Basal Septal Hypertrophy Research Articles

Prognosis and clinical features according to types of hypertrophic cardiomyopathy

Abstract Introduction Hypertrophic cardiomyopathy (HCMP) is a condition characterized by hypertrophy of the myocardium, which can be classified into types based on the location of the hypertrophy. Among these, the most common type is the group with septal hypertrophy. However, prognosis and clinical features according to the type are not well known. Method This study was conducted on 137 patients with HCMP from March 2016 to August 2023. Their echocardiographic findings and demographic features were retrospectively collected, and Single photon emission computed tomography(SPECT) and clinical outcomes were also analyzed. The types of HCMP were classified based on Helmy's classification: basal septal hypertrophy alone (Type I), hypertrophy of the septum and adjacent segments sparing the apex (Type II), apical hypertrophy with hypertrophy of other segments (Type III), and apical hypertrophy alone (Type IV). Additionally, the clinical outcomes, including mortality and cardiovascular hospitalization rates, were analyzed by dividing them into Type I and other types (II~IV). Results The prevalence of type I, II, III, and IV was 23.3% (n = 32), 0% (n = 0), 30.6% (n = 42) and 46% (n = 63). The patients were divided into two groups as septal HCMP (Group I) and non septal HCMP (Group II), with more patients in Group II (n=105, 76.6%) than in Group I (n=35, 23.3%). Mean age, systolic blood pressure, heart rate and body mass index were similar between two groups. In the subgroup analysis of echocardiographic parameter, left ventricular mass (LVM) and relative wall thickness (RWT) were significantly lower in Type IV compared to the other types. In contrast, there was no significant difference between Type I and Type III. In the strain analysis, the global strain values of Type III were significantly lower. (Type I vs. Type III vs. Type IV; -14.7 ± 3.7 vs. -11.1 ± 3.0 vs. -14.2 ± 4.0; p<0.01). Analysis of LV perfusion scores using SPECT showed that cardiac perfusion during stress compared to rest was significantly more impaired in Type III than Type I (p=0.03). In terms of clinical outcomes, mortality was higher in the order of Type I, III, and IV. However, there was no significant difference between Type I and Type III compared to Type IV. Regarding hospitalization, there were no significant differences between the types. Conclusion Patients with non-septal type HCMP accounted for a significant proportion of all HCMP cases. Non-septal types showed differences in echocardiographic parameters and perfusion compared to the septal type. Although the septal type is known to have a worse prognosis, this study did not find a significant difference in hospitalization rates. Further research is warranted.

Marked Improvements in Basal Interventricular Septal Hypertrophy After Aortic Root Replacement for Thoracic Aortic Aneurysm

Marked Improvements in Basal Interventricular Septal Hypertrophy After Aortic Root Replacement for Thoracic Aortic Aneurysm

Mildly elevated left ventricular outflow tract gradients are associated with increased short term mortality in inpatients without septal hypertrophy

Abstract Background The significance of left ventricular outflow tract gradients (LVOTG) on the clinical outcomes of hypertrophic cardiomyopathy (HCM) has been well studied. An LVOTG of ≥ 30 mmHg is considered significant. However, mildly elevated LVOTG at rest in individuals without basal septal hypertrophy is sometimes encountered in the echocardiography laboratory and data on its association with survival in this group is lacking. Purpose Here we explore the association between LVOTG and short term all cause mortality in inpatients without basal septal hypertrophy. Methods We retrospectively reviewed 47,866 consecutive inpatients who had an echocardiography study during their hospital stay between March 2010 and February 2021 . After excluding cases with incomplete data (10,882) and patients with basal septal hypertrophy > 12 mm (9,486), we remained with 27,498 patients. Demographic, baseline clinical and echocardiographic characteristics were derived from electronic records. Mortality data was validated against the ministry of health national records. A binary logistic regression model for predicting 30-day mortality according to LVOTG dichotomized at each point was used. Then we divided the cohort into 4 LVOTG groups (0-6, 6-10, 10-20 and > 20 mmHg) and the same regression model was used to compare between the groups. Results The mean age in our cohort was 66 ± 17 years and 54% were male. The mean LVOTG was 4.2 ± 2.4 mmHg (Median 4 (IQR=3-5) and the mean left ventricular ejection fraction was 55 ± 9%. A binary logistic regression model showed that when different LVOTG cut-points were used, even a mildly elevated LVOTG predicted short-term survival in this population (figure 1). We then divided our cohort into 4 groups based on LVOTG. There were 24,703 (90%) patients in group 1, 2549 (9%) in group 2, 201 (1%) in group 3 and 25 (0.1%) individuals in group 4. Patients in groups 1 and 2 were younger, had higher hemoglobin levels, lower C-reactive protein (CRP) levels, mildly lower septal thickness, and lower left ventricular ejection fraction compared to the groups with higher LVOTG (table 1). We then applied the same multivariate binary regression model to predict short term mortality with group 1 as a reference. The hazard ratio (HR) for group 2 was 1.3 (CI 95%: 1-1.6, p=0.03), for group 3 HR=2.8 (CI 95%: 1.6-5.1, p<0.001) and for group 4 HR=2.8 (CI 95%: 0.6-12.8, p=0.18). Conclusions We have shown in a large cohort of inpatients without basal septal hypertrophy that a mildly elevated rest LVOTG (6-10 and 10-20 mmHg) predicted all cause 30-day mortality. Patients in the elevated LVOTG groups were older with lower hemoglobin and higher CRP levels, but LVOTG remained an independent predictor in a multivariate regression model. This could potentially aid early detection of at-risk populations.Mortality at different LVOTG cut-pointsBaseline characteristics

