Left ventricular aneurysm associated with apical hypertrophic cardiomyopathy

Clinical Outcomes of Myocardial Bridging versus No Myocardial Bridging in Patients with Apical Hypertrophic Cardiomyopathy

Objective: To determine the prevalence and clinical effects of myocardial bridging (MB) in patients with apical hypertrophic cardiomyopathy (AHCM). Methods: Angiograms from 212 AHCM patients were reviewed to identify MB. The patients were classified into 2 groups: AHCM with and AHCM without MB. We reviewed patient records on cardiovascular (CV) risk factors, symptoms, CV events, and CV mortality. Results: In all, 60 patients with MB and 100 without MB were included. Rates of angina (61.7 vs. 40%; p = 0.008), mimicking non-ST-segment elevation myocardial infarction (15 vs. 3%, p = 0.013), and Canadian Cardiovascular Society class III/IV angina (18.3 vs. 4%; p = 0.003) were higher in patients with MB than in those without. Mean follow-up periods (65.5 ± 50.5 vs. 64.4 ± 43.6 months, p = 0.378) and CV mortality (3.3 vs. 1%; p = 0.652) were similar in the 2 groups. Kaplan-Meier estimates demonstrated that CV event-free survival rates were lower in patients with MB than in those without (71.7 vs. 88%; p = 0.022). MB, late gadolinium enhancement, and female sex were independent risk factors for CV events in a multivariate Cox regression analysis adjusted for other risk factors. Conclusion: More serious symptoms and a higher risk of CV events were observed in AHCM patients with MB than in those without MB. CV mortality was similar in these 2 groups.

Impact of coronary artery anatomy on clinical course and prognosis in apical hypertrophic cardiomyopathy: analysis of coronary angiography and computed tomography

Background and Objectives

Apical hypertrophic cardiomyopathy (AHCM) is an uncommon variant of hypertrophic cardiomyopathy with a relatively benign course. However, the prognostic factors of AHCM-particularly those associated with coronary artery disease (CAD) and its anatomical subtypes-are not well known.

Subjects and Methods

We enrolled 98 consecutive patients with AHCM who underwent coronary angiography or coronary computed tomography scanning at two general hospitals in Korea from January 2002 to March 2012. Patient charts were reviewed for information regarding cardiovascular (CV) risk factors, symptoms, and occurrence of CV events and/or mortality. We also reviewed echocardiographic data and angiography records.

Results

The mean age at the time of enrollment was 61.45±9.78 years, with female patients comprising 38.6%. The proportions of mixed and pure types of AHCM were 34.4% and 65.6%, respectively. CAD was found in 31 (31.6%) patients. The mean follow-up period was 53.1±60.7 months. CV events occurred in 22.4% of patients, and the mortality rate was 5.1%. The mixed-type was more frequent in CV event group although this difference was not statistically significant (50% vs. 30%, p=0.097). The presence of CAD emerged as an independent risk factor for CV events in univariate and multivariate Cox regression analysis after adjusting for other CV risk factors.

Conclusion

Coronary artery disease is an independent risk factor for CV events in AHCM patients. However, AHCM without CAD has a benign natural course, comparable with the general population.

Hypertrophic Cardiomyopathy in a Young Adult with RV Aneurysm: Report of a Rare Finding and Review of the Literature

We report a case of a 22-year-old patient with a severe form of hypertrophic cardiomyopathy involving both ventricles, for which he underwent surgical treatment. Echocardiogram and magnetic resonance imaging confirmed the presence of an aneurysm in the inferior-anterior portion of the right ventricle.

Clinical and echocardiographic predictors of outcomes in patients with apical hypertrophic cardiomyopathy

