Advanced pharmacologic and interventional therapies have improved survival in heart failure. Implantable cardioverter‐defibrillators (ICD) have been shown to reduce mortality in patients with heart ...failure, but the benefit appears to be uneven in this population. We reviewed the evidence showing the benefit of ICD therapy in heart failure patients, the main issues arising from these studies, and the possible answers for a better risk stratification. In addition, we showed that multimodality imaging could improve patient selection for the implantation of ICDs, in both primary and secondary prevention, beyond the selection using only the left ventricular ejection fraction, by concentrating on arrhythmic substrate.
Implantable cardioverter‐defibrillators (ICD) have been shown to reduce mortality in patients with heart failure, but the benefit appears to be uneven. We showed that multimodality imaging could improve patient selection for the implantation of ICDs, in both primary and secondary prevention, beyond the selection using left ventricular ejection fraction, by concentrating on arrhythmic substrate.
There are no clear recommendations regarding cirrhotic cardiomyopathy (CC) evaluation in patients with pre-transplant liver cirrhosis. The roles of new methods, tissue Doppler imaging (TDI) and ...speckle tracking echocardiography (STE) in the diagnosis and prognosis of cirrhotic cardiomyopathy remain controversial. We investigated the utility of TDI/STE parameters in cirrhotic cardiomyopathy diagnosis and also in predicting mortality in patients with liver cirrhosis. Left/right ventricular function was studied using conventional TDI (velocities) and STE (strain/strain rate). We assessed left ventricular diastolic dysfunction, graded into four new classes (I/Ia/II/III). Serum NTproBNP (N-terminal prohormone of brain natriuretic peptide), troponin I, β-crosslaps, QTc interval, arterial compliance and endothelial function were measured. Liver-specific scores (Child-Pugh, MELD, MELDNa) were computed. There was a 1-y follow-up visit to determine mortality. We observed resting biventricular diastolic myocardial dysfunction, not presently included in the definition of cirrhotic cardiomyopathy. We provided an improved characterization of cardiac dysfunction in patients with liver cirrhosis. This might change the current definition. However, the utility of STE/TDI parameters in predicting long-term mortality in patients with liver cirrhosis remains controversial.
Introduction and Objectives. Patients with dilated cardiomyopathy (DCM) and functional mitral regurgitation (FMR) present altered geometry and dynamics of the mitral annulus (MA). We aimed to further ...assess the relationship between the MA dysfunction, FMR severity, and LA dysfunction in patients with ischemic and nonischemic DCM by using three-dimensional transthoracic echocardiography (3DTTE). Methods. 56 patients (58 ± 17 years, 42 men) with DCM and FMR and 52 controls, prospectively enrolled, underwent 3DTTE dedicated for mitral valve (MV), LA, and left ventricle (LV) quantitative analysis. Results. Patients with FMR vs. controls presented increased MA size and sphericity during the entire systole, whereas MA fractional area change (MAFAC) and MA displacement were decreased (15 ± 5 vs. 28 ± 5%; and 5 ± 3 vs. 10 ± 2 mm, p<0.001). In patients with moderate/severe FMR, MA diameters correlated with PISA radius, EROA, and regurgitant volume (Rvol), as also did the MA area (with PISA radius, EROA, and Rvol: r = 0.48, r = 0.58, and r = 0.47, p<0.05). MAFAC correlated inversely with EROA and Rvol (r = −0.32 and r = −0.35, p<0.05), with both active and total LA emptying fractions and with LV ejection fraction as well. In a stepwise multivariate regression model, decreased MAFAC and increased LA volume independently predicted patients with severe FMR. Conclusions. Patients with DCM and FMR have MA geometry remodeling and contractile dysfunction, correlated with the severity of FMR. MA contractile dysfunction correlated with both LA and left LV pumps dysfunctions and predicted patients with severe FMR. Our results provide new insights that might help with better selection of patients for MV transcatheter procedures.
None of the conventional echocardiographic parameters alone predict increased NTproBNP level and symptoms, making diagnosis of heart failure with preserved ejection fraction (HFpEF) very difficult in ...some cases, in resting condition. We evaluated LA functions by 2D speckle tracking echocardiography (STE) on top of conventional parameters in HFpEF and preHF patients with diastolic dysfunction (DD), in order to establish the added value of the LA deformation parameters in the diagnosis of HFpEF.
