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Gerhardy B, Sivapathan S, Bowcock E, Orde S, Morgan L. Right Ventricular Dysfunction on Transthoracic Echocardiography and Long-Term Mortality in the Critically Unwell: A Systematic Review and Meta-Analysis. J Intensive Care Med 2024; 39:203-216. [PMID: 38056074 DOI: 10.1177/08850666231218713] [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] [Subscribe] [Scholar Register] [Indexed: 12/08/2023]
Abstract
OBJECTIVE Right ventricular dysfunction (RVD) is common in the critically ill. To date studies exploring RVD sequelae have had heterogenous definitions and diagnostic methods, with limited follow-up. Additionally much literature has been pathology specific, limiting applicability to the general critically unwell patient. METHOD AND STUDY DESIGN We conducted a systematic review and meta-analysis to evaluate the impact of RVD diagnosed with transthoracic echocardiography (TTE) on long-term mortality in unselected critically unwell patients compared to those without RVD. A systematic search of EMBASE, Medline and Cochrane was performed from inception to March 2022. All RVD definitions using TTE were included. Patients were those admitted to a critical or intensive care unit, irrespective of disease processes. Long-term mortality was defined as all-cause mortality occurring at least 30 days after hospital admission. A priori subgroup analyses included disease specific and delayed mortality (death after hospital discharge/after the 30th day from hospital admission) in patients with RVD. A random effects model analysis was performed with the Dersimionian and Laird inverse variance method to generate effect estimates. RESULTS Of 5985 studies, 123 underwent full text review with 16 included (n = 3196). 1258 patients had RVD. 19 unique RVD criteria were identified. The odds ratio (OR) for long term mortality with RVD was 2.92 (95% CI 1.92-4.54, I2 76.4%) compared to no RVD. The direction and extent was similar for cardiac and COVID19 subgroups. Isolated RVD showed an increased risk of delayed mortality when compared to isolated left/biventricular dysfunction (OR 2.01, 95% CI 1.05-3.86, I2 46.8%). CONCLUSION RVD, irrespective of cause, is associated with increased long term mortality in the critically ill. Future studies should be aimed at understanding the pathophysiological mechanisms by which this occurs. Commonly used echocardiographic definitions of RVD show significant heterogeneity across studies, which contributes to uncertainty within this dataset.
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Affiliation(s)
- Benjamin Gerhardy
- Department of Intensive Care Medicine, Nepean Hospital, Kingswood, NSW, Australia
- Nepean Clinical School, University of Sydney School of Medicine, Sydney, NSW, Australia
- Department of Respiratory Medicine, Nepean Hospital, Kingswood, NSW, Australia
| | - Shanthosh Sivapathan
- Department of Intensive Care Medicine, Nepean Hospital, Kingswood, NSW, Australia
- Nepean Clinical School, University of Sydney School of Medicine, Sydney, NSW, Australia
| | - Emma Bowcock
- Department of Intensive Care Medicine, Nepean Hospital, Kingswood, NSW, Australia
- Nepean Clinical School, University of Sydney School of Medicine, Sydney, NSW, Australia
| | - Sam Orde
- Department of Intensive Care Medicine, Nepean Hospital, Kingswood, NSW, Australia
- Nepean Clinical School, University of Sydney School of Medicine, Sydney, NSW, Australia
| | - Lucy Morgan
- Nepean Clinical School, University of Sydney School of Medicine, Sydney, NSW, Australia
- Department of Respiratory Medicine, Nepean Hospital, Kingswood, NSW, Australia
- Department of Respiratory Medicine, Concord Repatriation Hospital, Concord, NSW, Australia
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Gerhardy B, Sivapathan S, Orde S, Morgan L. Simultaneous Cardiopulmonary Exercise Testing and Echocardiography for Investigation of Cardiopulmonary Dysfunction in Outpatients: Protocol for a Scoping Review. JMIR Res Protoc 2024; 13:e52076. [PMID: 38345834 PMCID: PMC10897791 DOI: 10.2196/52076] [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] [Received: 08/22/2023] [Revised: 12/27/2023] [Accepted: 12/28/2023] [Indexed: 03/01/2024] Open
Abstract
BACKGROUND Cardiopulmonary dysfunction is a complex process with a broad range of etiologies. Investigations performed either at rest or those that only assess the function of a single organ (heart or lungs) are often insufficient. A simultaneous cardiopulmonary exercise test with stress echocardiography is a new approach to assessing cardiopulmonary dysfunction as it provides anatomical and functional imaging simultaneously while under increasing stress. To date, the application of cardiopulmonary exercise test-stress echocardiography (CPET-SE) has been broad and without structure, and its effect on patient outcomes is unclear. OBJECTIVE The objective of this scoping review is to explore and analyze the evidence regarding the role of simultaneous CPET-SE in investigating cardiopulmonary dysfunction in outpatients. It will include any published study in which adult (older than or equal to 18 years of age) patients have completed a CPET-SE for the investigation of cardiopulmonary dysfunction. METHODS This review will follow the Arksey and O'Malley framework, supported by the Joanna Briggs Institute methodology for scoping reviews. It will use the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) checklist. Data sources will include MEDLINE, Scopus, Embase, and Cochrane (including reviews, trials, and protocols) electronic databases, with no date range defined. The search will be limited to the English language with no restrictions regarding pathology. Secondary references of the included sources will also be assessed by a hand search for suitability. A 2-person title-abstract screen and data charting process will be used. Independent experts will be used for consultation including an academic librarian and clinicians. The Covidence software will be used for article screening. RESULTS This scoping review will provide a unified and detailed description of the applications of CPET-SE in investigating cardiopulmonary dysfunction. This will provide a platform for future research harnessing this investigatory method. The results will be presented in both tabular and graphical formats to ensure clarity. The results of this scoping review will be submitted to a relevant peer-reviewed academic journal for publication. CONCLUSIONS The CPET-SE is a powerful tool for investigating cardiopulmonary dysfunction but remains in its infancy with a patchwork approach to indications, data reporting, and interpretation. This scoping review will unify the literature and provide a platform for future researchers and the development of a comprehensive application guideline. TRIAL REGISTRATION Open Science Framework; https://osf.io/98r3e. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) PRR1-10.2196/52076.