Myocardial scar in end-stage hypertrophic cardiomyopathy: correlation with systolic function and prognostic significance

Abstract Background Hypertrophic cardiomyopathy with systolic impairment, often referred to as end-stage HCM (ES-HCM), has a poor prognosis. Scar is a significant contributor but the patterns and prognostic significance are unknown. Aim To understand role of scar in ES-HCM and investigate potential predictors of outcome. Methods A retrospective 4 centre study of ES-HCM (LVEF≤55%) who had undergone CMR between 2006 and 2022 for unexplained LVH. Exclusion criteria were: scaring therapies (septal reduction), phenocopies (amyloidosis, storage) and dual pathologies (severe aortic valve disease, previous infarction). CMR followed standardized protocols. All images were core-lab analysed de-novo with scar quantified using the full width at half maximum technique for late gadolinium enhancement (LGE) quantification in grams (LGEm) and percentage of total LV mass (LGE%). Cox models used to identify risk factors for all-cause mortality. Results From 3810 HCM CMR scans, 128 were ES-HCM pts (3%), 25(20%) were excluded due to known infarction. 103 (male n=82, 81%; age 57yrs[IQR51–68]) formed the study cohort. Of the 54% genotyped, 62% carried a (likely)pathogenic sarcomere mutation: MYBPC3 (n=20), MYH7 (n=7), TNNT2 (n=4), TMP1 (n=2),ALPK3 (n=1). Heart morphology was: 38(37%) isolated basal septal hypertrophy, 30(29%) reverse septal curvature, 7(7%) mid-cavity LVH with apical aneurysm, 3(3%) apical HCM, 24%other. The median EF was 46%(IQR 39-50). In only one third (34%) the ventricle was dilated (LVEDd mean 97ml/m2 IQR 79-112). The RV was impaired in 19(18%). Median max wall thickness was 17mm(IQR15-20) and LVmass 74mg/Kg(IQR65-90). Scar was present in 94(93%) and was typically extensive: median LGE% 23%(IQR 13-33), LGEm 31g(IQR 16-45) – although 7% had no scar. The LGE pattern was diffuse in 38%, patchy in 35%, ring-like in 9%, and infarct-like in 7% (all without coronary narrowing at invasive/non-invasive coronary artery assessment). LGE and cardiac function were effectively independent with low or no correlation between scar and LVEF% or global longitudinal strain (r2=0.015,p=0.227 or r2= 0.048,p=0.028 for LGE% and LGEm against LVEF; r2=0.059,p=0.021 or r2=0.196,p<0.001 for LGE% and LGEm against GLS) with poor correlation also with indexed stroke volume. During a 5 year (IQR 3-7) follow-up (516patient-years), 30 deaths occurred: mean age at death was 62(52-74). Using multivariate Cox regression analysis EF and demographics such as age were not predictive, but LGE% (HR 1.046, 95%IC 1.007-1.086, p=0.019 and GLS (HR 1.172, 95%IC 1.004-1.368, p=0.044) were independent all-cause mortality predictors (C-index 0.708; table). Conclusion Myocardial scar is almost always present in ES-HCM and is typically extensive – but with some unexpected features: 7% of patients have no LGE, dual pathology(infarction) is not rare, and ringlike LGE (ALVClike) may occur. LGE correlates poorly with any measure of LV impairment but is a strong predictor of mortality, as is GLS.