We prospectively enrolled 125 patients, 88 with HFpEF (68±9 yrs), and 37 asymptomatic with similar risk factors with DD (preHF) (61±8 yrs). We evaluated them by NTproBNP, conventional DD parameters, and STE. Global longitudinal strain (GS) was added. LA reservoir (R), conduit (C), and pump function (CT) were assessed both by volumetric and STE. 2 reservoir strain (S) derived indices were also measured, stiffness (SI) and distensibility index (DI).
LA R and CT functions were significantly reduced in HFpEF compared to preHF group (all p<0.001), whereas conduit was similarly in both groups. SI was increased, whereas DI was reduced in HFpEF group (p<0.001). By adding LA strain analysis, from all echocardiographic parameters, SR_CT<-1.66/s and DI<0.57 (AUC = 0.76, p<0.001) demonstrated the highest accuracy to identify HFpEF diagnosis. However, by multivariate logistic regression, the model that best identifies HFpEF included only SR_CT, GS and sPAP (R2 = 0.506, p<0.001). Moreover, SR_CT, DI, and sPAP registered significant correlation with NTproBNP level.
By adding LA functional analysis, we might improve the HFpEF diagnosis accuracy, compared to present guidelines. LA pump function is the only one able to differentiates preHF from HFpEF patients at rest. A value of SR_CT < -1.66/s outperformed conventional parameters from the scoring system, reservoir strain, and LA overload indices in HFpEF diagnosis. We suggest that LA function by STE could be incorporated in the current protocol for HFpEF diagnosis at rest as a major functional criterion, in order to improve diagnostic algorithm, and also in the follow-up of patients with risk factors and DD, as a prognostic marker. Future studies are needed to validate our findings.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Abstract
Background
Three-dimensional echocardiography (3DE) presents an increasingly important role in the management of interventional cardiac procedures, overcoming limitations of conventional ...two-dimensional echocardiography (2DE). Early use of 3DE might have an added value in the diagnosis of device-related complications, such as lead induced tricuspid regurgitation (LITR), by providing better understanding of its mechanisms and ensuring a prompt and individually tailored treatment strategy.
Case summary
We report the case of a female patient with repeated hospitalizations for congestive heart failure in the past 2 years, who had a permanent single-chamber ventricular pacemaker (PM) implanted 10 years ago and a misleading diagnosis of severe tricuspid regurgitation (TR) secondary to annular dilation, based on 2DE. Conversely, current 3DE assessment of the TR mechanisms revealed that the PM lead was not placed between the commissures, but in the middle segment of the septal leaflet, causing impingement of the leaflet and severe TR.
Discussion
Given the growing indication for cardiac devices, it is necessary to better define LITR and to establish its impact on patient prognosis. Due to lacking in proper diagnostic techniques, LITR is generally recognized as a late complication of PM/ICD implantation. Two-dimensional echocardiography has important limitations, whereas 3DE provides more accurate information on the TV apparatus in relation to the endocardial leads. Our case shows the usefulness of 3DE for a correct diagnosis of a device-related complication. Its utility in the follow-up of patients receiving cardiac devices remains to be determined, as well as its potential value in the guidance of lead insertion.
Tachycardia-Induced Cardiomyopathy Danet, Ruxandra; Velcea, Andreea Elena; Mihaila-Baldea, Sorina ...
Revista română de cardiologie,
05/2022, Letnik:
31, Številka:
2
Journal Article
Recenzirano
Odprti dostop
Tachycardia-induced cardiomyopathy (TIC) is characterized by reversible left ventricular (LV) dysfunction caused by long-standing tachycardia. The diagnosis of TIC is challenging due to lack of ...guidelines and specific assessment tools. Advanced imaging and endomyocardial biopsy should be taken into consideration in the future as contributors in the diagnostic process.
There are numerous unknowns to TIC, the most pressing being the lack of diagnostic and prognostic tools. The presence of persistent negative LV remodeling after the normalization of the LV ejection fraction with adequate treatment of the tachycardia gives us a glimpse into the complex pathophysiologic processes at play, as well as the disease prognosis.
Systemic lupus erythematosus (SLE) is characterized by numerous immunological abnormalities that lead to multiorgan involvement. Central and peripheral nervous system manifestations are present in 8% ...to 92% of the cases of SLE. Furthermore, there have been reported cases of secondary autoimmune myelofibrosis associated with SLE.