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Affiliation(s)
- Benjamin Gerhardy
- Department of Respiratory Medicine, Nepean Hospital, Kingswood, Australia
- Department of Intensive Care Medicine, Nepean Hospital, Kingswood, Australia
- Faculty of Medicine and Health Sciences, University of Sydney, Kingswood, Australia
| | - Shanthosh Sivapathan
- Department of Intensive Care Medicine, Nepean Hospital, Kingswood, Australia
- Faculty of Medicine and Health Sciences, University of Sydney, Kingswood, Australia
| | - Sam Orde
- Department of Intensive Care Medicine, Nepean Hospital, Kingswood, Australia
- Faculty of Medicine and Health Sciences, University of Sydney, Kingswood, Australia
| | - Lucy Morgan
- Department of Respiratory Medicine, Nepean Hospital, Kingswood, Australia
- Faculty of Medicine and Health Sciences, University of Sydney, Kingswood, Australia
- Department of Respiratory Medicine, Concord Repatriation General Hospital, Concord, Australia
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Geenty P, Sivapathan S, Stefani LD, Zada M, Boyd A, Richards D, Kwok F, Thomas L. A novel echocardiographic risk score for light-chain amyloidosis. Eur Heart J Open 2023; 3:oead040. [PMID: 37143609 PMCID: PMC10152390 DOI: 10.1093/ehjopen/oead040] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 04/12/2023] [Accepted: 04/13/2023] [Indexed: 05/06/2023]
Abstract
Aims The prognosis of light-chain (AL) amyloidosis, a plasma cell dyscrasia, is largely determined by the presence of cardiac involvement. Conventional staging is achieved using cardiac biomarkers (high-sensitivity troponin, N-terminal pro-beta natriuretic peptide) and free light-chain difference (Mayo staging). We sought to evaluate the role of echocardiographic parameters as prognostic markers in AL amyloidosis and examine their utility compared with conventional staging. Methods and results Seventy-five consecutive patients with AL amyloidosis reviewed at a referral amyloid clinic who underwent comprehensive echocardiographic assessment were retrospectively identified. The evaluated echocardiographic parameters included left ventricular (LV) ejection fraction, mass, diastolic function parameters, global longitudinal strain (GLS), and left atrial (LA) volume. Mortality was assessed through a review of clinical records. During a median follow-up of 51 months, 29/75 (39%) patients died. Patients who died had a larger LA volume (47 ± 12 vs. 35 ± 10 mL/m2, P < 0.001) and a higher E/e' (18 ± 10 vs. 14 ± 6, P = 0.026). Univariate clinical and echocardiographic predictors of survival included LA volume, E/e', e', LVGLS, and Mayo stage (at significance of P < 0.1). Left atrial volume and LVGLS were significant determinants of mortality when examined using clinical cut-offs, although E/e' was not. A composite echocardiographic risk score comprising LA volume and LVGLS provided similar prognostic performance to Mayo stage [area under the curve (AUC) 0.75, 95% confidence interval (CI) 0.64-0.85 vs. AUC 0.75, 95% CI 0.65-0.858, P = 0.91]. Conclusion Left atrial volume and LVGLS were independent predictors of mortality in AL amyloidosis. A composite echocardiographic score combining LA volume and LVGLS has similar prognostic power to Mayo stage for all-cause mortality.
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Affiliation(s)
- Paul Geenty
- Department of Cardiology, Westmead Hospital, Hawkesbury Road, Sydney, Australia
- The University of Sydney School of Medicine, Westmead Clinical School, University of Sydney, Hawkesbury Road, Westmead, Australia
| | - Shanthosh Sivapathan
- The University of Sydney School of Medicine, Westmead Clinical School, University of Sydney, Hawkesbury Road, Westmead, Australia
| | - Luke D Stefani
- Department of Cardiology, Westmead Hospital, Hawkesbury Road, Sydney, Australia
| | - Matthew Zada
- Department of Cardiology, Westmead Hospital, Hawkesbury Road, Sydney, Australia
- The University of Sydney School of Medicine, Westmead Clinical School, University of Sydney, Hawkesbury Road, Westmead, Australia
| | - Anita Boyd
- Westmead Private Cardiology, Mons Rd, Westmead, Australia
| | - David Richards
- Westmead Private Cardiology, Mons Rd, Westmead, Australia
| | - Fiona Kwok
- The University of Sydney School of Medicine, Westmead Clinical School, University of Sydney, Hawkesbury Road, Westmead, Australia
- Department of Haematology, Westmead Hospital, Hawkesbury Road, Sydney, Australia
| | - Liza Thomas
- Corresponding author. Tel: +61 2 8890 5555, Fax: +61 0 8890 8323,
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Geenty P, Sivapathan S, Stefani LD, Zada M, Boyd A, Kwok F, Thomas L. A novel echocardiographic risk score predicts prognosis in AL-amyloidosis. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.151] [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: 11/12/2022] Open
Abstract
Abstract
Background
Prognosis in light chain (AL) amyloidosis is largely determined by the severity of cardiac involvement. Conventional (Mayo) staging includes 1) hs troponin 2) N-terminal pro-beta natriuretic peptide (NT-pro BNP) and 3)free light chain difference.
Methods
In a retrospective study of 75 AL amyloidosis patients referred to a quaternary amyloid clinic, all patients underwent comprehensive echocardiographic assessment. Echocardiographic parameters included left ventricular (LV) ejection fraction, LV mass, diastolic function, global longitudinal strain (GLS) and indexed left atrial volume (LAVI). Mortality was assessed through review of clinical records.
