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Malcolmson JW, Hughes RK, Husselbury T, Khan K, Learoyd AE, Lees M, Wicks EC, Smith J, Simms AD, Moon JC, Lopes LR, O'Mahony C, Sekhri N, Elliott PM, Petersen SE, Dhinoja MB, Mohiddin SA. Distal Ventricular Pacing for Drug-Refractory Mid-Cavity Obstructive Hypertrophic Cardiomyopathy: A Randomized, Placebo-Controlled Trial of Personalized Pacing. Circ Arrhythm Electrophysiol 2024; 17:e012570. [PMID: 39012930 DOI: 10.1161/circep.123.012570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 05/14/2024] [Indexed: 07/18/2024]
Abstract
BACKGROUND Patients with refractory, symptomatic left ventricular (LV) mid-cavity obstructive (LVMCO) hypertrophic cardiomyopathy have few therapeutic options. Right ventricular pacing is associated with modest hemodynamic and symptomatic improvement, and LV pacing pilot data suggest therapeutic potential. We hypothesized that site-specific pacing would reduce LVMCO gradients and improve symptoms. METHODS Patients with symptomatic-drug-refractory LVMCO were recruited for a randomized, blinded trial of personalized prescription of pacing (PPoP). Multiple LV and apical right ventricular pacing sites were assessed during an invasive hemodynamic study of multisite pacing. Patient-specific pacing-site and atrioventricular delays, defining PPoP, were selected on the basis of LVMCO gradient reduction and acceptable pacing parameters. Patients were randomized to 6 months of active PPoP or backup pacing in a crossover design. The primary outcome examined invasive gradient change with best-site pacing. Secondary outcomes assessed quality of life and exercise following randomization to PPoP. RESULTS A total of 17 patients were recruited; 16 of whom met primary end points. Baseline New York Heart Association was 3±0.6, despite optimal medical therapy. Hemodynamic effects were assessed during pacing at the right ventricular apex and at a mean of 8 LV sites. The gradients in all 16 patients fell with pacing, with maximum gradient reduction achieved via LV pacing in 14 (88%) patients and right ventricular apex in 2. The mean baseline gradient of 80±29 mm Hg fell to 31±21 mm Hg with best-site pacing, a 60% reduction (P<0.0001). One cardiac vein perforation occurred in 1 case, and 15 subjects entered crossover; 2 withdrawals occurred during crossover. Of the 13 completing crossover, 9 (69%) chose active pacing in PPoP configuration as preferred setting. PPoP was associated with improved 6-minute walking test performance (328.5±99.9 versus 285.8±105.5 m; P=0.018); other outcome measures also indicated benefit with PPoP. CONCLUSIONS In a randomized placebo-controlled trial, PPoP reduces obstruction and improves exercise performance in severely symptomatic patients with LVMCO. REGISTRATION URL: https://clinicaltrials.gov/study; Unique Identifier: NCT03450252.
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Affiliation(s)
- James W Malcolmson
- Barts Heart Center, St Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom (J.W.M., R.K.H., T.H., M.L., J.C.M., L.R.L., C.O.M., N.S., P.M.E., S.E.P., M.B.D., S.A.M.)
- William Harvey Research Institute, NIHR Barts Biomedical Research Centre, Queen Mary University of London, United Kingdom (J.W.M., K.K., A.E.L., S.E.P., S.A.M.)
| | - Rebecca K Hughes
- Barts Heart Center, St Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom (J.W.M., R.K.H., T.H., M.L., J.C.M., L.R.L., C.O.M., N.S., P.M.E., S.E.P., M.B.D., S.A.M.)
- Institute of Cardiovascular Science, University College London, United Kingdom (R.K.H., E.C.W., J.C.M., L.R.L., C.O.M., P.M.E.)
| | - Tim Husselbury
- Barts Heart Center, St Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom (J.W.M., R.K.H., T.H., M.L., J.C.M., L.R.L., C.O.M., N.S., P.M.E., S.E.P., M.B.D., S.A.M.)
| | - Kamran Khan
- William Harvey Research Institute, NIHR Barts Biomedical Research Centre, Queen Mary University of London, United Kingdom (J.W.M., K.K., A.E.L., S.E.P., S.A.M.)
| | - Annastazia E Learoyd
- William Harvey Research Institute, NIHR Barts Biomedical Research Centre, Queen Mary University of London, United Kingdom (J.W.M., K.K., A.E.L., S.E.P., S.A.M.)
| | - Martin Lees
- Barts Heart Center, St Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom (J.W.M., R.K.H., T.H., M.L., J.C.M., L.R.L., C.O.M., N.S., P.M.E., S.E.P., M.B.D., S.A.M.)
| | - Eleanor C Wicks
- Institute of Cardiovascular Science, University College London, United Kingdom (R.K.H., E.C.W., J.C.M., L.R.L., C.O.M., P.M.E.)
