The prognostic impact of right ventricular-pulmonary arterial coupling in heart failure: a systematic review and meta-analysis

The echocardiographic tricuspid annular plane systolic excursion/pulmonary artery systolic pressure (TAPSE/PASP) ratio is a non-invasive surrogate of right ventricular-pulmonary arterial (RV-PA) coupling which corresponds well with the respective invasively derived index. Recently, a wealth of observational data has arisen, outlining its prognostic value in heart failure (HF) patients. To systematically appraise and quantitatively synthesize the evidence of the prognostic value of TAPSE/PASP ratio in left-sided HF regardless of etiology or left ventricular ejection fraction. A systematic literature review was conducted in electronic databases to identify studies reporting the association of TAPSE/PASP ratio with outcomes in patients with HF and, when appropriate, a random-effects meta-analysis was conducted to quantify the unadjusted and adjusted hazard ratios [(a)HRs] for all-cause death and the composite outcome of all-cause death or HF hospitalization. Eighteen studies were deemed eligible encompassing 8,699 HF patients. The applied cut-off value for RV-PA uncoupling varied substantially from 0.27 to 0.58 mm/mmHg, and in most studies values lower than the applied cutoff conveyed dismal prognosis. Eleven studies reported appropriate data for meta-analysis. TAPSE/PASP reduction by 1 mm/mmHg was independently associated with all-cause death (pooled aHR=1.32 [1.06-1.65]; p=0.01; I2=56%) and the composite outcome (pooled aHR=3.48 [1.67-7.25]; p<0.001; I2=0%). When a TAPSE/PASP cutoff value of 0.36 mm/mmHg was applied it yielded independent association with all-cause death (pooled aHR=2.84 [2.22-3.64]; p<0.001; I2=82%). RV-PA coupling assessed by echocardiographic TAPSE/PASP ratio appears to be an independent outcome predictor for HF patients.

The patient pathway in ATTR-CM in Greece and how to improve it: A multidisciplinary perspective

Transthyretin amyloid cardiomyopathy (ATTR-CM) is an underdiagnosed disease associated with high mortality rates and the patient journey is characterized by increased complexities. Accurate and timely diagnosis and prompt initiation of disease-modifying treatment constitute the contemporary unmet need in ATTR-CM. ATTR-CM diagnosis is characterized by considerable delays and high rates of misdiagnosis. The majority of patients present themselves to primary care physicians, internists, and cardiologists, and many have undergone repeated medical evaluations before an accurate diagnosis has been made. The disease is diagnosed mainly after the development of heart failure symptoms, reflecting a long course of missed opportunities before diagnosis and disease-modifying treatment initiation. Early referral to experienced centers ensures prompt diagnosis and therapy. Early diagnosis, better care coordination, acceleration of digital transformation and reference networks, encouragement of patient engagement, and implementation of rare disease registries are the key pillars to improve the ATTR-CM patient pathway and achieve important benefits in ATTR-CM outcomes.

Prevalence, characteristics, and natural history of apical phenotype in a large cohort of patients with hypertrophic cardiomyopathy

BACKGROUND

Apical hypertrophic cardiomyopathy (ApHCM) is a variant of hypertrophic cardiomyopathy (HCM) with distinct imaging and clinical characteristics. Data on the prognosis of this HCM subgroup appear conflicting. Our study aims to clarify the natural history of ApHCM and identify predictors of outcomes.

MATERIALS AND METHODS

A total of 856 patients with HCM were retrospectively examined. ApHCM was defined as asymmetric left ventricular hypertrophy confined predominantly at the apex, either isolated (pure ApHCM type) or with co-existent hypertrophy of the interventricular septum (mixed ApHCM). Echocardiographic, clinical, and survival data were compared between individuals with ApHCM and non-ApHCM.

RESULTS

A total of 143 (16.7%) patients were diagnosed with ApHCM. Compared with non-ApHCM, subjects with apical HCM were diagnosed at an older age and had better echocardiographic indices and more comorbidities at baseline. Apical aneurysms were more prevalent among the ApHCM phenotype (6.3% vs. 1.7%, p = 0.003). During a mean follow-up of 6 ± 3 years, ApHCM was characterized by lower all-cause, cardiovascular, heart failure-related mortality, and ventricular arrhythmic events compared with non-ApHCM. Multivariate analysis identified atrial fibrillation and HCM risk-sudden cardiac death (SCD) as independent predictors of the composite outcome of overall mortality and hospitalizations for cardiovascular reasons (hazard ratio [HR] 4.3, 95% confidence interval [CI] 1.9-9.5 for atrial fibrillation and HR 1.2, 95% CI 1.02-1.3 for HCM risk-SCD) in ApHCM.

CONCLUSIONS

ApHCM exhibited a lower rate of all-cause mortality and arrhythmic events in the middle-aged population of patients with HCM. Atrial fibrillation and HCM risk-sudden cardiac death were independent predictors of a composite of overall mortality and cardiovascular hospitalizations among those with ApHCM.

Differences in Demographics, in-Hospital Management and Short-Term Prognosis in Admissions for Acutely Decompensated Heart Failure to Cardiology vs. Internal Medicine Departments: A Prospective Study

Heart failure (HF) is among the leading causes of unplanned hospital admissions worldwide. Patients with HF carry a high burden of comorbidities; hence, they are frequently admitted for non-cardiac conditions and managed in Internal Medicine Departments (IMD). The aim of our study was to investigate differences in demographics, in-hospital management, and short-term outcomes of HF patients admitted to IMD vs. cardiology departments (CD). A prospective cohort study enrolling consecutive patients with acutely decompensated HF either as primary or as secondary diagnosis during the index hospitalization was conducted. Our primary endpoint was a combined endpoint of in-hospital mortality and 30-day rehospitalization for HF. A total of 302 patients participated in the study, with 45% of them admitted to IMD. Patients managed by internists were older with less pronounced HF symptoms on admission. In-hospital mortality was higher for patients admitted to IMD vs. CD (21% vs. 6%, p < 0.001). The composite endpoint of in-hospital death and heart failure hospitalizations at 30 days post-discharge was higher for patients admitted to IMD both in univariate [OR: 3.2, 95% CI (1.8-5.7); p < 0.001] and in multivariate analysis [OR 3.74, 95% CI (1.72-8.12); p = 0.001]. In addition, the HF rehospitalization rate at 6 months after discharge was higher in IMD patients [HR 1.65, 95% CI (1.1, 2.4), p = 0.01]. Overall, HF patients admitted to IMD have worse short-term outcomes compared to patients admitted to CD.

