Madrid, Spain; CIBER Cardiovascular, Instituto de Salud Carlos III, Madrid, Spain; European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart (ERN-GUARDHEART), Madrid, Spain; Universidad Francisco de Vitoria (UFV), Pozuelo de Alarcón, Spain.
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5
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Garcia-Pinilla JM, Couto-Mallon D, Robles-Mezcua A. The cardiomyopathies: from epidemiology to clinical work-up. Eur J Prev Cardiol 2022; 29:1188-1189. [DOI: 10.1093/eurjpc/zwaa051] [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: 11/13/2022]
Affiliation(s)
- Jose M Garcia-Pinilla
- Virgen de la Victoria Universitary Hospital , Campus Teatinos S/N, Malaga 29010, Spain
- Ciber-Cardiovascular. Instituto de Salud Carlos III . Madrid
- IBIMA
| | - David Couto-Mallon
- Virgen de la Victoria Universitary Hospital , Campus Teatinos S/N, Malaga 29010, Spain
- Ciber-Cardiovascular. Instituto de Salud Carlos III . Madrid
- IBIMA
- Complejo Hospitalario Universitario A Coruña
| | - Ainhoa Robles-Mezcua
- Virgen de la Victoria Universitary Hospital , Campus Teatinos S/N, Malaga 29010, Spain
- Ciber-Cardiovascular. Instituto de Salud Carlos III . Madrid
- IBIMA
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6
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Casas G, Escalona R, Gonzalez Del Hoyo MI, Palomino-Doza J, Garcia-Pinilla JM, Bayes-Genis A, Ripoll-Vera T, Jimenez-Jaimez J, Villacorta E, Gimeno-Blanes JR, Zorio E, Garcia-Pavia P, Barriales-Villa R, Ferreira-Gonzalez I, Rodriguez-Palomares JF. Outcomes of patients with left ventricular noncompaction and preserved ejection fraction. Eur Heart J Cardiovasc Imaging 2022. [DOI: 10.1093/ehjci/jeab289.419] [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] [Indexed: 11/14/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: None.
INTRODUCTION
Left ventricular noncompaction (LVNC) is a poorly defined entity with heterogeneous prognosis. LV ejection fraction (LVEF) is one of the main predictors of major adverse cardiovascular events (MACE). However, outcomes of LVNC patients with preserved LVEF (pEF) remain uncertain.
PURPOSE
The aim of our study was to determine the incidence and predictors of MACE in LVNC patients with pEF as well as to assess the evolution of LVEF throughout follow-up.
METHODS
We conducted a retrospective, longitudinal, multicentre cohort study. Consecutive patients with transthoracic echocardiography (TTE) and/or cardiac magnetic resonance (CMR) diagnostic criteria for LVNC and initially pEF (LVEF≥50%) were recruited. MACE were defined as a composite of heart failure (HF), ventricular arrhythmias (VA), systemic embolisms (SE) and/or all-cause mortality. Progressive systolic dysfunction was defined as an LVEF < 50% at last TTE and/or an absolute ≥10-point decrease in LVEF from first to last TTE. Lower limit of LVEF CMR values were considered 50-57% according to current recommendations. Cox-regression analysis was used for MACE and logistic regression was used for progressive systolic dysfunction (only first and last TTE were available).
RESULTS
A total of 305 patients from 12 centres were included from 2000 to 2018. Age was 38 ± 19 years and 165 (54%) were men. LVEF was 62 ± 8% and 8% had late gadolinium enhancement (LGE). During a median follow-up of 4.7 (IQR 2.1-7.4) years, MACE occurred in 40 (13%) patients with an incidence rate of 2.73 (95% CI 2.00-3.72) events per 100 person-years: 8 HF, 27 VA, 3 SE and 5 deaths. LVEF by CMR (HR 0.95, 95% CI 0.91-0.99, p = 0.0048) and hypertension (HR 2.30, 95% CI 1.08-4.89, p = 0.031) were the only variables independently associated with the endpoint. Patients with lower limit LVEF values showed an increased risk of MACE (Figure 1). LGE was not associated.
Sixty-one (21%) patients experienced progressive systolic dysfunction: 31 (11%) had an LVEF < 50% and 48 (17%) an absolute ≥10-point decrease in LVEF at last follow-up. On multivariate analysis, LVEF by CMR was the only independent predictor (OR 0.93, 95% CI 0.89-0.98, p = 0.008). Patients with lower limit LVEF values had an increased risk (Figure 2). In this subgroup, LGE was also associated with the endpoint (HR 10.69, 95% CI 1.97-58.13, p = 0.006).