The Science Behind Stress: From Theory to Clinic, Is Basal Septal Hypertrophy the Missing Link between Hypertension and Takotsubo Cardiomyopathy?

The modern theory of stress, initially proposed by Hans Selye in 1956, signifies an important development in our understanding of this phenomenon. Selye’s The Stress of Life serves as a foundational book for subsequent scientific questions. In this article, we focus on a comprehensive look at stress and use a literature review to explain its theoretical foundations as well as its clinical equivalent. Our research focuses on the complex mechanisms of stress, with a particular emphasis on the consequences of cardiac remodeling and adaptation processes. Myocardial remodeling might be seen as a response to increased stress in acute or chronic situations. Stressed heart morphology (SHM) is a very interesting description representing basal septal hypertrophy (BSH), which is detectable in both acute emotional stress and chronic stress due to increased afterload in hypertension. Acute stress cardiomyopathy (ASC) and hypertension in the same individuals could be clinically linked. Also, in this report, we mention the geometric and functional similarity of the left ventricle (LV) septal base in both acute and chronic clinical situations. Therefore, cardiac imaging methods are crucial to assessing LV segmental aspects in ASC patients. We propose a new paradigm that ASC may develop in hypertensive patients with SHM. We document the segmental progression of microscopic LV remodeling using a third-generation microscopic ultrasound and note that BSH takes a longer time to occur morphologically than an acutely developed syndrome. However, the majority of ASC events have a predominant base, and the absence of segmental remodeling details, including BSH and cardiac decompensation with apical ballooning, on echocardiographic reports may mask the possible underlying hypertensive disease. In fact, beyond ASC cases, previously undiagnosed hypertension is very common, even in developed countries, and is associated with masked target organ damage.

Stress and Heart in Remodeling Process: Multiple Stressors at the Same Time Kill.

Myocardial remodeling is developed by increased stress in acute or chronic pathophysiologies. Stressed heart morphology (SHM) is a new description representing basal septal hypertrophy (BSH) caused by emotional stress and chronic stress due to increased afterload in hypertension. Acute stress cardiomyopathy (ASC) and hypertension could be together in clinical practice. Therefore, there are some geometric and functional aspects regarding this specific location, septal base under acute and chronic stress stimuli. The findings by our and the other research groups support that hypertension-mediated myocardial involvement could be pre-existed in ASC cases. Beyond a frequently seen predominant base, hyperkinetic tissue response is detected in both hypertension and ASC. Furthermore, hypertension is the responsible factor in recurrent ASC. The most supportive prospective finding is BSH in which a hypercontractile base takes a longer time to exist morphologically than an acutely developed syndrome under both physiologic exercise and pressure overload by transaortic binding in small animals using microimaging. However, cardiac decompensation with apical ballooning could mask the possible underlying hypertensive disease. In fact, enough time for the assessment of previous hypertension history or segmental analysis could not be provided in an emergency unit, since ASC is accepted as an acute coronary syndrome during an acute episode. Additional supportive findings for SHM are increased stress scores in hypertensive BSH and the existence of similar tissue aspects in excessive sympathetic overdrive like pheochromocytoma which could result in both hypertensive disease and ASC. Exercise hypertension as the typical form of blood pressure variability is the sum of physiologic exercise and pathologic increased blood pressure and results in increased mortality. Hypertension is not rare in patients with a high stress score and leads to repetitive attacks in ASC supporting the important role of an emotional component as well as the potential danger due to multiple stressors at the same time. In the current review, the impact of multiple stressors on segmental or global myocardial remodeling and the hazardous potential of multiple stressors at the same time are discussed. As a result, incidentally determined segmental remodeling could be recalled in patients with multiple stressors and contribute to the early and combined management of both hypertension and chronic stress in the prevention of global remodeling and heart failure.

