Myocardial reverse remodeling

Passive heat therapy for cardiovascular disease: current evidence and future directions

Passive heat therapy is gaining popularity as an intervention to promote cardiovascular, physiological, and, to a lesser degree, thermoregulatory adaptations in patients with cardiovascular disease. Despite this, the efficacy of heat therapy to elicit these adaptations remains unknown. We searched five databases for original research, screening 2913 studies and identifying 18 eligible studies. Heat therapies included Waon therapy, balneotherapy, water perfused trousers, Finnish sauna, and foot immersion. Interventions were administered across various time frames (20-90 min) and performed 3-7 times per week, for durations of 2-8 weeks. The studies collectively involved a diverse population (mean age: 67 (10) years) with cardiovascular diseases. Heat therapy was consistently shown to improve ejection fraction, flow-mediated dilation, brain natriuretic peptide levels, New York Heart Association classification, and 6 min walk distance. However, positive effects on resting heart rate and blood pressure were infrequently observed, and thermoregulatory responses scarcely reported. Heat therapy may increase sweat rate during heat exposure and reduce resting core temperature, but adaptive skin blood flow responses were not observed. Passive heat therapy shows promising utility in patients with cardiovascular disease, while secondary benefits such as markers of thermoregulatory adaptation may also be observed, these require further investigation.

Efficacy of Beta-Blockers and Angiotensin-Converting Enzyme Inhibitors in Non-Ischemic Dilated Cardiomyopathy: A Systematic Review and Meta-Analysis

Background

Non-ischemic dilated cardiomyopathy (NIDCM) is a form of heart failure with a poor prognosis and unclear optimal management. The aim of the study was to systematically review the literature and assess the efficacy and safety of beta-blockers and angiotensin-converting enzyme (ACE) inhibitors in the management of chronic heart failure secondary to NIDCM and explore their putative mechanisms of action.

Methods

Studies from 1990 to 2023 were reviewed using PubMed and EMBASE, focusing on their effects on left ventricular ejection fraction (LVEF) in NIDCM patients, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

Results

Beta-blockers showed a significant beneficial effect on LVEF improvement in NIDCM, with an overall effect size of Cohen's d = 1.30, 95% confidence interval (CI) (0.76, 1.84), high heterogeneity (Tau2 = 0.90; Chi2 = 162.05, df = 13, P < 0.00001; I2 = 92%), and a significant overall effect (Z = 4.72, P < 0.00001). ACE inhibitors also showed a beneficial role, but with less heterogeneity (Tau2 = 0.02; Chi2 = 1.09, df = 1, P = 0.30; I2 = 8%) and a nonsignificant overall effect (Z = 1.36, P = 0.17), 95% CI (-0.24, 1.31).

Conclusions

The study highlights the efficacy of carvedilol in improving LVEF in NIDCM patients over ACE inhibitors, recommends beta-blockers as first-line therapy, and advocates further research on ACE inhibitors.

The Inflammation-Fibrosis Combined Index: A Novel Marker for Predicting Left Ventricular Reverse Remodeling and Prognosis in Patients with HFrEF

Background

Inflammation and cardiac fibrosis are important pathogenic drivers of heart failure. The fibrosis-4 index (FIB-4) is associated with a higher degree of fibrosis. The systemic immune inflammation index (SII) is associated with a higher degree of systemic inflammation status. Previous studies have shown that they are associated with a poor prognosis for cardiovascular disease. We sought to investigate the value of FIB-4 combined with the SII as a novel inflammation-fibrosis combined index (IFCI) in predicting left ventricular reverse remodeling (LVRR) and prognosis among reduced ejection fraction heart failure (HFrEF) patients.

Methods

A total of 895 patients with HFrEF were continuously recruited. Receiver operating characteristic curves were drawn to assess the abilities of inflammation-fibrosis indicators to predict LVRR. Multivariable Cox regression analysis was used to examine independent predictors of composite cardiac events and all-cause death.

Results

After six months of follow-up, 344 (38.4%) patients experienced LVRR. The IFCI had the largest area under the curve (0.835, P < 0.001). In multivariate-adjusted logistic regression analyses, FIB-4, SII, and IFCI were predictive of LVRR (P value < 0.05). The IFCI was associated with a 3.686-fold higher risk of non-LVRR (odds ratio [OR] = 3.686, P < 0.001). Moreover, an increased IFCI predicted a poor prognosis in HFrEF patients. The highest risk of composite cardiac events (hazard ratio [HR] = 2.716, P < 0.001) was observed in the top IFCI-tertile group, and similar results were found regarding independent risk indicators of all-cause death.

Conclusion

In summary, this study indicated that increased IFCI at admission offers good predictability regarding non-LVRR and predicts the risk of all-cause mortality or composite cardiovascular events due to HFrEF patients and could be used as a novel marker.

Predictors and prognostic implications of left ventricular ejection fraction trajectory improvement in the spectrum of heart failure with reduced and mildly reduced ejection fraction

BACKGROUND

The latest guidelines emphasize the significance of evaluating the left ventricular ejection fraction (LVEF) trajectory in patients with heart failure (HF). Because patients with HF with reduced ejection fraction (HFrEF) and HF with mildly reduced ejection fraction (HFmrEF) have reduction in systolic function, they might be in a trajectory of LVEF improvement after medical and device-based therapies. While previous studies have primarily focused on LVEF improvement in HFrEF, there is limited research on LVEF trajectory improvement across the spectrum of HFrEF and HFmrEF. This study aimed to assess the determinants and prognostic implications of LVEF trajectory improvement in HFrEF and HFmrEF patients.

METHODS

The cohort was classified into the improved group (HFrEF-to-HF with improved ejection fraction (HFimpEF) and HFmrEF-to-HF with preserved ejection fraction (HFpEF)) and the unimproved group (lack of improved group criteria). The primary endpoints were the composite of all-cause mortality or HF hospitalization, all-cause mortality, and HF hospitalization. Predictors of LVEF trajectory improvement were also evaluated.

RESULTS

A total 1303 patients were included in the study (improved/unimproved group: n = 497/806). Cox regression analysis showed that the improved group experienced lower risks of prespecified end points than the unimproved group. Multivariate logistic regression analysis showed that atrial flutter, use of spironolactone, and treatment with catheter ablation were associated with LVEF trajectory improvement, while myocardial infarction, prior percutaneous catheter intervention or coronary artery bypass graft, E/e', and left ventricular end-diastolic diameter were identified as negative predictors of LVEF trajectory improvement. In the improved subgroup, the prognosis for the HFrEF-to-HFimpEF and HFmrEF-to-HFpEF was comparable.

CONCLUSIONS

LVEF trajectory improvement patients had improved clinical outcomes and it was associated with important clinical, baseline cardiac structure and function, and treatment factors. Outcomes were similar in both HFrEF-to-HFimpEF and HFmrEF-to-HFpEF subgroups. These results suggest that emphasis should be placed on LVEF trajectory improvement to improve the outcomes of this population.

The value of using left ventricular pressure-strain loops to evaluate myocardial work in predicting heart failure with improved ejection fraction

BACKGROUND

The ultrasound left ventricular pressure-strain loop (LV PSL) was applied to evaluate myocardial work in heart failure with improved ejection fraction (HFimpEF) versus patients with persistent heart failure with reduced ejection fraction (HFrEF) to investigate the value of myocardial work parameters in predicting HFimpEF.

METHODS

We collected 120 patients with HFrEF and recorded clinical characteristics and echocardiographic parameters (PSL technique) of patients. Patients were divided into HFimpEF group or persistent HFrEF group according to the outcome of follow-up. Furthermore, differential clinical and echocardiographic parameters were determined by Student's t-test. We recognized the important echocardiographic parameters to predict whether patients would recover to HFimpEF using the univariate logistic regression analysis and ROC curves. In addition, the multivariate logistic regression models were constructed and evaluated using Delong test and decision curve analysis.

RESULTS

Firstly, the HFimpEF group had a higher prevalence of hypertension and higher systolic blood pressure (P-values <0.05). In terms of echocardiographic parameters, HFimpEF group also had higher LVEF, LV GLS, GCW, GWE, and GWI and lower LVEDD (P-values <0.01). In particular, LVEF, LVEDD, GLS, GWI, and GCW were robust predictors of the conversion of HFrEF patients to HFimpEF (AUC >0.70, P-values <0.05). Finally, we determined that the predictive Model 4 (LVEF, LVEDD, GLS, and GCW) had the optimal diagnostic power.

CONCLUSION

The model constructed by GCW with LVEF, LVEDD, and GLS has important predictive value for HFimpEF, which is an effective clinical decision-making tool for providing disease assessment.