- Inherited Cardiovascular Diseases Unit, John Radcliffe Hospital, London, United Kingdom (E.C.W.)
| | - Jamie Smith
- Raigmore Hospital, NHS Highland, Inverness, United Kingdom (J.S.)
| | - Alexander D Simms
- Yorkshire Heart Centre, Leeds Teaching Hospital NHS Trust, Leeds, United Kingdom (A.D.S.)
| | - James C Moon
- Barts Heart Center, St Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom (J.W.M., R.K.H., T.H., M.L., J.C.M., L.R.L., C.O.M., N.S., P.M.E., S.E.P., M.B.D., S.A.M.)
- Institute of Cardiovascular Science, University College London, United Kingdom (R.K.H., E.C.W., J.C.M., L.R.L., C.O.M., P.M.E.)
| | - Luis R Lopes
- Barts Heart Center, St Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom (J.W.M., R.K.H., T.H., M.L., J.C.M., L.R.L., C.O.M., N.S., P.M.E., S.E.P., M.B.D., S.A.M.)
- Institute of Cardiovascular Science, University College London, United Kingdom (R.K.H., E.C.W., J.C.M., L.R.L., C.O.M., P.M.E.)
| | - Constantinos O'Mahony
- Barts Heart Center, St Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom (J.W.M., R.K.H., T.H., M.L., J.C.M., L.R.L., C.O.M., N.S., P.M.E., S.E.P., M.B.D., S.A.M.)
- Institute of Cardiovascular Science, University College London, United Kingdom (R.K.H., E.C.W., J.C.M., L.R.L., C.O.M., P.M.E.)
| | - Neha Sekhri
- Barts Heart Center, St Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom (J.W.M., R.K.H., T.H., M.L., J.C.M., L.R.L., C.O.M., N.S., P.M.E., S.E.P., M.B.D., S.A.M.)
| | - Perry M Elliott
- Barts Heart Center, St Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom (J.W.M., R.K.H., T.H., M.L., J.C.M., L.R.L., C.O.M., N.S., P.M.E., S.E.P., M.B.D., S.A.M.)
- Institute of Cardiovascular Science, University College London, United Kingdom (R.K.H., E.C.W., J.C.M., L.R.L., C.O.M., P.M.E.)
| | - Steffen E Petersen
- Barts Heart Center, St Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom (J.W.M., R.K.H., T.H., M.L., J.C.M., L.R.L., C.O.M., N.S., P.M.E., S.E.P., M.B.D., S.A.M.)
- William Harvey Research Institute, NIHR Barts Biomedical Research Centre, Queen Mary University of London, United Kingdom (J.W.M., K.K., A.E.L., S.E.P., S.A.M.)
- Health Data Research UK, London (S.E.P.)
| | - Mehul B Dhinoja
- Barts Heart Center, St Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom (J.W.M., R.K.H., T.H., M.L., J.C.M., L.R.L., C.O.M., N.S., P.M.E., S.E.P., M.B.D., S.A.M.)
| | - Saidi A Mohiddin
- Barts Heart Center, St Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom (J.W.M., R.K.H., T.H., M.L., J.C.M., L.R.L., C.O.M., N.S., P.M.E., S.E.P., M.B.D., S.A.M.)
- William Harvey Research Institute, NIHR Barts Biomedical Research Centre, Queen Mary University of London, United Kingdom (J.W.M., K.K., A.E.L., S.E.P., S.A.M.)
