Associations between N-terminal pro-B-type natriuretic peptide and cardiac function in adults with corrected tetralogy of Fallot

Background

Amino-terminal B-type natriuretic peptide (NT-proBNP) may detect early cardiac dysfunction in adults with tetralogy of Fallot (ToF) late after corrective surgery. We aimed to determine the value of NT-proBNP in adults with ToF and establish its relationship with echocardiography and exercise capacity.

Methods and results

NT-proBNP measurement, electrocardiography and detailed 2D-echocardiography were performed on the same day in 177 consecutive adults with ToF (mean age 34.6 ± 11.8 years, 58% male, 89% NYHA I, 29.3 ± 8.5 years after surgical correction). Thirty-eight percent of the patients also underwent a cardiopulmonary-exercise test. Median NT-proBNP was 16 [IQR 6.7–33.6] pmol/L, and was elevated in 55%. NT-proBNP correlated with right ventricular (RV) dilatation (r = 0.271, p < 0.001) and RV systolic dysfunction (r = − 0.195, p = 0.022), but more strongly with LV systolic dysfunction (r = − 0.367, p < 0.001), which was present in 69 patients (39%). Moderate or severe pulmonary regurgitation was not associated with higher NT-proBNP. Tricuspid and pulmonary regurgitation peak velocities correlated with NT-proBNP (r = 0.305, p < 0.001 and r = 0.186, p = 0.045, respectively). LV twist was measured with speckle-tracking echocardiography in 71 patients. An abnormal LV twist (20 patients, 28%) was associated with elevated NT-proBNP (p = 0.030). No relationship between NT-proBNP and exercise capacity was found.

Conclusions

NT-proBNP levels are elevated in more than 50% of adults with corrected ToF, while they are in stable clinical condition. Higher NT-proBNP is most strongly associated with elevated pulmonary pressures, and with LV dysfunction rather than RV dysfunction. NT-proBNP has the potential to become routine examination in patients with ToF to monitor ventricular function and may be used for timely detection of clinical deterioration.     

The effects of pregnancy on right ventricular remodeling in women with repaired tetralogy of Fallot

Objectives

The aim of this study was to better understand the quantitative volumetric changes associated with pregnancy in women with repaired tetralogy of Fallot (TOF), utilizing sequential cardiovascular magnetic resonance (CMR) imaging.

Background

An increasing number of women with repaired TOF are reaching childbearing age. Limited echocardiographic studies suggest accelerated remodeling of the right ventricle (RV) in women with repaired TOF after pregnancy.

Methods

Sequential CMRs from a group of women with repaired TOF who completed pregnancy and from a matched comparison group of nulliparous women with repaired TOF were evaluated. The two groups were matched according to baseline QRS duration, RV end-diastolic volume (EDV), age at CMR and time between CMRs. Longitudinal change of CMR parameters was compared between the groups.

Results

Thirteen women (mean age 26.6 ± 7.4 years) with repaired TOF who completed pregnancy and 26 nulliparous women with repaired TOF (mean age 22.6 ± 8.0 years) were included in this analysis. The rate of increase of RV EDV in the pregnancy group was higher than the comparison group (4.1 ± 1.1 ml/m²/year vs. 1.6 ± 0.6 ml/m²/year, p = 0.07). RV EF did not change significantly in either group. No definitive interaction between degree of pulmonary regurgitation and increase of RV EDV was identified.

Conclusions

Women with repaired TOF who have completed pregnancy appear to experience an accelerated rate of right ventricular remodeling, defined as an increase in end-diastolic volume; however RV systolic function does not deteriorate. Further investigations with a prospective study design, larger cohorts, and longer follow-up are needed to confirm these initial observations.     

Left anterior descending coronary artery flow impaired by right ventricular apical pacing: The role of systolic dyssynchrony

Introduction

Right ventricular (RV) pacing may affect myocardial perfusion and coronary blood flow; however, it remains unknown whether this is related to systolic dyssynchrony induced by RV pacing. This prospective study was aimed to assess the relationship between dyssynchrony and the changes of coronary blood flow.

Methods

Seventy patients with sinus node dysfunction were prospectively enrolled. Coronary flow was evaluated by measuring diastolic velocity time integral (VTI) and duration at the distal-portion of left anterior descending coronary artery (LAD) with transthoracic echocardiography at baseline and follow-up. Systolic dyssynchrony was assessed with tissue Doppler imaging by time standard deviation to peak systolic velocity of 12 left ventricular segments (Ts-SD, cutoff value ≥ 33 ms).