Amyloid Deposition Mainly Localized in the Basal Area of the Left Ventricle in a Patient with Amyloid Transthyretin Cardiac Amyloidosis

A 74-year-old Japanese man was admitted to our hospital for catheter ablation of paroxysmal atrial fibrillation. Transthoracic echocardiography revealed basal interventricular septal hypertrophy without apical sparing. Cardiac magnetic resonance imaging revealed late gadolinium enhancement in the hypertrophic lesions. The Kumamoto criteria was one point, and the patient had no carpal tunnel syndrome. However, technetium-99m pyrophosphate scintigraphy revealed an accumulation in the basal region of the left ventricle. A skin biopsy revealed transthyretin (TTR) amyloid deposition. A TTR gene examination revealed no variants. This case suggests that amyloid deposition in TTR may occur in the basal area of the interventricular septum.

Transaortic septal myectomy at the time of aortic valve replacement for severe aortic stenosis: a case series of 55 cases

Abstract Introduction Symptomatic aortic valve stenosis (AS) is associated with asymmetric basal septal hypertrophy (ABSH) in 10% of cases. In this cohort, it has been suggested that rectification of the left ventricular outflow tract obstruction (LVOTO) by concomitant septal myectomy (CSM) can improve the results of aortic valve replacement (AVR). Objective This study aims to present the technique of AVR with CSM for severe AS with ABSH and to determine the associated early and late post-operative outcomes. Methods Fifty-five patients were prospectively recruited to undergo AVR with CSM between 2011 and 2021 at two centres. The primary outcomes were mortality within 30 days, incidence of post-operative ventricular septal defects (VSD) and prosthetic valve sizing. The secondary outcomes were in-hospital complications, permanent pacemaker implantation (PPI), survival at 15 months and changes on transthoracic echocardiogram. Results Post-operative mortality was 1.8% and this figure was unchanged at 15-month follow-up. No patients developed a post-operative VSD. Intra-operatively, it was found that in 94.6% cases the direct valve sizing increased by one, when compared to the measurement made before CSM. The indexed effective orifice area (iEOA) was > 85 cm2/m2 in 96.4% and no patients had an iEOA ≤ 0.75 cm2/m2. Four patients (7.3%) required PPI due to complete atrioventricular block. Conclusion AVR with CSM is a simple technique that can be utilised in severe AS with ABSH. There does not appear to be an increase in mortality or incidence of iatrogenic VSDs. Importantly, CSM allows for the implantation of a larger aortic valve compared to measurements made before CSM.

Genotype-Phenotype Taxonomy of Hypertrophic Cardiomyopathy.

Hypertrophic cardiomyopathy (HCM) is an important cause of sudden cardiac death associated with heterogeneous phenotypes, but there is no systematic framework for classifying morphology or assessing associated risks. Here, we quantitatively survey genotype-phenotype associations in HCM to derive a data-driven taxonomy of disease expression. We enrolled 436 patients with HCM (median age, 60 years; 28.8% women) with clinical, genetic, and imaging data. An independent cohort of 60 patients with HCM from Singapore (median age, 59 years; 11% women) and a reference population from the UK Biobank (n=16 691; mean age, 55 years; 52.5% women) were also recruited. We used machine learning to analyze the 3-dimensional structure of the left ventricle from cardiac magnetic resonance imaging and build a tree-based classification of HCM phenotypes. Genotype and mortality risk distributions were projected on the tree. Carriers of pathogenic or likely pathogenic variants for HCM had lower left ventricular mass, but greater basal septal hypertrophy, with reduced life span (mean follow-up, 9.9 years) compared with genotype negative individuals (hazard ratio, 2.66 [95% CI, 1.42-4.96]; P<0.002). Four main phenotypic branches were identified using unsupervised learning of 3-dimensional shape: (1) nonsarcomeric hypertrophy with coexisting hypertension; (2) diffuse and basal asymmetrical hypertrophy associated with outflow tract obstruction; (3) isolated basal hypertrophy; and (4) milder nonobstructive hypertrophy enriched for familial sarcomeric HCM (odds ratio for pathogenic or likely pathogenic variants, 2.18 [95% CI, 1.93-2.28]; P=0.0001). Polygenic risk for HCM was also associated with different patterns and degrees of disease expression. The model was generalizable to an independent cohort (trustworthiness, M1: 0.86-0.88). We report a data-driven taxonomy of HCM for identifying groups of patients with similar morphology while preserving a continuum of disease severity, genetic risk, and outcomes. This approach will be of value in understanding the causes and consequences of disease diversity.