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2
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Hermida U, Stojanovski D, Raman B, Ariga R, Young AA, Carapella V, Carr-White G, Lukaschuk E, Piechnik SK, Kramer CM, Desai MY, Weintraub WS, Neubauer S, Watkins H, Lamata P. Left ventricular anatomy in obstructive hypertrophic cardiomyopathy: beyond basal septal hypertrophy. Eur Heart J Cardiovasc Imaging 2023; 24:807-818. [PMID: 36441173 PMCID: PMC10229266 DOI: 10.1093/ehjci/jeac233] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 10/21/2022] [Accepted: 10/23/2022] [Indexed: 11/29/2022] Open
Abstract
AIMS Obstructive hypertrophic cardiomyopathy (oHCM) is characterized by dynamic obstruction of the left ventricular (LV) outflow tract (LVOT). Although this may be mediated by interplay between the hypertrophied septal wall, systolic anterior motion of the mitral valve, and papillary muscle abnormalities, the mechanistic role of LV shape is still not fully understood. This study sought to identify the LV end-diastolic morphology underpinning oHCM. METHODS AND RESULTS Cardiovascular magnetic resonance images from 2398 HCM individuals were obtained as part of the NHLBI HCM Registry. Three-dimensional LV models were constructed and used, together with a principal component analysis, to build a statistical shape model capturing shape variations. A set of linear discriminant axes were built to define and quantify (Z-scores) the characteristic LV morphology associated with LVOT obstruction (LVOTO) under different physiological conditions and the relationship between LV phenotype and genotype. The LV remodelling pattern in oHCM consisted not only of basal septal hypertrophy but a combination with LV lengthening, apical dilatation, and LVOT inward remodelling. Salient differences were observed between obstructive cases at rest and stress. Genotype negative cases showed a tendency towards more obstructive phenotypes both at rest and stress. CONCLUSIONS LV anatomy underpinning oHCM consists of basal septal hypertrophy, apical dilatation, LV lengthening, and LVOT inward remodelling. Differences between oHCM cases at rest and stress, as well as the relationship between LV phenotype and genotype, suggest different mechanisms for LVOTO. Proposed Z-scores render an opportunity of redefining management strategies based on the relationship between LV anatomy and LVOTO.
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Affiliation(s)
- Uxio Hermida
- School of Biomedical Engineering and Imaging Sciences, King’s College London, 5th Floor Becket House, Lambeth Palace Road, London SE1 7EU, UK
| | - David Stojanovski
- School of Biomedical Engineering and Imaging Sciences, King’s College London, 5th Floor Becket House, Lambeth Palace Road, London SE1 7EU, UK
| | - Betty Raman
- Oxford Centre for Clinical Magnetic Resonance Research, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Rina Ariga
- Oxford Centre for Clinical Magnetic Resonance Research, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Alistair A Young
- School of Biomedical Engineering and Imaging Sciences, King’s College London, 5th Floor Becket House, Lambeth Palace Road, London SE1 7EU, UK
| | - Valentina Carapella
- School of Biomedical Engineering and Imaging Sciences, King’s College London, 5th Floor Becket House, Lambeth Palace Road, London SE1 7EU, UK
| | - Gerry Carr-White
- Department of Cardiovascular Imaging, School of Biomedical Engineering and Imaging Sciences, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Elena Lukaschuk
- NIHR Oxford Biomedical Research Centre, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, and Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Stefan K Piechnik
- NIHR Oxford Biomedical Research Centre, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, and Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Christopher M Kramer
- Division of Cardiovascular Medicine, University of Virginia Health System, Charlottesville, VA, USA
| | - Milind Y Desai
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland, OH, USA
| | - William S Weintraub
- MedStar Health Research Institute, Georgetown University, Washington, DC, USA
| | - Stefan Neubauer
- Oxford Centre for Clinical Magnetic Resonance Research, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, and Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Hugh Watkins
- NIHR Oxford Biomedical Research Centre, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, and Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Pablo Lamata
- School of Biomedical Engineering and Imaging Sciences, King’s College London, 5th Floor Becket House, Lambeth Palace Road, London SE1 7EU, UK
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Bayonas-Ruiz A, Muñoz-Franco FM, Sabater-Molina M, Oliva-Sandoval MJ, Gimeno JR, Bonacasa B. Current therapies for hypertrophic cardiomyopathy: a systematic review and meta-analysis of the literature. ESC Heart Fail 2023; 10:8-23. [PMID: 36181355 PMCID: PMC9871697 DOI: 10.1002/ehf2.14142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 08/13/2022] [Accepted: 08/24/2022] [Indexed: 01/27/2023] Open
Abstract
AIMS The aim of this study was to synthesize the evidence on the effect of the current therapies over the pathophysiological and clinical characteristics of patients with hypertrophic cardiomyopathy (HCM). METHODS AND RESULTS A systematic review and meta-analysis of 41 studies identified from 1383 retrieved from PubMed, Web of Science, and Cochrane was conducted. Therapies were grouped in pharmacological, invasive and physical exercise. Pharmacological agents had no effect on functional capacity measured by VO2max (1.11 mL/kg/min; 95% CI: -0.04, 2.25, P < 0.05). Invasive septal reduction therapies increased VO2max (+3.2 mL/kg/min; 95% CI: 1.78, 4.60, P < 0.05). Structured physical exercise programmes did not report contraindications and evidenced the highest increases on functional capacity (VO2max + 4.33 mL/kg/min; 95% CI: 0.20, 8.45, P < 0.05). Patients with left ventricular outflow tract (LVOT) obstruction at rest improved their VO2max to a greater extent compared with those without resting LVOT obstruction (2.82 mL/kg/min; 95% CI: 1.97, 3.67 vs. 1.18; 95% CI: 0.62, 1.74, P < 0.05). Peak LVOT gradient was reduced with the three treatment options with the highest reduction observed for invasive therapies. Left ventricular ejection fraction was reduced in pharmacological and invasive procedures. No effect was observed after physical exercise. Symptomatic status improved with the three options and to a greater extent with invasive procedures. CONCLUSIONS Invasive septal reduction therapies increase VO2max, improve symptomatic status, and reduce resting and peak LVOT gradient, thus might be considered in obstructive patients. Physical exercise emerges as a coadjuvant therapy, which is safe and associated with benefits on functional capacity. Pharmacological agents improve reported NYHA class, but not functional capacity.