CONCLUSIONS
Patients with left ventricular noncompaction and preserved ejection fraction carry a moderate risk of major adverse cardiovascular events and progressive systolic dysfunction. LVEF remains the main predictor of outcomes in this subgroup. Patients with lower limit LVEF values are at increased risk, probably suggesting subclinical systolic dysfunction. Therefore, they should be carefully monitored. Abstract Figure. Kaplan Meier cuves for MACE Abstract Figure. Risk of progressive systolic dysfunction
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Affiliation(s)
- G Casas
- University Hospital Vall d"Hebron, Cardiology, Barcelona, Spain
| | - R Escalona
- University Hospital Vall d"Hebron, Cardiology, Barcelona, Spain
| | | | | | | | | | | | | | - E Villacorta
- Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - JR Gimeno-Blanes
- Hospital Clinico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - E Zorio
- Hospital Universitario y Politecnico La Fe, Valencia, Spain
| | - P Garcia-Pavia
- University Hospital Puerta de Hierro Majadahonda, Madrid, Spain
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Casas G, Limeres J, Barriales-Villa R, Garcia-Pavia P, Zorio E, Gimeno-Blanes JR, Palomino-Doza J, Garcia-Pinilla JM, Bayes-Genis A, Ripoll-Vera T, Jimenez-Jaimez J, Villacorta E, Evangelista A, Ferreira-Gonzales I, Rodriguez-Palomares JF. Prognostic role of cardiac magnetic resonance in left ventricular noncompaction. Eur Heart J Cardiovasc Imaging 2021. [DOI: 10.1093/ehjci/jeab090.111] [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] [Indexed: 11/15/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: None.
Background
Left ventricular noncompaction (LVNC) is a heterogeneous entity with a wide phenotypic expression. Risk factors have not been well established and prognostic stratification remains challenging.
Purpose
Describe prognostic role of CMR on long term outcomes of LVNC patients.
Methods
Retrospective multicentric longitudinal cohort study of consecutive patients fulfilling imaging diagnostic criteria for LVNC (Jenni echo criteria and Petersen and Jacquier CMR criteria). Demographic, ECG, genetic, family and treatment variables were recorded. Baseline CMR was used for the analysis. LV ejection fraction (LVEF) was categorized according to heart failure (HF) guidelines and late gadolinium enhancement (LGE) was visually assessed in a binary way. End points were HF, ventricular arrhythmias (VA), systemic embolisms (SE) and all-cause death. Major adverse cardiovascular events (MACE) were the combination of the four previous end points. In patients with initially preserved LVEF (≥ 50%), LV adverse remodelling (LVAR) was defined as an LVEF < 50% and/or absolute decrease of ≥10% in LVEF at last follow-up.
Results
585 patients from 12 referral centres were included from 2000 to 2018. Age at diagnosis was 45 ± 20 years, 334 (57%) were male, baseline LVEF was 48 ± 17% and 18% presented LGE. During a median follow-up of 5.1 years (IQR 2.3-8.1), 110 (19%) patients presented HF, 87 (15%) VA, 18 (3%) SE and 34 (6%) died. MACE occurred in 223 (38%) patients.
LVEF was independently associated with HF, VA, SE and MACE: HR were 1.08, 1.02, 1.04 and 1.02 respectively (all p < 0.05). LGE was more frequent in patients with reduced LVEF (39 Vs 53%, p < 0.001) and was associated with higher HF and VA risk in patients with an LVEF > 35% (HR 2.69 and 2.48 respectively, p < 0.05) (Figure 1). No MACE (0%) occurred during long-term follow-up in patients with preserved LVEF, no LGE as well as no ECG abnormalities and no family aggregation.
305 (52%) patients presented with initially preserved LVEF, and 230 (75%) of those had LVEF available at last follow-up. LVAR occurred in 50 (22%) patients: 22 (10%) had an LVEF < 50% and 41 (18%) an absolute ≥ 10% decrease in LVEF. LGE was independently associated with LVAR (HR 3.51, p = 0.045) (Figure 2).
Conclusions
Cardiac magnetic resonance has an important prognostic role in LVNC. LVEF is the most powerful predictor of events. Myocardial fibrosis is associated with worse outcomes in patients without severe systolic dysfunction, as well as with left ventricular adverse remodelling in those with initially preserved LVEF. Besides, CMR may identify a low-risk subgroup of LVNC patients. Therefore, CMR should be used in risk stratification in LVNC.
