Baseline Left Ventricular End-systolic Volume Research Articles

CI-452767-4 NON-INVASIVE 3D ELECTRICAL ACTIVATION MAPPING TO PREDICT CRT RESPONSE: SITE OF LATEST LV ACTIVATION RELATIVE TO PACING SITE

Left ventricular (LV) pacing remote to the latest LV electrically activated site (LEAS) may diminish efficacy of cardiac resynchronization therapy (CRT). However, this has not been evaluated rigorously using global LV mapping. Test whether the distance “dp” between LV pacing site (LVPS) and LEAS influences the rate of CRT response. Consecutive CRT patients in 5 centers underwent noninvasive 3D electrical activation mapping and torso CT 6-24 months post-implant. LVPS, LEAS and dp were assessed. LV end-systolic volume (LVESV) reduction of ≥15% at clinical follow-up defined response. Logistic regression probabilistically modeled Non-Response; variables included demographics, heart failure classification, left bundle branch block (LBBB), ischemic heart disease, atrial fibrillation (AF), baseline QRS duration, baseline ejection fraction (EF), baseline LVESV, comorbidities, use of CRT optimization algorithm, ACE inhibitor/ARB, beta-blocker, diuretics, and dp. Of 111 patients (age 64 ± 11 years, baseline LVEF 28 ± 6%, baseline QRS duration 172 ± 21 ms, baseline LVESV 183 ± 87 mL, implant duration 12 ± 5 months (mean ± SD); 93%/7% had class I/IIa CRT indication, 31%/69% had NYHA Class II/III, 74% were males, 98% had LBBB, 38% had ischemic heart disease and 18% had a history of AF), 67% responded at 10 ±3 months post-implant (55% and 75% for ischemic and non-ischemic patients, respectively). LEAS were outside the mid and basal lateral segments in 35% of the patients. dp was 42 ± 23 mm (range 2-137): 31 ± 14 mm in Responders vs 63 ± 24 mm in Non-Responders. The distance dp, and the use of CRT optimization algorithms, remained the only independent predictors of non-response (area under the curve (AUC) 0.906). dp = 47 mm delineated Responders from Non-Responders (AUC 0.931). The distance between LV pacing site and site of latest electrical activation is a strong independent predictor for CRT response. Non-invasive electrical evaluation to characterize intrinsic activation and guide LV lead deployment may improve CRT efficacy.

Decreased Peak Left Atrial Longitudinal Strain Is Associated with Persistent Pulmonary Hypertension Associated with Left Heart Disease.

Pulmonary hypertension (PH) associated with left heart disease (PH-LHD) is the most common form of PH and has significantly higher morbidity and mortality. We estimated the prevalence of PH-LHD on the follow-up echocardiography and the role of left atrial (LA) function in PH-LHD. From the STRATS-AHF registry composed of 4312 acute heart failure (HF) patients, we analyzed peak atrial longitudinal strain (PALS) in 1729 patients with follow-up echocardiographic examinations during mean 18.1 ± 13.5 months. PH was determined by the maximal velocity of tricuspid regurgitation (TR Vmax ≥ 3.4 m/s). Persistent PH was found in 373 patients (21.6%). The PH-LHD group was significantly older, and the prevalence of atrial fibrillation (AF), hypertension, diabetes, and heart failure with preserved ejection fraction were higher compared with the no PH-LHD group. Baseline left ventricular end-systolic volume and PALS were lower, and LA diameter, mitral E/E’ ratio, and TR Vmax were higher in the PH-LHD group. In the multivariate analysis, PALS (HR = 1.024, p = 0.040) was a significant variable after adjustment of LA diameter and mitral E/E’. A decreased PALS of <12.5% was the best cutoff value in the prediction of persistent PH-LHD (AUC = 0.594, sensitivity = 65.3%, specificity = 46.1%). PH-LHD was associated with increased HF hospitalization (HR = 2.344, p < 0.001) and mortality (HR = 2.015, p < 0.001) after adjusting for age and sex. In conclusion, persistent PH-LHD was found in 21.6% in the follow-up echocardiography and was associated with decreased PALS (<12.5%). PH-LHD persistence was associated with poor clinical outcomes. Thus, AHF patients with decreased PALS, especially <12.5%, should be followed with caution.