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Affiliation(s)
- Adrián Bayonas-Ruiz
- Research Group of Physical Exercise and Human Performance, Faculty of Sport Sciences, University of Murcia, Murcia, Spain
| | | | - María Sabater-Molina
- Cardiogenetic Laboratory, Instituto Murciano de Investigación Biosanitaria (IMIB), Murcia, Spain
- European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart (ERN-Guard Heart), Amsterdam, The Netherlands
| | - María José Oliva-Sandoval
- Inherited Cardiac Disease Unit (CSUR), Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
- European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart (ERN-Guard Heart), Amsterdam, The Netherlands
| | - Juan R Gimeno
- Inherited Cardiac Disease Unit (CSUR), Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
- European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart (ERN-Guard Heart), Amsterdam, The Netherlands
- Departament of Internal Medicine (Cardiology), Universidad de Murcia, Murcia, Spain
| | - Bárbara Bonacasa
- Research Group of Physical Exercise and Human Performance, Faculty of Sport Sciences, University of Murcia, Murcia, Spain
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4
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Malcolmson JW, Hughes RK, Joshi A, Cooper J, Breitenstein A, Ginks M, Petersen SE, Mohiddin SA, Dhinoja MB. Therapeutic benefits of distal ventricular pacing in mid-cavity obstructive hypertrophic cardiomyopathy. Ther Adv Cardiovasc Dis 2022; 16:17539447221108816. [PMID: 35916371 PMCID: PMC9350522 DOI: 10.1177/17539447221108816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Hypertrophic cardiomyopathy (HCM) patients with left ventricular (LV) mid-cavity obstruction (LVMCO) often experience severe drug-refractory symptoms thought to be related to intraventricular obstruction. We tested whether ventricular pacing, guided by invasive haemodynamic assessment, reduced LVMCO and improved refractory symptoms. METHODS Between December 2008 and December 2017, 16 HCM patients with severe refractory symptoms and LVMCO underwent device implantation with haemodynamic pacing study to assess the effect on invasively defined LVMCO gradients. The effect on the gradient of atrioventricular (AV) synchronous pacing from sites including right ventricular (RV) apex and middle cardiac vein (MCV) was retrospectively assessed. RESULTS Invasive haemodynamic data were available in 14 of 16 patients. Mean pre-treatment intracavitary gradient was 77 ± 22 mmHg (in sinus rhythm) versus 21 ± 21 mmHg during pacing from optimal ventricular site (95% CI: -70.86 to -40.57, p < 0.0001). Optimal pacing site was distal MCV in 12/16 (86%), RV apex in 1/16 and via epicardial LV lead in 1/16. Pre-pacing Doppler-derived gradients were significantly higher than at follow-up (47 ± 15 versus 24 ± 16 mmHg, 95% CI: -37.19 to -13.73, p < 0.001). Median baseline NYHA class was 3, which had improved by ⩾1 NYHA class in 13 of 16 patients at 1-year post-procedure (p < 0.001). The mean follow-up duration was 4.6 ± 2.7 years with the following outcomes: 8/16 (50%) had continued symptomatic improvement, 4/16 had symptomatic decline and 4/16 died. Contributors to symptomatic decline included chronic atrial fibrillation (AF) (n = 5), phrenic nerve stimulation (n = 3) and ventricular ectopy (n = 1). CONCLUSION In drug-refractory symptomatic LVMCO, distal ventricular pacing can reduce intracavitary obstruction and may provide long-term symptomatic relief in patients with limited treatment options. A haemodynamic pacing study is an effective strategy for identifying optimal pacing site and configuration.