Clinical significance and genetic basis of hypertrophic cardiomyopathy with apical phenotype: comparison of pure-apical form and distal-dominant form

Abstract Background Apical hypertrophic cardiomyopathy (apical HCM) is a variant of HCM first reported in Japan. The definition of apical HCM in the Japanese Circulation Society guideline is left ventricular hypertrophy limited to the level of the apex below the papillary muscle level. On the other hand, apical HCM in Western countries often includes hypertrophy that extends to the ventricular septum beyond the true LV apex. Although these variations may have different clinical characteristics and prognoses, they are often considered the same. Therefore, we previously proposed two phenotypes of apical HCM. Pure-apical form follows the definition of the JCS guideline. Distal-dominant form is defined as demonstrating apical hypertrophy extended to the ventricular septum without basal septal hypertrophy. However, the clinical significance and genetic basis of these phenotypes have not been reported. This study aimed to clarify clinical differences and yield of genetic testing in apical phenotype of HCM. Methods Regarding clinical presentation and prognosis, we retrospectively investigated 111 consecutive HCM patients with apical phenotype. HCM-related adverse events were defined as HCM-related death and nonfatal HCM-related events: heart failure admission, embolic stroke admission, and sustained ventricular tachycardia with hemodynamic instability or appropriate implantable cardioverter-defibrillator discharge. Furthermore, we performed a genetic analysis including 145 genes associated with cardiomyopathy in 69 unrelated patients within the cohort. Results In the cohort, 60 patients were pure-apical, and 51 were distal-dominant. The age at diagnosis was about 60 years, and the majority were male in both groups. The comorbidity rate of hypertension did not indicate a statistically significant difference. During the follow-up period of 10.3 ± 6.9 years, the occurrence of HCM-related adverse events was significantly higher in the distal-dominant group than in the pure-apical group (log-rank p=0.007). Detection rate of pathogenic or likely pathogenic variants in sarcomeric protein-encoding genes was significantly higher in the distal-dominant group than in the pure-apical group (21% vs. 3%; p=0.044). Conclusions Two phenotypes of apical HCM should be recognized and distinguished clinically because they have different prognoses and genetic features.

Abstract 17878: Clinical Profile, Procedure-Related Complications and Long-Term Outcomes in Men and Women With Aortic Stenosis Undergoing Transcatheter Aortic Valve Implantation: Insights From TAVI-NOR Study

Introduction: The incidence of aortic stenosis (AS) is increasing. If left untreated, AS progresses to clinical heart failure, reduced quality of life and functional capacity, and ultimately death. Hypothesis: Gender difference in survival benefits of transcatheter aortic valve implantation (TAVI) and frequencies of procedural complications. Methods: We included 600 consecutive, less selected, patients with symptomatic AS who underwent TAVI at our hospital. Clinical and echocardiographic data was analysed in SPSS. Data distribution was checked for normality. The inter-group comparison by Student’s t-test or chi square as appropriate. The association between gender and all-cause mortality assessed by Kaplan-Meier survival analysis with Log-rank test. Results: Mean age was 80.8±6.5 years of the study population. Women (49.3%) were older (82.2 ±5.3 years vs 79.5±7.3 years, p&lt;0.001), had more severe AS and higher left ventricular ejection fraction and more often had basal septal hypertrophy. The prevalence of hypertension and use of antihypertensive medications were higher in women. The prevalence of diabetes mellitus, coronary artery disease, previous stroke, overall abnormal ECG, and atrial fibrillation was higher in men. The severity of symptoms, and prevalence of chronic kidney or lung diseases were comparable. The frequencies of procedure-related paravalvular leakage (PVL) ≥ grade II and endocarditis during follow-up were low, but significantly higher in men than women. No significant difference between genders in procedure-related access site dissection and pseudo-aneurysm, anaemia requiring blood transfusion, or new-onset renal failure. Need of permanent pacemaker implantation following TAVI was also comparable between genders. Mean event-free survival was 59±24 months for men and 66±25 months for women (p&lt;0.001). Most apparent benefits was seen at 3-year follow-up where survival estimate for men was 84% and for women 92%. Conclusions: Results from TAVI-NOR study demonstrates that women with AS were older and had a higher burden of hypertensive heart disease, and showed a significantly better outcome. Men more frequently developed a significant PVL or endocarditis during follow-up.