Results

Adequate data for analysis was available from 65 patients. At follow-up (mean follow up time: 127 ± 45 days), LAD velocity-time integral (LAD-VTI: 12.1 ± 4.2 vs. 10.7 ± 4.6 cm, p < 0.001) was decreased and there was deterioration of left ventricular systolic function (left ventricular ejection fraction: 65 ± 7% vs. 62 ± 7%). However, these changes were only detected in those with RV pacing induced systolic dyssynchrony. Significant reduction of LAD-VTI (defined as ≥ 5%) occurred in 34 (52%) patients which was more prevalent in those with pacing-induced systolic dyssynchrony than those without (85.3% versus 16.1%, χ² = 31.1, p < 0.001). Though similar at baseline, LAD-VTI was significantly lower in the dyssynchrony group at follow up (p < 0.001). Cox-regression analysis showed that pacing-inducing systolic dyssynchrony [hazard ratio (HR): 3.62, p = 0.009] and higher accumulative pacing percentage (HR: 1.02, p = 0.002) were independently associated with reduction of LAD-VTI. ROC curve demonstrated that accumulative pacing percentage ≥ 35% was 97% sensitive and 84% specific in revealing significant reduction (area under the curve: 0.961, p < 0.001).

Conclusions

RV pacing induced dyssynchrony is associated with reduced coronary flow and this may account for, in part, the deleterious effect of RV pacing on ventricular function over time.     

Diastolic ventricular interaction in patients after atrial switch for transposition of the great arteries: A speckle tracking echocardiographic study

Background

We tested the hypothesis that diastolic ventricular interaction occurs after atrial switch operation for transposition of the great arteries (TGA) and that subpulmonary LV diastolic function is influenced by septal geometry.

Methods

Twenty-nine patients (male 19) after atrial switch operation for TGA aged 20.8 ± 4.1 years and 27 healthy controls were studied. Two-dimensional longitudinal systolic strain, systolic (SRs), early diastolic (SRe), and late diastolic (SRa) strain rates of both ventricles were determined using speckle tracking echocardiography. Early diastolic trans-atrioventricular velocity (E) and myocardial early diastolic myocardial velocity (e) at the ventricular free wall-annular junction were measured. Geometry of the morphologic left ventricle was quantified by the diastolic eccentricity index (EI).

Results

In both systemic and subpulmonary ventricles, SRe and SRa were significantly lower and trans-atrioventricular E/e ratios higher in patients than controls (all p < 0.001). In patients, RV SRe correlated with left ventricular (LV) SRe (r = 0.49, p = 0.008), and RV SRa correlated with LV SRa (r = 0.46, p = 0.01). Significant leftward shifting of the septum in patients was reflected by the greater LV EI (p < 0.001). In patients, LV EI correlated with age- and sex-adjusted z score of LV end-diastolic volume. As a group, LV EI correlated negatively with LV SRe (r =−0.62, p < 0.001) and LV SRa (r = − 0.51, p < 0.001), and positively with mitral E/e ratio (r = 0.33, p = 0.02).

Conclusions

Systemic RV diastolic dysfunction occurs after atrial switch operation and correlates with subpulmonary LV diastolic dysfunction. The observed diastolic ventricular interaction may potentially be mediated through alteration of septal geometry.     

Assessment of right ventricular systolic function: Comparison between cardiac magnetic resonance derived ejection fraction and pulsed-wave tissue Doppler imaging of the tricuspid annulus

Background

Systolic right ventricular (RV) function is an important predictor in the course of various congenital and acquired heart diseases. Its practical determination by echocardiography remains challenging. We compared routine assessment of lateral tricuspid annular systolic motion velocity (TV_lat, cm/s) using pulsed-wave tissue Doppler imaging from the apical 4-chamber view with cardiac magnetic resonance (CMR) as reference method.

Methods and results

254 individuals (43 ± 18 years) underwent both CMR (contiguous short axis slices; retrogated cine steady state free precession technique; manual contour tracing) and echocardiography within 2 ± 2 months. Seventy-five had coronary artery disease, 87 congenital heart disease, 17 dilated cardiomyopathy, 15 pulmonary artery hypertension, and 47 normal findings. RV ejection fraction (EF) by CMR was 51 ± 12% (range 17-78%). There was a linear correlation between RVEF and TV_lat (r = 0.60; p < 0.0001). A TV_lat cut-off of 12 cm/s identified patients with normal EF (≥ 50%) with 81% sensitivity and 68% specificity, and a threshold of TV_lat < 9 cm/s identified patients with severely reduced RVEF (< 30%) with 82% sensitivity and 86% specificity.