Apical Hypertrophic Cardiomyopathy: Diagnosis, Natural History, and Management

Apical hypertrophic cardiomyopathy (ApHCM) represents a rare variant of hypertrophic cardiomyopathy (HCM) with distinct phenotypic characteristics. The prevalence of this variant varies according to each study's geographic region. The leading imaging modality for the diagnosis of ApHCM is echocardiography. Cardiac magnetic resonance, however, is the gold standard for ApHCM diagnosis in case of poor acoustic windows or equivocal echocardiographic findings but also in cases of suspected apical aneurysms. The prognosis of ApHCM was reported to be relatively benign, although more recent studies seem to contradict this, demonstrating similar incidence of adverse events compared with the general HCM population. The aim of this review is to summarize the available evidence for the diagnosis of ApHCM, highlight distinctions in comparison to more frequent forms of HCM with regards to its natural history, prognosis, and management strategies.

Iron therapy and severe arrhythmias in HFrEF: rationale, study design, and baseline results of the RESAFE-HF trial

AIMS

The Iron Intravenous Therapy in Reducing the burden of Severe Arrhythmias in HFrEF (RESAFE-HF) registry study aims to provide real-word evidence on the impact of intravenous ferric carboxymaltose (FCM) on the arrhythmic burden of patients with heart failure with reduced ejection fraction (HFrEF), iron deficiency (ID), and implanted cardiac implantable electronic devices (CIEDs).

METHODS AND RESULTS

The RESAFE-HF (NCT04974021) study was designed as a prospective, single-centre, and open-label registry study with baseline, 3, 6, and 12 month visits. Adult patients with HFrEF and CIEDs scheduled to receive IV FCM as treatment for ID as part of clinical practice were eligible to participate. The primary endpoint is the composite iron-related endpoint of haemoglobin ≥ 12 g/dL, ferritin ≥ 50 ng/L, and transferrin saturation > 20%. Secondary endpoints include unplanned HF-related hospitalizations, ventricular tachyarrhythmias detected by CIEDs and Holter monitors, echocardiographic markers, functional status (VO2 max and 6 min walk test), blood biomarkers, and quality of life. In total, 106 patients with a median age of 72 years (14.4) were included. The majority were male (84.9%), whereas 92.5% of patients were categorized to New York Heart Association II/III. Patients' arrhythmic burden prior to FCM administration was significant-19 patients (17.9%) received appropriate CIED therapy for termination of ventricular tachyarrhythmia in the preceding 12 months, and 75.5% of patients have frequent, repetitive multiform premature ventricular contractions.

CONCLUSIONS

The RESAFE-HF trial is expected to provide evidence on the effect of treating ID with FCM in HFrEF based on real-world data. Special focus will be given on the arrhythmic burden post-FCM administration.

A novel quantitative method for assessing the therapeutic response to Tafamidis therapy in patients with cardiac TTR amyloidosis. A preliminary report

OBJECTIVE

Cardiomyopathy is a common manifestation of transthyretin amyloidosis (ATTR), leading to heart failure, associated with high morbidity and mortality. The aim of this study was to investigate the effect of Tafamidis treatment by means of cardiac radiotracer uptake on myocardial scintigraphy.

SUBJECTS AND METHODS

Five male patients, mean age 76.2 years, with wild-type ATTR were included in the protocol. Total body scanning using technetium-99m-3,3-diphosphono-1,2-propanodicarboxylic acid (^99mTc-DPD) (in four patients) and technetium-99m-hydroxymethylene diphosphonate (^99mTc-HMDP) (in one) was performed pre- and one year post-Tafamidis therapy. A novel quantitation method for assessing radiotracer cardiac uptake was employed. The geometric mean was computed for both cardiac and thigh region of interest (ROI) and the heart-to-thigh (HtT) ratio was assessed by dividing the corresponding geometric mean counts.

RESULTS

Heart-to-thigh ratio was improved (decreased) in four of the patients receiving Tafamidis, in keeping with lower uptake to the cardiac region. These patients also demonstrated a relatively favorable clinical response to Tafamidis. The patient evaluated by ^99mTc-HMDP exhibited minimal HtT ratio reduction and stable clinical and echocardiographic characteristics.

CONCLUSION

Sequential HtT ratio measurements could potentially identify patients with a favorable response to Tafamidis treatment at earlier stages, compared to other imaging modalities or serological biomarkers.

Left atrial myopathy is associated with exercise capacity and ventilatory efficiency in hypertrophic cardiomyopathy

Funding Acknowledgements

Type of funding sources: None.

Background

Data about the predictive value of left atrial (LA) myopathy for exercise capacity and ventilatory efficiency in patients with hypertrophic cardiomyopathy (HCM) are limited.

Purpose

The aim of this study was to evaluate the association of LA myopathy, evaluated by echocardiography LA strain, with exercise capacity and ventilatory efficiency, evaluated by cardiopulmonary exercise testing (CPET), in HCM patients.

Methods

In total, 241 consecutive HCM patients (51 ± 16 years old; 67.2% male) on sinus rhythm that underwent CPET and transthoracic echocardiography at the same visit were studied. Exercise capacity (maximal oxygen consumption/predicted [%peakVO2]) and ventilatory efficiency (ventilation/carbon dioxide output [VE/VCO2] slope) were assessed by CPET. LA myopathy was examined by speckle tracking myocardial deformation parameters: LA reservoir, conduit and booster strain.

Results

All the three LA strain values were univariate predictors of exercise capacity and ventilatory efficiency. Among them, LA reservoir strain had the higher r correlation coefficient for predicting both %peakVO2 and VE/VCO2 slope and was included in multivariable analyses. LA reservoir strain, male gender and E/E’ ratio were independent predictors of exercise capacity. LA reservoir strain, male gender, non-sustained ventricular tachycardia and LA volume index were independent predictors of ventilatory efficiency (Table).