Results
Over a median follow up of 51 months, 29/75 (39%) of patients died. LAVI, E/e', e', LVGLS, were univariate predictors of mortality (p<0.1). LAVI was the only independent echocardiographic predictor in a multivariable model. Kaplan Meir analysis evaluated LAVI, LVGLS and E/e' using clinical cutoffs as a predictor of survival; only LAVI and LVGLS were significant. A novel “Echo score” comprising of LAVI (>42 ml/m2) and LVGLS (<−12%) was a predictor of mortality with similar prognostic performance as Mayo stage. (Echo score AUC 0.745, 95% CI 0.64–0.85 vs Mayo score AUC 0.752 95% CI 0.66–0.86, p=0.9).
Conclusion
LAVI, a simple, echocardiographic parameter was as an independent predictor of mortality in AL amyloidosis. A composite echocardiographic score combining LAVI and LVGLS stratified AL-amyloidosis patients into 3 distinct groups with similar prognostic power as Mayo stage for all-cause mortality.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- P Geenty
- Westmead Hospital , Sydney , Australia
| | | | | | - M Zada
- Westmead Hospital , Sydney , Australia
| | - A Boyd
- Westmead Private Cardiology , Sydney , Australia
| | - F Kwok
- Westmead Hospital , Sydney , Australia
| | - L Thomas
- Westmead Hospital , Sydney , Australia
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Sivapathan S, Geenty P, Deshmukh T, Boyd A, Richards D, Stewart G, Taylor MS, Kwok F, Thomas L. Alterations in multi-layer strain in AL amyloidosis. Amyloid 2022; 29:128-136. [PMID: 35188014 DOI: 10.1080/13506129.2022.2026914] [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] [Indexed: 11/01/2022]
Abstract
BACKGROUND Cardiac involvement in AL amyloidosis portends a poor prognosis. 2D-speckle tracking echocardiography (2D-STE) strain can identify subclinical cardiac involvement. This study performed multilayer and multiplanar 2D-STE myocardial strain analysis. METHODS We compared 75 AL amyloidosis patients to 49 hypertensive patients and 49 healthy controls. Longitudinal strain was obtained from epicardial, mid-myocardial and endocardial layers; segmental strain was measured from mid-myocardial basal, mid and apical segments. RESULTS Global longitudinal strain was reduced in epicardial (-14.3 ± -4.0% vs. -17.4 ± 2.2% vs. -17.5 ± -2.0%, p < .001), mid-myocardial (-16.3 ± -4.5% vs. -19.7 ± 2.5% vs. -19.7 ± -2.2%, p < .001) and endocardial layers (-18.7 ± -4.9% vs. -22.2 ± 3.0% vs. -22.3 ± -2.6%, p < .001) in amyloid patients compared to hypertensive and healthy controls. Segmental strain confirmed significant reduction in basal (-11.2 ± -3.9% vs. -17.6 ± 2.7% vs. -20.9 ± -3.4%, p < .001) and mid (-14.8 ± -4.3% vs. -19.2 ± 2.5% vs. -19.6 ± -2.2%, p < .001) LV segments in the AL amyloid group. Receiver operating curve analysis demonstrated that an optimal cut-off of -16% for basal segmental strain better differentiated AL amyloid from hypertensive group (sensitivity 96%, specificity 70%, AUC 0.93), compared to relative apical sparing (AUC of 0.85). CONCLUSION Strain demonstrated myocardial involvement in all layers in AL amyloidosis, with reduced basal segmental longitudinal strain a likely marker of early disease.
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Affiliation(s)
| | - Paul Geenty
- Westmead Clinical School, University of Sydney, Sydney, Australia.,Department of Cardiology, Westmead Hospital, Sydney, Australia
| | - Tejas Deshmukh
- Westmead Clinical School, University of Sydney, Sydney, Australia.,Department of Cardiology, Westmead Hospital, Sydney, Australia
| | - Anita Boyd
- Westmead Private Cardiology, Sydney, Australia
| | - David Richards
- Westmead Clinical School, University of Sydney, Sydney, Australia.,Westmead Private Cardiology, Sydney, Australia
| | - Graeme Stewart
- Department of Cardiology, Westmead Hospital, Sydney, Australia.,Department of Clinical Immunology and Allergy, Westmead Hospital, Sydney, Australia
| | - Mark S Taylor
- Department of Clinical Immunology and Allergy, Westmead Hospital, Sydney, Australia.,Westmead Amyloidosis Clinic, Westmead Hospital, Sydney, Australia
| | - Fiona Kwok
- Department of Clinical Immunology and Allergy, Westmead Hospital, Sydney, Australia.,Westmead Amyloidosis Clinic, Westmead Hospital, Sydney, Australia.,Department of Haematology, Westmead Hospital, Sydney, Australia
| | - Liza Thomas
- Westmead Clinical School, University of Sydney, Sydney, Australia.,Department of Cardiology, Westmead Hospital, Sydney, Australia.,Westmead Amyloidosis Clinic, Westmead Hospital, Sydney, Australia.,South West Clinical School, University of New South Wales, Sydney, Australia
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Sivapathan S, Jeyaprakash P, Zaman SJ, Burgess SN. Management of Multivessel Disease and Physiology Testing in ST Elevation Myocardial Infarction. Interv Cardiol Clin 2021; 10:333-343. [PMID: 34053620 DOI: 10.1016/j.iccl.2021.03.005] [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: 10/21/2022]
Abstract
For decades, advances in ST elevation myocardial infarction (STEMI) care have been driven by timely reperfusion of the occluded culprit vessel. More recently, however, the focus has shifted to revascularization of nonculprit vessels in STEMI patients. Five landmark randomized trials, all published in the past 7 years, have highlighted the importance of complete revascularization in STEMI treatment. This review focuses on evidence-based management of STEMI in the setting of multivessel disease, highlighting contemporary data that investigate the impact of complete revascularization.