Conclusions

Systolic long-axis velocity measurements of the lateral tricuspid annulus allow a reliable assessment of RVEF in clinical routine. A threshold of TV_lat < 9 cm/s identifies patients with severely reduced RVEF (< 30%) with high sensitivity and specificity.     

N-terminal Pro brain natriuretic peptide is a reliable biomarker of reduced myocardial contractility in patients with lamin A/C gene mutations

Background

Recently, concerns have been raised about a possible lack of sensitivity of biomarkers to detect left ventricular (LV) dysfunction in patients with myopathies. We examined the ability of the N-terminal brain natriuretic peptide (NT-proBNP) to detect LV or right ventricular (RV) dysfunction in patients with lamin A/C (LMNA) gene mutations.

Methods

We prospectively measured plasma NT-proBNP in consecutive patients with documented LMNA mutations and age-sex matched controls. All patients underwent standard echocardiography implemented by pulsed tissue-Doppler echocardiography (TDE).

Results

Twenty-three patients were included (10 males, mean age 39.2 ± 18.9 years);10 had previous atrial arrhythmias, 8 had been implanted with cardioverter defibrillator for primary prevention of sudden death, 5 patients were of NYHA class II and 18 of NHYA class I. Sinus rhythm was recorded in all. NT-proBNP was increased in LMNA patients versus controls (123 ± 229 versus 26 ± 78 pg/ml, p = 0.0004); 7 patients had depressed LV and/or RV contractility. Patients with reduced LV or RV contractility had increased mean NT-proBNP (341 ± 1032 pg/ml versus 80 ± 79 pg/ml in patients with normal myocardial contractility, p = 0.004). Receiver-operating-characteristics analysis shows that NT-proBNP reliably detected depressed contractility (area under the curve 0.889 [0.697-1.000]). Sensitivity and specificity were 88% and 83% respectively, applying manufacturer's recommended cut-off concentration of 125 pg/ml.

Conclusion

NT-proBNP reliably detected the presence of reduced LV/RV contractility in LMNA patients.     

Evaluation of the right ventricle: Comparison of gated blood-pool single photon electron computed tomography and echocardiography with cardiac magnetic resonance

Background

The evaluation of the right ventricle (RV) is a challenge; as a result six transthoracic echocardiography (TTE) parameters have been suggested. While gated blood-pool single photon electron computed tomography (GBPS) is a promising technique, there is currently no completely automated and validated processing software available clinically. Consequently, cardiac magnetic resonance (CMR) imaging remains the gold standard for RV assessment. We aimed to compare RV evaluation by GBPS and TTE to CMR.

Methods

Fifty-eight patients underwent CMR, GBPS and TTE for RV assessment, including volumes, RVEF and TTE's indices of RV function (fractional area change (FAC), RV myocardial performance index by pulsed wave Doppler (MPI-PWD) and tissue Doppler (MPI-TDI) and tricuspid annular plane systolic excursion (TAPSE) by M-Mode and tissue Doppler (TAPSE-TDI)). GBPS was performed using both a commercial (QBS) and the Montreal Heart Institute (MHI) proprietary software.

Results

Nuclear medicine derived volumes quantification showed very good correlations with CMR, for RV end-diastolic (r = 0.84 and 0.77, all p < 0.001) and end-systolic (r = 0.82 and 0.67, all p < 0.001) volumes by MHI and QBS software respectively. RVEF showed a significant correlation with CMR in patients with RVEF ≤ 45% (r = 0.54, p = 0.029 and r = 0.55, p = 0.028, by MHI and QBS respectively). Among TTE parameters, only FAC and MPI-TDI were significantly correlated with CMR-RVEF, mainly for RVEF ≤ 45% (r = 0.63, p = 0.011 and r = 0.58, p = 0.046).

Conclusions

GBPS, both with MHI and QBS software, exhibited significant correlations with CMR for evaluation of the RV (volumes and decreased RVEF estimation). Among TTE's parameters, only FAC and MPI-TDI showed significant correlation with CMR with RVEF ≤ 45%.     

Early pacing-induced systolic dyssynchrony is a strong predictor of left ventricular adverse remodeling: Analysis from the Pacing to Avoid Cardiac Enlargement (PACE) trial

Background

Right ventricular apical (RVA) pacing is associated with adverse left ventricular (LV) remodeling and biventricular (BiV) pacing may prevent it although the mechanisms remain unclear. The current study aimed to assess the role of early pacing-induced systolic dyssynchrony (DYS) to predict adverse LV remodeling.