Heart failure with improved ejection fraction: Beyond diagnosis to trajectory analysis

Left ventricular (LV) systolic dysfunction represents a highly treatable cause of heart failure (HF). A substantial proportion of patients with HF with reduced ejection fraction (EF;HFrEF) demonstrate improvement in LV systolic function (termed HF with improved EF [HFimpEF]), either spontaneously or when treated with guideline-directed medical therapy (GDMT). Although it is a relatively new HF classification, HFimpEF has emerged in recent years as an important and distinct clinical entity. Improvement in LVEF leads to decreased rates of mortality and adverse HF-related outcomes compared to patients with sustained LV systolic dysfunction (HFrEF). While numerous clinical and imaging factors have been associated with HFimpEF, identification of which patients do and do not improve requires further investigation. In addition, patients improve at different rates, and what determines the trajectory of HFimpEF patients after improvement is incompletely characterized. A proportion of patients maintain improvement in LV systolic function, while others experience a recrudescence of systolic dysfunction, especially with GDMT discontinuation. In this review we discuss the contemporary guideline-recommended classification definition of HFimpEF, the epidemiology of improvement in LV systolic function, and the clinical course of this unique patient population. We also offer evidence-based recommendations for the clinical management of HFimpEF and provide a roadmap for future directions in understanding and improving outcomes in the care of patients with HFimpEF.

Factors Associated With Maintenance of an Improved Ejection Fraction: An Echocardiogram-Based Registry Study

Background Heart failure with improved ejection fraction (EF) is increasingly recognized as a sizable and distinct entity. While the features associated with improvedEF have been explored and new guidelines have emerged, factors associated with sustaining an improved EF over time have not been defined. We aimed to assess factors associated with maintenance of an improved EF in a large real-world patient cohort. Methods and Results A total of 7070 participants with heart failure with improved EF and a subsequent echocardiogram performed after at least 9 months of follow-up were included in a retrospective cohort study conducted at the Cleveland Clinic in Cleveland, Ohio. Multiple logistic regression models, adjusted for demographics, comorbidities, and medications were built to identify characteristics and therapeutic interventions associated with maintaining an improved EF. Mean age (SD) was 64.9 (13.8) years, 62.7% were men, and 75.1% were White participants. White race and the use of angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, or angiotensin receptor-neprilysin inhibitors were associated with maintaining the EF at least 9 months after EF improvement. In contrast, male sex or having atrial fibrillation/flutter, coronary artery disease, history of myocardial infarction, presence of an implanted cardioverter-defibrillator, and use of loop diuretics were associated with a decline in EF after previously documented improvement. Conclusions Continued use of renin-angiotensin-aldosterone system inhibitors was associated with maintaining the EF beyond the initial improvement phase.

LVAD therapy as a catalyst to heart failure remission and myocardial recovery

The management of chronic heart failure over the past decade has witnessed tremendous strides in medical optimization and device therapy including the use of left ventricular assist devices (LVAD). What we once thought of as irreversible damage to the myocardium is now demonstrating signs of reverse remodeling and recovery. Myocardial recovery on the structural, molecular, and hemodynamic level is necessary for sufficient recovery to withstand explant and achieve sustained recovery post-LVAD. Guideline-directed medical therapy and unloading have been shown to aid in recovery with the potential to successfully explant the LVAD. This review will summarize medical optimization, assessment for recovery, explant methodologies and outcomes post-recovery with explant of durable LVAD.

The complete reversal effect following angiotensin-converting enzyme inhibitors or angiotensin receptor blockers and beta-blockers after the primary diagnosis of dilated cardiomyopathy

Background

Whether combination administration of angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), and beta-blockers (BBs) has a "reversal" effect on cardiac structure and function for first-diagnosed idiopathic dilated cardiomyopathy (FSIDCM) patients with unclear etiologies and inducements is unknown.

Materials and Methods

We studied the effect of the protocol on FSIDCM patients. The effect was investigated in 26 FSIDCM patients. The criteria of "complete reversal" included left ventricular end-diastolic diameter (LVEDD) ≤50 mm for females or ≤55 mm for males and left ventricular ejection fraction (LVEF) ≥45%; the criteria of "partial reversal" was the decreased rate of LVEDD (ΔLVEDD) >10% or the increase rate of LVEF (ΔLVEF) >10%; the criteria of "no reversal" included LVEDD >50 mm for females or >55 mm for males and ΔLVEDD <10%, and LVEF <45% and ΔLVEF <10%.

Results

Within the follow-up period, nine patients showed "complete reversal," eight "partial reversal," and nine "no reversal." Improvements in echocardiogram parameters were the most significant in "complete reversal" patients (P < 0.001), followed by "partial reversal" and "no reversal" patients (P < 0.05). The QRS (Q wave, R wave, S wave) duration and symptoms duration in "complete reversal" patients were the shortest, followed by "partial reversal" and "no reversal" patients.

Conclusion

ACEIs or ARBs and BBs have a "complete reversal" effect on the left ventricular size and function of some FSIDCM patients. Patients with a narrow QRS and short symptom duration may have a good response.

Targeting the Autophagy-Lysosome Pathway in a Pathophysiologically Relevant Murine Model of Reversible Heart Failure

The key biological "drivers" that are responsible for reverse left ventricle (LV) remodeling are not well understood. To gain an understanding of the role of the autophagy-lysosome pathway in reverse LV remodeling, we used a pathophysiologically relevant murine model of reversible heart failure, wherein pressure overload by transaortic constriction superimposed on acute coronary artery (myocardial infarction) ligation leads to a heart failure phenotype that is reversible by hemodynamic unloading. Here we show transaortic constriction + myocardial infarction leads to decreased flux through the autophagy-lysosome pathway with the accumulation of damaged proteins and organelles in cardiac myocytes, whereas hemodynamic unloading is associated with restoration of autophagic flux to normal levels with incomplete removal of damaged proteins and organelles in myocytes and reverse LV remodeling, suggesting that restoration of flux is insufficient to completely restore myocardial proteostasis. Enhancing autophagic flux with adeno-associated virus 9-transcription factor EB resulted in more favorable reverse LV remodeling in mice that had undergone hemodynamic unloading, whereas overexpressing transcription factor EB in mice that have not undergone hemodynamic unloading leads to increased mortality, suggesting that the therapeutic outcomes of enhancing autophagic flux will depend on the conditions in which flux is being studied.

Reverse Remodeling and Non-Contrast T1 Hypointense Infarct Core in Patients With Reperfused Acute Myocardial Infarction

BACKGROUND

Non-contrast T1 hypointense infarct cores (ICs) within infarcted myocardium detected using cardiac magnetic resonance imaging (CMR) T1 mapping may help assess the severity of left ventricular (LV) injury. However, because the relationship of ICs with chronic LV reverse remodeling (LVRR) is unknown, this study aimed to clarify it.

METHODS AND RESULTS

We enrolled patients with reperfused AMI who underwent baseline CMR on day-7 post-primary percutaneous coronary intervention (n=109) and 12-month follow-up CMR (n=94). Correlations between ICs and chronic LVRR (end-systolic volume decrease ≥15% at 12-month follow-up from baseline CMR) were investigated. We detected 52 (47.7%) ICs on baseline CMR by non-contrast-T1 mapping. LVRR was found in 52.1% of patients with reperfused AMI at 12-month follow-up. Patients with ICs demonstrated higher peak creatine kinase levels, higher B-type natriuretic peptide levels at discharge, lower LV ejection fraction at discharge, and lower incidence of LVRR than those without ICs (26.5% vs. 73.3%, P<0.001) at follow-up. Multivariate logistic regression analysis showed that the presence of ICs was an independent and the strongest negative predictor for LVRR at 12-month follow-up (hazard ratio: 0.087, 95% confidence interval: 0.017-0.459, P=0.004). Peak creatine kinase levels, native T1 values at myocardial edema, and myocardial salvaged indices also correlated with ICs.

CONCLUSIONS

ICs detected by non-contrast-T1 mapping with 3.0-T CMR were an independent negative predictor of LVRR in patients with reperfused AMI.

Early prediction of clinical scores for left ventricular reverse remodeling using extreme gradient random forest, boosting, and logistic regression algorithm representations

Objective

At present, there is no early prediction model of left ventricular reverse remodeling (LVRR) for people who are in cardiac arrest with an ejection fraction (EF) of ≤35% at first diagnosis; thus, the purpose of this article is to provide a supplement to existing research.