Apical hypertrophic cardiomyopathy (HC) is considered to have a favorable prognosis, but recent observations have suggested less benign clinical courses. We investigated the outcomes in patients with apical HC and evaluated the predictors. All 454 patients with apical HC (316 men, age 61 ± 11 years) were recruited. Major cardiovascular events (MACE) were defined as unplanned hospitalization because of heart failure, stroke, or cardiovascular mortality. The patients were divided into 2 groups: group 1 with MACE and group 2 without MACE. During the follow-up period (43 ± 20 months), the all-cause mortality rate was 9% (39 of 454), and 110 patients (25%) had MACE. The subjects in group 1 were older and a greater proportion had diabetes, hypertension, and atrial fibrillation. On the echocardiogram, the left atrial volume index (left atrial volume index 36 ± 17 vs 31 ± 12 ml/m(2)), transmitral E velocity (65 ± 17 vs 61 ± 16 cm/s), mitral annulus Ea velocity (4.5 ± 1.4 vs 5.1 ± 1.8 cm/s), Sa velocity (5.8 ± 1.4 vs 6.6 ± 1.4 cm/s), E/Ea ratio (15 ± 5 vs 13 ± 5), and right ventricular systolic pressure (31 ± 8 vs 28 ± 7 mm Hg) were significantly different between groups 1 and 2 (p <0.05 for all). The left atrial volume index (for each 1-ml/m(2) increase, hazard ratio 1.01, 95% confidence interval 1.00 to 1.03; p = 0.047), Sa velocity (hazard ratio 0.83, 95% confidence interval 0.72 to 0.96, p = 0.014), and E/Ea ratio (hazard ratio 1.04, 95% confidence interval 1.00 to 1.09, p = 0.030) were independent predictors of a poor prognosis, along with age and the presence of diabetes or hypertension. In conclusion, the clinical outcomes of patients with apical HC were less benign in older patients and in those with hypertension or diabetes. In addition, the left atrial volume index, Sa velocity, and E/Ea ratio were predicters of a poor prognosis in patients with apical HC.

Two hundred eight patients with apical hypertrophic cardiomyopathy in china: clinical feature, prognosis, and comparison of pure and mixed forms

BACKGROUND

Apical hypertrophic cardiomyopathy (AHCM) is a relatively rare form of hypertrophic cardiomyopathy (HCM), originally described in Japan and later in the West. Limited information is available on this disease in China.

HYPOTHESIS

This study was designed to describe clinical features and prognoses of patients with AHCM in China.

METHODS

A retrospective study of 208 consecutive patients with AHCM examined at FuWai Hospital was performed. Clinical features, mortality, and cardiovascular morbidity were analyzed.

RESULTS

The 208 patients with AHCM represented 16.0% of all HCM patients. Among them, 64.4% were pure form and 35.6% were mixed form. Compared with the pure group, the mixed group had a significantly larger left atrial diameter and thicker apical thickness. One hundred ninety-nine patients had a mean follow-up of 8.0 ± 3.5 years, cardiovascular mortality was 1.0%, and annual cardiovascular mortality was 0.1%. The 2 cardiovascular deaths were both mixed form. The probability of survival was 97.0 ± 2% at 10 years. Of the patients, 17.8% had 1 or more cardiovascular events. The probability of survival without morbid events at 10 years was 77 ± 4%. Three independent predictors of cardiovascular morbidity were identified: age at diagnosis ≥60 years, left atrial diameter ≥36 mm, and New York Heart Association class ≥III at baseline.

CONCLUSIONS

The prevalence of AHCM is relatively high, and it has a benign prognosis in China. However, 17.8% of patients may develop cardiovascular events. It is important to distinguish the 2 phenotypes of AHCM; the mixed form is less common but more serious than the pure form.

Severe symptoms in mid and apical hypertrophic cardiomyopathy

BACKGROUND

We analyzed the clinical and quantitative echocardiographic characteristics of patients with sub-basal hypertrophic cardiomyopathy (HCM) to define the characteristics of patients (pts) with severe symptoms.

METHODS

Of 444 pts in a referral-based HCM program, 22 (5%) had midventricular or apical HCM. Quality of life (QoL) questionnaire was administered as an independent confirmer of symptomatic state.

RESULTS

Ten pts were NYHA III and IV, and 12 pts were NYHA I and II; QoL scores (41 +/- 26 vs. 10 +/- 13, P = 0.001) confirmed a priori division of two groups based on NYHA classification. Pts with more severe symptoms were more likely female (70% vs. 25%, P = 0.001) with atrial fibrillation (40% vs. 0%, P = 0.02). They more frequently had midventricular HCM 60% versus 8% (P = 0.01) (mid-LV thickness 17 +/- 6 vs. 12 +/- 2 mm, P = 0.03) and had much smaller LV diastolic volumes 68 +/- 12 versus 102 +/- 22 ml (39 +/- 4 vs. 53 +/- 12 ml/m(2), P = 0.001). Septal E/E' was higher in the severely symptomatic pts (15 +/- 5 vs. 7 +/- 3, P = 0.001) indicating higher estimated LV filling pressure. Midobstruction with apical akinetic chamber was noted in 4/10 pts who developed refractory symptoms. Cardiac mortality was higher in the severely symptomatic patients, 4/10 who had midventricular HCM as compared to 0/12 in the mildly symptomatic apical HCM group (P = 0.03).

CONCLUSIONS

In subbasal HCM, pts with severe symptoms have midventricular hypertrophy, with encroachment of the LV cavity and consequent very small LV volumes that may be complicated by mid-LV obstruction. Pts with mid-LV hypertrophy are more symptomatic than those with apical HCM, are often refractory to therapy, and have higher mortality.