Geomeric and functional aspects in hypertension and takotsubo: importance of basal septal hypertrophy.

Geomeric and functional aspects in hypertension and takotsubo: importance of basal septal hypertrophy.

Specifics of Left Ventricular Hypertrophy and Characteristic of Phenotypic Variants in Patients with Hypertrophic Cardiomyopathy

Hypertrophic cardiomyopathy is characterized by genetic and phenotypic heterogeneity which manifests in different variants of localization and extent of myocardial hypertrophy.Aim: to evaluate specifics of left ventricular hypertrophy, the prevalence and characteristics of clinical and instrumental features of phenotypic variants of hypertrophic cardiomyopathy.Materials and methods. The study includes 295 patients with hypertrophic cardiomyopathy aged 18 to 88 years (60.3±13.4 years), 183 men (62 %), and women 112 (38 %). The diagnosis of which was established by 2D echocardiography. The severity, localization and extent of myocardial hypertrophy, the maximum thickness of the hypertrophied segment, left ventricular myocardial mass, left ventricular myocardial mass index, the presence and severity of mid-ventricular and left ventricular outflow tract obstruction were evaluated. Depending on the predominant localization and extent of hypertrophy, patients were divided into 8 groups according to the recommendations for hypertrophic cardiomyopathy of the Ministry of Health of the Russian Federation. The analysis and comparison of the obtained results are carried out.Results. The average duration of the disease is 10.5±7.52 years. The mean values of the body mass index in patients — 28.2±2.82 kg/m2. The phenotype with basal hypertrophy of the septum (n=130, 44.1 %), group 1 was most often noted. In 47 (15.9 %) patients, hypertrophy of the septum of “reverse curve” (2 group) was detected, in 41 (13.9 %) — “neutral septum” (3 group), in 36 (12.2 %) — symmetrical hypertrophy of the left ventricle (8 group), 11 (3.7 %) of patients had combined hypertrophy of the septum and other parts of the left or right ventricle (4 group) and the free left ventricular wall (7 group), in 10 (3.4 %) — middle ventricular hypertrophy of the left ventricle (6 group) and in 9 (3.1 %) — apical hypertrophy (5 group). The highest value of the maximum thickness of the myocardium was noted in patients of the 6th group 19.3 (1920.4 mm). Mid-ventricular obstruction was detected in group 6 (90 %), left ventricular outflow tract obstruction was more often registered in groups 4 and 8 (81.8 % and 77.8 %), and less often in group 5 (22.2 %) (p &lt;0.01). In group 7, there were no cases of rest obstruction of left ventricular outflow tract. The maximum values of myocardial mass and left ventricular myocardial mass index were noted in group 8 — 402 (356-439) g and 195 (173218) g/m2, respectively (p &lt;0.01).Conclusion. Echocardiography is an informative tool for assessing the presence, severity myocardial hypertrophy and determination of the phenotypic variant of hypertrophic cardiomyopathy. Variants of septal hypertrophy are most commonly registered one, among which the most frequent is the phenotype of basal septal hypertrophy. Each phenotype of hypertrophic expression is characterized by its echocardiographic parameters.

Case Report: Late Presentation of Hypertrophic Cardiomyopathy in a 65- Year- Old Sudanese Man at Royal Care International Hospital

Background: HCM Syndrome is a left ventricle hypertrophic in the absence of another cardiac or other systemic condition. An epidemiologic study reported that the prevalence of HCM is 0.02in the general population. Case Presentation: We report a case report of a 65- year- old man who was referred to the clinic after presenting with a typical symptom. Past medical history and family history were insignificant. Echocardiography showed asymmetrical basal septal hypertrophy with a preserved ejection fraction of 65%. The patient was asymptomatic with no functional limitation but later developed atrial fibrillation with mild diastolic heart failure, which was treated by pharmacological medication and cardio version. Conclusion: In conclusion, the earlier the diagnosis, better the prognosis. HCM has a lot of complications including atrial fibrillation. Therefore, awareness of how often AF and other arrhythmias are associated with HCM patients will lead to lower mortality as a follow-up ECG and echocardiography can be performed to prevent subsequent complications.

