Left Ventricular Geometry in Takayasu Arteritis Complicated by Severe Aortic Regurgitation

Risk assessment model for heart failure in Chinese patients with Takayasu's arteritis

OBJECTIVES

We aimed to construct and validate a risk assessment model to identify risk factors for heart failure (HF) in patients with Takayasu's arteritis (TAK).

METHODS

Three hundred sixty-five patients with TAK were recruited in the East China Takayasu Arteritis Cohort from January 2012 to December 2019. Patients were assigned into training and validation sets following a 2:1 ratio according to the date of enrollment. Clinical characteristics were compared between heart failure (HF) and non-HF subgroups in the training set, and a risk assessment model for HF and its scoring algorithm was established based on logistic regression, which was tested in the validation set.

RESULTS

Among total of 74 (20.27%) TAK patients exhibited HF, and 55 cases (74.32%) were in the training set. The risk factors for HF of TAK patients included onset age >38 years, serum tumor necrosis factor (TNF)-α concentration >10 pg/ml, aortic valve involvement, coronary artery involvement, and pulmonary hypertension. We constructed the model without TNF-α (Model 1) and with TNF-α (Model 2). Patients in the training set with the score ≥ 3 appeared to be associated with an increased risk of HF with an area under curve (AUC) of 0.88 and 0.90 in Model 1 and Model 2 respectively. The AUC reached to 0.88 and 0.89 in the validation set that proved the accuracy of the model.

CONCLUSIONS

We presented a risk assessment model of HF in TAK, which may help clinicians alert the complication of HF in the patients with specifically cardiac impairments. Key Points • Heart failure was not rare in Chinese Takayasu's arteritis patients, and there were approximately 20% of patients with heart failure in ECTA cohort. • Cardiac involvements on echocardiography include pathological valvular and atrioventricular abnormalities. • The onset age >38 years, serum tumor necrosis factor (TNF)-α concentration >10 pg/ml, aortic valve involvement, coronary artery involvement, and pulmonary hypertension were risk factors for heart failure in Takayasu's arteritis patients. • We constructed the model without TNF-α (Model 1) and with TNF-α (Model 2). Patients with the risk assessment model score of ≥ 3 appeared to be associated with an increased risk of heart failure.

Acquired cardiac hypertrophy with outflow tract obstruction in a patient with severe Takayasu arteritis

Takayasu arteritis with coronary artery involvement is rare and its association with secondary cardiac hypertrophy with severe outflow tract obstruction is not common. We describe a case of Takayasu arteritis, diagnosed 10 years ago, whose coronary artery involvement and obstructive cardiac hypertrophy are ascertained after our investigations.

Usefulness of beta blocker therapy in patients with Takayasu arteritis and moderate or severe aortic regurgitation

The objective of the present study was to evaluate the benefit of beta-blocker therapy for patients with Takayasu arteritis complicated by moderate or severe aortic regurgitation. Clinical and echocardiographic evaluation was performed in 20 Japanese women in a follow-up period of 7.0 +/- 2.0 years. The patients were divided into 2 groups: Group A (n=10) patients who did not receive beta-blockers, and Group B (n=10) patients treated with long-term (5.1 +/- 1.6 years) therapeutic doses of beta-blockers. Left ventricular wall thickness increased significantly in all Takayasu patients who did not receive beta-blockers. Consequently, a remarkable increment in left ventricular mass took place (232 +/- 59 to 361 +/- 79 g; p < 0.005). In the same group, progressive worsening of the symptoms, with no reduction in the percent fractional shortening, was observed in 2 patients, while reduction of this last index was present in 1 asymptomatic patient. On the other hand, among the patients who were treated with beta-blockers, left ventricular mass still increased in 6 cases, while it clearly decreased in the other 4 cases (290 +/- 171 to 284 +/- 61 g; NS). The increment in wall thickness or left ventricular mass observed among patients with beta-blocker therapy was clearly less than the one registered among those who had not received beta-blockers. Furthermore, no worsening of the symptoms and/or left ventricular performance was observed during the follow-up period for patients receiving beta-blockers. We conclude that beta-blocker therapy can slow and even reverse the progression of left ventricular hypertrophy in patients with Takayasu arteritis complicated by moderate or severe aortic regurgitation. The mechanism still needs to be elucidated. We believe an effective reduction in the excessive afterload imposed on the left ventricle to be most likely responsible, but cardiac beta-receptor up-regulation might also be involved. Deterioration of the clinical status and/or impairment of left ventricular function were not associated with beta-blocker therapy in our patients. Therefore, these agents can be used safely alone or in addition to standard anti-hypertensive therapy when attempting to reduce excessive afterload, in spite of the presence of severe aortic regurgitation.