Methods

Patients with standard pacing indications and normal LV ejection fraction were randomized either to BiV (n = 89) or RVA pacing (n = 88). Pacing-induced DYS, defined as the standard deviation of the time to peak systolic velocity (Dyssynchrony Index) > 33 ms in a 12-segmental model of LV, was measured by tissue Doppler echocardiography at 1 month.

Results

At 1 month, 59 patients (33%) had DYS which was more prevalent in RVA than BiV pacing group (52% vs. 15%, χ² = 28.3, p < 0.001), though Dyssynchrony Index was similar at baseline (30 ± 14 vs. 26 ± 11 ms, p = 0.06). At 12 months, those developing DYS had significantly lower LV ejection fraction (55.1 ± 9.7 vs. 62.2 ± 7.9%, p < 0.001) and larger LV end-systolic volume (35.3 ± 14.3 vs. 27.0 ± 10.4 ml, p < 0.001) when compared to those without DYS. Reduction of ejection fraction ≥ 5% occurred in 67% (39 out of 58) of patients with DYS, but only in 18% (21 out of 115) in those without DYS (χ² = 40.8, p < 0.001). Both DYS at 1 month (odds ratio [OR]: 4.725, p = 0.001) and RVA pacing (OR: 3.427, p = 0.009) were independent predictors for reduction of ejection fraction at 12 months.

Conclusion

Early pacing-induced DYS is a significant predictor of LV adverse remodeling and the observed benefit of BiV pacing may be related to the prevention of DYS.

Clinical trial registration

Centre for Clinical Trials number, CUHK_CCT00037 (URL: http://www.cct.cuhk.edu.hk/Registry/publictrialrecord.aspx?trialid=CUHK_CCT00037).     

Long-term significance of Killip class and left ventricular systolic dysfunction

Background

Killip classification is an independent predictor of early mortality after myocardial infarction, and the presence of left ventricular systolic dysfunction (left ventricular ejection fraction <50%) and high Killip class predicts poor short-term prognosis. The long-term prognostic significance of Killip class and left ventricular systolic dysfunction, however, is unknown.

Methods

We studied the impact of Killip class and left ventricular systolic dysfunction on all-cause mortality (assessed in May 2007 using the Social Security Death Index) in myocardial infarction patients admitted from July 1995 to December 1996.

Results

Of 282 patients, 60% (n = 168) were Killip class 1, 23% (n = 64) were Killip class 2, and 17% (n = 50) were Killip class 3 or 4. Patients with higher Killip class were older and more likely to have diabetes, a non-Q-wave myocardial infarction, renal insufficiency, chronic obstructive pulmonary disease, and left ventricular systolic dysfunction. There were 152 deaths at 10 years after myocardial infarction, and patients with Killip class 2, 3, or 4 had higher mortality compared with Killip class 1 in unadjusted analyses. Patients with left ventricular systolic dysfunction and Killip class of 2 or more had significantly higher 10-year mortality (70 deaths or 76.9%) compared with Killip class 1 patients without left ventricular systolic dysfunction (29 deaths or 34.5%, P <.001). This risk persisted after adjusting for demographics, cardiovascular risk factors, and co-morbidities. Much of the risk was explained by deaths in the first 5 years after myocardial infarction.

Conclusions

Killip class is a strong predictor of long-term mortality, and patients with high Killip class and left ventricular systolic dysfunction are at highest risk.     

Étude de la fonction ventriculaire droite par 2D speckle imaging et échographie tridimensionnelle. Comparaison à l’IRM myocardique

Purpose

The echocardiographic assessment of right ventricular (RV) function requires many different parameters. We studied and compared with magnetic resonance imaging (MRI) two markers of RV function derived from new imaging tools: 2D speckle imaging (2DSI) and three dimensional echography.

Methods and results

Thirty-two patients (19 with RV ejection fraction [RVEF] ≤ 45%) underwent both complete echocardiography - including standard parameters of RV function (fractional area change [FAC], Tei index, systolic velocity of tricuspid annulus by DTI), 3D full-volume acquisition on RV - and MRI for the evaluation of RV volumes and RVEF. 2DSI was applied to high frame rate cine loops centred on the RV free wall with measurement of peak systolic strain (%) in the basal, median and apical segments of this wall. Strain, especially in RV median and apical segments, is reduced in patients with RVEF less or equal to 45% (median strain: −16,39 ± 5,27 vs. −24,74 ± 8,00 [p = 0,002]; apical strain −13,01 ± 6,84 vs. 22,53 ± 11,32 [p = 0,03]) with a very good correlation with RVEF (r = −0,717, p = 0,0001) but also with the usual echographic parameters of RV function, (FAC: r = 0,019; Tei: r = 0,01; peak systolic velocity: r = 0,002). The 3D RVEF is also but poorly correlated with MRI RVEF, (r = 0,447, p = 0,017). Furthermore, 3D significantly underestimated RV volumes. By multivariate analysis, apical strain (p = 0,004) and FAC (p = 0,029) were predictive of a decreased RVEF.