Post myocardial infarction left ventricular thrombus assessment using cardiac magnetic resonance

Left ventricular thrombus (LVT) is a frequent complication after an acute myocardial infarction (MI) and is associated with systemic thromboembolism. Cardiovascular magnetic resonance imaging (CMR) is the diagnostic gold-standard, but its limited availability makes screening tools necessary. This study sought to identify the clinical and imaging determinants of LVT early and late after an acute MI. The study grouped the data of 2 observational cohorts of patients with reperfused ST-segment elevation MI patients, including a longitudinal and prospective CMR assessment at baseline, and 3 to 6 months after the inaugural event. An LVT was found in 51 patients out of the 700 (7.3%) baseline CMR scans, and in 26 out of the 607 (4.3%) at follow-up. LVT patients presented higher rates of anterior infarction, greater infarct size and left ventricular (LV) volumes, and lower LV ejection fraction (LVEF), but similar age, cardiovascular risk factors, and MVO prevalence. At baseline Multivariable analysis showed anterior infarction (OR = 5.216 [1.156-23.538] P < 0.05) and LV end-systolic volume (LVESV) (OR = 1.045 [1.026 - 1.064], P -value < 0.001) to be the best correlates among clinical, biological and CMR parameters. At follow-up, LVEF was the best correlate (OR = 0.911 [0.867-0.958] P < 0.001). At baseline LVESV index lower than 50 ml/m 2 presented a negative predictive value (NPV) of 98.78% [CI: 96.70-99.60] to exclude LVT presence. The specificity to detect an LVT by the use of an LVESV index of 50 mL/m 2 was 50.07% [80.25-97.45]. At follow up LVEF > 50% had a NPV of 98.26% [96.06-99.29] and a specificity of 58.44% {54.30-62.47] ( Fig. 1 ). The prevalence of left ventricular thrombus reached 10.6% of STEMI patients. We identified an anterior infarction and greater LV end-systolic volume to be the best determinants of LV thrombus occurrence at baseline, while LVEF was the best predictor at follow-up.

Mid-term repair durability after MitraClip implantation in patients with functional mitral regurgitation

The aim of this study was to identify variables that are associated with the durability of percutaneous repair of secondary mitral regurgitation at 6-month follow-up. Thirty-five consecutive patients with functional mitral regurgitation scheduled for MitraClip implant were enrolled. Left ventricular (LV) volumes and function and mitral valve characteristics were assessed before and immediately after MitraClip implantation using three-dimensional transesophageal echocardiography. Five patients with an unsuccessful procedure were excluded. The other patients were subdivided according to repair durability: group 1 with a durable repair (19 patients, 65%) and group 2 with significant mitral regurgitation recurrence (11 patients, 35%). At baseline, group 1 patients had smaller and more elliptical mitral valve annulus (1055 ± 241 vs. 1273 ± 359 mm, P = 0.02 and 125 ± 11 vs. 117 ± 16%, P = 0.02), a smaller left atrial volume (54.1 ± 26 vs. 71.5 ± 20 ml, P = 0.005) and lower systolic pulmonary artery pressure (38 ± 11 vs. 49 ± 12 mmHg, P = 0.03). Baseline LV end systolic volume had a linear correlation with the 3D annulus area (P = 0.048) and an inverse correlation with annulus ellipticity (P = 0.021). Group 1 patients showed an increase in annulus ellipticity after MitraClip (125 ± 17 vs. 141 ± 23%, P = 0.014). Percutaneous mitral valve repair leads to a significant and stable mitral regurgitation reduction in a large number of patients. Annulus dimensions and remodeling as well as left atrial area and pulmonary hypertension seem to be associated with durability of the procedure.