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Affiliation(s)
- Shanthosh Sivapathan
- Department of Cardiology, University of Sydney and Nepean Hospital, Derby Street, Kingswood, New South Wales 2747, Australia. https://twitter.com/drsonyaburgess
| | - Prajith Jeyaprakash
- Department of Cardiology, University of Sydney and Nepean Hospital, Derby Street, Kingswood, New South Wales 2747, Australia
| | - Sarah J Zaman
- Department of Cardiology, University of Sydney, Monash University and Westmead Hospital, Corner of Darcy Road, Westmead 2145, Australia
| | - Sonya N Burgess
- University of New South Wales, University of Sydney, and Department of Cardiology, Nepean Hospital, Derby Street, Sydney, New South Wales 2747, Australia.
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Jeyaprakash P, Moussad A, Pathan S, Sivapathan S, Ellenberger K, Madronio C, Thomas L, Negishi K, Pathan F. A Systematic Review of Scaling Left Atrial Size: Are Alternative Indexation Methods Required for an Increasingly Obese Population? J Am Soc Echocardiogr 2021; 34:1067-1076.e3. [PMID: 34023453 DOI: 10.1016/j.echo.2021.05.009] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [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: 03/06/2021] [Revised: 05/12/2021] [Accepted: 05/12/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Left atrial (LA) size indexed to body surface area (BSA) is a clinically important marker of cardiovascular prognosis. However, indexation using a scaling variable such as BSA has inherent flaws, particularly in an obese population. The aim of this study was to determine whether alternative indexation methods may more accurately scale for LA size. METHODS The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used to execute a structured search of medical databases, to identify articles discussing alternative methods of LA indexation in echocardiography. Articles that stratified indexed LA size by obesity class were also included. Two independent reviewers identified relevant articles and extracted baseline characteristics, alternative indexation methods, scaling variables, obesity class characteristics, and correlation coefficients. RESULTS A total of 3,804 articles were found in the database search after removing duplicates. After abstract and full-text screening, 13 relevant articles were identified. Twelve studies used alternative methods of LA indexation, of which nine reported allometric indices. Seven of the included studies reported LA size by obesity class, of which six reported alternative indices. Correlation coefficients plotted for indexed LA size against absolute measured LA size showed that allometric indices (specifically to height) were more likely to maintain proportionality to body size compared with isometric indices such as BSA. Allometric indices were less likely to overcorrect for body size compared with isometric indices. CONCLUSIONS Compared with isometric indexation to BSA, allometric indexation (specifically to height) improves scaling of LA volumes to maintain proportionality and avoid overcorrection for body size.
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Affiliation(s)
- Prajith Jeyaprakash
- Department of Cardiology, Nepean Hospital, Sydney, Australia; Sydney Medical School Nepean, Faculty of Medicine and Health, Charles Perkins Centre Nepean, The University of Sydney, New South Wales, Sydney, Australia
| | - Andrew Moussad
- Department of Cardiology, Nepean Hospital, Sydney, Australia; Sydney Medical School Nepean, Faculty of Medicine and Health, Charles Perkins Centre Nepean, The University of Sydney, New South Wales, Sydney, Australia
| | - Shahab Pathan
- Sydney Medical School Nepean, Faculty of Medicine and Health, Charles Perkins Centre Nepean, The University of Sydney, New South Wales, Sydney, Australia; Department of Cardiology, Concord Hospital, Sydney, Australia
| | - Shanthosh Sivapathan
- Department of Cardiology, Nepean Hospital, Sydney, Australia; Sydney Medical School Nepean, Faculty of Medicine and Health, Charles Perkins Centre Nepean, The University of Sydney, New South Wales, Sydney, Australia
| | - Katherine Ellenberger
- Department of Cardiology, Nepean Hospital, Sydney, Australia; Sydney Medical School Nepean, Faculty of Medicine and Health, Charles Perkins Centre Nepean, The University of Sydney, New South Wales, Sydney, Australia
| | - Christine Madronio
- Department of Cardiology, Nepean Hospital, Sydney, Australia; Sydney Medical School Nepean, Faculty of Medicine and Health, Charles Perkins Centre Nepean, The University of Sydney, New South Wales, Sydney, Australia
| | - Liza Thomas
- Cardiology Department, Westmead Hospital, Sydney, Australia; Sydney Medical School Westmead, Faculty of Medicine and Health, Charles Perkins Centre Westmead, Sydney, Australia
| | - Kazuaki Negishi
- Department of Cardiology, Nepean Hospital, Sydney, Australia; Sydney Medical School Nepean, Faculty of Medicine and Health, Charles Perkins Centre Nepean, The University of Sydney, New South Wales, Sydney, Australia
| | - Faraz Pathan
- Department of Cardiology, Nepean Hospital, Sydney, Australia; Sydney Medical School Nepean, Faculty of Medicine and Health, Charles Perkins Centre Nepean, The University of Sydney, New South Wales, Sydney, Australia.