Conclusion

LA myopathy, as reflected by the LA strain values, was associated with exercise capacity and ventilatory efficiency in HCM individuals. LA reservoir strain was the only common independent predictor for %peakVO2 and VE/VCO2 slope. Abstract Table

Left atrial myopathy and mitral regurgitation in hypertrophic cardiomyopathy

Funding Acknowledgements

Type of funding sources: None.

Background

Recent studies have shown that mitral regurgitation (MR) represents a major determinant of left atrial (LA) function in patients with heart failure with preserved ejection fraction. The role of MR in determining LA myopathy in hypertrophic cardiomyopathy (HCM) is unknown.

Purpose

The aim of this study was to examine the association of MR with LA myopathy, assessed by LA strain in HCM patients.

Methods

 In total 250 consecutive patients (mean age 51 ± 16years, 67.2% male) with an established diagnosis of HCM and with sinus rhythm at index echocardiography evaluation were included. LA reservoir, conduit and booster strain were analyzed, besides LA size, left ventricular (LV) systolic and diastolic function. The predictors of LA strain values were identified with linear regression analysis.

Results

More than mild MR was a significant univariate predictor of all the three LA strain values. In multivariate linear regression analysis, independent predictors of LA reservoir strain were more than mild MR (r= -0.23), LV global longitudinal strain (r= -0.49), LA volume index (r= -0.27) and patient age (r= -0.22). More than mild MR was also an independent determinant of LA conduit (r=-0.17) and booster strain (r=-0.12) (Table 1). In patients with LA volume index &lt;34ml/m2 more than mild MR was an independent predictor of LA reservoir (r= -0.32) and conduit strain (r= -0.27), but not LA booster strain (Table 2).

Conclusion

The severity of MR is associated with LA myopathy with independently of the LV diastolic and systolic function and LA size. Abstract Table 1  Abstract Table 2

Deciphering hypertrophic cardiomyopathy with electrocardiography

The comprehensive assessment of patients with hypertrophic cardiomyopathy is a complex process, with each step concurrently focusing on confirmation of the diagnosis, differentiation between sarcomeric and non-sarcomeric disease (phenocopy), and prognostication. Novel modalities such as genetic testing and advanced imaging have allowed for substantial advancements in the understanding of this condition and facilitate patient management. However, their availability is at present not universal, and interpretation requires a high level of expertise. In this setting, electrocardiography, a fast and widely available method, still retains a significant role in everyday clinical assessment of this population. In our review, we follow a stepwise approach for the interpretation of each electrocardiographic segment, discussing clinical implications of electrocardiographic patterns in sarcomeric disease, their value in the differential diagnosis from phenocopies, and impact on patient management. Outlining the substantial amount of information to be obtained from a simple tracing, we exhibit how electrocardiography is likely to remain an integral diagnostic tool in the future as well.

Risk Prediction Models and Scores in Hypertrophic Cardiomyopathy

Hypertrophic cardiomyopathy (HCM) has historically been linked with sudden cardiac death (SCD). Currently, it is well established that only a subset of patients is at the highest risk stratum for such a catastrophic event. Detection of patients belonging to this high-risk category can allow for timely defibrillator implantation, changing the natural history of HCM. Inversely, device implantation in patients deemed at low risk leads to an unnecessary burden of device complications with no apparent protective benefit. Previous studies have identified a series of markers, now considered established risk factors, with genetic testing and newer imaging allowing for the detection of novel, highly promising indices of increased risk for SCD. Despite the identification of a number of risk factors, there is noticeable discrepancy in the utility of such factors for risk stratification between the current American and European guidelines. We sought to systematically review the data available on these two approaches, presenting their rationale and respective predictive capacity, also discussing the potential of novel markers to augment the precision of currently used risk stratification models for SCD in HCM.

Prognostic role of left ventricular apical aneurysm in hypertrophic cardiomyopathy: A systematic review and meta-analysis

OBJECTIVES

The aim of this study was to systematically review and quantitatively synthesize existing evidence about the prognostic value of LV apical aneurysm in patients with HCM.

BACKGROUND

Hypertrophic cardiomyopathy (HCM) represents a common inherited heart disease associated with enormous diversity in morphologic expression and clinical course. With the increasing penetration of advanced high resolution cardiovascular imaging into routine HCM practice, a subset of HCM patients with left ventricular (LV) apical aneurysm have become more widely recognized.

METHODS

Medline was searched for studies describing the prognostic implication of LV apical aneurysm in patients with HCM. In the main analysis the combined endpoint of major HCM-related outcomes was assessed. Separate analyses for sudden cardiac death (SCD) events and thromboembolic events were also performed.

RESULTS

Six studies comprising of 2382 patients met the inclusion criteria. In the pooled analysis, the presence of LV apical aneurysm was significantly associated with major adverse outcomes (pooled OR: 5.13, 95 CI: 2.85 to 9.23, I²:31%), increased risk of SCD arrhythmic events (pooled OR: 4.67, 95% CI: 2.30 to 9.48, I²: 38%) and thromboembolic events (pooled OR: 6.30, 95% CI: 1.52 to 26.19, I²: 66%).

CONCLUSIONS

These data demonstrate that LV apical aneurysm in HCM patients is associated with an increased risk for SCD events and thromboembolism. This finding might encourage the inclusion of LV apical aneurysm into the HCM SCD risk stratification algorithm as a novel risk marker that supports consideration for primary prevention implantable cardioverter defibrillator and anticoagulation for stroke prophylaxis.

Cardiovascular magnetic resonance as a complementary method to transthoracic echocardiography for aortic valve area estimation in patients with aortic stenosis: A systematic review and meta-analysis

BACKGROUND

Aortic stenosis (AS) is the most common valvular heart disease. While two-dimensional transthoracic echocardiography (2D-TTE) is the standard imaging modality for AS assessment, cardiac magnetic resonance (CMR) offers a reliable and reproducible alternative. The aim of this study was to compare AVA measurements as determined by TTE and CMR in patients with AS.

METHODS

Electronic databases were searched to identify studies comparing TTE continuity equation to CMR planimetry for AVA assessment. A meta-analysis of mean difference was conducted by using the random effects model. Sensitivity analysis was performed after excluding studies reporting AVA indexed to body surface area (BSA). Heterogeneity was assessed with I².