IMPACT OF LEFT VENTRICULAR END-SYSTOLIC VOLUME ON THE EFFECTIVENESS OF CARDIAC RESYNCHRONIZATION THERAPY: A MADIT-CRT LONG-TERM SUB-STUDY

Patients with varying degrees of LV dilation could potentially have differences in response to cardiac resynchronization therapy (CRT) therefore we aimed to assess CRT outcomes by baseline left ventricular end-systolic volume (LVESV). In 1,274 patients with mild heart failure (HF), reduced LVEF <30

Vitamin D deficiency and functional response to CRT in heart failure patients

VitaminD deficiency has been associated with apoor outcome in patients with heart failure (HF). We examined the role of vitaminD in the response of HF patients to cardiac resynchronization therapy (CRT). The study comprised 50patients (30men and 20women) with HF undergoing CRT implantation who were prospectively enrolled. Response to CRT was defined as acombination of ≥15% reduction in left ventricular end-systolic volume (LVESV) and ≥10% improvement in the 6‑Minute Walk Test within 6months. Patients were grouped based on their levels of vitaminD prior to CRT implantation. Clinical and echocardiographic examinations were performed prior to and 6months after the procedure. Of the patients, 11 (22%) failed to respond to CRT; two patients died within 6months and an additional nine patients showed no improvement in the 6‑Minute Walk Test and no reduction in their baseline LVESV. A comparison was made between 25patients with sufficient levels of vitaminD and 25patients with insufficient levels. Nine patients (36%) in the "insufficient" group and two patients (8%) in the "sufficient" group failed to respond to CRT implantation (p= 0.037). Adequate serum concentrations of vitaminD play asignificant role in improving the functional status of patients with systolic HF following CRT implantation.

Predictive value of cardiac magnetic resonance-derived parameters on the improvement of left ventricular function in patients with acute viral myocarditis

Objective: To evaluate the predictive value of cardiac magnetic resonance (CMR)-derived parameters on the improvement of left ventricular function in patients with acute viral myocarditis. Methods: Forty patients, who referred for acute viral myocarditis in our hospital from September 2011 to September 2015, were prospectively enrolled in this study.All patients were examined by CMR during hospitalization for acute viral myocarditis (baseline) and after 12 months.The CMR sequences include: two dimension steady state free precession, 2D SSFP; triple inversion recovery, triple IR; early gadolinium enhancement; phase sensitive inversion recovery turbo field echo, PSIR TFE. Results: Thirty out of 40 patients with susceptive acute viral myocarditis met the CMR criteria of acute viral myocarditis (Lake Louise Criteria) (LL+ ) and the other 10 patients did not meet the diagnostic criteria (LL-). Left ventricular ejection fraction (LVEF) values were significantly lower in LL+ group than in LL- group at baseline and at 12 months after discharge (P<0.01 or 0.05, respectively). The baseline left ventricular end-systolic volume index (LVESVI) was significantly higher in LL+ group than in LL- group (P<0.05) and was similar between the groups at 12 months follow up.Left ventricular end-diastolic volume index (LVEDVI )was similar between the two groups at baseline and at 12 months follow up.LVEF was significantly higher during 12 months follow up compared to baseline in LL+ group and remained unchanged in LL- group during the two time points.LVESVI and LVEDVI remained unchanged at baseline and during 12 months follow up both in LL+ and LL- groups (P>0.05). Results showed that LL+ , edema ratio (ER) positive and global relative enhancement (gRE) positive were associated with significant increase of LVEF at 12 months follow up.However, LL-, ER negative, gRE negative, late gadolinium enhancement(LGE) negative and LGE positive linked with unchanged LVEF at 12 months follow up (P>0.05). Patients were further divided into LVEF increase (ΔLVEF≥5%) group and non LVEF increase group (ΔLVEF<5%), the results of Chi-square test showed that LL+ and ER positive were related to the improvement of LVEF (P<0.05), while gRE and LGE were not associated with improvement of cardiac function (P>0.05). Multiple linear regression analysis, using ER, gRE and LGE as independent variables and LVEF as dependent variables, showed that the presence of myocardial edema was the strongest independent predictor of an increase in LVEF at follow up (full model: non-standardized coefficient 0.445, P=0.043; reduced model: non-standardized coefficient 0.442, P=0.12). Conclusion: Cardiac magnetic resonance imaging monitoring is valuable to observe the cardiac function and morphology changes in patients with acute viral myocarditis, and myocardial edema imaging is the most powerful parameter to predict the improvement of LVEF in this patient cohort.