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Jeyaprakash P, Sangha S, Ellenberger K, Sivapathan S, Pathan F, Negishi K. Cardiotoxic Effect of Modern Anthracycline Dosing on Left Ventricular Ejection Fraction: A Systematic Review and Meta-Analysis of Placebo Arms From Randomized Controlled Trials. J Am Heart Assoc 2021; 10:e018802. [PMID: 33660514 PMCID: PMC8174208 DOI: 10.1161/jaha.120.018802] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [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: 01/27/2023]
Abstract
Background Anthracyclines are a key chemotherapeutic agent used against hematological and solid organ malignancies. However, their benefits in cancer survival are limited by cumulative, dose‐related cardiotoxicity. The impact of anthracyclines on left ventricular ejection fraction (LVEF), in the era of modern chemotherapy regimens, remains unclear. Methods and Results Three databases (CENTRAL, MEDLINE, and SCOPUS) were systematically searched for randomized trials evaluating cardioprotective agents against placebo, in preventing cardiotoxicity. Echocardiography or magnetic resonance measured LVEF pre‐ and post‐anthracycline‐based chemotherapy was abstracted from placebo trial arms. The key terms included “anthracycline,” “cardiotoxicity” and “randomized.” A doxorubicin equivalent anthracycline dose metric was calculated to compare different anthracyclines. A random‐effects model was used to pool mean difference in LVEF after anthracycline. Meta‐regressions were calculated to identify variation sources. We included 660 patients from 19 trials. The weighted mean baseline LVEF across studies was 62.6%, and follow‐up LVEF assessment was performed at 6 months. The pooled mean decline in LVEF among placebo arms was 5.4% (95% CI, 3.5%–7.3%) with a doxorubicin equivalent anthracycline dose of 385 mg/m2. Meta‐regression analysis showed no significant difference in LVEF against doxorubicin equivalent anthracycline dose as continuous (P=0.29) or against published cut‐offs for cardiotoxicity (250 mg/m2, P=0.21; 360 mg/m2, P=0.40; and 400 mg/m2, P=0.66). The differences in mean LVEF were not associated with sex, adjunct chemotherapy, or cancer type. Conclusions The magnitude of LVEF impairment post‐anthracycline therapy appears less than previously described with modern dosing regimens. This may improve the accuracy of power calculation for future clinical trials assessing the role of cardioprotective therapy.
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Affiliation(s)
- Prajith Jeyaprakash
- Department of Cardiology Nepean Hospital Sydney New South Wales Australia.,Sydney Medical School Nepean Faculty of Medicine and Health Charles Perkins Centre NepeanThe University of Sydney Penrith New South Wales Australia
| | - Sukhmandeep Sangha
- Department of Cardiology Nepean Hospital Sydney New South Wales Australia.,Sydney Medical School Nepean Faculty of Medicine and Health Charles Perkins Centre NepeanThe University of Sydney Penrith New South Wales Australia
| | - Katherine Ellenberger
- Department of Cardiology Nepean Hospital Sydney New South Wales Australia.,Sydney Medical School Nepean Faculty of Medicine and Health Charles Perkins Centre NepeanThe University of Sydney Penrith New South Wales Australia
| | - Shanthosh Sivapathan
- Department of Cardiology Nepean Hospital Sydney New South Wales Australia.,Sydney Medical School Nepean Faculty of Medicine and Health Charles Perkins Centre NepeanThe University of Sydney Penrith New South Wales Australia
| | - Faraz Pathan
- Department of Cardiology Nepean Hospital Sydney New South Wales Australia.,Sydney Medical School Nepean Faculty of Medicine and Health Charles Perkins Centre NepeanThe University of Sydney Penrith New South Wales Australia
| | - Kazuaki Negishi
- Department of Cardiology Nepean Hospital Sydney New South Wales Australia.,Sydney Medical School Nepean Faculty of Medicine and Health Charles Perkins Centre NepeanThe University of Sydney Penrith New South Wales Australia
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Geenty P, Sivapathan S, Stefani L, Zada M, Taylor M, Kwok F, Thomas L. The Prognostic Value of Left Atrial Volume in AL Amyloidosis. Heart Lung Circ 2021. [DOI: 10.1016/j.hlc.2021.06.110] [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] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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10
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Pathan F, Lam P, Sivapathan S, Orde S, Nanan R, Negishi K. The impact of maternal diabetes on fetal left atrial size and function. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.0125] [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
The developmental impact of maternal diabetes on the fetal left atrium (LA) is unclear.
Purpose
To determine if maternal diabetes mellitus (DM) impacts fetal LA size and function (fetal LA strain (LAS)).
Methods
We evaluated LA area (LAA) and LAS on fetuses of diabetic and control mothers who attended a mandated 24 week fetal morphology scan. Participants were excluded from the study if: there was a history of pre-eclampsia or if the fetus did not have adequate images for LAS analysis
We used fetal cardiac 4-chamber view for analysis. A region of interest was drawn along the LA endocardial border for tracking and was used for assessment of maximum LAA.
Baseline variables were compared using Student t test or Mann-Whitney U test and are presented as Mean ± Standard Deviation or Median (Interquartile range (IQR)). Body mass index (BMI), maternal age, gestational age, fetal heart rate (FHR), smoking status, estimated fetal weight (EFW) and Maternal DM were analysed in univariate and multivariate models with respect to LAA and LAS.
Results
160 pregnant women (50 controls, 110 diabetics) were scanned. 9 were excluded due to poor image quality, resulting in 104 mothers with diabetes (T1DM 9, T2DM 8, and gestational DM 87) and 47 controls without diabetes.
The mothers were well matched for age, blood pressure, smoking prevalence and gestational age. The diabetic mothers had a significantly higher BMI: Median (IQR) ((30.4 kg/m2 (25.1–34.8) vs 20.8 kg/m2 (21.4–27.4), p<0.001) and had higher weight (77 kg (65–93) vs 64 kg (62–68), p<0.001).
FHR was higher in fetuses of diabetic mothers (147±10 vs 144±8, p 0.04). Maternal DM resulted in larger LAA 1.68 cm2±0.39 cm2 vs 1.56 cm2±0.36 cm2; p=0. 08, however the result was not significant. The LAS was significantly lower in fetuses with maternal DM compared to fetuses of controls: 28.8% ± 8.8% vs 32.3% ± 9.2%; p 0.033.
On multivariate analysis (Table 1), the predictors of LAS were Maternal DM and FHR and predictors of LAA were EFW and Maternal DM.
Conclusions
Maternal diabetes modulates both LA size and LA function. The association between LA function and FHR may provide an explanation for fetal tachycardia in Maternal DM.