RESULTS

A total of 12 studies, encompassing 621 patients, were included in our systematic review. In the pooled analysis, measurements of AVA by CMR planimetry were found to be significantly higher than those calculated by the continuity equation in TTE (pooled mean difference: 0.09, 95% confidence intervals (CI): 0.01, 0.17, and I²: 93%). The results remained significant, albeit with moderate heterogeneity this time, after excluding the analysis measurements of AVA indexed to BSA (pooled mean difference: 0.08, 95% CI: 0.03 to 0.13, and I² = 61%).

CONCLUSIONS

CMR planimetry slightly overestimates AVA compared to TTE continuity equation. Although, 2D-TTE should be the primary imaging modality for the estimation of AVA, CMR may be useful when there is discrepancy with the clinical assessment or when TTE results are discordant or difficult to obtain.

Implantable cardioverter defibrillators for primary prevention of sudden death in hypertrophic cardiomyopathy

AIMS

Sudden cardiac death (SCD) may complicate hypertrophic cardiomyopathy (HCM) natural course. Patient selection for implantable cardioverter defibrillator (ICD) therapy in the primary prevention setting is still a challenge.

METHODS

Thirty-seven HCM patients with a primary prevention ICD were included. All patients underwent preimplantation SCD risk assessment and semi-annual device interrogation during follow-up. Primary end point was the time to first appropriate ICD intervention including antitachycardia pacing or shock. Inappropriately delivered ICD therapies served as secondary end point.

RESULTS

During a median follow-up of 3.1 years, 10 (27%) patients received one or more appropriate ICD therapies. First appropriate ICD intervention rate was 7.2%/year (95% CI: 3.4-13.2) with a 5-year cumulative probability of 29.2 ± 7.4%. No SCD risk marker was significantly associated with the primary end point, whereas event rates were comparable among patients with one, two or three or more SCD risk markers (log-rank P = 0.58). Patients with a history of SCD in first-degree relatives with HCM were at 3.8 times higher risk of experiencing an ICD intervention compared with those with no family history of SCD (HR: 3.8; 95% CI: 1.0-14.1, P = 0.05). Seven (18.9%) patients experienced one or more inappropriate ICD therapies; beta-blocker therapy was associated with 75% fewer inappropriate ICD interventions (HR: 0.15; 95% CI: 0.03-0.89).

CONCLUSION

Current criteria identify a subgroup of patients with HCM at increased risk of major arrhythmic events as indicated by high ICD intervention rates. However, no individual risk marker demonstrated superior predictive ability over the others, whereas simple arithmetic summing of risk markers was not associated with increased ICD intervention rates.

Atrial fibrillation in hypertrophic cardiomyopathy: A turning point towards increased morbidity and mortality

BACKGROUND

Atrial fibrillation (AF) is the most common arrhythmic event in patients with hypertrophic cardiomyopathy (HCM). The aim of this study was to identify the clinical impact and prognostic significance of AF on a large cohort of patients with HCM.

METHODS

Echocardiographic and clinical correlates, risk factors for AF and thromboembolic stroke and the prognostic significance of AF were evaluated in 509 patients with an established diagnosis of HCM.

RESULTS

A total of 119 patients (23.4%) were diagnosed with AF during the index evaluation visit. AF patients had a higher prevalence of stroke and presented with worse functional impairment. Left atrial diameter (LA size) was a common independent predictor of the arrhythmia (OR: 2.2, 95% CI 1.6-3.3) and thromboembolic stroke (OR: 1.6, 95% CI 1.01-2.40). AF was an important risk factor for overall mortality (HR=3.4, 95% CI: 1.7-6.5), HCM-related mortality (HR=3.9, 95% CI: 1.8-8.2) and heart failure-related mortality (HR=6.0, 95% CI: 2.0-17.9), even after adjusting for statistically significant clinical and demographic risk factors. However, AF did not affect the risk for sudden death.

CONCLUSIONS

LA size is an independent predictor of both AF and thromboembolic stroke. Moreover, patients with AF, regardless of type, have significantly higher mortality rates than patients without AF.

Left Ventricular Doppler Characteristics in First-Degree Relatives of Patients with Hypertrophic Cardiomyopathy

Left ventricular (LV) diastolic function may be affected early in patients with hypertrophic cardiomyopathy (HCM), regardless of the phenotypic expression of the disease. The aim of the present study was to detect whether LV diastolic performance, evaluated by conventional Doppler echocardiography, is impaired in first-degree relatives of patients with phenotypically expressed HCM, who had no clinical, electrocardiographic, or echocardiographic signs of the disease. Twenty-two young adults having the previously described characteristics comprised the study population and 22 sex- and age-matched healthy individuals served as controls. The 2 groups were compared according to several echocardiographic parameters and the following diastolic function indices: peak velocity of E wave, representing early filling; peak velocity of A wave, representing late filling; ratio of peak early to peak late velocity (E/A); deceleration time of E wave; and LV isovolumic relaxation time. Slower deceleration time of transmitral early filling in first-degree relatives of patients with HCM (192 ±31 vs 149 ±31 msec, p<0.001) was the only variable that significantly differentiated the 2 groups. This study shows that in healthy persons with a family history of HCM, Doppler-derived mitral filling pattern shifted toward that observed in HCM and the slower deceleration time may serve as an early sign of disease development.

Mechanical aberrations in hypetrophic cardiomyopathy: emerging concepts

Hypertrophic cardiomyopathy is the most common monogenic disorder in cardiology. Despite important advances in understanding disease pathogenesis, it is not clear how flaws in individual sarcomere components are responsible for the observed phenotype. The aim of this article is to provide a brief interpretative analysis of some currently proposed pathophysiological mechanisms of hypertrophic cardiomyopathy, with a special emphasis on alterations in the cardiac mechanical properties.

Myocardial crypts as a preclinical sign of hypertrophic cardiomyopathy

BACKGROUND

The identification by cardiac magnetic resonance of myocardial crypts in the left ventricle (LV) of individuals carrying hypertrophic cardiomyopathy causative mutations, but without overt hypertrophy, has been proposed as an early sign of the disease. Myocardial crypts are usually identified in the offsprings of patients with a complete penetrance of the disease.

CASE DESCRIPTION

We present a case of familial hypertrophic cardiomyopathy displaying an unusual pattern of disease distribution; the 14-year-old child was affected, demonstrating a typical LV asymmetrical hypertrophy, his grandfather, and the 2 brothers of his mother were also affected, but the 41-year-old mother was unaffected (no hypertrophy) displaying 3 myocardial crypts in inferior LV wall, suggesting a preclinical involvement.