Pre-Load–Induced Changes in Forward LV Stroke and Functional Mitral Regurgitation: Echocardiographic Detection of the Descending Limb of Starling's Curve

ObjectivesThe purpose of this study was to clarify the prognostic significance of diagnosing whether the failing heart is functioning on the descending limb of the Starling curve by using echocardiography with passive leg lifting (PLL). BackgroundPatients with advanced heart failure can shift to the descending limb of the Starling curve, in which pre-load does not lead to an expected increase in forward left ventricular stroke volume (LVSV). MethodsThirty-five consecutive patients with left ventricular (LV) ejection fraction of <40% underwent echocardiography at rest during baseline and during PLL to increase pre-load. ResultsDespite PLL, a paradoxical decrease in forward LVSV was observed in 15 (43%) patients. Changes in forward LVSV inversely correlated with those in functional mitral regurgitation (r = −0.56). The primary endpoint of cardiac death or hospitalization due to worsening heart failure occurred in 15 (43%) patients during follow-up (2.8 ± 2.2 years). There were a number of significant predictors of the primary endpoint in the univariate Cox analysis: baseline E/A ratio (p = 0.0002), paradoxical decrease in LVSV despite PLL (hazard ratio: 4.44; 95% confidence interval: 1.41 to 14.0; p = 0.011), baseline LV end-systolic volume (p = 0.023), and baseline LV ejection fraction (p = 0.034). In the bivariate Cox analysis, an addition of the paradoxical decrease in LVSV significantly enhanced the predictive power of all other univariate predictors. ConclusionsHeart failure patients with LV systolic dysfunction on the descending limb of the Starling curve can be recognized by the paradoxical decrease in LVSV despite PLL, and the prognostic predicting power is additive to the other traditional echocardiographic predictors. Also, our results suggest that functional mitral regurgitation is an important reason for the descending limb of the Starling curve, which is clinically recognized as the pre-load–induced decrease in forward LVSV.

Time course, predictors, and prognostic implications of significant mitral regurgitation after ST-segment elevation myocardial infarction

Ischemic mitral regurgitation (MR) is a known complication of ST-segment elevation myocardial infarction (STEMI) with important prognostic implications. We evaluated changes over time in ischemic MR after STEMI and the prevalence and predictors of significant (grade ≥2) MR at 12 months. Furthermore, the prognostic additional value of significant MR at 12-month follow-up over acute MR was assessed. STEMI patients (n = 1,599; 77% male; 60 ± 12 years) treated with primary percutaneous coronary intervention underwent echocardiography <48 hours of admission (baseline) and at 12 months. Mortality data were collected during long-term follow-up. At baseline, significant MR was present in 103 (6%) patients. After 12 months, MR worsened ≥1 grade in 321 (20%) patients, remained stable in 963 (60%), and improved ≥1 grade in 315 (20%). Significant MR was present in 135 patients at 12 months (8%, P = .01 vs baseline). Age, left ventricular end-systolic volume, and significant MR at baseline were independently associated with significant MR at follow-up. During follow-up (median, 50 months), 121 (8%) patients died (40% of cardiovascular cause). Significant MR at follow-up was independently associated with all-cause (hazard ratio, 1.65, 95% CI, 1.02-2.99) and cardiovascular mortality (hazard ratio, 2.47; 95% CI, 1.24-4.92), also after adjusting for significant MR at baseline. The prevalence of significant MR after STEMI increases over time. Age, baseline left ventricular end-systolic volume, and baseline significant MR are independently associated with significant MR at follow-up. Significant MR at 12 months is associated with subsequent all-cause and cardiovascular mortality and shows additional prognostic value over acute MR.

Not left ventricular lead position, but the extent of immediate asynchrony reduction predicts long-term response to cardiac resynchronization therapy