Four years follow-up study in patients with Takayasu arteritis and severe aortic regurgitation; assessment by echocardiography

We prospectively performed the follow-up study in 11 female patients with Takayasu arteritis and severe aortic regurgitation by echocardiography. A mean follow-up period was 4 years. The inflammatory state was controlled in all patients. Antihypertensive agents including beta-blocker were administered in nine patients. Heart failure did not progress in all patients except one. No candidate for cardiac surgery appeared during the follow-up period. Aortic root diameter, left atrial, left ventricular end-diastolic and end-systolic dimensions, wall thickness, left ventricular mass, and percent fractional shortening of the left ventricle showed no significant change in echocardiography. These data indicate that left ventricular disturbance might be slowly progressive in patients with Takayasu arteritis and severe aortic regurgitation. Systemic hypertension and the inflammatory state should be well controlled in managing the patients. beta-blocker might be useful in some patients with Takayasu arteritis and severe aortic regurgitation. Further follow-up is necessary for the decision of the cardiac surgical indication.

Concentric left ventricular hypertrophy in patients with Takayasu arteritis

Although aortic regurgitation (AR) in patients with Takayasu arteritis (TA) is believed to be caused by dilatation of the aortic ring or thickening of the aortic cusps, the pattern of left ventricular hypertrophy (LVH) in these patients has not been described. To clarify the geometry of the LV in patients with TA that had been documented both echocardiographically and hemodynamically, the authors evaluated 22 patients with TA and severe AR (group 1), 10 with TA and systemic hypertension (group 2), and 17 with isolated severe AR of other etiologies (group 3). M-mode echocardiography showed that LV dimensions were smaller in groups 1 and 2 than in group 3 and that wall thickness was greater in group 1 than in group 3. The concentric hypertrophic ratio (CHR = wall thickness/LV end-diastolic dimension+wall thickness) was larger than group 1 (p < 0.001) and group 2 (p < 0.01) than in group 3. CHR was similar in groups 1 and 2. Systolic blood pressure was significantly increased in group 2 and showed a tendency to increase in group 1 as compared with group 3. The results confirmed the presence of concentric LVH related to a pressure overload in patients with TA, even when TA was complicated by severe AR.

Aortic regurgitation in patients with Takayasu arteritis: Assessment by color Doppler echocardiography

To characterize aortic regurgitation in patients with Takayasu arteritis, we studied 48 females with arteritis (mean age 47 +/- 12 years) by means of color Doppler echocardiography. Aortic regurgitation was confirmed in 32 out of 48 patients (67%) by color-flow mapping. Twenty-four patients had mild or no aortic regurgitation (group A), 9 had moderate (group B), and 15 had severe (group C) aortic regurgitation. We compared the echocardiographic data obtained from patients with Takayasu arteritis with those of 14 normal controls and 9 patients with severe aortic regurgitation of valvular origins (group V). The aortic root diameter (AOD) in group B (23 +/- 4 mm/M2) and group C (22 +/- 3 mm/M2) revealed a statistically significant large value as compared with that in group A (18 +/- 2 mm/M2) and normal controls (17 +/- 3 mm/M2). However, the differences, between groups B and C and groups C and V, were not significant. The AOD was not obviously dilated in a considerable number of group C patients. Aortic valve involvement was seen in several group C patients and moderate concentric left ventricular hypertrophy was present in all group C patients. Group C patients therefore, have concentric left ventricular hypertrophy but may or may not have dilatation of the aortic root which can be detected on echocardiography. We conclude that aortic valve involvement may cause aortic regurgitation in some patients with Takayasu arteritis and that aortic regurgitation is more common than previously believed.