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Affiliation(s)
- G Casas
- University Hospital Vall d"Hebron, Cardiology, Barcelona, Spain
| | - J Limeres
- University Hospital Vall d"Hebron, Cardiology, Barcelona, Spain
| | | | - P Garcia-Pavia
- University Hospital Puerta de Hierro Majadahonda, Madrid, Spain
| | - E Zorio
- Hospital Universitario y Politecnico La Fe, Valencia, Spain
| | | | | | | | | | | | | | - E Villacorta
- University Hospital of Salamanca, Salamanca, Spain
| | - A Evangelista
- University Hospital Vall d"Hebron, Cardiology, Barcelona, Spain
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Casas G, Oristrell G, Limeres J, Sao-Aviles A, Barriales R, Garcia-Pavia P, Diez C, Zorio E, Villacorta E, De Antonio M, Garcia-Pinilla JM, Valverde M, Evangelista A, Ferreira-Gonzalez I, Rodriguez-Palomares JF. P5555Predictors of systemic embolisms in a large cohort of left ventricular noncompaction patients. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz746.0499] [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] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Left ventricular noncompaction (LVNC) is associated with an increased risk of systemic embolisms (SE). However, incidence and risk factors are not well established.
Purpose
To evaluate the rate of SE in LVNC and describe risk factors.
Methods
LNVC patients were included in a multicentric registry. Those with SE were considered for the analysis.
Results
514 patients with LVNC from 10 Spanish centres were recruited from 2000 to 2018. During a median follow-up of 4.2 years (IQR 1.9–7.1), 23 patients (4.5%) had a SE. Patients with SE (Table 1) were older at diagnosis, with no differences in gender and had similar cardiovascular risk factors. They were more frequently under oral anticoagulation (OAC). Besides, they had a more reduced LVEF, and more dilated LV and left atrium (LA). Late gadolinium enhancement (LGE) was more frequent, altogether suggesting a more severe phenotype.
Patients with SE had non-significantly higher rates of hospitalization for heart failure (33% vs 24%, p=0.31) and atrial fibrillation (35% vs 19%, p=0.10). In multivariate analysis, only LA diameter was an independent predictor of SE (OR 1.04, p=0.04). A LA diameter>45 mm had an independent 3 fold increased risk of SE (OR 3.04, p=0.02) (Image 1).
Table 1 Systemic embolisms (n=23) No systemic embolisms (n=491) p Men, n (%) 15 (65) 289 (56) 0.52 Median age at diagnosis (IQR), yr 60 (48–76) 48 (30–64) 0.02 Median follow up (IQR), yr 5.9 (3.1–7.8) 4.2 (1.8–7.1) 0.18 Hypertension, % 8 (33) 118 (24) 0.31 Diabetes mellitus, % 3 (14) 39 (8) 0.41 OAC, % 19 (83) 118 (24) 0.01 LVEF (SD), % 37 (15) 48 (17) 0.01 LVEDD (SD), mm 58 (11) 54 (10) 0.04 LVESD (SD), mm 45 (13) 38 (11) 0.01 LA diameter (SD), mm 46 (9) 39 (9) 0.01 LVEDV CMR (SD), mL 193 (75) 163 (70) 0.12 LVESV CMR (SD), mL 121 (64) 85 (64) 0.04 LGE, % 9 (40) 88 (18) 0.04
Conclusions
LVNC carries a moderate mid-term risk of SE, which appears to be irrespective of atrial fibrillation and associated with age, LV dilatation and systolic dysfunction and mainly LA dilatation. This subgroup of patients should be considered for oral anticoagulation in primary prevention.
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Affiliation(s)
- G Casas
- University Hospital Vall d'Hebron, Cardiology, CIBER-CV, Barcelona, Spain
| | - G Oristrell
- University Hospital Vall d'Hebron, Cardiology, CIBER-CV, Barcelona, Spain
| | - J Limeres
- University Hospital Vall d'Hebron, Cardiology, CIBER-CV, Barcelona, Spain
| | - A Sao-Aviles
- University Hospital Vall d'Hebron, Cardiology, CIBER-CV, Barcelona, Spain
| | - R Barriales
- University Hospital Complex A Coruña, A Coruna, Spain
| | - P Garcia-Pavia
- University Hospital Puerta de Hierro Majadahonda, Madrid, Spain
| | - C Diez
- University Hospital of Bellvitge, Barcelona, Spain
| | - E Zorio
- University Hospital La Fe, Valencia, Spain
| | - E Villacorta
- Hospital Clinico Universitario, Salamanca, Spain
| | - M De Antonio
- Germans Trias i Pujol University Hospital, Barcelona, Spain
| | | | - M Valverde
- University Hospital 12 de Octubre, Madrid, Spain
| | - A Evangelista
- University Hospital Vall d'Hebron, Cardiology, CIBER-CV, Barcelona, Spain
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Ochoa JP, Sabater-Molina M, Garcia-Pinilla JM, Restrepo-Cordoba A, Palomino-Doza AJ, Limeres-Freire J, Climent-Paya V, Villacorta E, Garcia-Granja PE, Bautista-Paves A, Barriales-Villa R, Mogensen J, Elliott PM, Gimeno JR, Monserrat L. P6320FHOD3 is a novel disease causing gene in hypertrophic cardiomyopathy. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy566.p6320] [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: 11/12/2022] Open
