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Electroanatomic Properties of the Myocardium Predict Response to CD34+ Cell Therapy in Patients With Ischemic and Nonischemic Heart Failure. J Card Fail 2017; 23:153-160. [DOI: 10.1016/j.cardfail.2016.08.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 07/24/2016] [Accepted: 08/09/2016] [Indexed: 12/27/2022]
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Mikuz U, Poglajen G, Fister M, Starc V, Wu JC, Hsia H, Haddad F, Vrtovec B. The presence of electromechanical mismatch in nonischemic dilated cardiomyopathy is associated with ventricular repolarization instability. J Card Fail 2014; 20:891-8. [PMID: 25305502 DOI: 10.1016/j.cardfail.2014.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2014] [Revised: 09/29/2014] [Accepted: 10/01/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND We analyzed electromechanical mismatch (EMM) and its relationship to ventricular repolarization in patients with nonischemic dilated cardiomyopathy (DCM). METHODS AND RESULTS In 39 DCM patients with left ventricular ejection fraction (LVEF) <40% and New York Heart Association functional class ≥III, electroanatomic mapping was used to quantify areas of EMM. High-resolution electrocardiograph was used to measure heart rate variability (HRV) and QT variability index (QTVI). EMM was present in 22 patients (56%, group 1), whereas 17 patients presented no mismatched segments (44%, group 2). The groups did not differ in age (56 ± 10 years in group 1 vs 57 ± 7 years in group 2; P = .82), sex (male: 82% vs 94%; P = .40), LVEF (27 ± 8% vs 25 ± 6%; P = .18), or N-terminal pro-B-type natriuretic peptide (2,350 pg/mL vs 2,831 pg/mL; P = .32). Although heart rate and HRV were similar in both groups (rate: 80 ± 20 beats/min in group 1 vs 74 ± 19 beats/min in group 2 [P = .47]; standard deviation of normal-to normal RR intervals: 106 ± 79 vs 88 ± 115 [P = .61]), we found significantly higher QTVI values in patients from group 1 (-1.15 ± 0.46 vs -1.62 ± 0.51 in group 2; P = .005). In patients with implantable cardioverter-defibrillators, ventricular arrhythmias recorded ≤1 year before enrollment were more frequent in group 1 than in group 2 (58% vs 13%; P = .02). CONCLUSIONS EMM is present in a majority of patients with DCM and is associated with ventricular repolarization instability.
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Affiliation(s)
- Ursa Mikuz
- Advanced Heart Failure and Transplantation Center, Department of Cardiology, University Medical Center, Ljubljana, Slovenia
| | - Gregor Poglajen
- Advanced Heart Failure and Transplantation Center, Department of Cardiology, University Medical Center, Ljubljana, Slovenia
| | - Misa Fister
- Department of Intensive Care Medicine, University Medical Center, Ljubljana, Slovenia
| | - Vito Starc
- Institute of Physiology, University of Ljubljana School of Medicine, Ljubljana, Slovenia
| | - Joseph C Wu
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California
| | - Henry Hsia
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California
| | - François Haddad
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California
| | - Bojan Vrtovec
- Advanced Heart Failure and Transplantation Center, Department of Cardiology, University Medical Center, Ljubljana, Slovenia; Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California.