Materials and methods

A total of 109 patients suffering from heart attack with an EF of ≤35% at first diagnosis were involved in this single-center research study. LVRR was defined as an absolute increase in left ventricular ejection fraction (LVEF) from ≥10% to a final value of >35%, with analysis features including demographic characteristics, diseases, biochemical data, echocardiography, and drug therapy. Extreme gradient boosting (XGBoost), random forest, and logistic regression algorithm models were used to distinguish between LVRR and non-LVRR cases and to obtain the most important features.

Results

There were 47 cases (42%) of LVRR in patients suffering from heart failure with an EF of ≤35% at first diagnosis after optimal drug therapy. General statistical analysis and machine learning methods were combined to exclude a number of significant feature groups. The median duration of disease in the LVRR group was significantly lower than that in the non-LVRR group (7 vs. 48 months); the mean values of creatine kinase (CK) and MB isoenzyme of creatine kinase (CK-MB) in the LVRR group were lower than those in the non-LVRR group (80.11 vs. 94.23 U/L; 2.61 vs. 2.99 ng/ml; 27.19 vs. 28.54 mm). Moreover, AUC values for our feature combinations ranged from 97 to 94% and to 87% when using the XGBoost, random forest, and logistic regression techniques, respectively. The ablation test revealed that beats per minute (BPM) and disease duration had a greater impact on the model's ability to accurately forecast outcomes.

Conclusion

Shorter disease duration, slightly lower CK and CK-MB levels, slightly smaller right and left ventricular and left atrial dimensions, and lower mean heart rates were found to be most strongly predictive of LVRR development (BPM).

Left ventricular reverse remodelling and its predictors in non-ischaemic cardiomyopathy

Adverse remodelling following an initial insult is the hallmark of heart failure (HF) development and progression. It is manifested as changes in size, shape, and function of the myocardium. While cardiac remodelling may be compensatory in the short term, further neurohumoral activation and haemodynamic overload drive this deleterious process that is associated with impaired prognosis. However, in some patients, the changes may be reversed. Left ventricular reverse remodelling (LVRR) is characterized as a decrease in chamber volume and normalization of shape associated with improvement in both systolic and diastolic function. LVRR might occur spontaneously or more often in response to therapeutic interventions that either remove the initial stressor or alleviate some of the mechanisms that contribute to further deterioration of the failing heart. Although the process of LVRR in patients with new‐onset HF may take up to 2 years after initiating treatment, there is a significant portion of patients who do not improve despite optimal therapy, which has serious clinical implications when considering treatment escalation towards more aggressive options. On the contrary, in patients that achieve delayed improvement in cardiac function and architecture, waiting might avoid untimely implantable cardioverter‐defibrillator implantation. Therefore, prognostication of successful LVRR based on clinical, imaging, and biomarker predictors is of utmost importance. LVRR has a positive impact on prognosis. However, reverse remodelled hearts continue to have abnormal features. In fact, most of the molecular, cellular, interstitial, and genome expression abnormalities remain and a susceptibility to dysfunction redevelopment under biomechanical stress persists in most patients. Hence, a distinction should be made between reverse remodelling and true myocardial recovery. In this comprehensive review, current evidence on LVRR, its predictors, and implications on prognostication, with a specific focus on HF patients with non‐ischaemic cardiomyopathy, as well as on novel drugs, is presented.

The use of angiotensin II receptor blocker is associated with greater recovery of cardiac function than angiotensin-converting enzyme inhibitor in dilated cardiomyopathy

AIMS

Angiotensin-converting enzyme inhibitors (ACEis) or angiotensin II receptor blockers (ARBs) have been shown to be associated with recovery of cardiac function in patients with dilated cardiomyopathy (DCM). The aim of this study was to assess comparative effectiveness of ACEis vs. ARBs on recovery of left ventricular ejection fraction (LVEF) among patients with DCM.

METHODS AND RESULTS

We analysed the clinical personal records of DCM, a national database of the Japanese Ministry of Health, Labour and Welfare, from 2003 to 2014. Patients with LVEF < 40% and on either ACEis or ARBs were included. Eligible patients were divided into two groups according to the use of ACEis or ARBs. A one-to-one propensity case-matched analysis was used. The primary outcome was defined as LVEF ≥ 40% at 3 years of follow-up. Out of 4618 eligible patients, 2238 patients received ACEis and 2380 patients received ARBs. Propensity score matching yielded 1341 pairs. Mean age was 56.0 years, 2041 (76.1%) were male, median duration of heart failure was 1 year, and mean LVEF was 27.6%. The primary outcome was observed more frequently in ARB group than in ACEi group (59.8% vs. 54.1%; odds ratio 1.26; 95% confidence interval 1.08-1.47; P = 0.003). The per-protocol analysis showed similar results (62.0% vs. 54.0%; odds ratio 1.39; 95% confidence interval 1.17-1.66; P < 0.001). The change in LVEF from baseline to 3 years of follow-up was greater in ARB group than in ACEi group (15.8 ± 0.4% vs. 14.0 ± 0.4%, P = 0.003). The subgroup analysis showed that this effect was observed independently of systolic blood pressure, heart rate, LVEF, chronic kidney disease, and concomitant use of beta-blockers and mineralocorticoid receptor antagonists.

CONCLUSIONS

The use of ARBs was associated with LVEF recovery more frequently than ACEis among patients with DCM and reduced LVEF.

Application value of myocardial work technology by non-invasive echocardiography in evaluating left ventricular function in patients with chronic heart failure

BACKGROUND

Accurate evaluation of left ventricular (LV) systolic function is the premise for diagnosing and treating chronic heart failure. This study aimed to explore the incremental value of echocardiographic myocardial work in evaluating the LV systolic dysfunction in patients with chronic heart failure.

METHODS

A total of 206 participants were enrolled, including 155 patients with chronic heart failure and 51 healthy controls (HC). The chronic heart failure patients were divided into three groups according to LV ejection fraction (LVEF): Heart failure with preserved ejection fraction (HFpEF group, 54 cases, LVEF ≥50%), heart failure with mid-range ejection fraction (HFmrEF group, 50 cases, 40%≤ LVEF <50%), and heart failure with reduced ejection fraction (HFrEF group, 51 cases, LVEF <40%). Except for the conventional echocardiographic parameters, the left ventricular myocardial work parameters, including the global myocardial work index (GWI), global constructive work (GCW), global wasted work (GWW), and global work efficiency (GWE), were calculated in the study participants. One-way analysis of variance test followed by Fisher's least significant difference (LSD) t-test were used to obtain parameters with significant differences, which were then fed into a machine learning model established for subsequent multi-classification of the four groups. The selected myocardial work parameters with high importance rankings resulting from the machine learning model were further compared with the traditional LVEF in the multi-classification of the four groups.

RESULTS

All conventional echocardiographic parameters were significantly different between the HFmrEF and HFrEF groups, but only E/e', left atrium showed notable differences between the HFpEF and HC groups (P<0.05). All myocardial work parameters were markedly different between the four groups (P<0.05). LVEF and GWI were more important than the other parameters according to the multi-classification machine learning model. The multi-classification diagnostic performances of LVEF, GWI, and LVEF + GWI were 82%, 88%, and 98%, respectively, which confirmed that GWI + LVEF could complementarily improve the diagnosis accuracy in classifying the four groups, with a performance increase of approximately 10% than each individually.

CONCLUSIONS

GWI can play a complementary role to LVEF in the early diagnosis of HFpEF patients from the HC group and improve the clinical evaluation accuracy in chronic heart failure patients. Echocardiographic myocardial work should be utilized along with conventional LVEF to evaluate the systolic function of chronic heart failure patients in clinical practice.

A Functional Data Analysis Approach to Left Ventricular Remodeling Assessment

Left ventricular remodeling is a mechanism common to various cardiovascular diseases affecting myocardial morphology. It can be often overlooked in clinical practice since the parameters routinely employed in the diagnostic process (e.g., the ejection fraction) mainly focus on evaluating volumetric aspects. Nevertheless, the integration of a quantitative assessment of structural modifications can be pivotal in the early individuation of this pathology. In this work, we propose an approach based on functional data analysis to evaluate myocardial contractility. A functional representation of ventricular shape is introduced, and functional principal component analysis and depth measures are used to discriminate healthy subjects from those affected by left ventricular hypertrophy. Our approach enables the integration of higher informative content compared to the traditional clinical parameters, allowing for a synthetic representation of morphological changes in the myocardium, which could be further explored and considered for future clinical practice implementation.

Prognostic significance of longitudinal strain in dilated cardiomyopathy with recovered ejection fraction

OBJECTIVE

Patients with non-ischaemic dilated cardiomyopathy (NICM) may experience a normalisation in left ventricular ejection fraction (LVEF). Although this correlates with improved prognosis, it does not correspond to a normalisation in the risk of death during follow-up. Currently, there are no tools to risk stratify this population. We tested the hypothesis that absolute global longitudinal strain (aGLS) is associated with mortality in patients with NICM and recovered ejection fraction (LVEF).