Clinical features and outcome of patients with apical hypertrophic cardiomyopathy in Taiwan

OBJECTIVES

The aim of this study was to analyze clinical characteristics and the outcome of patients with apical hypertrophic cardiomyopathy (ApHCM) followed in a Taiwan tertiary referral medical center.

BACKGROUND

ApHCM is regarded as a subgroup of nonobstructive HCM that occurs largely in Japanese patients. The clinical features, gender differences and prognosis of the disease in Taiwan are poorly understood.

METHODS

A retrospective cohort study with 40 patients was performed. Diagnosis was based on the demonstration of left ventricular hypertrophy by echocardiography. Clinical features, cardiovascular morbidity and mortality were analyzed. Multiple logistic regression was used to adjust for potential confounding factors.

RESULTS

Among 40 patients, males predominated with a percentage of 75%. The female patients obviously had later onset of presentation (mean age +/- SD, 62.2 +/- 5.7 vs. 54.1 +/- 11.4 years; p = 0.038). During a mean follow-up of 72.2 +/- 60.1 months, there was no mortality. However, 13 patients (32.5%) had one or more major cardiovascular morbidities, the most frequent being syncope or near syncope (15%) and ischemic stroke-associated atrial fibrillation (10%). In a multivariate analysis, left atrial enlargement (odds ratio 5.85, 95% CI 1.15-29.40; p = 0.034) was the only predictor of cardiovascular morbidity.

CONCLUSIONS

Patients with ApHCM in Taiwan have a benign clinical course without association with sudden death and cardiovascular mortality. Left atrial enlargement was the only identified predictor of cardiovascular morbidity

Sustained cavity obliteration and apical aneurysm formation in apical hypertrophic cardiomyopathy

OBJECTIVES

In patients with apical hypertrophic cardiomyopathy (ApHCM), we estimated the severity of cavity obliteration (CO) in the apical potion of the left ventricle and correlated it with various clinical findings including apical aneurysm.

BACKGROUND

Apical hypertrophic cardiomyopathy sometimes develops apical aneurysm. The apical CO is often exhibited in ApHCM along with apical hypertrophy and ischemia. It remains unclear, however, how the CO and others are related to aneurysm.

METHODS

In 46 patients with ApHCM, we measured CO time on M-mode echocardiography and corrected it by the R-R interval (cCOT). We divided the 46 patients into the following groups: 17 with cCOT <or=200 ms (no/mild CO group); 18 with cCOT >200 to <or=350 ms (moderate CO group); and 11 with cCOT >350 ms (severe CO group). We then compared apical aneurysm, hypertrophy, ischemia, QT interval, and the like between the three groups.

RESULTS

The severe CO group exclusively comprised 11 patients having apical aneurysm and paradoxic jet flow. Of the 11 patients, 10 exhibited irreversible defects on exercise single photon emission computed tomography with thallium-201. All with moderate CO showed reversible defects, and none with no/mild CO showed any defects. Left ventricular hypertrophy and the corrected QT interval (QTc) were largest in the severe CO group. There were high correlations between the cCOT, hypertrophy, ischemia, and QTc. Of the 11 patients with severe CO, 6 had nonsustained ventricular tachycardia and 1 had mural thrombus.

CONCLUSIONS

In ApHCM, sustained CO is an important pathophysiologic condition as well as hypertrophy, ischemia, and prolonged QTc, which are considered jointly related to the development of aneurysm through interactions.

Left ventricular aneurysm, aortic valve disease and coronary narrowing in a patient with Hunter's syndrome

Hunter's syndrome (mucopolysaccharidosis type 2, MPS 2) is an inherited disorder of glycosaminoglycan degradation commonly associated with cardiac disease. We present the case of a young man with unusual cardiac manifestations of this syndrome. When mixed aortic valve disease was noted in childhood, other classical features of the milder form of Hunter's syndrome were present. There was no symptomatic or echocardiographic cardiovascular deterioration until age 27 when the patient presented in severe biventricular failure. Investigations demonstrated cardiomegaly and a large apical left ventricular aneurysm. The patient died suddenly soon after this diagnosis. Post mortem examination demonstrated a hypertrophied left ventricle with a 6-cm apical aneurysm. Coronary arterial walls were diffusely thickened but with only mild lumenal stenosis. Mitral and aortic valve disease was also present. There is one previous report of ventricular aneurysm in Hunter's syndrome. Pathophysiological contributions to aneurysm formation may include abnormal coronary flow, the presence of aortic stenosis and abnormal myocardium. This patient's sudden deterioration after a long period of clinical stability reinforces the need for careful follow-up of patients with cardiac manifestations of Hunter's disease.