We present the case of a 64-year-old female who was transferred from the Cardiology Department, where she was admitted for pericardial-pleural-peritoneal effusion after being discharged from another hospital following the resolution of a febrile episode. During hospitalization, she presented multiple oculomotor nerves palsies and weakness in the lower limbs. Serial cerebral magnetic resonance imaging (MRI) revealed extensive cerebral venous thrombosis. Nerve conduction studies showed sensory-motor axonal polyneuropathy. Thoracic MRI revealed a rare finding in patients with SLE - lytic lesions.
Extensive clinical, imaging, blood, and urine tests were performed. The patient exhibited pancytopenia, elevated inflammatory markers, hyperhomocysteinemia, mild hypoproteinemia, and severe proteinuria. The Hematology consultation ascertained that the peripheral blood smear and the bone marrow aspiration showed no alterations suggestive for a primary hematological disease and the thoracic vertebral-medullary MRI changes had a very low probability of representing osteolytic lesions in the context of plasma cells dyscrasia, but could not exclude their being result of a secondary autoimmune myelofibrosis. Immunology blood tests highlighted the presence of antinuclear antibodies and lupus anticoagulants. In this context, the Rheumatology consultation established the diagnosis of SLE with multiple complications.
The patient received treatment with cyclophosphamide.
The ocular motricity problems and the paraparesis showed improvement. However, 1 week later, the patient developed weakness, dyspnea, and right lower quadrant abdominal pain. The abdominal-pelvic computed tomography scan indicated an acute right retroperitoneal hematoma with active bleeding for which she underwent arterial embolization of the spinal lumbar arteries with optimal result, but she died a few days later.
We chose to present this case in order to highlight the importance of interdisciplinarity in diagnosing and managing patients with SLE and multiorgan ailments, especially when faced with rare constellations of complications such as extensive cerebral venous thrombosis and osseous lytic lesions caused by secondary autoimmune myelofibrosis.
Left ventricular non-compaction (LVNC) with preserved ejection fraction (EF) is still a controverted entity. We aimed to characterize structural and functional changes in LVNC with heart failure with ...preserved EF (HFpEF).
We enrolled 21 patients with LVNC and HFpEF and 21 HFpEF controls. For all patients, we performed CMR, speckle tracking echocardiography (STE), and biomarker assessment for HFpEF (NT-proBNP), for myocardial fibrosis (Galectin-3), and for endothelial dysfunction ADAMTS13, von Willebrand factor, and their ratio. By CMR, we assessed native T1 and extracellular volume (ECV) for each LV level (basal, mid, and apical). By STE, we assessed longitudinal strain (LS), globally and at each LV level, base-to-apex gradient, LS layer by layer, from epicardium to endocardium, and transmural deformation gradient.
In the LVNC group, mean NC/C ratio was 2.9 ± 0.4 and the percentage of NC myocardium mass was 24.4 ± 8.7%. LVNC patients, by comparison with controls, had higher apical native T1 (1061 ± 72 vs. 1008 ± 40 ms), diffusely increased ECV (27.2 ± 2.9 vs. 24.4 ± 2.5%), with higher values at the apical level (29.6 ± 3.8 vs. 25.2 ± 2.8%) (all
< 0.01); they had a lower LS only at the apical level (-21.4 ± 4.4 vs. -24.3 ± 3.2%), with decreased base-to-apex gradient (3.8 ± 4.7 vs. 6.9 ± 3.4%) and transmural deformation gradient (3.9 ± 0.8 vs. 4.8 ± 1.0%). LVNC patients had higher NT-proBNP 237 (156-489) vs. 156 (139-257) pg/mL and Galectin-3 7.3 (6.0-11.5) vs. 5.6 (4.8-8.3) ng/mL, and lower ADAMTS13 (767.3 ± 335.5 vs. 962.3 ± 253.7 ng/mL) and ADAMTS13/vWF ratio (all
< 0.05).
LVNC patients with HFpEF have diffuse fibrosis, which is more extensive at the apical level, explaining the decrease in apical deformation and overexpression of Galectin-3. Lower transmural and base-to-apex deformation gradients underpin the sequence of myocardial maturation failure. Endothelial dysfunction, expressed by the lower ADAMTS13 and ADAMTS13/vWF ratio, may play an important role in the mechanism of HFpEF in patients with LVNC.