METHODS

We designed a retrospective, international, longitudinal cohort study enrolling patients with NICM with LVEF <40% improved to the normal range (>50%). We studied the relationship between aGLS measured at the time of the first recording of a normalised LVEF and all-cause mortality during follow-up. We considered aGLS >18% as normal and aGLS ≥16% as of potential prognostic value.

RESULTS

206 patients met inclusion criteria. Median age was 53.5 years (IQR 44.3-62.8) and 56.6% were males. LVEF at diagnosis was 32.0% (IQR 24.0-38.8). LVEF at the time of recovery was 55.0% (IQR 51.7-60.0). aGLS at the time of LVEF recovery was 13.6%±3.9%. 166 (80%) and 141 (68%) patients had aGLS ≤18% and <16%, respectively. During a follow-up of 5.5±2.8 years, 35 patients (17%) died. aGLS at the time of first recording of a recovered LVEF correlated with mortality during follow-up (HR 0.90, 95% CI 0.91 to 0.99, p=0.048 in adjusted Cox model). No deaths were observed in patients with normal aGLS (>18%). In unadjusted Kaplan-Meier survival analysis, aGLS <16% was associated with higher mortality during follow-up (31 deaths (22%) in patients with GLS <16% vs 4 deaths (6.2%) in patients with GLS ≥16%, HR 3.2, 95% CI 1.1 to 9, p=0.03).

CONCLUSIONS

In patients with NICM and normalised LVEF, an impaired aGLS at the time of LVEF recovery is frequent and associated with worse outcomes.

The Use of Angiotensin-Converting Enzyme Inhibitors or Angiotensin II Receptor Blockers Is Associated with the Recovered Ejection Fraction in Patients with Dilated Cardiomyopathy

Angiotensin-converting enzyme inhibitors (ACEi) and angiotensin II receptor blockers (ARB) have been shown to prevent left ventricular remodeling and improve outcomes of patients with heart failure (HF). This study aimed to investigate whether the use of ACEi/ARB could be associated with HF with recovered ejection fraction (HFrecEF) in patients with dilated cardiomyopathy (DCM).We collected individual patient data regarding demographics, echocardiogram, and treatment in DCM between 2003 and 2014 from the clinical personal record, a national database of the Japanese Ministry of Health, Labour and Welfare. Patients with left ventricular ejection fraction (LVEF) < 40% were included. Eligible patients were divided into two groups according to the use of ACEi/ARB. A propensity score matching analysis was employed. The primary outcome was defined as LVEF ≥ 40% at 3 years of follow-up.Out of 5,955 patients with DCM and LVEF < 40%, propensity score matching yielded 830 pairs. The mean age was 58.8 years, and 1,184 (71.3%) of the patients were male. The primary outcome was observed more frequently in the ACEi/ARB group than in the no ACEi/ARB group (57.0% versus 49.3%; odds ratio 1.36; 95% confidence interval (CI) 1.12-1.65; P = 0.002). Subgroup analysis revealed that the use of ACEi and ARB was associated with recovery of LVEF regardless of atrial fibrillation. The change in LVEF from baseline to 3 years of follow-up was greater in the ACEi-ARB group (14.9% ± 0.6% versus 12.3% ± 0.5%; P = 0.001).The use of ACEi/ARB is associated with HFrecEF in patients with DCM and reduced LVEF.

Unsupervised cluster analysis of patients with recovered left ventricular ejection fraction identifies unique clinical phenotypes

Background

Patients with heart failure (HF) with recovered ejection fraction (HFrecEF) are a recently identified cohort that are phenotypically and biologically different from HFrEF and HFpEF patients. Whether there are unique phenotypes among HFrecEF patients is not known.

Methods

We studied all patients at a large medical center, who had an improvement in LVEF from ≤ 35% to ≥ 50% (LVrecEF) between January 1, 2005 and December 31, 2013. We identified a set of 11 clinical variables and then performed unsupervised clustering analyses to identify unique clinical phenotypes among patients with LVrecEF, followed by a Kaplan-Meier analysis to identify differences in survival and the proportion of LVrecEF patients who maintained an LVEF ≥ 50% during the study period.

Results

We identified 889 patients with LVrecEF who clustered into 7 unique phenotypes ranging in size from 37 to 420 patients. Kaplan-Meier analysis demonstrated significant differences in mortality across clusters (logrank p<0.0001), with survival ranging from 14% to 87% at 1000 days, as well as significant differences in the proportion of LVrecEF patients who maintained an LVEF ≥ 50%.

Conclusion

There is significant clinical heterogeneity among patients with LVrecEF. Clinical outcomes are distinct across phenotype clusters as defined by clinical cardiac characteristics and co-morbidities. Clustering algorithms may identify patients who are at high risk for recurrent HF, and thus be useful for guiding treatment strategies for patients with LVrecEF.

Clinical significance of ischemia-like electrocardiographic finding during heart failure treatment on left ventricular recovery in patients with non-ischemic dilated cardiomyopathy

BACKGROUND

Patients with non-ischemic dilated cardiomyopathy (DCM) often show ischemia-like electrocardiographic findings. We aimed to elucidate the clinical impact of ischemia-like electrocardiographic findings in DCM, focusing on left ventricular reverse remodeling (LVRR).

METHODS

We evaluated 195 patients hospitalized with heart failure (HF) and diagnosed with DCM. All patients underwent twelve-lead electrocardiography (ECG) and echocardiography during hospitalization and at the 2-year follow-up.

RESULTS

During hospitalization, 152 (78%) patients experienced ischemia-like ECG findings (Minnesota codes I3, IV1-3, V1-3, or VII1); 43 patients (22%, non-ischemia-like group) did not experience these findings. Ischemia-like ECG findings were normalized during hospitalization in 64 patients (33%, transient-ischemia-like group) but were unchanged in 88 patients (45%, persistent-ischemia-like group). The highest rates of LVRR, defined as an increase in LV ejection fraction from ≥10% to a final value of ≥35%, along with decreased LV end-diastolic dimension of ≥10% during 2 years of follow-up, were shown in the transient-ischemia-like group (transient-ischemia-like group, 91%; persistent-ischemia-like group, 40%; non-ischemia-like-group, 51%; p < 0.001). The transient-ischemia-like group had lowest composite event rates, including readmission for HF, the detection of major ventricular arrhythmia, and sudden cardiac death.

CONCLUSIONS

Normalization of ischemia-like ECG findings during the first HF treatments was associated with a higher occurrence of mid-term LVRR and favorable long-term outcome in patients with DCM.

Heart Failure With Recovered Left Ventricular Ejection Fraction: JACC Scientific Expert Panel

Reverse left ventricular (LV) remodeling and recovery of LV function are associated with improved clinical outcomes in patients with heart failure with reduced ejection fraction. A growing body of evidence suggests that even among patients who experience a complete normalization of LV ejection fraction, a significant proportion will develop recurrent LV dysfunction accompanied by recurrent heart failure events. This has led to intense interest in understanding how to manage patients with heart failure with recovered ejection fraction (HFrecEF). Because of the lack of a standard definition for HFrecEF, and the paucity of clinical data with respect to the natural history of HFrecEF patients, there are no current guidelines on how these patients should be followed up and managed. Accordingly, this JACC Scientific Expert Panel reviews the biology of reverse LV remodeling and the clinical course of patients with HFrecEF, as well as provides guidelines for defining, diagnosing, and managing patients with HFrecEF.

Clinical and echocardiographic predictors of left ventricular remodeling following anterior acute myocardial infarction

OBJECTIVES

Coronary artery disease is the primary cause of death and is responsible for a high number of hospitalizations worldwide. Ventricular remodeling is associated with worse prognosis following ST-segment elevation myocardial infarction (STEMI) and is a risk factor for ventricular dysfunction and heart failure. This study aimed to identify the predictors of ventricular remodeling following STEMI. Additionally, we evaluated the clinical, laboratory, and echocardiographic characteristics of patients with anterior wall STEMI who underwent primary percutaneous intervention in the acute phase and at 6 months after the infarction.

METHODS

This prospective, observational, and longitudinal study included 50 patients with anterior wall STEMI who were admitted to the coronary care unit (CCU) of a tertiary hospital in Brazil between July 2017 and August 2018. During the CCU stay, patients were evaluated daily and underwent echocardiogram within the first three days following STEMI. After six months, the patients underwent clinical evaluation and echocardiogram according to the local protocol.