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Affiliation(s)
- James W Malcolmson
- Barts Heart Centre, St Bartholomew's Hospital, London, UK.,The William Harvey Heart Centre, William Harvey Research Institute, Queen Mary University of London, London, UK.,NIHR Biomedical Research Centre at Barts, London, UK
| | - Rebecca K Hughes
- Barts Heart Centre, St Bartholomew's Hospital, London, UK.,Institute of Cardiovascular Science, University College London, London, UK
| | - Abhishek Joshi
- Barts Heart Centre, St Bartholomew's Hospital, London, UK.,NIHR Biomedical Research Centre at Barts, London, UK
| | - Jackie Cooper
- NIHR Biomedical Research Centre at Barts, London, UK
| | | | | | - Steffen E Petersen
- Barts Heart Centre, St Bartholomew's Hospital, London, UK.,The William Harvey Heart Centre, William Harvey Research Institute, Queen Mary University of London, London, UK.,NIHR Biomedical Research Centre at Barts, London, UK
| | - Saidi A Mohiddin
- Barts Heart Centre, St Bartholomew's Hospital, London, UK.,The William Harvey Heart Centre, William Harvey Research Institute, Queen Mary University of London, London, UK.,NIHR Biomedical Research Centre at Barts, London, UK
| | - Mehul B Dhinoja
- Barts Heart Centre, St Bartholomew's Hospital, West Smithfield, London EC1A 7BE, UK
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5
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Hughes RK, Knott KD, Malcolmson J, Augusto JB, Mohiddin SA, Kellman P, Moon JC, Captur G. Apical Hypertrophic Cardiomyopathy: The Variant Less Known. J Am Heart Assoc 2020; 9:e015294. [PMID: 32106746 PMCID: PMC7335568 DOI: 10.1161/jaha.119.015294] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Affiliation(s)
- Rebecca K Hughes
- Institute of Cardiovascular Science University College London London United Kingdom.,The Cardiovascular Magnetic Resonance Imaging Unit and The Inherited Cardiovascular Diseases Unit Barts Heart Center St Bartholomew's Hospital London United Kingdom
| | - Kristopher D Knott
- Institute of Cardiovascular Science University College London London United Kingdom.,The Cardiovascular Magnetic Resonance Imaging Unit and The Inherited Cardiovascular Diseases Unit Barts Heart Center St Bartholomew's Hospital London United Kingdom
| | - James Malcolmson
- The Cardiovascular Magnetic Resonance Imaging Unit and The Inherited Cardiovascular Diseases Unit Barts Heart Center St Bartholomew's Hospital London United Kingdom
| | - João B Augusto
- Institute of Cardiovascular Science University College London London United Kingdom.,The Cardiovascular Magnetic Resonance Imaging Unit and The Inherited Cardiovascular Diseases Unit Barts Heart Center St Bartholomew's Hospital London United Kingdom
| | - Saidi A Mohiddin
- The Cardiovascular Magnetic Resonance Imaging Unit and The Inherited Cardiovascular Diseases Unit Barts Heart Center St Bartholomew's Hospital London United Kingdom.,William Harvey Institute Queen Mary University of London London United Kingdom
| | - Peter Kellman
- National Heart, Lung, and Blood Institute National Institutes of Health DHHS Bethesda MD
| | - James C Moon
- Institute of Cardiovascular Science University College London London United Kingdom.,The Cardiovascular Magnetic Resonance Imaging Unit and The Inherited Cardiovascular Diseases Unit Barts Heart Center St Bartholomew's Hospital London United Kingdom
| | - Gabriella Captur
- Institute of Cardiovascular Science University College London London United Kingdom.,Inherited Heart Muscle Conditions Clinic Department of Cardiology Royal Free London NHS Foundation Trust Hampstead United Kingdom.,University College London MRC Unit of Lifelong Health and Ageing London United Kingdom
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6
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Malcolmson JW, Hamshere SM, Joshi A, O'Mahony C, Dhinoja M, Petersen SE, Sekhri N, Mohiddin SA. Doppler echocardiography underestimates the prevalence and magnitude of mid-cavity obstruction in patients with symptomatic hypertrophic cardiomyopathy. Catheter Cardiovasc Interv 2018; 91:783-789. [PMID: 28766836 DOI: 10.1002/ccd.27143] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 04/04/2017] [Accepted: 05/03/2017] [Indexed: 11/07/2022]
Abstract