Conclusion

Apical strain as measured from 2DSI seems a promising parameter in the estimation of RV function. 3D estimation of RVEF is more disappointing because of an important underestimation of RV volumes.     

Prolonged impact of home versus clinic-based management of chronic heart failure: Extended follow-up of a pragmatic,multicentre randomized trial cohort

Objectives

We compared the longer-term impact of the two most commonly applied forms of post-discharge management designed to minimize recurrent hospitalization and prolong survival in typically older patients with chronic heart failure (CHF).

Methods

We followed a multi-center randomized controlled trial cohort of Australian patients hospitalized with CHF and initially allocated to home-based or specialized CHF clinic-based intervention for 1368 ± 216 days. Blinded endpoints included event-free survival from all-cause emergency hospitalization or death, all-cause mortality and rate of all-cause hospitalization and stay.

Results

280 patients (73% male, aged 71 ± 14 years and 73% left ventricular systolic dysfunction) were initially randomized to home-based (n = 143) or clinic-based (n = 137) intervention. During extended follow-up (complete for 274 patients), 1139 all-cause hospitalizations (7477 days of hospital stay) and 121 (43.2%) deaths occurred. There was no difference in the primary endpoint; 20 (14.0%) home-based versus 13 (7.4%) clinic-based patients remained event-free (adjusted HR 0.89, 95% CI 0.70 to 1.15; p = 0.378). Significantly fewer home-based (51/143, 35.7%) than clinic-based intervention (71/137, 51.8%) patients died (adjusted HR 0.62, 95% CI 0.42 to 0.90: p = 0.012). Home-based versus clinic-based intervention patients accumulated 592 and 547 all-cause hospitalizations (p = 0.087) associated with 3067 (median 4.0, IQR 2.0 to 6.8) versus 4410 (6.0, IQR 3.0 to 12.0) days of hospital stay (p < 0.01 for rate and duration of hospital stay).

Conclusions

Relative to clinic-based intervention, home-based intervention was not associated with prolonged event-free survival. Home-based intervention was, however, associated with significantly fewer all-cause deaths and significantly fewer days of hospital stay in the longer-term.

Trial registration

Australian New Zealand Clinical Trials Registry number 12607000069459 (http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=81803)     

Comparison of cardiac magnetic resonance with gated SPECT for evaluation of left ventricular function and volumes in patients with severe and multiple myocardial perfusion defects

Objectives

Gated SPECT is an accurate technique for assessment of myocardial perfusion (MP), left ventricular ejection fraction (LVEF), end-diastolic volume (EDV) and end-systolic volume (ESV). However recent studies have concluded that there are large discrepancies in assessment of LVEF and volumes by gated SPECT in patients with multiple severe myocardial perfusion defects. We sought to investigate the correlation between LVEF and volumes calculated by gated SPECT and cardiac magnetic resonance (CMR) in patients with severe multiple perfusion defects who are referred for CMR.

Methods

Twenty-nine patients (20 male and 9 female, mean age: 63 years ± 11) with multiple severe fixed perfusion defects (mean 5 ± 3 segments) were referred to undergo CMR. The average time between CMR and SPECT was 4 weeks. LVEF, EDV, and ESV were derived automatically from gated SPECT. In the CMR studies, the endocardial and epicardial borders were delineated manually in the short axis planes to calculate the LVEF and volumes.

Results

The different parameters were compared using linear regression, and correlation coefficients were calculated. Substantial correlation was found between CMR and gated SPECT for EDV: r = 0.7, p < 0.001. Moderate correlation between CMR and gated SPECT for LVEF: r = 0.5, p < 0.007 and ESV r =0 .53, p < 0.003.

Conclusion

Our data showed that the gated SPECT correlates substantially with MRI for measurement of EDV and moderately for ESV and LVEF in patients with multiple and severe perfusion defects. Thus, when accurate measurement is required, cardiac MRI is recommended.     

Is systemic right ventricular function by cardiac MRI related to the degree of tricuspid regurgitation in congenitally corrected transposition of the great arteries?