RESULTS

Differences were noted between those who developed ventricular remodeling and those who did not in the mean±standard deviation levels of creatine phosphokinase MB isoenzyme (CKMB) peak (no remodeling group: 323.7±228.2 U/L; remodeling group: 522.4±201.6 U/L; p=0.008) and the median and interquartile range of E/E' ratio (no remodeling group: 9.20 [8.50-11.25] and remodeling group: 12.60 [10.74-14.40]; p=0.004). This difference was also observed in multivariate logistic regression.

CONCLUSIONS

Diastolic dysfunction and CKMB peak in the acute phase of STEMI can be predictors of ventricular remodeling following STEMI.

Echocardiographic parameters associated with recovery in heart failure with reduced ejection fraction

OBJECTIVE

The study aims to determine the clinical and echocardiographic parameters of patients with recovered heart failure (HFrecEF).

METHODOLOGY

Sixty-seven patients (cases) were identified as heart failure with recovered ejection fraction (HFrecEF), defined as improvement in EF ≥ 10%. Sixty-nine patients (controls) were randomly selected by convenience sampling with no or <10% improvement in EF (HFrEF non-recovered).

RESULTS

The mean interval between baseline and follow-up echocardiography was 10.5 months in cases and 11.2 months in the control group. HFrecEF showed a 22.7% improvement in mean ejection fraction, and HFrEF non-recovered group also showed a minor increment of 5.5%. HFrecEF patients were significantly younger (49.51 vs 57.54 years, P .001) with non-ischemic cardiomyopathy (86.6% vs 52.2%). Patients with HFrecEF had significantly less left ventricular end-diastolic and end-systolic volumes (LVEDV: 162.51 mL vs 208.54 mL, P < .001; LVESV: 119.81 mL vs 157.13 mL, P < .001) and index left atrial volume (37.66 mL vs 47.09 mL, P < .001) than patients with non-recovered EF. The right ventricle (RV) and inferior vena cava were significantly dilated with higher mean tricuspid annular plane systolic excursion (TAPSE) among patients with HFrecEF than HFrEF non-recovered.

CONCLUSION

Based on univariate analysis, younger age, non-ischemic etiology, LVEDV, LVESV, deceleration time, better TAPSE, dilated right ventricle, dilated IVC, and smaller left atrial volumes were found significant, but on multivariate logistic regression model only left ventricle end-diastolic volume, left atrial volume, and TAPSE were linked to the recovery of ejection fraction.

Preoperative myocardial expression of E3 ubiquitin ligases in aortic stenosis patients undergoing valve replacement and their association to postoperative hypertrophy

Currently, aortic valve replacement is the only treatment capable of relieving left ventricle pressure overload in patients with severe aortic stenosis. It aims to improve cardiac function and revert hypertrophy, by triggering myocardial reverse remodeling. Despite immediately relieving afterload, reverse remodeling turns out to be extremely variable. Among other factors, the extent of reverse remodeling may depend on how well ubiquitin-proteasome system tackle hypertrophy. Therefore, we assessed tagged ubiquitin and ubiquitin ligases in the left ventricle collected from patients undergoing valve replacement and tested their association to the degree of reverse remodeling. Patients were classified according to the regression of left ventricle mass (ΔLVM) and assigned to complete (ΔLVM≥15%) or incomplete (ΔLVM≤5%) reverse remodeling groups. No direct inter-group differences were observed. Nevertheless, correlation analysis supports a fundamental role of the ubiquitin-proteasome system during reverse remodeling. Indeed, total protein ubiquitination was associated to hypertrophic indexes such as interventricular septal thickness (r = 0.55, p = 0.03) and posterior wall thickness (r = 0.65, p = 0.009). No significant correlations were observed for Muscle Ring Finger 3. Surprisingly, though, higher levels of atrogin-1 were associated to postoperative interventricular septal thickness (r = 0.71, p = 0.005). In turn, Muscle Ring Finger 1 correlated negatively with this postoperative hypertrophy marker (r = -0.68, p = 0.005), suggesting a cardioprotective role during reverse remodeling. No significant correlations were found with left ventricle mass regression, although a trend for a negative association between the ligase Murine Double Minute 2 and mass regression (r = -0.44, p = 0.10) was found. Animal studies will be necessary to understand whether this ligase is protective or detrimental. Herein, we show, for the first time, an association between the preoperative myocardial levels of ubiquitin ligases and postoperative hypertrophy, highlighting the therapeutic potential of targeting ubiquitin ligases in incomplete reverse remodeling.

Patient-specific heart simulation can identify non-responders to cardiac resynchronization therapy

To identify non-responders to cardiac resynchronization therapy (CRT), various biomarkers have been proposed, but these attempts have not been successful to date. We tested the clinical applicability of computer simulation of CRT for the identification of non-responders. We used the multi-scale heart simulator “UT-Heart,” which can reproduce the electrophysiology and mechanics of the heart based on a molecular model of the excitation–contraction mechanism. Patient-specific heart models were created for eight heart failure patients who were treated with CRT, based on the clinical data recorded before treatment. Using these heart models, bi-ventricular pacing simulations were performed at multiple pacing sites adopted in clinical practice. Improvement in pumping function measured by the relative change of maximum positive derivative of left ventricular pressure (%ΔdP/dt_max) was compared with the clinical outcome. The operators of the simulation were blinded to the clinical outcome. In six patients, the relative reduction in end-systolic volume exceeded 15% in the follow-up echocardiogram at 3 months (responders) and the remaining two patients were judged as non-responders. The simulated %ΔdP/dt_max at the best lead position could identify responders and non-responders successfully. With further refinement of the model, patient-specific simulation could be a useful tool for identifying non-responders to CRT.

Redefining Adverse and Reverse Left Ventricular Remodeling by Cardiovascular Magnetic Resonance Following ST-Segment-Elevation Myocardial Infarction and Their Implications on Long-Term Prognosis

BACKGROUND

Cut off values for change in left ventricular end-diastolic volume (LVEDV) and LV end-systolic volume (LVESV) by cardiovascular magnetic resonance following ST-segment-elevation myocardial infarction have recently been proposed and 4 patterns of LV remodeling were described. We aimed to assess their long-term prognostic significance.

METHODS

A prospective cohort of unselected patients with ST-segment-elevation myocardial infarction with paired acute and 6-month cardiovascular magnetic resonance, with the 5-year composite end point of all-cause death and hospitalization for heart failure was included. The prognosis of the following groups (group 1: reverse LV remodeling [≥12% decrease in LVESV]; group 2: no LV remodeling [changes in LVEDV and LVESV <12%]; group 3: adverse LV remodeling with compensation [≥12% increase in LVEDV only]; and group 4: adverse LV remodeling [≥12% increase in both LVESV and LVEDV]) was compared.

RESULTS

Two hundred eighty-five patients were included with a median follow-up was 5.8 years. The composite end point occurred in 9.5% in group 1, 12.3% in group 2, 7.1% in group 3, and 24.2% in group 4. Group 4 had significantly higher cumulative event rates of the composite end point (log-rank test, P=0.03) with the other 3 groups showing similar cumulative event rates (log-rank test, P=0.51). Cox proportional hazard for group 2 (hazard ratio, 1.3 [95% CI, 0.6-3.1], P=0.53) and group 3 (hazard ratio, 0.6 [95% CI, 0.2-2.3], P=0.49) were not significantly different but was significantly higher in group 4 (hazard ratio, 3.0 [95% CI, 1.2-7.1], P=0.015) when compared with group 1.

CONCLUSIONS

Patients with ST-segment-elevation myocardial infarction developing adverse LV remodeling at 6 months, defined as ≥12% increase in both LVESV and LVEDV by cardiovascular magnetic resonance, was associated with worse long-term clinical outcomes than those with adverse LV remodeling with compensation, reverse LV remodeling, and no LV remodeling, with the latter 3 groups having similar outcomes in a cohort of stable reperfused patients with ST-segment-elevation myocardial infarction. Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT02072850.

Epigenetic-sensitive liquid biomarkers and personalised therapy in advanced heart failure: a focus on cell-free DNA and microRNAs

Dilated cardiomyopathy (DCM) represents a common genetic cause of mechanical and/or electrical dysfunction leading to heart failure (HF) onset for which truncating variants in titin (TTN) gene result in the most frequent mutations. Moreover, myocyte and endothelial cell apoptosis is a key endophenotype underlying cardiac remodelling. Therefore, a deeper knowledge about molecular networks leading to acute injury and apoptosis may reveal novel circulating biomarkers useful to better discriminate HF phenotypes, patients at risk of heart transplant as well as graft reject in order to improve personalised therapy. Remarkably, increased plasma levels of cell-free DNA (cfDNA) may reflect the extent of cellular damage, whereas circulating mitochondrial DNA (mtDNA) may be a promising biomarker of poor prognosis in patients with HF. Furthermore, some panels of circulating miRNAs may improve the stratification of natural history of disease. For example, a combination of miR-558, miR-122* and miR-520d-5p, as well as miR-125a-5p, miR-550a-5p, miR-638 and miR-190a, may aid to discriminate different phenotypes of HF ranging from preserved to reduced ejection fraction. We give update on the most relevant genetic determinants involved in DCM and discuss the putative role of non-invasive biomarkers to overcome current limitations of the reductionist approach in HF management.