OBJECTIVES To evaluate utility of Doppler echocardiography in the assessment of left ventricular (LV) mid-cavity obstructive (LVMCO) hypertrophic cardiomyopathy (HCM). BACKGROUND LVMCO is a relatively under-diagnosed complication of HCM and may occur alone or in combination with LV outflow tract obstruction (LVOTO). Identifying and quantifying LVMCO and differentiating it from LVOTO has important implications for patient management. We aimed to assess diagnostic performance of Doppler echocardiography in the assessment of suspected LV obstruction. METHODS Forty symptomatic HCM patients with suspected obstruction underwent cardiac catheterization, and comparison of location and magnitude of Doppler derived gradients with synchronous invasive measurements (reference standard), at rest and isoprenaline stress (IS). RESULTS Doppler's diagnostic accuracy for any obstruction (≥30 mmHg) in this cohort was 75% with false positive and false negative rates of 2.5 and 22.5%, respectively. During subanalysis, Doppler's diagnostic accuracy for isolated LVOTO in this selected cohort is 83% with false positive and false negative rates of 4 and 12.5%, respectively. For LVMCO, the accuracy is only 50%, with false positive and false negative rates of 10 and 40%, respectively. Doppler gradients for isolated LVOTO were similar to invasive: 85 ± 51 and 87 ± 35 mmHg, respectively (P = 0.77). Doppler gradients in LVMCO were consistently lower than invasive: 45 ± 38 and 81 ± 31 mmHg, respectively (P = 0.0002). Mid-systolic flow cessation and/or contamination of spectral signals were identified as causes of Doppler-derived inaccuracies. CONCLUSIONS Doppler echocardiography under-diagnoses and underestimates severity of LVMCO in symptomatic HCM patients. Recognition of abrupt mid-systolic flow cessation and invasive measurements may improve detection of LVMCO in HCM.
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Affiliation(s)
- James W Malcolmson
- Barts Heart Centre, Barts Health NHS Trust, Whitechapel, London E1 1BB, United Kingdom
| | - Stephen M Hamshere
- Barts Heart Centre, Barts Health NHS Trust, Whitechapel, London E1 1BB, United Kingdom.,William Harvey Research Institute, Queen Mary University of London, United Kingdom
| | - Abhishek Joshi
- Barts Heart Centre, Barts Health NHS Trust, Whitechapel, London E1 1BB, United Kingdom.,William Harvey Research Institute, Queen Mary University of London, United Kingdom
| | - Constantinos O'Mahony
- Barts Heart Centre, Barts Health NHS Trust, Whitechapel, London E1 1BB, United Kingdom.,UCL Centre for Heart Muscle Disease, Institute of Cardiovascular Science, University College London, Gower St, London WC1E, United Kingdom
| | - Mehul Dhinoja
- Barts Heart Centre, Barts Health NHS Trust, Whitechapel, London E1 1BB, United Kingdom
| | - Steffen E Petersen
- Barts Heart Centre, Barts Health NHS Trust, Whitechapel, London E1 1BB, United Kingdom.,William Harvey Research Institute, Queen Mary University of London, United Kingdom.,NIHR Biomedical Research Unit at Barts, London, United Kingdom
| | - Neha Sekhri
- Barts Heart Centre, Barts Health NHS Trust, Whitechapel, London E1 1BB, United Kingdom
| | - Saidi A Mohiddin
- Barts Heart Centre, Barts Health NHS Trust, Whitechapel, London E1 1BB, United Kingdom.,William Harvey Research Institute, Queen Mary University of London, United Kingdom.,NIHR Biomedical Research Unit at Barts, London, United Kingdom
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7
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MacLea H, Boon J, Bright J. Doppler Echocardiographic Evaluation of Midventricular Obstruction in Cats with Hypertrophic Cardiomyopathy. J Vet Intern Med 2013; 27:1416-20. [DOI: 10.1111/jvim.12175] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2012] [Revised: 06/04/2013] [Accepted: 07/24/2013] [Indexed: 11/27/2022] Open
Affiliation(s)
- H.B. MacLea
- Department of Clinical Sciences; College of Veterinary Medicine and Biomedical Sciences; Colorado State University; Fort Collins CO
| | - J.A. Boon
- Department of Clinical Sciences; College of Veterinary Medicine and Biomedical Sciences; Colorado State University; Fort Collins CO
| | - J.M. Bright
- Department of Clinical Sciences; College of Veterinary Medicine and Biomedical Sciences; Colorado State University; Fort Collins CO
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8