Intravenous thrombolysis for bioprosthetic valve thrombosis.

A 77-year-old woman experienced new-onset dyspnoea on exertion 1 year after alcohol septal ablation and transcatheter aortic valve implantation (TAVI) with a balloon-expandable valve for symptomatic severe aortic stenosis and basal septal hypertrophy. Transthoracic echocardiographic assessment (TTE) revealed an incremental transvalvular peak velocity from 2.9 m/s 3 days after TAVI to 4.3 m/s. Multislice computed tomography (MSCT) demonstrated hypoattenuated leaflet thickening (HALT) of all leaflets and reduced leaflet motion (RLM) of one leaflet (Panel A). Her antithrombotic regimen was changed from apixaban 5 mg bi-daily to acenocoumarol with a target international normalized ratio (INR) of 2.5–3.5. Six weeks later, symptoms persisted and the transvalvular peak velocity was 3.9 m/s (Panel B). A decision was made to attempt to resolve the thrombus with repeated intravenous infusions of alteplase.1,2 Four sequential infusions of 25 mg alteplase/25 h resulted in an uneventful but stepwise decrease of the transvalvular peak velocity to 2.8 m/s (Panel C–F). Multislice computed tomography confirmed normalization of leaflet motion with some residual remaining leaflet thickening (Panel F). MSCT cine images before and after alteplase infusion are available in the Supplementary data online (Videos S1 and S2).

SEPTAL AND LEFT ATRIAL VOLUME INDEX AS PREDICTORS FOR HFPEF AMONGST TYPE 2 DIABETES MELLITUS PATIENTS

Objective: The aim of this study is to determine the prevalence and determination of risk factors of heart failure with preserved ejection fraction (HFpEF) diagnosed based on the consensus recommendation from the Heart Failure Association (HFA) and European Society of Cardiology (ESC) 2019 in type 2 diabetes mellitus (T2DM) patients in Malaysia. Design and method: We conducted a cross sectional study on patients with T2DM of more than 18 years old that were under Hospital UiTM follow-up from December 2021 until May 2021 (6 month). The participants were chosen via simple random sampling. Data's on demographic data, comorbid profile, symptoms and clinical examination including vitals sign, chemical profile and proceed with echocardiography and NTproBNP test to diagnosed HFpEF. Results: 201 diabetic patients were recruited and screened for HFpEF. 40 patients were confirmed with the diagnosis of HFpEF. Mean age was 61 ± 5.4 years. A significant difference in mean septal e’ was found between diabetic patients with HFpEF (5.5 ± 1.5 cm/s) and non-heart failure subjects (7.6 ± 1.0 cm/s)(p&lt;0.001, 95% CI -2.40,-1.49). There was also significant difference in mean left atrial volume index (LAVI) between diabetic patients with HFpEF (35.5 ± 1.5 ml/m2) and non-heart failure subjects (28.6 ± 1.0 ml/m2)(p&lt;0.001, 95% CI -2.50,-1.33). A stepwise increase in cortisol level corresponding to NTproBNP was observed(p&lt;0.061). Basal septal hypertrophy was seen in 30% of HFpEF diabetic patients (p&lt;0.081). Multiple linear regression analysis revealed septal e’ and LAVI as independent predictors of HFpEF in diabetic patients (r2 = 0.249, p&lt;0.001). Conclusions: One fifth of diabetic population had HFpEF and specific echocardiography parameters including septal e’ and LAVI were predictors for HFpEF. Emerging early imaging and chemical biomarkers for HFpEF such as basal septal hypertrophy and cortisol should be further studied.

Clinical outcomes in patients with primary arterial hypertension and basal septal hypertrophy after 7 years of follow-up

Clinical outcomes in patients with primary arterial hypertension and basal septal hypertrophy after 7 years of follow-up

Detection of haemodynamic obstruction in hypertrophic cardiomyopathy using the sub-aortic complex: a cardiac MRI and Doppler study