CONCLUSION

The findings underscore the diverse clinical spectrum of the disease, even in a single family and also the need to revise the diagnostic criteria of hypertrophic cardiomyopathy.Hippokratia 2014; 18 (4): 359-361.

Surgical septal myectomy for hypertrophic cardiomyopathy in Greece: a single-center initial experience

INTRODUCTION

Surgical septal myectomy is thought to be the gold standard of treatment for obstructive hypertrophic cardiomyopathy (HCM) with obstruction symptoms refractory to optimal medical therapy. In Europe, during the last 2 decades, myectomy has been set aside, while alcohol septal ablation has been widely promoted. In this paper, we analyze our first experience of surgical septal myectomy in a small cohort of patients with HCM coming from a single tertiary center.

METHODS

Thirty-two patients (16 male, 50%) with a mean age of 58.1 ± 14.4 (range 12-79 years) underwent myectomy for HCM symptoms refractory to negative inotropic agents. The technique used for the myectomy was the one introduced by Andrew Morrow. Mean follow-up time after procedure was 16.8 ± 13.3 months with a median of 13 months (range 4-58 months).

RESULTS

Post-myectomy, there was a significant improvement in patients' NYHA class (from 3.3 ± 0.46 to 1.38 ± 0.49, p<0.0005), while interventricular septum thickness was reduced from 2.3 ± 0.4 cm to 1.6 ± 0.4 cm (p<0.0005), and peak gradient at the site of obstruction from 94.9 ± 29 to 16.7 ± 7.9 mmHg (p<0.0005). During the follow-up period, only 1 out of 32 patients died, from non-cardiovascular causes, with the overall survival post-myectomy being 97.2% (95%CI: 94.5-99.9%) at 1-year follow up.

CONCLUSIONS

Surgical septal myectomy in patients with HCM and drug-refractory symptoms is a safe procedure that greatly improves symptoms and quality of life. Further follow-up of our patients is mandatory in order to determine whether the good survival rate achieved at 1 year will persist.

Hypertrophic cardiomyopathy in 2013: Current speculations and future perspectives

Hypertrophic cardiomyopathy (HCM), the most variable cardiac disease in terms of phenotypic presentation and clinical outcome, represents the most common inherited cardiomyopathic process with an autosomal dominant trait of inheritance. To date, more than 1400 mutations of myofilament proteins associated with the disease have been identified, most of them “private” ones. This striking allelic and locus heterogeneity of the disease certainly complicates the establishment of phenotype-genotype correlations. Additionally, topics pertaining to patients’ everyday lives, such as sudden cardiac death (SCD) risk stratification and prevention, along with disease prognosis, are grossly related to the genetic variation of HCM. This review incorporates contemporary research findings and addresses major aspects of HCM, including preclinical diagnosis, genetic analysis, left ventricular outflow tract obstruction and SCD. More specifically, the spectrum of genetic analysis, the selection of the best method for obstruction alleviation and the need for a unique and accurate factor for SCD risk stratification are only some of the controversial HCM issues discussed. Additionally, future perspectives concerning HCM and myocardial ischemia, as well as atrial fibrillation, are discussed. Rather than enumerating clinical studies and guidelines, challenging problems concerning the disease are critically appraised by this review, highlighting current speculations and recommending future directions.

Clinical characteristics and natural history of hypertrophic cardiomyopathy with midventricular obstruction

BACKGROUND

The prevalence, clinical characteristics and natural history of patients with hypertrophic cardiomyopathy (HCM) and midventricular obstruction (MVO) have not been adequately studied.

METHODS AND RESULTS

A single-center cohort consisting of 423 patients (mean age, 49.3±17.2 years; 66.2% male) was thoroughly followed up for a median of 84 months (7 years; range, 6-480 months). MVO, characterized by the echocardiographic appearance of midventricular muscular apposition with a simultaneous mid-cavitary gradient ≥30mmHg, was identified in 34 patients (8%). Patients with MVO tended to be more symptomatic during their initial evaluation (>90% presented with NYHA class ≥II) compared to the rest of the HCM cohort. Apical aneurysm formation was identified in more than one-fourth of patients with MVO (26.5%), being a characteristic of the group. On multivariate Cox regression hazard analysis, presence of MVO strongly predicted progression to end-stage (burnt out) HCM and related heart failure (HF) deaths (hazard ratio, [HR], 2.62; 95% confidence interval [CI]: 1.2-8.8; P=0.047), as well as sudden death and associated lethal arrhythmic events (HR, 3.3; 95% CI: 1.26-8.85; P=0.016).

CONCLUSIONS

MVO is a distinct phenotype of HCM associated with unfavorable prognosis in terms of end-stage HCM, sudden death and lethal arrhythmic events. The high adverse outcome rate necessitates early recognition of MVO and appropriate therapeutic interventions.

Hypertrophic cardiomyopathy associated with an anomalous origin of right coronary artery. Case report and review of the literature

We present a case of patient with hypertrophic cardiomyopathy and an anomalous right coronary artery with left main artery origin and an interarterial course. The coexistence of these two different entities is extremely rare but of major clinical significance because both are associated with an increased risk of sudden cardiac death. In addition, a review of the literature comprising 14 other cases with this combination is provided.

Carbon dioxide balneotherapy and cardiovascular disease

Carbon dioxide (CO(2)) balneotherapy is a kind of remedy with a wide spectrum of applications which have been used since the Middle Ages. However, its potential use as an adjuvant therapeutic option in patients with cardiovascular disease is not yet fully clarified. We performed a thorough review of MEDLINE Database, EMBASE, ISI WEB of Knowledge, COCHRANE database and sites funded by balneotherapy centers across Europe in order to recognize relevant studies and aggregate evidence supporting the use of CO(2) baths in various cardiovascular diseases. The three main effects of CO(2) hydrotherapy during whole body or partial immersion, including decline in core temperature, an increase in cutaneous blood flow, and an elevation of the score on thermal sensation, are analyzed on a pathophysiology basis. Additionally, the indications and contra-indications of the method are presented in an evidence-based way, while the need for new methodologically sufficient studies examining the use of CO(2) baths in other cardiovascular substrates is discussed.