Myocardial slices come to age: an intermediate complexity in vitro cardiac model for translational research

Although past decades have witnessed significant reductions in mortality of heart failure together with advances in our understanding of its cellular, molecular, and whole-heart features, a lot of basic cardiac research still fails to translate into clinical practice. In this review we examine myocardial slices, a novel model in the translational arena. Myocardial slices are living ultra-thin sections of heart tissue. Slices maintain the myocardium's native function (contractility, electrophysiology) and structure (multicellularity, extracellular matrix) and can be prepared from animal and human tissue. The discussion begins with the history and current advances in the model, the different interlaboratory methods of preparation and their potential impact on results. We then contextualize slices' advantages and limitations by comparing it with other cardiac models. Recently, sophisticated methods have enabled slices to be cultured chronically in vitro while preserving the functional and structural phenotype. This is more timely now than ever where chronic physiologically relevant in vitro platforms for assessment of therapeutic strategies are urgently needed. We interrogate the technological developments that have permitted this, their limitations, and future directions. Finally, we look into the general obstacles faced by the translational field, and how implementation of research systems utilizing slices could help in resolving these.

Zi Shen Huo Luo Formula Enhances the Therapeutic Effects of Angiotensin-Converting Enzyme Inhibitors on Hypertensive Left Ventricular Hypertrophy by Interfering With Aldosterone Breakthrough and Affecting Caveolin-1/Mineralocorticoid Receptor Colocalization and Downstream Extracellular Signal-Regulated Kinase Signaling

Left ventricular hypertrophy (LVH) is an important characteristic of hypertensive heart disease. Renin-angiotensin system (RAS) blockers have been shown to be effective drugs for the reversal of LVH. Clinical and experimental studies have shown that Zi Shen Huo Luo Formula (ZSHLF) can improve the efficacy of perindopril in the treatment of hypertensive LVH, but its mechanism is unclear. This study aimed to investigate the possible mechanism to improve the efficacy of perindopril. First, we identified 23 compounds in ZSHLF by ultra performance liquid chromatography/tandem mass spectrometry (UPLC-MS/MS) analysis, among which ferulic acid, caffeic acid, vanillic acid, berberine, rutin, quercetin, kaempferol, stachydrine, and tiliroside have been reported to reduce blood pressure and exhibit cardioprotective effects. Second, we treated spontaneously hypertensive rats (SHRs) with perindopril and ZSHLF for 12 continuous weeks and found that chronic use of perindopril could increase the aldosterone (ALD) levels and cause aldosterone breakthrough (ABT). ZSHLF combined with perindopril reduced the ALD levels, interfered with ABT, decreased blood pressure, improved left ventricular diastolic dysfunction, and decreased the collagen volume fraction; these effects were superior to those of perindopril alone. In vitro experiments, ALD-induced cardiomyocytes (H9c2 cells) and cardiac fibroblasts were treated with ZSHLF-containing serum, which suppressed ALD-induced cardiomyocyte hypertrophy and cardiac fibroblast proliferation, increased mineralocorticoid receptor (MR) and Cav-1 colocalization and decreased phosphorylated epidermal growth factor receptor (pEGFR) and phosphorylated extracellular signal-regulated kinase (pERK) protein expression the cells. In conclusion, ZSHLF can interfere with ABT and affect the pathological role of ALD by affecting MR and Cav-1 interactions and EGFR/ERK signaling pathway. These effects represent a possible mechanism by which ZSHLF improves the efficacy of angiotensin-converting enzyme inhibitors (ACEIs) in hypertensive LVH treatment. However, the major bioactive components or metabolites responsible for the effects and the implications of these findings in patients need further verification.

Systolic function recovery in Heart Failure: Frequency, prognostic impact and predictors

BACKGROUND

Systolic function recovery in patients with Heart failure (HF) with reduced ejection fraction (EF) is well recognized but not completely understood. We aimed to characterize HF patients with systolic function recovery, its prognostic impact and predictors.

METHODS

We analysed patients followed in a HF clinic (2006-2015) with 2 echocardiograms performed. Partial recovery: EF recovery without attaining EF ≥ 50%; total recovery: patients reached EF ≥ 50%. Median follow-up from first echocardiogram: 69 months. Multivariate logistic regression models to determine recovery predictors.

RESULTS

We analysed 304 patients with at least mild left ventricular dysfunction. During a median 34 months between echocardiogram re-evaluation 150 (49.3%) patients showed no EF recovery; 55 (18.1%) had partial recovery and 99 (32.6%) totally recovered. Mean patients age: 66; 71.1% men, high comorbidity burden; ischemic HF: 35.5%. Non-recovered patients were mostly men (80.7% vs 61.8% in partially; 61.6% in fully-recovered) with ischemic HF (46.0% vs 32.5% in partially; 21.2% in fully-recovered). Comorbidity burden, NYHA class and therapy were similar. During follow-up, 156 patients (46.7%) died. Patients with total recovery had a multivariate-adjusted 54% lower risk of dying when compared to non-recovered. Partially-recovered patients showed a non-significant adjusted 8% mortality reduction. Independent predictors of systolic function recovery were female gender(OR: 2.17, 95% CI 1.11-4.35), non-ischemic aetiology (OR: 2.78, 95% CI 1.35-5.56), and end diastolic left ventricular diameter < 60 mm (OR: 3.12, 95% CI 1.56-6.25).

CONCLUSIONS

HF-recovered patients were mainly women with non-ischemic HF and smaller left ventricles. These patients had significantly better prognosis than those with persistently reduced EF.

IK1 Channel Agonist Zacopride Alleviates Cardiac Hypertrophy and Failure via Alterations in Calcium Dyshomeostasis and Electrical Remodeling in Rats

Intracellular Ca²⁺ overload, prolongation of the action potential duration (APD), and downregulation of inward rectifier potassium (I_K1) channel are hallmarks of electrical remodeling in cardiac hypertrophy and heart failure (HF). We hypothesized that enhancement of I_K1 currents is a compensation for I_K1 deficit and a novel modulation for cardiac Ca²⁺ homeostasis and pathological remodeling. In adult Sprague-Dawley (SD) rats in vivo, cardiac hypertrophy was induced by isoproterenol (Iso) injection (i.p., 3 mg/kg/d) for 3, 10, and 30 days. Neonatal rat ventricular myocytes (NRVMs) were isolated from 1 to 3 days SD rat pups and treated with 1 μmol/L Iso for 24 h in vitro. The effects of zacopride, a selective I_K1/Kir2.1 channel agonist, on cardiac remodeling/hypertrophy were observed in the settings of 15 μg/kg in vivo and 1 μmol/L in vitro. After exposing to Iso for 3 days and 10 days, rat hearts showed distinct concentric hypertrophy and fibrosis and enhanced pumping function (P < 0.01 or P < 0.05), then progressed to dilatation and dysfunction post 30 days. Compared with the age-matched control, cardiomyocytes exhibited higher cytosolic Ca²⁺ (P < 0.01 or P < 0.05) and lower SR Ca²⁺ content (P < 0.01 or P < 0.05) all through 3, 10, and 30 days of Iso infusion. The expressions of Kir2.1 and SERCA2 were downregulated, while p-CaMKII, p-RyR2, and cleaved caspase-3 were upregulated. Iso-induced electrophysiological abnormalities were also manifested with resting potential (RP) depolarization (P < 0.01), APD prolongation (P < 0.01) in adult cardiomyocytes, and calcium overload in cultured NRVMs (P < 0.01). Zacopride treatment effectively retarded myocardial hypertrophy and fibrosis, preserved the expression of Kir2.1 and some key players in Ca²⁺ homeostasis, normalized the RP (P < 0.05), and abbreviated APD (P < 0.01), thus lowered cytosolic [Ca^{2 +}]_i (P < 0.01 or P < 0.05). I_K1channel blocker BaCl₂ or chloroquine largely reversed the cardioprotection of zacopride. We conclude that cardiac electrical remodeling is concurrent with structural remodeling. By enhancing cardiac I_K1, zacopride prevents Iso-induced electrical remodeling around intracellular Ca²⁺ overload, thereby attenuates cardiac structural disorder and dysfunction. Early electrical interventions may provide protection on cardiac remodeling.