Fetal left atrial strain
Funding Acknowledgement
Type of funding source: None
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Affiliation(s)
- F Pathan
- University of Sydney, Department of Cardiology, Nepean Hospital, Sydney, Australia
| | - P Lam
- University of Sydney, Charles Perkins Centre, Sydney, Australia
| | - S Sivapathan
- University of Sydney, Department of Cardiology, Nepean Hospital, Sydney, Australia
| | - S Orde
- Nepean Hospital, Department of Intensive Care, Sydney, Australia
| | - R Nanan
- University of Sydney, Charles Perkins Centre, Sydney, Australia
| | - K Negishi
- University of Sydney, Department of Cardiology, Nepean Hospital, Sydney, Australia
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11
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Jeyaprakash P, Sangha S, Robeldo K, Ellenberger K, Sivapathan S, Pathan F, Negishi K. The role of cardio-protective agents in breast cancer patients to prevent anthracycline induced cardiotoxicity: a systematic review and network meta-analysis. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.3291] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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
Background
Anthracycline (ANT)-based chemotherapy for breast malignancies have significantly improved cancer outcomes. However, the cardiotoxicity induced by ANTs in the breast cancer population has increased major adverse cardiac events. While randomised controlled trials (RCTs) have explored different primary preventative agents to confer cardio-protection pre chemotherapy, comparisons between agents has been limited. It is unclear which drug is the most efficacious in preserving Left Ventricular Ejection Fraction (LVEF) amongst this population.
Purpose
To perform a network meta-analysis of RCTs comparing the impact on LVEF of various prophylactic cardio-protective agents, when prescribed to breast cancer patients prior to ANT-based chemotherapy.
Methods
Two independent authors performed a literature search as per the PRISMA guidelines using four databases (CENTRAL, Cochrane Reviews, MEDLINE, SCOPUS), to find RCTS evaluating cardio protective agents. The trial population was limited to patients with breast cancer without prior ANT exposure. Trials were only included if the cardio-protective agents were commenced prior to ANT dosing. The assessed outcome was a mean change in LVEF pre and post ANT dosing, compared to placebo prevention. Extracted data included age, ANT dose, and LVEF pre and post chemotherapy. The Cochrane Risk of Bias tool was used to appraise included RCTs.
Results
From 2807 search results, we identified twelve RCTs which evaluated 1126 patients. Seven studies assessed beta-blockers alone and two assessed combination ACE inhibitors and beta blockers. Individual studies assessing ACE inhibitors, spironolactone or rosuvastatin alone were also included. All patients were female with an average age of 50.5 and average ANT dose of 412 mg/m2. Our network meta-analysis showed beta-blockers showed significant protection with higher LVEF than placebo by 2.38% [0.52, 4.25]. ACE inhibitors showed a similar magnitude of LVEF preservation 2.59% [−0.20, 5.38] but not statistically significant due to wider CI because of lower sample size (n=250). Spironolactone showed a statistically significant preservation in LVEF by 12.80% [3.44, 22.16], however this was based on a single study (n=83), with marked measurement bias and deviations from intended intervention. All included trials had an intermediate or high risk of bias, with marked heterogeneity in ANT dosing and LVEF monitoring.
Conclusion
Beta-blockers minimise LVEF decline when administered prior to anthracycline chemotherapy, compared against alternate agents. Data may be underpowered to demonstrate the benefit of ACE inhibitor and combination beta blocker/ACE inhibitor prescription. The quality of RCT data to date is limited by a high risk of bias and significant heterogeneity between RCA reporting. This analysis is likely to inform clinical practice, and allow clinicians to prescribe primary cardio-protection in patients at high risk of cardiotoxicity.
Funding Acknowledgement
Type of funding source: None
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Affiliation(s)
| | - S Sangha
- Nepean Hospital, Sydney, Australia
| | - K Robeldo
- University of Sydney, Sydney, Australia
| | | | | | - F Pathan
- Nepean Hospital, Sydney, Australia
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12
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Deshmukh T, Geenty P, Geraghty L, Emmerig D, Sivapathan S, Hogg M, Brown P, Panicker S, Altman M, Gottlieb D, Thomas L. P790 Bi-ventricular dysfunction in patients after bone marrow transplant: the value of strain imaging. Eur Heart J Cardiovasc Imaging 2020. [DOI: 10.1093/ehjci/jez319.447] [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
Background
Cardiovascular events are a significant cause of morbidity and mortality in cancer survivors, particularly occurring at 5-10 years after their cancer therapy.
Purpose
To assess the utility of strain imaging by 2-dimensional (2D) speckle tracking echocardiography in detecting bi-ventricular dysfunction, as compared to traditional measures, in patients post bone marrow transplantation (BMT) with previous anthracycline (AC) therapy for haematological conditions.
Methods
50 consecutive patients post BMT + AC, reviewed at a long-term survivor clinic, were compared to 50 age and gender matched controls. 48/50 patients received AC doses below the recommended cumulative lifetime thresholds set by the European Society of Medical Oncology. 2D left ventricular global longitudinal strain (LV GLS) and right ventricle free wall strain (RV FWS) were compared to conventional measures of bi-ventricular function.
Results
The mean LVEF (58 ± 6% vs 63 ± 6%) and RV fractional area change (FAC) (39 ± 5% vs 44 ± 5%), although reduced in the BMT + AC group vs controls, were within normal limits. LV GLS was reduced in BMT + AC patients as compared to controls (-17.8 ± 3.1% vs -20.5 ± 2.2%, p < 0.01) while RV FWS was also reduced (-23.2 ± 4.0% vs -27.9 ± 2.7%, p < 0.001). In BMT + AC patients with a preserved LVEF (LVEF > 53%), 28% (11/40) had reduced GLS (GLS < -17%) while 52% (24/46) of those with preserved FAC (FAC > 35%) had reduced FWS (FWS < -25%). Major adverse cardiac events (MACE) occurred in 9/50 patients in the BMT + AC group and none in the control group. 8/9 patients had normal biventricular function as assessed by traditional parameters (LVEF and RV FAC) but 5/9 patients had reduced LV GLS and/or RV FWS.