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Vrtovec B, Poglajen G, Lezaic L, Sever M, Socan A, Domanovic D, Cernelc P, Torre-Amione G, Haddad F, Wu JC. Comparison of transendocardial and intracoronary CD34+ cell transplantation in patients with nonischemic dilated cardiomyopathy. Circulation 2013; 128:S42-9. [PMID: 24030420 DOI: 10.1161/circulationaha.112.000230] [Citation(s) in RCA: 128] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND In an open-label blinded study, we compared intracoronary and transendocardial CD34(+) cell transplantation in patients with nonischemic dilated cardiomyopathy. METHODS AND RESULTS Of the 40 patients with dilated cardiomyopathy, 20 were randomized to receive intracoronary injection and 20 received transendocardial CD34(+) cell delivery. In both groups, CD34(+) cells were mobilized by filgrastim, collected via apheresis, and labeled with technetium-99m radioisotope for single-photon emission computed tomographic imaging. In the intracoronary group, cells were injected intracoronarily in the artery supplying segments of greater perfusion defect on myocardial perfusion scintigraphy. In the transendocardial group, electroanatomic mapping was used to identify viable but dysfunctional myocardium, and transendocardial cell injections were performed. Nuclear single-photon emission computed tomographic imaging for quantification of myocardial retention was performed 18 hours thereafter. At baseline, groups did not differ in age, sex, left ventricular ejection fraction, or N-terminal pro-brain natriuretic peptide levels. The number of CD34(+) cells was also comparable (105 ± 31 × 10(6) in the transendocardial group versus 103 ± 27 × 10(6) in the intracoronary group, P=0.62). At 18 hours after procedure, myocardial retention was higher in the transendocardial group (19.2 ± 4.8%) than in the intracoronary group (4.4 ± 1.2%, P<0.01). At 6 months, left ventricular ejection fraction improved more in the transendocardial group (+8.1 ± 4.3%) than in the intracoronary group (+4.2 ± 2.3%, P=0.03). The same pattern was observed for the 6-minute walk test distance (+125 ± 33 m in the transendocardial group versus +86 ± 13 m in the intracoronary group, P=0.03) and N-terminal pro-brain natriuretic peptide (-628 ± 211 versus -315 ± 133 pg/mL, P=0.04). CONCLUSIONS In patients with dilated cardiomyopathy, transendocardial CD34(+) cell transplantation is associated with higher myocardial retention rates and greater improvement in ventricular function, N-terminal pro-brain natriuretic peptide, and exercise capacity compared with intracoronary route. CLINICAL TRIAL REGISTRATION URL http://www.clinicaltrials.gov. Unique identifier: NCT01350310.
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Affiliation(s)
- Bojan Vrtovec
- Advanced Heart Failure and Transplantation Center (B.V., G.P.), Department of Nuclear Medicine (L.L., A.S.), and Department of Hematology (M.S., P.C.), University Medical Center Ljubljana, Ljubljana, Slovenia; National Blood Transfusion Institute, Ljubljana, Slovenia (D.D.); Methodist DeBakey Heart Center, Houston, TX (G.T.-A.); Stanford Cardiovascular Institute (F.H., J.C.W.) and Department of Medicine, Division of Cardiology (B.V., F.H., J.C.W.), Stanford University School of Medicine, Stanford, CA
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Vrtovec B, Poglajen G, Sever M, Lezaic L, Socan A, Haddad F, Wu JC. CD34+ stem cell therapy in nonischemic dilated cardiomyopathy patients. Clin Pharmacol Ther 2013; 94:452-8. [PMID: 23903668 DOI: 10.1038/clpt.2013.134] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Accepted: 07/08/2013] [Indexed: 01/09/2023]
Abstract
Recent trends indicate that patients with nonischemic dilated cardiomyopathy represent the largest subpopulation of heart failure patients with a significant need for alternative treatment modalities. Similar to patients with ischemic cardiomyopathy, patients with nonischemic dilated cardiomyopathy have been found to have myocardial regions with flow abnormalities, which may represent targets for neoangiogenic therapies. CD34(+) stem cells might contribute to the formation of new blood vessels from existing vascular structures in ischemic tissues by the direct incorporation of injected cells into the newly developing vasculature or by the production and secretion of angiogenic cytokines. This review summarizes the long-term clinical effects and potential underlying mechanisms of CD34(+) cell therapy in patients with nonischemic dilated cardiomyopathy.
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Affiliation(s)
- B Vrtovec
- 1] Department of Cardiology, Advanced Heart Failure and Transplantation Center, University Medical Center Ljubljana, Ljubljana, Slovenia [2] Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California, USA
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Porras AR, Piella G, Berruezo A, Hoogendoorn C, Andreu D, Fernandez-Armenta J, Sitges M, Frangi AF. Interventional endocardial motion estimation from electroanatomical mapping data: application to scar characterization. IEEE Trans Biomed Eng 2012. [PMID: 23204274 DOI: 10.1109/tbme.2012.2230327] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Scar presence and its characteristics play a fundamental role in several cardiac pathologies. To accurately define the extent and location of the scar is essential for a successful ventricular tachycardia ablation procedure. Nowadays, a set of widely accepted electrical voltage thresholds applied to local electrograms recorded are used intraoperatively to locate the scar. Information about cardiac mechanics could be considered to characterize tissues with different viability properties. We propose a novel method to estimate endocardial motion from data obtained with an electroanatomical mapping system together with the endocardial geometry segmented from preoperative 3-D magnetic resonance images, using a statistical atlas constructed with bilinear models. The method was validated using synthetic data generated from ultrasound images of nine volunteers and was then applied to seven ventricular tachycardia patients. Maximum bipolar voltages, commonly used to intraoperatively locate scar tissue, were compared to endocardial wall displacement and strain for all the patients. The results show that the proposed method allows endocardial motion and strain estimation and that areas with low-voltage electrograms also present low strain values.