Load-Dependent Changes in Left Ventricular Structure and Function in a Pathophysiologically Relevant Murine Model of Reversible Heart Failure

BACKGROUND

To better understand reverse left ventricular (LV) remodeling, we developed a murine model wherein mice develop LV remodeling after transverse aortic constriction (TAC) and a small apical myocardial infarct (MI) and undergo reverse LV remodeling after removal of the aortic band.

METHODS AND RESULTS

Mice studied were subjected to sham (n=6) surgery or TAC+MI (n=12). Two weeks post-TAC+MI, 1 group underwent debanding (referred to as heart failure debanding [HF-DB] mice; n=6), whereas the aortic band remained in a second group (heart failure [HF] group; n=6). LV remodeling was evaluated by 2D echocardiography at 1 day, 2 weeks and 6 weeks post-TAC+MI. The hearts were analyzed by transcriptional profiling at 4 and 6 weeks and histologically at 6 weeks. Debanding normalized LV volumes, LV mass, and cardiac myocyte hypertrophy at 6 weeks in HF-DB mice, with no difference in myofibrillar collagen in the HF and HF-DB mice. LV ejection fraction and radial strain improved after debanding; however, both remained decreased in the HF-DB mice relative to sham and were not different from HF mice at 6 weeks. Hemodynamic unloading in the HF-DB mice was accompanied by a 35% normalization of the HF genes at 2 weeks and 80% of the HF genes at 4 weeks.

CONCLUSIONS

Hemodynamic unloading of a pathophysiologically relevant mouse model of HF results in normalization of LV structure, incomplete recovery of LV function, and incomplete reversal of the HF transcriptional program. The HF-DB mouse model may provide novel insights into mechanisms of reverse LV remodeling.

Effect of Peritoneal Dialysis on Serum Fibrosis Biomarkers in Patients with Refractory Congestive Heart Failure

Background: Cardiac collagen remodeling is important in the progression of heart failure. Estimation of cardiac collagen turnover by serum levels of serological markers is used for monitoring cardiac tissue repair and fibrosis. Peritoneal dialysis (PD) is used for the long-term management of refractory congestive heart failure (CHF). In this study, we investigated the effect of PD treatment on circulating fibrosis markers levels in patients with refractory CHF and fluid overload. Methods: Twenty-five patients with refractory CHF treated with PD were prospectively enrolled in the study. Circulating fibrosis markers procollagen type III C-peptide (PIIINP), matrix metalloproteinase 2 (MMP-2), and tissue inhibitor of metalloproteinases I (TIMP-1) levels were checked at baseline and after three and six months of treatment. Results: The clinical benefit of PD manifested by improved NYHA functional class and reduced hospitalization rate. Serum brain natriuretic peptide (BNP) levels decreased significantly during the treatment. Serum MMP-2 and TIMP-1 decreased significantly on PD. Circulating PIIINP showed two patterns of change, either decreased or increased following PD treatment. Patients in whom circulating PIIINP decreased had significantly lower baseline serum albumin, lower baseline mean arterial blood pressure, higher serum CRP, and a less significant improvement in hospitalization rate compared to the patients in whom circulating PIIINP increased. Patients in whom all three markers decreased demonstrated a trend to longer survival compared to patients whose markers increased or did not change. Conclusion: In refractory CHF patients PD treatment was associated with a reduction in circulating fibrosis markers.

Changes in left ventricular shape and morphology in the presence of heart failure: a four-dimensional quantitative and qualitative analysis

PURPOSE

The presence and progression of heart failure (HF) are associated with cardiac remodelling, defined as cellular, molecular and interstitial changes which occur after injury and manifest as changes in left ventricular (LV) size, mass, geometry and function. This research study was designed to investigate the changes to LV morphology and shape which occur in the presence of heart failure using three-dimensional (3D) modelling and analysis of cardiac-gated CT scans from both healthy individuals and patients classified with HF.

METHODS

A number of quantitative and qualitative strategies were applied to cardiac CT scans of HF patients and healthy controls (n = 7) in order to analyse changes to LV size, shape and structure and to examine LV remodelling in the different classes of HF. Three-dimensional wireframe representations of endocardial and epicardial borders were created, three-dimensional computer stereolithography models of the inner LV cavity and myocardial wall segments were generated and three-dimensionally printed and a number of clinical LV dimension and shape indices were measured. All data were analysed using one-way ANOVA with post hoc Tukey method for multiple comparisons for significant variables.

RESULTS

Results of most significance included abnormalities in LV mass and end-systolic dimensions and significantly increased septal wall thickness among mid-range ejection fraction cases. Also of importance were significant increases in both dimension-based and volumetric sphericity index measures in all HF cases. Three-dimensional printed models provided qualitative information as to changes in inner LV cavity and myocardial wall morphology across the cardiac cycle for healthy and HF cases and validated quantitative findings.

CONCLUSION

Findings from this study can successfully be applied to motivate the research and development of new HF treatment strategies and devices as well as for the development of a realistic cardiac simulator system.

Long-term and clinical profile of heart failure with recovered ejection fraction in a non-tertiary hospital

INTRODUCTION

Heart failure (HF) with recovered ejection fraction (EF) is emerging as a different HF subtype. There is little information about his clinical profile in hospitals that are not a reference.

METHODS

We analysed characteristics and prognosis in patients with recovered HF followed prospectively in the HF Unit of a non-tertiary hospital.

RESULTS

A total of 431 patients with HF with reduced EF were followed (median 50 months, 79.3% males, mean age 70.3±12.2years). Of the patients, 26.9% (N 116) recovered EF, mainly in the first year of follow-up (76.7%). Compared with patients that did not recovered EF in the follow-up, they were younger, rate of ischemic origin of cardiomyopathy was less frequent and presented less comorbidity. Mortality was lower in patients with recovered HF (survival median of 85.2±2.1 vs. 74.2±1.9 months [log-rank χ² 11.5, P=0.001], hazard ratio 0.37, 95% confidence interval [CI]: 0.21-0.67, P=0.002). Aetiology of deaths was not mainly secondary to HF. Younger age of 68 years (odds ratio [OR] 0-98, 95% CI: 0.96-0,99; P=0.025), ischemic origin (OR 1.12, 95% CI: 1.01-1.21; P=0.003) and use of aldosterone antagonists (OR 1.89, 95% CI: 1.09-3.26; P=0.023) were the variables independently associated to normalisation of EF.

CONCLUSION

HF with recovered EF is a frequent phenomenon. It has a more favourable clinical course, prognosis and basal characteristics than HF with persistent reduced EF. Further studies are needed to identify natural history and optimal medications for HF-recovered patients.

Heart failure with recovered ejection fraction

Substantial or complete myocardial recovery occurs in many patients with heart failure (HF). HF patients with myocardial recovery or recovered left ventricular (LV) ejection fraction (EF; HFrecEF) are a distinct population of HF patients with different underlying etiologies, comorbidities, response to therapies, and outcomes compared with HF patients with persistent reduced or preserved EF. Improvement in LVEF has been systematically linked to improved quality of life, and lower rehospitalization rates and mortality. However, the mortality and morbidity in HFrecEF patients remain higher than those in the normal population. Currently, data to guide the management of HFrecEF patients are lacking. This review discusses specific characteristics, pathophysiology, and clinical implications for HFrecEF.

Naringenin inhibits NG-nitro-L-arginine methyl ester-induced hypertensive left ventricular hypertrophy by decreasing angiotensin-converting enzyme 1 expression

Naringenin (NGN) is a natural flavonoid that exerts antiinflammatory, antioxidant and cardioprotective effects. The present study investigated the effects of NGN on left ventricular hypertrophy in rats with N^G-nitro-L-arginine methyl ester (L-NAME)-induced hypertension, and sought to determine the underlying mechanism of action. The rats received the following by gavage daily for 56 days: L-NAME (50 mg/kg/day) + NGN (100 mg/kg/day), L-NAME (50 mg/kg/day) + saline, or saline + saline. Blood pressure, heart rate and body weight were recorded. Left ventricular hypertrophy was assessed by echocardiography and hematoxylin-eosin staining. Angiotensin II (Ang II) and angiotensin-converting enzyme 1 (ACE1), which serve a pivotal role in cardiac remodeling, were evaluated by ELISA, reverse transcription-quantitative polymerase chain reaction and western blot analysis. NGN had no significant effect on body weight, heart rate or blood pressure. The extent of left ventricular hypertrophy in the L-NAME + NGN group was lower than in the L-NAME + saline group on day 56. NGN decreased Ang II and ACE1 protein levels in myocardial tissues. In conclusion, Ang II and ACE1 expression in cardiac tissue was inhibited by NGN in L-NAME-treated rats, which may contribute to the inhibitory effects of NGN on left ventricular hypertrophy that is induced by pressure overload.