Conclusions
Subclinical bi-ventricular dysfunction is common in patients post BMT + AC therapy, and can be detected using strain analysis, despite preserved LV and RV systolic function using conventional measures. MACE occurred at a significantly higher rate in BMT patients exposed to AC. More than half of MACE events occurred in patients with reduced LV or RV strain, with preserved bi-ventricular function by traditional measures. LV GLS and RV FWS should be utilised for early identification of subclinical dysfunction in BMT patients.
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Affiliation(s)
- T Deshmukh
- Westmead Hospital, Cardiology, Sydney, Australia
| | - P Geenty
- Westmead Hospital, Cardiology, Sydney, Australia
| | | | - D Emmerig
- Westmead Hospital, Sydney, Australia
| | - S Sivapathan
- Westmead Hospital, Cardiology, Sydney, Australia
| | - M Hogg
- Westmead Hospital, Haematology, Sydney, Australia
| | - P Brown
- Westmead Hospital, Cardiology, Sydney, Australia
| | - S Panicker
- Westmead Hospital, Cardiology, Sydney, Australia
| | - M Altman
- Westmead Hospital, Cardiology, Sydney, Australia
| | - D Gottlieb
- Westmead Hospital, Haematology, Sydney, Australia
| | - L Thomas
- Westmead Hospital, Cardiology, Sydney, Australia
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13
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Pathan F, Lam P, Sivapathan S, Orde S, Negishi K, Nanan R. P1378 Impact of maternal diabetes on fetal left atrial function. Eur Heart J Cardiovasc Imaging 2020. [DOI: 10.1093/ehjci/jez319.812] [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/Introduction: Diabetes impacts 12- 14% of pregnancies. Evaluating the impact of maternal diabetes on the fetal heart is challenging due to variable image quality and limited time for structural changes to manifest. Left atrial reservoir strain (ER) is a sensitive marker of early left atrial dysfunction which may elucidate fetal atrial dysfunction resulting from maternal diabetes.
Purpose
We sought to evaluate if fetal ER can detect impairment of left atrial function in the fetal heart as a result of maternal diabetes.
Methods
We performed a prospective observational study evaluating patients who were referred to the high risk pregnancy service as a result of maternal diabetes (pre-existing or gestational) and healthy controls.
Patients were excluded if adequate imaging of the fetal myocardium was not possible. Baseline characteristics of the mother and cardio-metabolic risk factors were recorded.
The fetal echocardiogram focused on the 4 chamber view. We used the 4 chamber view with closure of the mitral valve as the zero reference point (R-R) gating. The strain curves from 6 atrial segments were averaged.
Normality of the data was assessed using the Shapiro-Wilk test. The Mann-Whitney U test was used to compare ER between fetuses, whose mothers had diabetes versus those fetuses whose mothers were healthy controls.
Results
A total of 120 fetal scans were performed. 5 were excluded due to poor image quality, which prevented strain analysis. 115 fetal scans were analysed (87 with maternal diabetes and 27 healthy controls). The diabetic subjects and controls did not defer significantly in age Mean ± SD (31± 5 vs 30± 5, p= 0.81). The mothers with diabetes had a higher body mass index than controls (Median [IQR]) (30.5 kg/m2 [25.1, 35.3] vs 24.6 kg/m2 [22.1, 28.6] p < 0.001).
The presence of maternal diabetes resulted in lower fetal ER (28.5% [22.1, 36.2] vs 33.4% [26.6, 41.6] P = 0.01).
Figure 1 illustrates the Box-Whisker plot comparing Fetal ER between fetuses exposed to maternal diabetes and fetuses where mothers were healthy controls.
Conclusion
The presence of maternal diabetes results in impaired fetal left atrial function as measured by fetal left atrial strain (ER).
Abstract P1378 Figure 1
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Affiliation(s)
- F Pathan
- University of Sydney, Department of Cardiology, Nepean Hospital, Sydney, Australia
| | - P Lam
- Nepean Hospital, Sydney, Australia
| | | | - S Orde
- Nepean Hospital, Sydney, Australia
| | - K Negishi
- University of Sydney, Department of Cardiology, Nepean Hospital, Sydney, Australia
| | - R Nanan
- University of Sydney, Charles Perkins Centre, Sydney, Australia
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14
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Paul V, Joseph A, Sivapathan S, Madronio C, Pathan F. 644 The Impact of a Nurse Led Heart Failure Optimization Clinic. Heart Lung Circ 2020. [DOI: 10.1016/j.hlc.2020.09.651] [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] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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15
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Ellenberger K, Neigishi K, Thai W, Jeyaprakash P, Sivapathan S, Pathan F. 278 A Real World Comparison of Body Surface Area Formulae. Heart Lung Circ 2020. [DOI: 10.1016/j.hlc.2020.09.285] [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] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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16
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Geenty P, Sivapathan S, Deshmukh T, Brown P, Boyd A, Kwok F, Richards D, Altman M, Stewart G, Thomas L. P309 The use of echocardiographic parameters to predict clinical outcomes in AL-amyloidosis cardiomyopathy. Eur Heart J Cardiovasc Imaging 2020. [DOI: 10.1093/ehjci/jez319.162] [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
AL-amyloidosis has a rapid clinical progression, with cardiac involvement associated with a particularly poor prognosis. Cardiac amyloidosis is diagnosed by either invasive biopsy or conventional echocardiographic parameters such as increased wall thickness, in the absence of other causes. More recently, novel parameters including 2D longitudinal strain have demonstrated diagnostic utility in a range of infiltrative cardiomyopathies including cardiac amyloidosis.
Aim/Method: We sought to evaluate traditional and novel echocardiographic parameters in their ability to predict adverse outcomes in a cohort of AL-amyloid patients. 80 patients who had transthoracic echocardiograms at a single centre were included. Comprehensive echocardiographic assessment was performed, including left ventricular ejection fraction (LVEF), LV Global Longitudinal Strain (GLS), LV mass (indexed to BSA). The primary endpoint was a composite of of major adverse cardiac events (MACE) and all-cause mortality, that was assessed by interrogation of the medical records on a specified censor date.