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Affiliation(s)
- Antonio R Porras
- Center for Computational Imaging and Simulation Technologies in Biomedicine, Universitat Pompeu Fabra, Barcelona 08018, Spain.
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Endoventricular Electromechanical Mapping—The Diagnostic and Therapeutic Utility of the NOGA® XP Cardiac Navigation System. J Cardiovasc Transl Res 2008; 2:48-62. [DOI: 10.1007/s12265-008-9080-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2008] [Accepted: 11/04/2008] [Indexed: 01/16/2023]
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Fuchs S, Kornowski R. Correlation between endocardial voltage mapping and myocardial perfusion: implications for the assessment of myocardial ischemia. Coron Artery Dis 2005; 16:163-7. [PMID: 15818085 DOI: 10.1097/00019501-200505000-00005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Recent clinical studies using a non-fluoroscopic three-dimensional (3D) left ventricular (LV) mapping system suggested reduced endocardial voltage amplitudes measured in zones sustaining myocardial ischemia or infarction. However, the direct relationship between myocardial perfusion and endomyocardial voltage amplitudes has not been fully elucidated. METHODS In a pig model of chronic myocardial ischemia (n = 20), LV endocardial unipolar voltage (UpV) mapping was performed using the Biosense 3D navigation system (Johnson and Johnson, Warren, New Jersey, USA) 4 weeks after ameroid constrictor placement around the left circumflex coronary artery. Echocardiography was used to assess regional changes in myocardial wall thickening (MT) and fluorescent microspheres (4 x 10/injection) were used to quantify rest regional myocardial blood flow (MBF) in ischemic (left circumflex) and remote non-ischemic (left anterior descending) regions. RESULTS UpV measurements were reduced in ischemic compared to non-ischemic zones (9.9+/-3.3 compared with 13.3+/-3.3 mV, P = 0.03). This corresponded to changes in endocardial MBF and MT, which were both noted to be significantly reduced in the ischemic compared to the non-ischemic area (MBF, 0.50+/-0.16 compared with 0.74+/-0.15 ml/g per min, P = 0.001; MT, 26.1+/-12.0 compared with 37.4+/-10.1%, P=0.003). A positive linear correlation was found between UpV at rest and endomyocardial (but not epicardial) perfusion: UpV (mV) = 7.8+5.9xMBFendocardial (r = 0.32, P = 0.05). CONCLUSIONS Chronic myocardial ischemia, resulting in reduced perfusion and function at rest (that is, hibernating myocardium), is characterized by a significant reduction ( approximately 25%) in endocardial UpV potentials, which correlates with reduced endomyocardial blood flow and tissue perfusion at rest.
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Affiliation(s)
- Shmuel Fuchs
- Catheterization Laboratory, Cardiology Department, Rabin Medical Center, Tel-Aviv University, Israel.
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Koch KC, vom Dahl J, Schaefer WM, Nowak B, Kapan S, Hanrath P. Prognostic value of endocardial electromechanical mapping in patients with left ventricular dysfunction undergoing percutaneous coronary intervention. Am J Cardiol 2004; 94:1129-33. [PMID: 15518606 DOI: 10.1016/j.amjcard.2004.07.078] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2004] [Revised: 07/28/2004] [Accepted: 07/28/2004] [Indexed: 11/24/2022]
Abstract
Endocardial electromechanical mapping (EEM) has been proposed as a method for myocardial viability assessment. However, the impact of EEM data on clinical outcome has not been studied before. We sought to assess the prognostic value of EEM in patients with left ventricular (LV) dysfunction undergoing percutaneous coronary intervention (PCI). Seventy-five patients with coronary artery disease and LV dysfunction (angiographic LV ejection fraction [EF] 49 +/- 15%) underwent LV EEM for myocardial viability assessment before coronary revascularization. EEM parameters included mean unipolar electrographic amplitude, mean local shortening, LV volumes, LVEF, number of regions with electrographic amplitudes <7.5 mV, number of electromechanical mismatch, and match regions. Cardiac death, nonfatal myocardial infarction, nonfatal stroke, and acute heart failure requiring hospitalization were defined as clinical events. During a follow-up of 3.6 +/- 1.8 years, 20 clinical events occurred. Event-free survival after coronary revascularization was significantly better in patients with a mean unipolar electrographic amplitude of >/=9.5 mV than in patients with a mean unipolar electrographic amplitude of <9.5 mV (88% vs 57%; p <0.005). Cox regression analysis revealed angiographic LVEF, mean electrographic amplitude, number of regions with electrographic amplitudes <7.5 mV, number of electromechanical match regions, and EEM EF as univariate predictors of clinical events. In a multivariate analysis, angiographic LVEF <40% (hazard ratio 4.78, p <0.005) and mean electrographic amplitude <9.5 mV (hazard ratio 2.92, p <0.05) were independent predictors of clinical events. Thus, EEM provides prognostic information in patients with LV dysfunction undergoing coronary revascularization.