Affiliation(s)
| | - M Sabater-Molina
- Hospital Clínico Univeristario Virgen de la Arrixaca, Murcia, Spain
| | | | | | | | | | - V Climent-Paya
- General University Hospital of Alicante, ISABIAL-FISABIO, Alicante, Spain
| | - E Villacorta
- Hospital Clínico Universitario, Salamanca, Spain
| | | | | | | | - J Mogensen
- Odense University Hospital, Odense, Denmark
| | - P M Elliott
- University College London, St. Bartholomew's Hospital, London, United Kingdom
| | - J R Gimeno
- Hospital Clínico Univeristario Virgen de la Arrixaca, Murcia, Spain
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Dominguez Rodriguez F, Cuenca S, Bilinska Z, Toro R, Charron P, Barriales-Villa R, Asselbergs F, Akhtar M, Morris Hey T, Rangel-Sousa D, Limeres JM, Garcia-Pinilla JM, Ochoa JP, Elliott P, Garcia-Pavia P. P3169Clinical characteristics and natural history of dilated cardiomyopathy due to BAG3 mutations. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy563.p3169] [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: 11/13/2022] Open
Affiliation(s)
- F Dominguez Rodriguez
- University Hospital Puerta de Hierro Majadahonda, Inherited Cardiac Disease Unit, CNIC, CIBERCV, Madrid, Spain
| | - S Cuenca
- University Hospital Gregorio Maranon, Madrid, Spain
| | - Z Bilinska
- The Cardinal Stefan Wyszynski Institute of Cardiology, Warsaw, Poland
| | - R Toro
- University Hospital Puerta del Mar, Cadiz, Spain
| | - P Charron
- Hospital Pitie-Salpetriere, Paris, France
| | | | - F Asselbergs
- University Medical Center Utrecht, Utrecht, Netherlands
| | - M Akhtar
- St Bartholomew's Hospital, London, United Kingdom
| | | | | | - J M Limeres
- University Hospital Vall d'Hebron, Barcelona, Spain
| | - J M Garcia-Pinilla
- University Hospital Virgen de la Victoria, IBIMA, CIBERCV, Malaga, Spain
| | | | - P Elliott
- St Bartholomew's Hospital, London, United Kingdom
| | - P Garcia-Pavia
- University Hospital Puerta de Hierro Majadahonda, Inherited Cardiac Disease Unit, CNIC, CIBERCV, Madrid, Spain
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Cabrera-Bueno FJ, Gómez-Doblas JJ, Garcia-Pinilla JM, Montiel-Trujillo A, Jiménez-Navarro M, Martinez-del-Valle D, Jiménez-Hoyuela JM, de Teresa-Galván E. Dobutamine Stress Echocardiography Identifies Patients with Angina and Dynamic Left Ventricular Outflow Obstruction in Physiological Exercise. Echocardiography 2009; 26:272-80. [DOI: 10.1111/j.1540-8175.2008.00808.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
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Rodriguez-Losada N, Garcia-Pinilla JM, Jimenez-Navarro MF, Gonzalez FJ. Endothelial progenitor cells in cell-based therapy for cardiovascular disease. Cell Mol Biol (Noisy-le-grand) 2008; 54:11-23. [PMID: 18954547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2008] [Accepted: 10/16/2008] [Indexed: 05/27/2023]
Abstract
Coronary Artery Diseases (CAD) is the first mortality cause in industrialized countries. The possibility of regenerating myocardium injured tissue using the cell therapy is a promising option to regenerate cardiac tissue. Currently, a variety of adult stem/ progenitor cells are undergoing clinical evaluation, but it is very important to study and characterize the bone marrow-derived progenitor/ stem cells, the main source of cells used for human cardiac repair, before their clinical use. Bone marrow-derived endothelial progenitor cells (EPC) home sites of ischemia and differentiate into endothelial cells, increase the neovascularization of ischemic tissue. Moreover recently, it has been observed that EPC can be able to differentiate or transdifferentiate to like-adult cells resident in cardiac tissues. The characterization of phenotype EPC is complex, because express hematopoietic stem cells (CD133 and/or CD34) and endothelial markers such as vascular endothelial growth factor receptor 2 (KDR). Several studies described subpopulation of EPC expressing CD34+D133+KDR+ phenotype in literature, but some other authors suggest other phenotype. The EPC capacity of mobilization or recruitment/ homing to ischemic tissue areas by cytokines are reviewed. Finally are described clinical studies in CAD using bone marrow-derived progenitor cells permitting human cardiac tissue repair.
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Affiliation(s)
- N Rodriguez-Losada
- Virgen de la Victoria University Hospital, Campus Teatinos s/n Research Laboratory, Heart Unit, Malaga, Spain
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