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Qintar M, Morad A, Alhawasli H, Shorbaji K, Firwana B, Essali A, Kadro W. Pacing for drug-refractory or drug-intolerant hypertrophic cardiomyopathy. Cochrane Database Syst Rev 2012; 2012:CD008523. [PMID: 22592731 PMCID: PMC8094451 DOI: 10.1002/14651858.cd008523.pub2] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Hypertrophic cardiomyopathy (HCM) is a genetic disease with an autosomal-dominant inheritance for which negative inotropes are the most widely used initial therapies. Observational studies and small randomised trials have suggested symptomatic and functional benefits using pacing and several theories have been put forward to explain why. Pacing, although not the primary treatment for HCM, could be beneficial to patients with relative or absolute contraindications to surgery or alcohol ablation. Several randomised controlled trials comparing pacing to other therapeutic modalities have been conducted but no Cochrane-style systematic review has been done. OBJECTIVES To assess the effects of pacing in drug-refractory or drug-intolerant hypertrophic cardiomyopathy patients. SEARCH METHODS We searched the following on the 14/4/2010: CENTRAL (The Cochrane Library 2010, Issue 1), MEDLINE OVID (from 1950 onwards ), EMBASE OVID (from 1980 onwards ), Web of Science with Conference Proceedings (from 1970 onwards). No language restrictions were applied. SELECTION CRITERIA Randomised controlled trials of either parallel or crossover design that assess the beneficial and harmful effects of pacing for hypertrophic cardiomyopathy were included. When crossover studies were identified, we considered data only from the first phase. DATA COLLECTION AND ANALYSIS Data from included studies were extracted onto a pre-formed data extraction paper by two authors independently. Data was then entered into Review Manager 5.1 for analysis. Risk of bias was assessed using the guidance provided in the Cochrane Handbook. For dichotomous data, relative risk was calculated; and for continuous data, the mean differences were calculated. Where appropriate data were available, meta-analysis was performed. Where meta-analysis was not possible, a narrative synthesis was written. A QUROUM flow chart was provided to show the flow of papers. MAIN RESULTS Five studies (reported in 10 papers) were identified. However, three of the five studies provided un-usable data. Thus the data from only two studies (reported in seven papers) with 105 participants were included for this review. There was insufficient data to compare results on all-cause mortality, cost effectiveness, exercise capacity, Quality of life and Peak O2 consumption.When comparing active pacing versus placebo pacing on exercise capacity, one study showed that exercise time decreased from (13.1 ± 4.4) minutes to (12.6 ± 4.3) minutes in the placebo group and increased from (12.1 ± 5.6) minutes to (12.9 ± 4.2) minutes in the treatment group (MD 0.30; 95% CI -1.54 to 2.14). Statistically significant data from the same study showed that left ventricular outflow tract obstruction decreased from (71 ± 32) mm Hg to (52 ± 34) mm Hg in the placebo group and from (70 ± 24) mm Hg to (33 ± 27) mm Hg in the active pacing group (MD -19.00; 95% CI -32.29 to -5.71). This study was also able to show that New York Heart Association (NYHA) functional class decreased from (2.5 ± 0.5) to (2.2 ± 0.6) in the inactive pacing group and decreased from (2.6 ± 0.5) to (1.7 ± 0.7) in the placebo group (MD -0.50; 95% CI -0.78 to -0.22).When comparing active pacing versus trancoronary ablation of septal hypertrophy (TASH), data from one study showed that NYHA functional class decreased from (3.2 ± 0.7) to (1.5 ± 0.5) in the TASH group and decreased from (3.0 ± 0.1) to (1.9 ± 0.6) in the pacemaker group. This study also showed that LV wall thickness remained unchanged in the active pacing group compared to reduction from (22 ± 4) mm to (17 ± 3) mm in the TASH group (MD 0.60; 95% CI -5.65 to 6.85) and that LV outflow tract obstruction decreased from (80 ± 35.5) mm Hg in the TASH group to (49.3 ± 37.7) mm Hg in the pacemaker group. AUTHORS' CONCLUSIONS Trials published to date lack information on clinically relevant end-points. Existing data is derived from small trials at high risk of bias, which concentrate on physiological measures. Their results are inconclusive. Further large and high quality trials with more appropriate outcomes are warranted.
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Affiliation(s)
- Mohammed Qintar
- Cleveland Clinic, OH, USA, Faculty of Medicine, Damascus University, Damascus, Syrian Arab Republic.