Long-term outcome in patients with apical hypertrophic cardiomyopathy

OBJECTIVES

The aim of this study was to describe long-term outcome in patients with apical hypertrophic cardiomyopathy (ApHCM) followed in a tertiary referral center.

BACKGROUND

Apical hypertrophic cardiomyopathy is a relatively rare form of hypertrophic cardiomyopathy (HCM), first described in Japan. Initial reports, based on a limited number of patients, emphasized the benign nature of this condition.

METHODS

A retrospective study of 105 patients with ApHCM diagnosed at the Toronto General Hospital from 1975 to 2000 was performed. Symptoms, clinical findings, mortality and cardiovascular morbidity were analyzed.

RESULTS

The mean age at presentation was 41.4 +/- 14.5 years. During a mean follow-up of 13.6 +/- 8.3 years from presentation, cardiovascular mortality was 1.9% (2/105) and annual cardiovascular mortality was 0.1%. Overall survival was 95% at 15 years. Thirty-two patients (30%) had one or more major morbid events, the most frequent being atrial fibrillation (12%) and myocardial infarction (10%). Probability of survival without morbid events was 74% at 15 years. Three predictors of cardiovascular morbidity were identified: age at presentation <41 years, left atrial enlargement, and New York Heart Association (NYHA) class > or = II at baseline. Forty-four percent of the patients were asymptomatic at the time of last follow-up.

CONCLUSIONS

Apical hypertrophic cardiomyopathy in North American patients is not associated with sudden cardiac death and has a benign prognosis in terms of cardiovascular mortality. Nevertheless, one third of these patients experience serious cardiovascular complications, such as myocardial infarction and arrhythmias. These data are likely to influence the counseling and management of patients with ApHCM.

Prognostic significance of left ventricular aneurysms with normal global function caused by myocarditis

OBJECTIVES

To evaluate the prognosis of left ventricular (LV) aneurysms with normal global function caused by myocarditis.

BACKGROUND

LV aneurysms may result from idiopathic or viral myocarditis. The prognosis of inflammatory LV aneurysms when associated with a normal cardiac function is unknown.

METHODS

Among 353 patients with a histologic diagnosis of myocarditis, 12 (3.3%) had single or multiple localized LV aneurysms (length, 10.6 +/- 3.1 mm; width, 7.4 +/- 4.2 mm) with normal cardiac function. Presenting symptoms were ventricular tachycardia (VT) in nine patients and unexplained chest pain in three. All patients underwent laboratory tests and noninvasive and invasive cardiac examinations, including biventricular endomyocardial biopsy.

RESULTS

In all patients, LV endomyocardial biopsy specimen showed a lymphocytic myocarditis with focal intense myocytolysis or damage of intramural vessels, whereas right ventricular biopsy was diagnostic for myocarditis only in three. Serologic study suggested a viral infection in 3 patients and an immunologic disorder in 2, although it was negative in 7. Treatment included antiarrhythmics in 9 patients with VT, ss-blockers in 1 with chest pain, and immunosuppression (prednisone and azathioprine for 5 months) in 4 with active myocarditis (2 with chest pain and 2 with VT). At intermediate-term follow-up (mean, 53 months; range, 12 to 120 months), LV function was persistently normal in all patients, with an LV aneurysm occlusion being observed in two patients. All patients were asymptomatic, with no VT recurrence or major clinical events. None required implantable electrical devices or a surgical intervention.

CONCLUSIONS

LV aneurysms with normal global function caused by myocarditis are an uncommon benign entity in which major therapeutic regimens are usually unnecessary.

Apical hypertrophic cardiomyopathy: a study of 14 patients and their first degree relatives

Although apical hypertrophic cardiomyopathy is generally accepted as a form of hypertrophic cardiomyopathy, its underlying genetic factors, clinical course and complications may be different. The characteristics of 14 Brazilian patients with a diagnosis of apical hypertrophic cardiomyopathy are described. Symptoms were frequent and abnormal filling of the left ventricle by Doppler criteria was recorded in all patients. Rest electrocardiograms showed giant negative T waves in 5 patients, all had low exercise capacity on an exercise stress test while significant arrhythmias were detected by 24-h ambulatory monitoring in just one patient. Forty-eight first degree relatives were studied and 3 had some form of hypertrophy of the left ventricle as seen by echocardiography. Apical hypertrophic cardiomyopathy in Brazilians seems to be expressed somewhat differently from that reported in Japanese patients, since "giant' T waves are less frequent and women more involved.