We sought to analyze if left ventricular (LV) volumes and ejection fraction (EF) measured by three-dimensional echocardiography (3DE) have incremental prognostic value over measurements obtained from ...two-dimensional echocardiography (2DE) in patients referred to a high-volume echocardiography laboratory for routine, clinically-indicated studies.
We measured LV volumes and EF using both 2DE and 3DE in 725 consecutive patients (67% men; 59 ± 18 years) with various clinical indications referred for a routine clinical study.
LV volumes were significantly larger, and EF was lower when measured by 3DE than 2DE. During follow-up (3.6 ± 1.2 years), 111 (15.3%) all-cause deaths and 248 (34.2%) cardiac hospitalizations occurred. Larger LV volumes and lower EF were associated with worse outcome independent of age, creatinine, hemoglobin, atrial fibrillation, and ischemic heart diseases). In stepwise Cox regression analyses, the associations of both death and cardiac hospitalization with clinical data (CD: age, creatinine, hemoglobin, atrial fibrillation, and ischemic heart disease) whose Harrel's C-index (HC) was 0.775, were augmented more by the LV volumes and EF obtained by 3DE than by 2DE parameters. The association of CD with death was not affected by LV end-diastolic volume (EDV) either measured by 2DE or 3DE. Conversely, it was incremented by 3DE LVEF (HC = 0.84,
< 0.001) more than 2DE LVEF (HC = 0.814,
< 0.001). The association of CD with the composite endpoint (HC = 0.64,
= 0.002) was augmented more by 3DE LV EDV (HC = 0.786,
< 0.001), end-systolic volume (HC = 0.801,
< 0.001), and EF (HC = 0.84,
< 0.001) than by the correspondent 2DE parameters (HC = 0.786, HC = 0.796, and 0.84, all
< 0.001) In addition, partition values for mild, moderate and severe reduction of the LVEF measured by 3DE showed a higher discriminative power than those measured by 2DE for cardiac death (Log-Rank: χ
= 98.3 vs. χ
= 77.1;
< 0.001). Finally, LV dilation defined according to the 3DE threshold values showed higher discriminatory power and prognostic value for death than when using 2DE reference values (3DE LVEDV: χ
= 15.9,
< 0.001 vs. χ
= 10.8,
= 0.001; 3DE LVESV: χ
= 24.4,
< 0.001 vs. χ
= 17.4,
= 0.001).
In patients who underwent routine, clinically-indicated echocardiography, 3DE LVEF and ESV showed stronger association with outcome than the corresponding 2DE parameters.
Patent foramen ovale (PFO) is a prevalent cardiac remnant of fetal anatomy that may pose a risk factor for stroke in some patients, while others can present with asymptomatic white matter (WM) ...lesions. The current study aimed to test the hypothesis that patients with a PFO who have a history of stroke or transient ischemic attack, compared to those without such a history, have a different burden and distribution of cerebral WM hyperintensities. Additionally, we tested the association between PFO morphological characteristics and severity of shunt, and their impact on the occurrence of ischemic cerebral vascular events and on the burden of cerebral WM lesions.
Retrospective, case-control study that included patients with PFO confirmed by transesophageal echocardiography. Right-to-left shunt size was assessed using transcranial Doppler ultrasound. Cerebral MRIs were analyzed for all participants using the semi-automated Quantib NDTM software for the objective quantification of WM lesions. WM lesions volume was compared between patients with and without a history of stroke. Additionally, the anatomical characteristics of PFOs were assessed to explore their relation to stroke occurrence and WM lesions volume.
Of the initial 264 patients diagnosed with PFO, 67 met the inclusion criteria and were included in the analysis. Of them, 62% had a history of PFO-related stroke/TIA. Overall burden of WM lesions, including stroke volume, was not significantly different (
= 0.103). However, after excluding stroke volume, WM lesions volume was significantly higher in patients without stroke (0.27 cm
, IQR 0.03-0.60) compared to those with stroke/TIA (0.08 cm
, IQR 0.02-0.18),
= 0.019. Patients with a history of PFO-related stroke/TIA had a tendency to larger PFO sizes by comparison to those without, in terms of length and height, and exhibited greater right-to-left shunt volumes.
We suggest that PFO may be associated with the development of two distinct cerebrovascular conditions (stroke and "silent" WM lesions), each characterized by unique imaging patterns. Further studies are needed to identify better the "at-risk" PFOs and gain deeper insights into their clinical implications.
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