[Predictive factors of left ventricular reverse remodeling in patients with idiopathic or secondary dilated cardiomyopathy]

OBJECTIVE

To investigate the occurrence of left ventricular reverse remodeling (LVRR) and its predictive factors in patients with idiopathic or secondary dilated cardiomyopathy (DCM).

METHODS

A cross-sectional survey was conducted in a consecutive cohort of patients with DCM admitted in our department between January, 2012 and June, 2016. Based on dynamic echocardiographic findings, LVRR was defined as an absolute increase in left ventricular ejection fraction (LVEF) by ≥100% or an absolute value of LVEF ≥45% with simultaneously an absolute decrease in end-diastolic diameter (LVEDD) ≥10 mm or an absolute value of LVEDD ≤55 mm (in men) or ≤50 mm (in women). The patients with LVRR and those without LVRR were compared for clinical data at admission to identify the potential factors for predicting LVRR.

RESULTS

A total of 462 patients, who were followed up for 24.13±15.60 months, were included in this survey. In patients with idiopathic DCM who had LVRR, LVEDD was reduced (P < 0.01), LVEF was improved (P < 0.01) and the mean exercise tolerance was increased significantly (P < 0.01) compared with those in patients without LVRR. Multiple logistic regression analysis showed that a shorter course of heart failure (OR=0.913, P < 0.01), a high systolic blood pressure (OR=1.062, P < 0.01), absence of electrolyte imbalance (OR=0.347, P < 0.01), a low red cell distribution width (OR=0.205, P < 0.01), a smaller LVEDD (OR=0.799, P < 0.01) and a greater LVEF (OR= 1.142, P < 0.01) were independent predictors of LVRR in the idiopathic patients. In patients with secondary DCM, LVEDD was reduced (P < 0.01), LVEF was improved (P < 0.01), and the mean exercise tolerance was increased significantly (P < 0.01) compared with those in patients without LVRR. Multiple logistic regression analysis showed that a shorter course of heart failure (OR= 0.954, P < 0.01), a low red cell distribution width (OR=1.011, P < 0.01), and implementation of etiological treatment (OR=1.073, P < 0.01) were independent predictors of LVRR in patients with secondary DCM.

CONCLUSIONS

The exercise tolerance, cardiac structure and function can be reversed in some of the patients with idiopathic or secondary DCM by administration of standard therapy for heart failure and etiological treatment.

Histological evidence for reversible cardiomyocyte changes and serum cardiac troponin T elevation after exercise in rats

This study characterized cardiac troponin T (cTnT) appearance and associated histological evidence of reversible or irreversible changes in myocardial ultrastructure, determined via electron microscopy, in rats undertaking isoproterenol (ISO) infusion or an endurance exercise challenge. Male rats were randomized into ISO and exercise groups. In ISO trials rats were killed 5 h (ISO‐5H) and 24 h (ISO‐REC19H) after a single ISO or saline injection (SAL‐5H; SAL‐REC19H). In the exercise trials rats were killed before, as a control (EXE‐CON), immediately after (EXE‐END5H) and 19 h after (EXE‐REC19H) a 5‐h bout of swimming with 5% body weight attached to their tail. Serum cTnT was quantified by electrochemiluminescence, and myocardial samples in ISO‐REC19H, EXE‐REC19H and SAL‐REC19H were harvested for assessment of specific mitochondrial injury scores using electron‐microscopy. cTnT was undetectable in all control animals (SAL‐5H/SAL‐REC19H and EXE‐CON). cTnT increased in all animals after ISO and exercise but the response was significantly higher (P < 0.05) at ISO‐5H (median [range]: 2.60 [1.76–6.18] μg · L⁻¹) than at EXE‐END5H (median [range]: 0.05 [0.02–0.14] μg · L⁻¹). cTnT returned to baseline at EXE‐REC19H, but had not completely recovered at ISO‐REC19H (median [range]: 0.17 [0.09–1.22] μg · L⁻¹). Mitochondrial “injury scores” were significantly higher (P < 0.05) in ISO‐REC19H compared to EXE‐REC19H and SAL‐REC19H, with no difference between EXE‐REC19H and SAL‐REC19H. Mitochondria from EXE‐REC19H appeared aggregated in nonlinear clusters in a small number of scans. These findings suggest that acute exercise‐induced appearance of cTnT in this animal model is only associated with reversible changes in cardiomyocyte structure.

Treatment of the cardiac hypertrophic response and heart failure with ginseng, ginsenosides, and ginseng-related products

Heart failure is a major medical and economic burden throughout the world. Although various treatment options are available to treat heart failure, death rates in both men and women remain high. Potential adjunctive therapies may lie with use of herbal medications, many of which possess potent pharmacological properties. Among the most widely studied is ginseng, a member of the genus Panax that is grown in many parts of the world and that has been used as a medical treatment for a variety of conditions for thousands of years, particularly in Asian societies. There are a number of ginseng species, each possessing distinct pharmacological effects due primarily to differences in their bioactive components including saponin ginsenosides and polysaccharides. While experimental evidence for salutary effects of ginseng on heart failure is robust, clinical evidence is less so, primarily due to a paucity of large-scale well-controlled clinical trials. However, there is evidence from small trials that ginseng-containing Chinese medications such as Shenmai can offer benefit when administered as adjunctive therapy to heart failure patients. Substantial additional studies are required, particularly in the clinical arena, to provide evidence for a favourable effect of ginseng in heart failure patients.

A Patient with Heart Failure and Sleep-disordered Breathing Who Presented with Marked Reverse Remodeling by Continuous Positive Airway Pressure Therapy

A 49-year-old Japanese man with worsening dyspnea was admitted with the diagnosis of new-onset heart failure (HF). His HF symptoms improved with standard treatment, but his left ventricular ejection fraction (LVEF) 21% remained unchanged. After he was discharged, he was diagnosed with severe sleep-disordered breathing (SDB). Continuous positive airway pressure (CPAP) therapy was introduced. Seven months later, his cardiac function had greatly improved (LVEF 50%). We report this case of a HF patient with SDB whose cardiac function greatly improved by CPAP therapy, and we discuss the pathophysiologic mechanisms of successful cardiac "reverse remodeling" in this case.

Abnormal Global Longitudinal Strain Predicts Future Deterioration of Left Ventricular Function in Heart Failure Patients With a Recovered Left Ventricular Ejection Fraction

BACKGROUND

Patients with recovery of left ventricular ejection fraction (LVEF) remain at risk for future deterioration of LVEF. However, there are no tools to risk stratify these patients. We hypothesized that global longitudinal strain (GLS) could predict sustained recovery within this population.

METHODS AND RESULTS

We retrospectively identified 96 patients with a reduced LVEF <50% (screening echocardiogram), whose LVEF had increased by at least 10% and normalized (>50%) on evidence-based medical therapies (baseline echocardiogram). We examined absolute GLS on the baseline echocardiogram in relation to changes in LVEF on a follow-up echocardiogram. Patients with recovered LVEF had a wide range of GLS. The GLS on the baseline study correlated with the LVEF at the time of follow-up (r=0.33; P<0.001). The likelihood of having an LVEF >50% on follow-up increased by 24% for each point increase in absolute GLS on the baseline study (odds ratio, 1.24; P=0.001). An abnormal GLS (≤16%) at baseline had a sensitivity of 88%, a specificity of 46%, and an accuracy of 0.67 (P<0.001) as a predictor of a decrease in LVEF >5% during follow-up. A normal GLS (>16%) on the baseline study had a sensitivity of 47%, a specificity of 83%, and an accuracy of 0.65 (P=0.002) for predicting a stable LVEF (-5% to 5%) on follow-up.

CONCLUSIONS

In patients with a recovered LVEF, an abnormal GLS predicts the likelihood of having a decreased LVEF during follow-up, whereas a normal GLS predicts the likelihood of stable LVEF during recovery.

Highlights of articles published in annals of nuclear medicine 2016

This article is the first installment of highlights of selected articles published during 2016 in the Annals of Nuclear Medicine, an official peer-reviewed journal of the Japanese Society of Nuclear Medicine. A companion article highlighting selected articles published during 2016 in the European Journal of Nuclear Medicine and Molecular Imaging, which is the official peer-reviewed journal of the European Association of Nuclear Medicine, will also appear in the Annals Nuclear Medicine. This new initiative by the respective journals will continue as an annual endeavor and is anticipated to not only enhance the scientific collaboration between Europe and Japan but also facilitate global partnership in the field of nuclear medicine and molecular imaging.