Results
At a mean follow-up (time from echo to censor date) of 5.4 ± 2.6years, 38/80 (47.5%) of patients experienced the primary endpoint of MACE or death, of which 25/80 (31%) were deaths. LVEF (59 ± 5.6%vs56 ± 6.4%, p = 0.04), GLS (17.4 ± 3.9%vs14.8 ± 4.9%, p = 0.01) basal longitudinal strain (12.3 ± 3.2%vs9.6 ± 3.9%, p = 0.002), indexed LV mass (107 ± 36g/m2vs130 ± 34g/m2, p = 0.06) and E/E’ (13.7 ± 4.9vs20.6 ± 9.6, p < 0.001) were all significantly different between patients who experienced the primary endpoint and those that didn’t. The strongest predictors of outcome were E/E’ (AUC 0.74), LV mass (AUC 0.73) and the ratio GLS:LV mass (AUC 0.73). An E/E’ of 15 had a sensitivity of 71% and specificity of 69%, while an indexed LV mass of 108 had a sensitivity and specificity of 74% and 67% respectively. GLS to LV mass as a cutoff of 0.16 had a sensitivity and specificity of 70% and 69% respectively.
Conclusion
In a cohort of 80 patients with AL-amyloid cardiomyopathy, almost half (47.5%) reached the primary composite endpoint. Diastolic dysfunction as expressed as E/E’, and LV mass were the most powerful predictors of outcome, while global longitudinal strain and LV basal strain were also reduced, and showed superiority over LV ejection fraction in predicting prognosis.
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Affiliation(s)
- P Geenty
- Westmead Hospital, Sydney, Australia
| | | | | | - P Brown
- Westmead Hospital, Sydney, Australia
| | - A Boyd
- Westmead Private Hospital, Cardiology Department, Sydney, Australia
| | - F Kwok
- Westmead Hospital, Sydney, Australia
| | - D Richards
- Westmead Private Hospital, Cardiology Department, Sydney, Australia
| | - M Altman
- Westmead Hospital, Sydney, Australia
| | - G Stewart
- Westmead Hospital, Sydney, Australia
| | - L Thomas
- Westmead Hospital, Sydney, Australia
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17
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Jeyaprakash P, Khor L, Madan K, Sivapathan S, Hill L, Robledo K, Hallani H, Roy P, Ellenberger K, Jepson N, Roy J, Pressley L, Patal S, Thomas L, French J, Burgess S. 887 STEMI in the Time of COVID-19: NSW Data. Heart Lung Circ 2020. [PMCID: PMC8435296 DOI: 10.1016/j.hlc.2020.09.894] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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18
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Vilcek J, Moussad A, Sivapathan S, Jeyaprakash P, Negishi K, Pathan F. 333 Echocardiography Reporting in Ischaemic Heart Disease and Compliance With European Association Cardiovascular Imaging (EACVI) Recommendations. Heart Lung Circ 2020. [DOI: 10.1016/j.hlc.2020.09.340] [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] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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19
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Deshmukh T, Geenty P, Geraghty L, Emmerig D, Sivapathan S, Hogg M, Brown P, Panicker S, Altman M, Gottlieb D, Thomas L. Biventricular Dysfunction in Patients After Bone Marrow Transplant. JACC CardioOncol 2019; 1:301-304. [PMID: 34396195 PMCID: PMC8352188 DOI: 10.1016/j.jaccao.2019.11.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Liza Thomas
- Department of Cardiology, Hawkesbury Road, Westmead Hospital, Westmead 2145, Sydney NSW, Australia
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20
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Ellenberger K, Kitley J, Jeyaprakash P, Darshni A, Sangha S, Sivapathan S, Pathan F. THE RELATIONSHIP BETWEEN OBESITY AND ECHOCARDIOGRAPHIC IMAGE QUALITY: A CASE FOR CONTRAST. J Am Coll Cardiol 2019. [DOI: 10.1016/s0735-1097(19)32219-3] [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: 10/27/2022]
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21
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Deshmukh T, Geraghty L, Emmerig D, Sivapathan S, Hogg M, Panicker S, Brown P, Altman M, Gottlieb D, Thomas L. Alterations in Multiplanar Strain in Bone Marrow Transplant Patients Previously Treated with Anthracyclines. Heart Lung Circ 2019. [DOI: 10.1016/j.hlc.2019.06.240] [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] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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22
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Geenty P, Sivapathan S, Deshmukh T, Boyd A, Brown P, Altman M, Kwok F, Stewart G, Richards D, Thomas L. Right Ventricular Dysfunction in AL-Amyloidosis Cardiomyopathy. Heart Lung Circ 2019. [DOI: 10.1016/j.hlc.2019.06.318] [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] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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23
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Sivapathan S, Boyd A, Deshmukh T, Kwok F, Altman M, Stewart G, Richards D, Denniss A, Thomas L. Relative Apical Sparing Using Longitudinal Strain to Diagnose Cardiac Amyloidosis. Heart Lung Circ 2018. [DOI: 10.1016/j.hlc.2018.06.505] [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] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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24
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Deshmukh T, Geragthy L, Sivapathan S, Hogg M, Do L, Brown P, Panicker S, Altman M, Gottlieb D, Thomas L. Strain Analysis Identifies Subclinical Left Ventricular Dysfunction in Patients who have had a Bone Marrow Transplant. Heart Lung Circ 2018. [DOI: 10.1016/j.hlc.2018.06.518] [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] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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25
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Sivapathan S, Boyd A, Deshmukh T, Kwok F, Altman M, Stewart G, Richards D, Robert Denniss A, Thomas L. Multi-Layer Strain as a Useful Technique to Identify Cardiac Amyloidosis. Heart Lung Circ 2018. [DOI: 10.1016/j.hlc.2018.06.478] [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] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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