To investigate the "sub-aortic complex (SAC)", a new cardiac magnetic resonance imaging (CMRI)-derived parameter, for the evaluation of left ventricular (LV) outflow tract (LVOT) obstruction in patients with hypertrophic cardiomyopathy (HCM), compared with conventional CMRI parameters and Doppler echocardiography. A total of 157 consecutive patients with HCM were recruited retrospectively. The patients were divided into two groups, 87 with LVOT obstruction and 70 without obstruction. The SAC was defined as a specific anatomical SAC affecting the LVOT, which were measured on the LV three-chamber steady-state free precession (SSFP) cine image at the end-systolic phase. The relations between the existence and severity of obstruction and SAC index (SACi) were evaluated using Pearson's correlation coefficient, receiver operating characteristic (ROC) curves, and logistic regression. The SACs were significantly different between the obstructive and non-obstructive groups. The ROC curves indicated that the SACi was able to discriminate obstructive and non-obstructive patients with the best predictive accuracy (AUC=0.949, p<0.001). The SACi was an independent predictor of LVOT obstruction and there was a significant negative correlation between resting LVOT pressure gradient and SACi (r=0.72 p<0.001). In the subgroup of patients with or without severe basal septal hypertrophy, the SACi was still able to predict LVOT obstruction with excellent diagnostic accuracy (AUC=0.944 and 0.948, p<0.001, respectively). The SAC is a reliable and straightforward CMRI marker for assessing LVOT obstruction. It is more effective than CMRI two-dimensional flow in diagnosing the severity of obstruction in patients with HCM.

Aorto-septal angle, isolated basal septal hypertrophy, and systolic murmur in 122 cats

Introduction/ObjectivesSystolic murmurs in the absence of cardiac structural abnormalities are common in cats. Narrow aorto-septal angle (AoSA) and septal remodeling can be a cause of a systolic murmur in elderly human beings. The aim of this study was to measure the AoSA in cats and to investigate the association between the AoSA and the presence of a murmur and isolated basal septal hypertrophy (IBSH). AnimalsThe study population comprised 122 cats. Materials and methodsA physical exam, blood pressure measurement, chest radiographs, and echocardiography were performed. ResultsA systolic murmur was audible in 39/122 cats. A difference between cats with and without a murmur was found for age (P=0.0001), interventricular basal septal thickness (BIVSd) (P=0.004), AoSA (P=0.003), aortic (P<0.0001), and pulmonic (P=0.021) flow velocity, the presence of IBSH (P<0.0001), and systolic anterior motion of the mitral valve (P=0.0002). More than 50% of cats with a murmur had an AoSA ≤122°. Less than 25% of the cats with an AoSA ≥137° had a murmur. The AoSA narrowed 0.55°/year of age (P<0.001), whereas the BIVSd increased 0.11 mm/year of age (P<0.0001); the BIVSd increased as the AoSA narrowed. In all cats with AoSA < 120°, IBSH was present. ConclusionsThis study demonstrates that the probability of having a systolic murmur in cats is increased by the presence of a narrow AoSA. Aging was associated with a narrower AoSA and a thicker basal septum; these findings might represent an age-related heart remodeling.

Clinical features of hypertrophic cardiomyopathy depending on the hereditary factor

The objective was to study the clinical features of symptomatic hypertrophic cardiomyopathy (HCM) depending on the form (familial / non-familial), the age of onset and the presence of arterial hypertension (AH).Methods and materials. During 6 years, we examined 250 HCM patients, 100 patients with symptomatic HCM aged from 18 to 86 years were included in the study. Results. Patients with the clinical manifestations onset at a young age more often had a familial form of the disease, an autosomal dominant type of inheritance, an asymmetric HCM with reverse curve interventricular septal morphology. On the contrary, patients with the clinical manifestations onset at the age of ≥45 years had non-familial form of the disease and asymmetric HCM with basal interventricular septal hypertrophy. The young HCM patients with associated AH more often were obese, had CHF of III–IV functional class (NYHA), larger anteroposterior left atrial diameter than patients without AH and more often needed interventricular septal reduction. HCM patients and associated AH with the disease onset at the age of ≥45 years significantly more often had angina syndrome. Absolute indications for interventricular septal reduction in HCM patients with the disease onset ≥45 years of age were determined only for HCM patients and associated AH. At the same time, 50 % of HCM+AH patients both at a young age and in the older group, had obesity. Conclusions. The interventricular septal morphology differs significantly depending on the age of clinical manifestations onset. Co-existing AH and obesity are predictors of the progressive HCM course and an increase in the proportion of patients with absolute indications for interventricular septal reductions regardless of the age of clinical manifestations onset.