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Samady H, Choi CJ, Ragosta M, Powers ER, Beller GA, Kramer CM. Electromechanical mapping identifies improvement in function and retention of contractile reserve after revascularization in ischemic cardiomyopathy. Circulation 2004; 110:2410-6. [PMID: 15477418 DOI: 10.1161/01.cir.0000145119.94542.ae] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND We hypothesized that (1) a significant proportion of ischemic dysfunctional segments that do not improve function will demonstrate postrevascularization contractile reserve and (2) electromechanical mapping (EMM) can identify segments that improve function as well as those with postrevascularization contractile reserve, a potential indicator of delayed functional improvement. METHODS AND RESULTS Eighteen patients with severe ischemic left ventricular dysfunction underwent EMM and dobutamine (D) cardiac magnetic resonance imaging (CMR) followed by revascularization. Four months after revascularization, all patients underwent a repeated D-CMR, and at 35 months, a subgroup (n=6) underwent a third CMR. Of 120 dysfunctional segments, 60 segments had improved rest function (IRF) and 60 did not. Twenty-eight of 60 segments (47%) that did not improve RF demonstrated postrevascularization contractile reserve (CR), and 32 of 60 segments (53%) that demonstrated neither IRF nor CR were persistently dysfunctional (PD). CR segments recovered significantly greater late function compared with IRF or PD: 14+/-12% vs 2+/-5% and 4+/-7%, respectively; P<0.05. EMM ratio, defined as the unipolar voltage divided by linear shortening, was significantly higher in IRF segments compared with segments that did not improve RF: 2.4+/-4.5 vs 0.7+/-3.5, P<0.05. Unipolar voltage was stepwise lower in normal, IRF, CR, and PD segments (10.5+/-4.7, 9.3+/-3.9, 8.8+/-3.2, and 7.4+/-2.3 mV, respectively; P<0.01 for trend). CONCLUSIONS Almost half of dysfunctional myocardial segments in chronic ischemic heart disease that do not improve RF early after revascularization demonstrate early CR and delayed functional recovery. EMM parameters can identify segments that improve RF and retain CR early after revascularization.
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Affiliation(s)
- Habib Samady
- Division of Cardiology, Eastern Virginia Medical School, Sentara Norfolk General Hospital, Norfolk, VA 23505, USA.
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Chen SL, Fang WW, Ye F, Liu YH, Qian J, Shan SJ, Zhang JJ, Chunhua RZ, Liao LM, Lin S, Sun JP. Effect on left ventricular function of intracoronary transplantation of autologous bone marrow mesenchymal stem cell in patients with acute myocardial infarction. Am J Cardiol 2004; 94:92-5. [PMID: 15219514 DOI: 10.1016/j.amjcard.2004.03.034] [Citation(s) in RCA: 814] [Impact Index Per Article: 40.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2003] [Revised: 03/15/2004] [Accepted: 03/15/2004] [Indexed: 12/13/2022]
Abstract
Sixty-nine patients who underwent primary percutaneous coronary intervention within 12 hours after onset of acute myocardial infarction were randomized to receive intracoronary injection of autologous bone marrow mesenchymal stem cell or standard saline. Several imagining techniques demonstrated that bone marrow mesenchymal stem cells significantly improved left ventricular function.
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Affiliation(s)
- Shao-liang Chen
- Division of Cardiology, Nanjing First Hospital, Nanjing University, Nanjing, Jiangsu Province, China.
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