Prevalence and clinical outcomes of incidentally diagnosed hypertrophic cardiomyopathy

The purpose of the present study was to evaluate the prevalence and prognosis of patients incidentally diagnosed with hypertrophic cardiomyopathy (HC). We studied 380 consecutive patients with HC (49.3 +/- 17.2 years; 65% men) for a median of 58 months (range 6 to 454). The patients were divided into 2 groups: those incidentally diagnosed from routine examination findings (precordial murmur and/or abnormal electrocardiographic findings) and those diagnosed either because of symptomatic status or by screening because of a family history of HC. Those patients who had been incidentally diagnosed constituted 29.2% of our study cohort. Although overall mortality did not differ between the 2 groups (p = 0.12), the patients diagnosed either because of symptoms or a family history tended to have at least a 4.5-fold greater risk of cardiovascular death (relative risk 4.5, 95% confidence interval 1.04 to 19.6, p = 0.04) and a 4.22 greater risk of sudden death (relative risk 4.22, 95% confidence interval 1.0 to 18.22, p = 0.04). Despite the greater sudden death mortality among the nonincidentally diagnosed patients, no statistically significant difference was found concerning the sudden death risk factor frequency (p = 0.96) between the 2 groups. In conclusion, the discrepancy between the low numbers of patients reported by published registries and the relatively high prevalence of the disease in the general population can be attributed to the large number of patients who remain asymptomatic, even throughout their life, awaiting an accidental diagnosis. Those patients with an incidental diagnosis have a more benign course, as shown by the total cardiovascular and composite sudden death mortality. A high level of awareness and suspicion for HC among physicians is essential for clinical recognition of such patients.

Brain natriuretic peptide and the athlete's heart: a pilot study

BACKGROUND

The role of brain natriuretic peptide (BNP) in differentiating the athlete's heart from maladaptive cardiac hypertrophy is unclear.

METHODS

To address this issue, an integrated M mode, two-dimensional B mode and Doppler echocardiographical study were performed and plasma BNP levels were measured in 25 strength athletes, 25 patients with established hypertrophic cardiomyopathy (HCM) and 25 healthy volunteers.

RESULTS

Among athletes, BNP levels correlated negatively with the total training time (r = -0.79, p = 0.002) and positively with ejection fraction (r = 0.58, p = 0.049) and fractional shortening (r = 0.57, p = 0.049). A BNP cut-off value of 11.8 pg/ml had 88% specificity and 74% negative predictive value for the exclusion of HCM.

CONCLUSIONS

Brain natriuretic peptide might be useful as a preparticipation screening test in athletes.

Rheolytic thrombectomy in patients with acute coronary syndrome and large thrombus burden: initial and mid-term results from a single centre experience

INTRODUCTION

The presence of a large intracoronary thrombus burden is a major complicating factor during percutaneous coronary intervention (PCI) in patients with an acute coronary syndrome (ACS). The use of rheolytic thrombectomy (RT) has been proposed to prevent thrombus-related complications, with conflicting results. The purpose of this study was to identify the feasibility and safety of this approach.

METHODS

We conducted a single-centre, retrospective, observational case-control study, comparing the outcomes of PCI in 26 consecutive patients with ACS and a large thrombus burden who underwent RT to those of a control group of 26 patients, matched with regard to artery location and initial TIMI flow grade.

RESULTS

Despite the higher prevalence of acute ST-elevation myocardial infarction and the larger thrombus burden in the RT group, there was less incidence of distal embolisation/no-reflow and less use of vasoactive intracoronary agents. The final TIMI flow was identical in both groups. There was no difference between the two groups in the in-hospital and mid-term incidence of major adverse coronary events.

CONCLUSIONS

In this study, the use of RT in patients with a large thrombus burden during acute PCI was both feasible and safe and reduced the incidence of initial no-reflow phenomenon.

Left ventricular outflow tract obstruction as a risk factor for sudden cardiac death in hypertrophic cardiomyopathy

The effect of left ventricular outflow tract obstruction (LVOTO) at rest on the incidence of sudden death (SD) in patients with hypertrophic cardiomyopathy is rather conflicting. The aim of this study was the evaluation of LVOTO at rest as a new potential risk factor for SD in hypertrophic cardiomyopathy. A total of 166 patients (112 men, 51.8 +/- 15.6 years) were studied; 50 patients (30.1%) had peak instantaneous LVOTO gradients of > or = 30 mm Hg at rest. During the follow-up period (median 32.4 months, range 1 to 209), 13 patients either died suddenly, or had cardiac arrest, documented sustained ventricular tachycardia, or implantable cardioverter defibrillator discharge. The cumulative event-free survival rate was 92% in patients with LVOTO, and 92% in patients without obstruction (p = NS). LVOTO at rest was associated with a particularly low positive predictive value for SD (8%), although a high negative predictive value (92%) was recorded. Patients having syncope or presenting with a maximum wall thickness > or =3 cm in echocardiography were more sensitive to SD emergence because they had a 13.07 (95% confidence interval 4.00 to 46.95, p <0.0001) and a 10.07 (95% confidence interval 2.92 to 34.79, p = 0.003) greater relative risk, respectively. In conclusion, our cohort study results do not support LVOTO as an independent risk factor for SD in patients with hypertrophic cardiomyopathy.

Identification of high risk patients with hypertrophic cardiomyopathy in a northern Greek population

Background

The percentage of hypertrophic cardiomyopathy (HCM) patients who are in high risk for Sudden Death (SD) constitutes only a minority of all HCM population but the incidence of SD in this subset is high (at least 5% annually). The identification of this small but important proportion of high risk HCM patients has been the clue in the clinical evaluation of these patients.

Methods

Our study cohort consisted from 123 patients with HCM who are currently followed up in our Institution. Five clinical risk factors were assessed: a family history of premature SD, unexplained syncope, Non Sustained Ventricular Tachycardia (NSVT) on 24-h ECG monitoring, Abnormal Blood Pressure Response (ABPR) during upright exercise testing and Maximum left ventricular Wall Thickness (MWT) ≥30 mm. The purpose of our study was the identification of high risk HCM patients coming from Northern Greece.