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Abstract
Japanese-variant or apical hypertrophic cardiomyopathy (HCM) is a specific type of HCM, first described in Japan and initially thought to carry a benign prognosis. However, current evidence suggests that these patients experience severe symptoms and are at increased risk of ventricular arrhythmias and death, especially in the presence of an apical akinetic chamber. The management of patients who do not respond to medical therapy is challenging. We describe a patient with Japanese-variant HCM, with an apical akinetic chamber and severe symptoms who failed medical therapy. The use of dual chamber pacing relieved obstruction and significantly improved the patient's symptoms.
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Clinical Implications of Midventricular Obstruction in Patients With Hypertrophic Cardiomyopathy. J Am Coll Cardiol 2011; 57:2346-55. [DOI: 10.1016/j.jacc.2011.02.033] [Citation(s) in RCA: 145] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2010] [Revised: 02/03/2011] [Accepted: 02/08/2011] [Indexed: 02/01/2023]
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Shah A, Duncan K, Winson G, Chaudhry FA, Sherrid MV. Severe symptoms in mid and apical hypertrophic cardiomyopathy. Echocardiography 2010; 26:922-33. [PMID: 19968680 DOI: 10.1111/j.1540-8175.2009.00905.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
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.
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Affiliation(s)
- Ajay Shah
- Division of Cardiology, St. Luke's-Roosevelt Hospital Center, College of Physicians and Surgeons, Columbia University, New York City, New York, USA
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12
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TOWBIN JEFFREYA. Hypertrophic Cardiomyopathy. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2009; 32 Suppl 2:S23-31. [DOI: 10.1111/j.1540-8159.2009.02381.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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14
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Sanghvi NK, Tracy CM. Sustained ventricular tachycardia in apical hypertrophic cardiomyopathy, midcavitary obstruction, and apical aneurysm. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2007; 30:799-803. [PMID: 17547615 DOI: 10.1111/j.1540-8159.2007.00753.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The prevalence of hypertrophic cardiomyopathy is estimated at 1:500 in the general population. Of these patients, approximately 1% develops midcavitary obstruction and subsequent apical aneurysm. We present a brief review of the literature on apical hypertrophic cardiomyopathy (HCM) using a rare case-based example. The etiology for apical aneurysm development is unclear but is thought to extend from apical fibrosis and necrosis secondary to subendocardial ischemia. The lifetime risk of cardiovascular death in patients with HCM is 2%. However, the risk may be higher in patients with apical aneurysms. Definitive therapy involves implantation of an automatic implantable cardioverter defibrillator, since medical therapy has variable success.
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Affiliation(s)
- Neil K Sanghvi
- Department of Medicine, George Washington University Hospital, Washington, DC.
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Tengiz I, Ercan E, Alioglu E, Turk UO. Percutaneous septal ablation for left mid-ventricular obstructive hypertrophic cardiomyopathy: a case report. BMC Cardiovasc Disord 2006; 6:15. [PMID: 16606458 PMCID: PMC1459201 DOI: 10.1186/1471-2261-6-15] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2005] [Accepted: 04/10/2006] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Mid-ventricular obstructive hypertrophic cardiomyopathy (MVOHC) is a rare type of cardiomyopathy. The diagnosis is based on the hourglass appearance on the left ventriculogram and the presence of pressure gradient between apical and basal chamber of the ventriculum on the hemodynamic assessment. CASE PRESENTATION The present case represents successful percutaneous treatment with septal ablation to patient with MVOHC associated with systolic anterior motion of the mitral valve and obstruction at both the mid-ventricular and outflow levels. CONCLUSION Alcohol septal ablation has been proposed as less invasive alternatives to surgery in patients with MVOHC.
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Affiliation(s)
- Istemihan Tengiz
- Central Hospital, Cardiology Department, 1644 sk. No:2/2, Bayrakli, Izmir, Turkey
| | - Ertugrul Ercan
- Central Hospital, Cardiology Department, 1644 sk. No:2/2, Bayrakli, Izmir, Turkey
| | - Emin Alioglu
- Central Hospital, Cardiology Department, 1644 sk. No:2/2, Bayrakli, Izmir, Turkey
| | - Ugur O Turk
- Central Hospital, Cardiology Department, 1644 sk. No:2/2, Bayrakli, Izmir, Turkey
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Abstract
Left ventricular outflow tract obstruction can occur at the supravalvar, valvar, or subvalvar level. Each level of obstruction is associated with distinct symptomatology, natural history, and operative approach. Reconstructive techniques can usually be used with low operative risk and excellent immediate and longer-term outcomes. Valve replacement for valvar obstruction is advised when reconstruction is not possible. The Ross procedure has greatly improved the results of valve replacement in children.
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