Long-term outcome and prognostic factors in dilated cardiomyopathy. Preliminary results

Meta-analysis of echocardiographic quantification of left ventricular filling pressure

Aims

The clinical reliability of echocardiographic surrogate markers of left ventricular filling pressures (LVFPs) across different cardiovascular pathologies remains unanswered. The main objective was to evaluate the evidence of how effectively different echocardiographic indices estimate true LVFP.

Methods and results

Design: this is a systematic review and meta‐analysis. Data source: Scopus, PubMed and Embase. Eligibility criteria for selecting studies were those that used echocardiography to predict or estimate pulmonary capillary wedge pressure or left ventricular end‐diastolic pressures. Twenty‐seven studies met criteria. Only eight studies (30%) reported both correlation coefficient and bias between non‐invasive and invasively measured LVFPs. The majority of studies (74%) recorded invasive pulmonary capillary wedge pressure as a surrogate for left ventricular end‐diastolic pressures. The pooled correlation coefficient overall was r = 0.69 [95% confidence interval (CI) 0.63–0.75, P < 0.01]. Evaluation by cohort demonstrated varying association: heart failure with preserved ejection fraction (11 studies, n = 575, r = 0.59, 95% CI 0.53–0.64) and heart failure with reduced ejection fraction (8 studies, n = 381, r = 0.67, 95% CI 0.61–0.72).

Conclusions

Echocardiographic indices show moderate pooled association to invasively measured LVFP; however, this varies widely with disease state. In heart failure with preserved ejection fraction, no single echocardiography‐based metric offers a reliable estimate. In heart failure with reduced ejection fraction, mitral inflow‐derived indices (E/e′, E/A, E/Vp, and EDcT) have reasonable clinical applicability. While an integrated approach of several echocardiographic metrics provides the most promise for estimating LVFP reliably, such strategies need further validation in larger, patient‐specific studies.

Dilated cardiomyopathy: an update

Despite many advances in he diagnosis and treatment of DCM, it continues to be an important cause of cardiovascular morbidity and mortality in large-breed dogs. In the coming years, it is hoped and anticipated tht further discoveries will be made in the areas of etiology, therapy, and assessment of prognosis, ultimately with a view to having a greater impact on the clinical management of these cases.

Cardiac expression of urocortin (Ucn) in diseased heart; preliminary results on possible involvement of Ucn in pathophysiology of cardiac diseases

Recently, several studies reported that urocortin (Ucn) had beneficial effects on cardiovascular system and was expressed both in the normal heart and in the heart of dilated cardiomyopathy (DCM), yet the relationship between high expression of Ucn and pathophysiology of Ucn in diseased heart has been discussed. Thus, the present study was designed to elucidate the expression of Ucn in the diseased heart by immunohistochemical approach using endomyocardial biopsy specimens. The involvement of immunoreactive Ucn in pathophysiology of cardiac disease was evaluated using endomyocardial biopsy specimens obtained from the patients with some heart diseases, including DCM and hypertrophic cardiomyopathy (HCM). Ucn was detected in all endomyocardial biopsy specimens of ventricular tissue obtained from the patients with such cardiac diseases, a specimens of atrial tissue, and normal heart specimens obtained from autopsy cases. In DCM patients, left ventricular end-diastolic pressure significantly elevated in severely stained group. On the contrary, in HCM patients, left ventricular ejection fraction was higher in the severely stained group. Ucn was expressed more abundantly in the diseased heart, especially in HCM and DCM, than in the normal heart. In conclusion, such close relationship between Ucn expression in the heart and cardiac function indicated that clinical features of Ucn resembled those of norepinephrine and Ucn could play a certain pathophysiological roles in the cardiac diseases.

Can the Extent of Change of the Left Ventricular Doppler Inflow Pattern During the Valsalva Maneuver Predict an Elevated Left Ventricular End-Diastolic Pressure?