Results

Fifteen patients (12.2%) of the whole cohort had MWT ≥ 30 mm, 30 patients (24.4%) had an ABPR to exercise, 17 patients (13.8%) had episodes of NSVT in 24-h Holter monitoring, 17 patients (13.8%) suffered from syncope, and 8 patients (6.5%) had a positive family history of premature SD. Data analysis revealed that 74 patients (60.1%) had none risk factor. Twenty four patients (19.5%) had 1 risk factor, 17 patients (13.8%) had 2 risk factors, 4 patients (3.25%) had 3 risk factors, and 4 patients (3.25%) had 4 risk factors, while none patient had 5 risk factors. Twenty five patients (20.3%) had 2 or more risk factors.

Conclusion

This study for the first time confirms that, although a 60% of patients with HCM coming from a regional Greek population are in low risk for SD, a substantial proportion (almost 20%) carries a high risk for SD justifying prophylactic therapy with amiodaron or ICD implantation.

Hypertrophic cardiomyopathy with midventricular obstruction and apical aneurysm formation in a single family: case report

Background

Hypertrophic cardiomyopathy (HCM) is an extremely heterogeneous disease. An under recognized and very often missed subgroup within this broad spectrum concerns patients with left ventricular (LV) apical aneurysms in the absence of coronary artery disease.

Case presentation

We describe a case of HCM with midventricular obstruction and apical aneurysm formation in 3 patients coming from a single family. This HCM pattern was detected by 2D-echocardiography and confirmed by cardiac magnetic resonance imaging. A cardioverter defibrillator was implanted in one of the patients because of non-sustained ventricular tachycardia detected in 24-h Holter monitoring and an abrupt drop in systolic blood pressure during maximal exercise test. The defibrillator activated 8 months after implantation by suppression of a ventricular tachycardia providing anti-tachycardia pacing. The patient died due to refractory heart failure 2 years after initial evaluation. The rest of the patients are stable after a 2.5-y follow-up period.

Conclusion

The detection of apical aneurysm by echocardiography in HCM patients may be complicated. Ventricular tachycardia arising from the scarred aneurysm wall may often occur predisposing to sudden death.

Differences in echocardiographic characteristics of functional mitral regurgitation in ischaemic versus idiopathic dilated cardiomyopathy: a pilot study

INTRODUCTION

Functional mitral regurgitation (FMR) is a common complication in patients with ischaemic (ICM) or idiopathic dilated cardiomyopathy (DCM), as a consequence of left ventricular (LV) remodelling. The aim of this study was to elucidate the differences in FMR between patients with ICM and DCM utilising conventional and tissue Doppler echocardiography.

METHODS

We studied 21 patients with ICM and 17 with DCM using conventional and tissue Doppler echocardiography. The severity of FMR was assessed quantitatively and by the PISA method. The 2 groups were similar in terms of NYHA class, LV ejection fraction and pharmacological treatment.

RESULTS

Patients with ICM had higher pulmonary artery systolic pressures (48 +/- 16 vs. 38 +/- 10 mmHg, p=0.04), more severe FMR as assessed by colour Doppler (1.9 +/- 0.9 vs. 1.1 +/- 0.5, p=0.006), and a larger effective regurgitant orifice (0.17 +/- 0.07 vs. 0.1 +/- 0.05 cm(2), p=0.003) and tenting area (2.3 +/- 0.8 vs. 1.7 +/- 0.7 cm(2), p=0.02). In addition, ICM subjects had lower mitral annular systolic (Sm 2.3 +/- 0.8 vs. 3.4 +/- 0.9 cm/s, p<0.001) and diastolic (Em 2.5 +/- 1 vs. 3.8 +/- 1.5 cm/s, p=0.005; Am 3.1 +/- 1.4 vs. 4.3 +/- 1.7 cm/s, p=0.02) myocardial velocities, and a higher ratio of early transmitral filling velocity to early mitral annular diastolic velocity (LV E/Em 42 +/- 29 vs. 22.7 +/- 7.6, p=0.008) compared to DCM patients. Systolic and diastolic mitral annular velocities were significantly correlated with effective regurgitant orifice. Tenting area >1.27 cm(2) exhibited the highest sensitivity and regurgitant volume >24 ml the highest specificity for predicting ischaemic aetiology of LV dysfunction. However, only age and Sm were independent predictors of the diagnosis of ICM rather than DCM.

CONCLUSIONS

Mitral apparatus deformity, incomplete closure of mitral leaflets and global remodelling are more prominent in patients with ICM and lead to more severe FMR than in patients with DCM.

Hypertrophic cardiomyopathy with late enhancement of the non-hypertrophied left ventricular segments

A 56-year-old asymptomatic man was referred for further evaluation because he displayed a rapid T-wave change on the ECG, from positive T waves to giant negative T waves in the anterolateral precordial leads, within 2 years. Transthoracic echocardiography revealed mild left ventricular apical hypertrophy without obstruction. Cardiac magnetic resonance imaging showed apical hypertrophic cardiomyopathy with focal hyperenhancement of the non-hypertrophic basal lateral segment of the left ventricle and absence of hyperenhancement of the hypertrophied apical segments.

The utility of the standard 12-lead electrocardiogram in the prediction of proximal right coronary artery occlusion in acute inferior myocardial infarction

Prior studies have proposed several electrocardiogram criteria for identifying patients with acute inferior ST-segment elevation myocardial infarction (iSTEMI) caused by obstruction of the proximal part of the right coronary artery (RCA). We applied 11 of these criteria and three new ones to the admission electrocardiograms of 80 patients admitted with an acute iSTEMI in order to evaluate their utility. All patients received thrombolytic treatment and underwent coronary angiography during the hospitalization. Four previously described criteria (ST-segment depression in lead V1, ST-segment depression in leads V1-V3, maximum ST-segment depression in the precordial leads, and ST-segment depression in lead V3 of <or= 50% of the magnitude of ST-segment elevation in lead III) and two new used criteria (the absence of ST-segment depression in lead V1 in combination with ST-segment depression in lead V2 and the arithmetic sum of the ST-segment: III + V3 > 1) were useful in identifying patients with obstruction of the proximal part of the RCA. Among the six criteria, ST depression in V1-V3 had the highest specificity (77.2%) and positive predictive value (56.5%), and a new criterion-the arithmetic sum of the ST-elevation in V3/ST-elevation in III < 0.5--had the highest sensitivity (80.9%) and negative predictive value (86.7%). Six criteria were helpful in identifying patients with acute iSTEMI caused by obstruction of the proximal part of the RCA. One of these has not been previously reported and has the higher specificity and negative predictive value.