Background and Methods

Systemic right ventricular dysfunction and tricuspid regurgitation (TR) are frequently encountered in patients with congenitally corrected transposition of the great arteries (CCTGA). Studies using echocardiography have suggested a relationship between the degree of TR and systemic right ventricular dysfunction; however, assessment of systemic right ventricular function by echocardiography is limited. Cardiac MRI (CMR) is the gold standard for volumetric assessment of the systemic right ventricle. We performed a retrospective cohort study at our center evaluating all adult patients with CCTGA who underwent a CMR between 1/1999 and 1/2013 to determine the relationship between the degree of TR and systemic right ventricular function.

Results

Of the 33 patients identified, 12 had ≤ mild TR (37%), 13 had moderate TR (40%), and 8 had severe TR (24%). Mean age at CMR was 38 years (23–64). Mean right ventricular ejection fraction (45% vs. 41% vs. 42%, p = 0.68) and mean indexed right ventricular end diastolic volume (122 ml/m² vs. 136 ml/m² vs. 138 ml/m²p = 0.36) were not significantly different for patients with ≤ mild TR, moderate TR or severe TR. The degree of TR was not associated with additional congenital lesions, prior procedures, presence of an intraventricular conduction delay, or decreased left ventricular function.

Conclusion

No association between the degree of TR and right ventricular volume or ejection fraction by CMR was identified. Failure to show worsening function or increased volume with greater degrees of TR suggests that the degree of regurgitation alone may not fully explain the heterogeneity in right ventricular size and function.     

Myocardial scar characteristics based on cardiac magnetic resonance imaging is associated with ventricular tachyarrhythmia in patients with ischemic cardiomyopathy

Objectives

We hypothesized that myocardial scar characterization using cardiac magnetic resonance imaging (CMR) may be associated with the occurrence of ventricular tachyarrhythmia (VT), appropriate implantable cardioverter-defibrillator (ICD) therapy and mortality.

Background

Since a minority of patients with prophylactic ICD implantation receive appropriate ICD therapy, there is a need for more effective risk stratification for primary prevention in patients with ischemic cardiomyopathy.

Methods and results

In 99 patients with ischemic cardiomyopathy, CMR was performed prior to ICD implantation. We assessed if CMR indices (cardiac mass, LVEF) and CMR scar characteristics (infarct core mass, peri-infarction mass and the ratio's between left ventricular mass, infarct core mass and peri-infarction mass) were associated with outcome. The primary endpoint was sustained VT and/or appropriate ICD therapy. The secondary endpoint was all-cause mortality. During a median follow-up of 5.4 years (IQR 4.5–6.6 years), 34 patients reached the primary end-point (17 appropriate ICD shocks) and 26 patients died. In multivariable Cox regression analysis, peri-infarction to core-infarction ratio (HR 2.01, 95%CI: 1.17–3.44, p = 0.01) was independently and significantly associated with the primary endpoint, whereas NYHA-class and lower LVEF were not. Conversely, age (HR 1.06, 95% CI: 1.01–1.12, p = 0.02) and lower LVEF (HR 0.95, 95% CI: 0.91–1.00, p = 0.04) were independently associated with all-cause mortality, mainly due to heart failure.

Conclusion

A relatively large peri-infarction mass is associated with sustained VT and/or appropriate ICD therapy, whereas age and lower LVEF are associated with mortality. CMR based tissue characterization could aid in the prediction of specific outcome measures and in clinical decision making.     

Pulmonary valve replacement in chronic pulmonary regurgitation in adults with congenital heart disease: Impact of preoperative QRS-duration and NT-proBNP levels on postoperative right ventricular function

Background

Chronic severe pulmonary regurgitation (PR) causes progressive right ventricular (RV) dysfunction and heart failure. Parameters defining the optimal time point for surgery of chronic PR are lacking. The present study prospectively evaluated the impact of preoperative clinical parameters, cardiorespiratory function, QRS duration and NT-proBNP levels on post operative RV function and volumes assessed by cardiac magnetic resonance imaging (CMR) in patients with chronic severe PR undergoing pulmonary valve replacement.