BACKGROUND: The objective of this study was to determine whether analysis of changes in the transmitral filling pattern during the Valsalva maneuver improves the diagnostic accuracy to noninvasively detect an elevated left ventricular end-diastolic pressure (LVEDP). METHODS: We prospectively compared the diagnostic accuracy of the mitral flow velocity indexes at baseline with those obtained during the Valsalva maneuver to detect an elevated LVEDP in 50 patients with coronary artery disease. RESULTS: Moderate correlations were found between LVEDP (mean, 11.8 +/- 6.2 mmHg) and deceleration time (r = 0.49), isovolumetric relaxation time (r = 0.52), and the E/A ratio (r = 0.48). There was a strong correlation (r = 0.73) between LVEDP and the percentile decrease in the E/A ratio during the Valsalva maneuver. Discriminant analysis showed that a decrease in E/A ratio during the Valsalva maneuver by >/=40% detected an elevated LVEDP with a sensitivity of 77% and a specificity of 94%, resulting in a diagnostic accuracy of 88%. In 11 patients, the constellation of pseudonormalization (normal E/A ratio and elevated LVEDP) was present. This could be identified in 73% with a diagnostic accuracy of 87%. CONCLUSIONS: For a comprehensive assessment of diastolic dysfunction by Doppler echocardiography, combined analysis of the E/A ratio at baseline and during the Valsalva maneuver should be performed routinely as an easy method of increasing diagnostic accuracy and uncovering pseudonormalization.

Comparison of post-stress ejection fraction and relative left ventricular volumes by automatic analysis of gated myocardial perfusion single-photon emission computed tomography acquired in the supine and prone positions

BACKGROUND

We have previously described an automatic method for measuring left ventricular ejection fraction (LVEF) for myocardial perfusion single-photon emission computed tomography (SPECT). The repeatability of this method has not been previously described.

METHODS AND RESULTS

This study compares LVEF and relative end-systolic and end-diastolic volumes assessed from myocardial perfusion SPECT by our automatic method in 180 consecutive patients undergoing gated myocardial perfusion SPECT with injection of 99mTc-labeled sestamibi in whom the acquisitions were performed sequentially in supine and prone positions. The algorithm operated completely automatically in the prone and supine positions in 178 of the 180 patients. Very high correlations were observed for LVEF (r = 0.93), relative left ventricular end-systolic volume (r = 0.98), and relative left ventricular end-diastolic volume (r = 0.97). The mean paired absolute difference between LVEFs in the prone and supine position was 3.8+/-3.2, for left ventricular end-systolic volume was 4.9+/-4.8 ml, and for left ventricular end-diastolic volume was 7.4+/-6.7 ml. When patients were classified by the extent and severity of stress perfusion defect, there was no significant difference in repeatability for the measurements in any category.

CONCLUSIONS

Our algorithm for automatic quantification of LVEF and relative end-systolic and end-diastolic volumes from gated 99mTc sestamibi myocardial perfusion SPECT is repeatable. When performed in the prone position, values of ejection fractions and ventricular volumes are essentially identical to those obtained in the supine position.

Prognostic evaluation of patients after myocardial infarction: incremental value of sestamibi single-photon emission computed tomography and echocardiography

BACKGROUND

This study compares the prognostic value of 99mTc-labeled methoxyisobutyl isonitrile (MIBI) single-photon emission computed tomographic (SPECT) imaging, echocardiography, and other clinical and laboratory prognostic factors in the long-term risk stratification of patients with stable uncomplicated infarcts.

METHODS AND RESULTS

Ninety-one consecutive patients affected by a first myocardial infarction without serious complications were enrolled. After at least 3 months from the infarction, they were submitted to stress-rest MIBI SPECT and rest echocardiography. Eighty-six patients completed a follow-up of at least 4 years (range 48 to 72 months; mean 55 months). By univariate (log-rank test) and multivariate analysis (Cox proportional hazards model), the main clinical, electrocardiographic, scintigraphic, and echocardiographic findings were evaluated and correlated statistically with the incidence of ensuing cardiac events. Twenty-five patients had cardiac events during the follow-up (four cardiac deaths, four myocardial infarctions, and 17 cases of unstable angina). At the multivariate analysis, the presence of reversible defects on MIBI SPECT (p = 0.008 and relative risk [RR] = 7.09), the wall motion score index, and the ejection fraction at echocardiography (respectively, p = 0.010, RR = 3.67, p = 0.036, and RR = 3.12), and stress angina (p = 0.007 and RR = 3.40) were significant and independent prognostic factors.

CONCLUSIONS

In our long-term follow-up, MIBI SPECT and echocardiography appeared to be significant and independent prognostic tools in the risk stratification of patients with stable, uncomplicated infarcts, furnishing complementary information. The reversibility of MIBI defects appeared the best indicator for a bad prognosis.