Prognostic significance of right ventricular diastolic function in thalassaemia major

While left ventricular (LV) restrictive filling pattern is an ominous echocardiographic finding in thalassaemia major (TM), the prognostic significance of right ventricular (RV) diastolic function in patients with TM has not been thoroughly investigated. We studied 45 TM asymptomatic transfusion-dependent patients with normal LV systolic function by Doppler echocardiography. The 15-year cumulative survival rate was 34% in patients with RV restrictive filling pattern (RFP) and 82% in patients with RV non-RFP (log-rank = 10.41, p = 0.0013). Doppler estimation of RV filling pattern is very important in evaluating the prognosis of TM patients and should be performed routinely and using a standardised followup protocol.

Clinical significance of tissue Doppler imaging in patients with hypertrophic cardiomyopathy

BACKGROUND

A transmitral E/septal Ea ratio > or =15 is a predictor of adverse outcome in cardiac disease, so it was hypothesized that a septal E/Ea >/=15 would predict the risk of adverse outcome, including sustained ventricular tachycardia (VT), cardiac arrest, implantable cardioverter defibrillator (ICD) discharge, or sudden death (SD) in patients with hypertrophic cardiomyopathy (HCM).

METHODS AND RESULTS

The study group comprised 96 consecutive patients with HCM (median age 53 years) who completed all noninvasive tests for risk stratification. The endpoint of the study was defined as death, cardiac arrest, documented sustained VT, or ICD-discharge. The median follow-up was 20.6 months. All patients were alive at the end of follow-up, although 8 patients had reached the endpoint during the study period. The variables that were predictive of adverse clinical outcome were family history of premature SD (p=0.03), syncope (p<0.001), maximum wall thickness > or =3 cm (p=0.02), and septal E/Ea > or =15 (p<0.001). In a stepwise multivariable model the only independent prognostic indicator was a septal E/Ea > or =15 (relative risk 0.26, 95% confidence interval 0.2-0.58, p<0.001). The cumulative event-free survival rate was 78.9% in patients with septal E/Ea > or =15, and 100% in patients with septal E/Ea <15 (p=0.0003).

CONCLUSIONS

Septal E/Ea > or =15 predicts patients with HCM who are at risk of sustained VT, cardiac arrest, ICD-discharge, or SD. (Circ J 2007; 71: 897 - 903).

Left ventricular diastolic dysfunction in idiopathic pulmonary fibrosis: a tissue Doppler echocardiographic [corrected] study

It was hypothesised that, apart from right ventricular (RV) dysfunction, patients with idiopathic pulmonary fibrosis (IPF) also exhibit left ventricular (LV) impairment, which may affect disease progression and prognosis. The aim of the present study was to evaluate LV performance in a cohort of IPF patients using conventional and tissue Doppler ECG. IPF patients exhibiting mild-to-moderate pulmonary arterial hypertension (mean age 65+/-9 yrs; n = 22) and healthy individuals (mean age 61+/-6 yrs; n = 22) were studied. Conventional and tissue Doppler ECG were used for the evaluation of RV and LV systolic and diastolic function. In addition to the expected impairment in RV function, all patients showed a characteristic reversal of LV diastolic filling to late diastole compared with controls (early diastolic peak filling velocity (E)/late diastolic peak filling velocity 0.7+/-0.2 versus 1.5+/-0.1, respectively). Patients with IPF also exhibited lower peak myocardial velocities in early diastole (E(m); 5.7+/-1.1 versus 10.3+/-1.6 cm x s(-1), respectively), higher in late diastole (A(m); 8.9+/-1.3 versus 5.5+/-0.8 cm x s(-1), respectively), lower E(m)/A(m) ratio (0.6+/-0.1 versus 1.9+/-0.5, respectively) and higher E/E(m) ratio (10.8+/-3 versus 6+/-0.6, respectively), all indicative of LV diastolic dysfunction. Moreover, LV propagation velocity was significantly lower in IPF patients (46+/-13 versus 83+/-21 cm x s(-1), respectively). Physicians should be aware that patients with idiopathic pulmonary fibrosis exhibit early impairment of left ventricular diastolic function.

Clinical significance of N-terminal-probrain natriuretic peptide in hypertrophic cardiomyopathy

N-Terminal-probrain natriuretic peptide (NT-proBNP) plasma levels are elevated in patients with congestive heart failure. Published data concerning the utility of NT-proBNP in hypertrophic cardiomyopathy (HCM) are lacking. Our aim was to evaluate the clinical significance of NT-proBNP in patients with HCM. A blood sample was collected for plasma NT-proBNP measurement from 43 consecutive patients with documented HCM. NT-proBNP was measured using a chemiluminescent immunoassay kit (Roche Diagnostics) on an Elecsys 2010 analyzer. Median value of NT-proBNP was 219 pg/ml (range 8-3 045 pg/ml) in NYHA class I patients, 698 pg/ml (125-2 463 pg/ml) in NYHA class II patients, and 2 683 pg/ml (131-11 542 pg/ml) in NYHA class III and IV patients. NT-proBNP plasma levels were significantly higher across the severity of functional limitation (i.e., NYHA class classification) (P = 0.002). NT-proBNP levels were significantly higher in female than male (P = 0.034), in referral vs nonreferral patients (P = 0.004), in symptomatic vs asymptomatic patients (P = 0.020), in patients with basal subaortic gradient >or=30 mmHg (P = 0.001) and in the patients who were on cardioactive medication (P = 0.010). In univariate analysis NT-proBNP was significantly correlated with age (P < 0.001), left ventricular maximum wall thickness (P = 0.001), left atrial size (P = 0.019), and subaortic gradient >or=30 mmHg (P < 0.001). In multivariate regression analysis, age (P < 0.001), maximum wall thickness (P = 0.007), and gradient >or=30 mmHg (P = 0.027) were independently associated with NT-proBNP levels. Our data support the idea that measurement of plasma NT-proBNP levels in HCM patients is useful to assess their clinical status, especially the severity of hypertrophy and the presence of obstruction, although age must be taken into account.