Methods and results

CMR was performed pre- and 6 months postoperatively in 27 patients (23.6 ± 2.9 years, 15 women) with severe PR. Postoperatively, RV endsystolic (RVESVI) and enddiastolic volume indices (RVEDVI) decreased significantly (RVESVI pre 78.2 ± 20.4 ml/m² BSA vs. RVESVI post 52.2 ± 16.8 ml/m²BSA, p < 0.001; RVEDVI pre 150.7 ± 27.7 ml/m²BSA vs. RVEDVI post 105.7 ± 26.7 ml/m²BSA; p < 0,001). With increasing preoperative QRS-duration, postoperative RVEF decreased significantly (r =−0.57; p < 0.005). Preoperative QRS-duration smaller than the median (156 ms) predicted an improved RVEF compared to QRS-duration ≥ 156 ms (54.9% vs 46.8%, p < 0.05). Multivariate analysis identified preoperative QRS duration as an independent predictor of postoperative RVEF (p < 0.005). NT-proBNP levels correlated with changes in RVEDI (r = 0.58 p < 0,005) and RVESVI (r = 0.63; p < 0,0001). Multivariate analysis identified NT-proBNP levels prior to PVR as an independent predictor of volume changes (p < 0.05).

Conclusion

Valve replacement in severe pulmonary regurgitation causes significant reduction of RV volumes. Both, preoperative NT-proBNP level elevation and QRS prolongation indicate patients with poorer outcome regarding RV function and volumes.     

The relationship between ascending aortic diameter with left atrial functions and left ventricular mass index in a population with normal left ventricular systolic function

Aim

Ascending aortic dilatation is a common clinical issue. In the present study, we aimed to evaluate the relationship between ascending aortic diameter with left ventricular (LV) and left atrial (LA) functions, and LV mass index (LVMI) in a population with normal LV systolic function.

Methods

A total of 127 healthy participants with normal LV systolic function took part in the study. Echocardiographic measurements were obtained from each subject.

Results

The mean age of the participants was 43 ± 14.1 years and 76 (59.8%) were female. The mean aortic diameter of the participants was 32.2 ± 4.7 mm. A negative correlation was found between aortic diameter and LV systolic function (LVEF r = -.516, p < .001; Gls r = -.370). In addition, there was a strong positive correlation between aortic diameter with LV wall thicknesses, LVMI (r = .745, p < .001), and systolic and diastolic diameters. The relationship between aortic diameter and diastolic parameters was evaluated, a negative correlation with Mitral E, Em, E/A ratio, and a positive correlation with MPI, Mitral A, Am, E/Em ratio were found.

Conclusion

A strong correlation between ascending aortic diameter with LV and LA functions, and LVMI in individuals with normal LV systolic function.     

A mismatch index based on the difference between measured left ventricular ejection fraction and that estimated by infarct size at three months following reperfused acute myocardial infarction

Background and Aim

The reduction of left ventricular ejection fraction (LVEF) following ST-segment elevation myocardial infarction (STEMI) is a result of infarcted myocardium and may involve dysfunctional but viable myocardium. An index that may quantitatively determine whether LVEF is reduced beyond the expected value when considering only infarct size (IS) has previously been presented based on cardiac magnetic resonance (CMR). The purpose of this study was to introduce the index based on the electrocardiogram (ECG) and compare indices based on ECG and CMR.

Method and Results

In 55 patients ECG and CMR were obtained 3 months after STEMI treated with primary percutaneous coronary intervention. Significant, however moderate inverse relationships were found between measured LVEF and IS. Based on IS and LVEF an IS estimated LVEF was derived and an MI–LVEF mismatch index was calculated as the difference between measured LVEF and IS estimated LVEF. In 41 (74.5%) of the patients there was agreement between the ECG and CMR indices in regards to categorizing indices as > 10 or ≤ 10 and generally no significant difference was detected, mean difference of 1.26 percentage points (p = 0.53).

Conclusion

The study found an overall good agreement between MI–LVEF mismatch indices based on ECG and CMR. The MI–LVEF mismatch index may serve as a tool to identify patients with potentially reversible dysfunctional but viable myocardium, but future studies including both ECG and CMR are needed.     

Cor Pulmonale Parvus in Chronic Obstructive Pulmonary Disease and Emphysema : The MESA COPD Study

Background

The classic cardiovascular complication of chronic obstructive pulmonary disease (COPD) is cor pulmonale or right ventricular (RV) enlargement. Most studies of cor pulmonale were conducted decades ago.

Objectives

This study sought to examine RV changes in contemporary COPD and emphysema using cardiac magnetic resonance (CMR) imaging.

Methods

We performed a case-control study nested predominantly in 2 general population studies of 310 participants with COPD and control subjects 50 to 79 years of age with ≥10 pack-years of smoking who were free of clinical cardiovascular disease. RV volumes and mass were assessed using magnetic resonance imaging. COPD and COPD severity were defined according to standard spirometric criteria. The percentage of emphysema was defined as the percentage of lung regions <−950 Hounsfield units on full-lung computed tomography; emphysema subtypes were scored by radiologists. Results were adjusted for age, race/ethnicity, sex, height, weight, smoking status, pack-years, systemic hypertension, and sleep apnea.

Results

Right ventricular end-diastolic volume (RVEDV) was reduced in COPD compared with control subjects (−7.8 ml; 95% confidence interval: −15.0 to −0.5 ml; p = 0.04). Increasing severity of COPD was associated with lower RVEDV (p = 0.004) and lower RV stroke volume (p < 0.001). RV mass and ejection fraction were similar between the groups. A greater percentage of emphysema also was associated with lower RVEDV (p = 0.005) and stroke volume (p < 0.001), as was the presence of centrilobular and paraseptal emphysema.

Conclusions

RV volumes are lower without significant alterations in RV mass and ejection fraction in contemporary COPD, and this reduction is related to the greater percentage of emphysema on computed tomography.     

Importance of pericardial fat in the formation of complex fractionated atrial electrogram region in atrial fibrillation

Background/Objectives

Pericardial fat (PF) and complex fractionated atrial electrogram (CFAE) are both associated with atrial fibrillation (AF). Therefore, we examined the relation between PF and CFAE area in AF.

Methods

The study population included 120 control patients without AF and 120 patients with AF (80 paroxysmal AF and 40 persistent AF) who underwent catheter ablation. Total cardiac PF volume, representing all adipose tissue within the pericardial sac, was measured by contrast-enhanced computed tomography. The location and distribution of CFAE region were identified by left atrial endocardial mapping using a three-dimensional mapping system. We analyzed the significance of total cardiac PF volume and total area of CFAE region on AF, persistence of AF from paroxysmal to persistent form, and the relation between total cardiac PF volume and total CFAE area. We also evaluated the regional distribution of PF volume and CFAE area in five areas of the left atrium (LA).

Results

Total cardiac PF volume correlated with AF (odds ratio [OR]: 1.024, p < 0.001). Total cardiac PF volume and total CFAE area were both independently associated with persistence of AF (OR: 1.018, p = 0.018, OR: 1.144, p = 0.002, respectively). Multivariate linear regression analysis identified total cardiac PF volume as a significant and independent determinant of total CFAE area (r = 0.488, p < 0.001). Furthermore, regional PF volume correlated with local CFAE area in an each LA area.

Conclusions

PF volume correlated significantly with CFAE area in patients with AF. This finding suggests that PF is directly related to the progression of CFAE area and promotes the pathogenic process of AF.     

Global longitudinal speckle-tracking strain is predictive of left ventricular remodeling after coronary angioplasty in patients with recent non-st elevation myocardial infarction

Aims

To test whether two-dimensional longitudinal strain (2DSE) performed after revascularization by percutaneous coronary intervention (PCI) could predict left ventricular (LV) remodeling in patients with recent non-ST elevation myocardial infarction (NSTEMI).

Methods

In 70 patients (62.7 ± 8.7 years) with recent NSTEMI (between 72 hours and 14 days), undergoing coronary angiography for recurrent angina, myocardial deformation parameters were measured by 2DSE before and 24 hours after reperfusion therapy. Strain in all LV segments was averaged to obtain a global value (Global longitudinal Strain - GLS). Infarct size was estimated by clinical parameters and cardiac markers. After 6 months from intervention, LV negative remodeling was defined as lack of improvement of LV function, with increase in LV end-diastolic volume of greater than or equal than 15%.

Results

At follow-up, patients were subdivided into remodeled (n = 32) and non-remodeled (n = 38) groups. Patients with negative LV remodeling had significantly lower baseline LV ejection fraction (44.8 ± 6.9 vs. 48.7 ± 5.5 %; p < 0.05), higher peak troponin I (p < 0.001) and reduced GLS (- 10.6 ± 6.1 vs - 17.6 ± 6.7 % p < 0.001) than those without LV remodeling. GLS showed a close correlation with peak troponin I after PCI (r = 0.64, P < 0.0001) and LV WMSI (r = 0.42, p < 0.01). By multivariable analysis, diabetes mellitus (P < 0.005), peak of Troponin I after PCI (P < 0.0005), GLS at baseline (OR: 4.3; p < 0.0001), and lack of improvement of GLS soon after PCI (OR: 1.45, P < 0.01) were powerful independent predictors of negative LV remodelling at follow-up. In particular, a GLS ≤ 12 % showed a sensitivity and a specificity respectively of 84.8% and 87.8% to predict negative LV remodelling at follow-up.

Conclusions

in patients with recent NSTEMI, longitudinal LV global and regional speckle-tracking strain measurements are powerful independent predictors of LV remodeling after reperfusion therapy.