Cardiac resynchronization therapy (CRT) is an effective treatment for a large subgroup of chronic heart failure patients. Various attempts to improve the high non-responder rate of 30 % by preoperative asynchrony assessment have failed. We hypothesized that superior response to CRT is correlated with greater acute reduction of asynchrony and that a concordant left ventricular (LV) lead is beneficial compared to a discordant lead. Hundred and eight consecutive CRT patients from our center were prospectively included. Clinical status and asynchrony parameters were assessed before, 1 day and 6 months after CRT implantation. Super-response was defined as an increase of the LV ejection fraction by ≥15 % and a decrease in LV end systolic volume (LVESV) by ≥30 %. When the criteria for super-response were not met, average response was given with a decrease of baseline LVESV ≥15 %. Sixty eight patients were classified as responders (63 %). Comparing super- (n = 19) and average (n = 49) responders, we found that greater acute reduction of LV asynchrony (change of asynchronous segments under CRT: -1.3 vs. -0.4, p < 0.05; decrease of LV intraventricular delay: -34 ms vs. -16 ms, p < 0.05) is associated with superior reverse remodeling after 6 months. Importantly, asynchrony parameters of super-, average and non-responders were almost identical at baseline. A concordant LV lead (n = 63) was not associated with improved LV reverse remodeling compared to a discordant lead (n = 28): LVEF: +8.6 % vs. +7.8 %, p = 0.91; LVESV: -30.5 ml vs. -23.8 mL, p = 0.84. A greater immediate reduction of LV asynchrony predicts superior response. Preoperative asynchrony parameters do not correlate with outcome. A concordant LV lead is not superior to a discordant lead.

Delayed intrinsicoid deflection onset in surface ECG lateral leads predicts left ventricular reverse remodeling after cardiac resynchronization therapy

Up to one-third of the patients who undergo cardiac resynchronization therapy (CRT) are not responders. To demonstrate that delayed lateral left ventricular activation time determined through time to intrinsicoid deflection onset (ID) predicts response after CRT. The ID in leads I, aVL, V₁ and V₂, and V₅ and V₆ were measured in 135 patients who underwent CRT. A CRT response was defined as a decrease in left ventricular end-systolic volume (LVESV) exceeding 15% at 6 months. In patients with left bundle branch block or nonspecific intraventricular conduction delay, response was predicted by longer ID in lead I (odds ratio [OR] 3.23; 95% confidence interval (CI) 1.4-7.4; per 20-ms increase), in lead aVL (OR 3.0; 95% CI 1.2-7.3; per 20-ms increase), and in lead I minus lead V₁ (OR 2.4; 95% CI 1.2-4.7) adjusting for baseline QRS duration and LVESV. Results were similar after adjusting for postimplant or change in QRS duration. The ID parameters were better predictors of response than QRS duration parameters. ID in lead I/QRS duration ratio (OR 3.1; 95% CI 1.6-5.9) also increased the odds of response after adjusting for baseline LVESV. Cutoff values for ID in leads--I, 110 ms; aVL, 130 ms; I minus V₁, 90 ms--and ID in lead I/QRS duration ratio of 0.69 yielded a sensitivity and a specificity as high as 83% and 81%. Measurement of ID on surface electrocardiography permits a preimplant, noninvasive means of determining left ventricle activation delay; is a good predictor of CRT response; and represents a promising alternative to QRS duration parameters.

QRS narrowing is associated with reverse remodeling in patients with chronic right ventricular pacing upgraded to cardiac resynchronization therapy.

Patients with chronic right ventricular pacing (RVP) upgraded to cardiac resynchronization therapy (CRT) have been excluded from the majority of clinical trials of CRT. Little is known about the predictors of response in this population. We hypothesized that reversal of RVP-induced electrical dyssynchrony (indexed by QRS duration) by CRT would predict a favorable response. The purpose of this study was to identify baseline characteristics associated with response in patients upgraded to CRT from chronic RVP. Consecutive patients presenting for CRT at the Cleveland Clinic between September 30, 2003, and July 8, 2008, with chronic RVP and serial echocardiograms were included in this analysis. RVP was defined as>85% pacing on a pre-CRT device check, previous AV nodal ablation, or complete pacer dependency per chart notes. Response was defined as a reduction in left ventricular end-systolic volume ≥ 15% from baseline. Clinical, ECG, and echocardiographic data were extracted to determine covariates associated with response. One hundred twelve patients met inclusion criteria, of whom 72 (64.3%) met criteria for response over median follow-up of 9.9 months (interquartile range [6.5-14.7]). No significant differences were noted in terms of male gender (68.1% vs 75.0%; P = .52), ischemic cardiomyopathy (55.6% vs 55.0%; P = 1), pre-CRT QRS duration (189.1 ± 20.7 ms vs 185.5 ± 26.8 ms; P = .47), duration of RVP before CRT upgrade (5.8 ± 3.9 years vs 6.2 ± 4.0 years; P = .57), or baseline left ventricular end-systolic volume (160.0 ± 60.7 mL vs 172.8 ± 67.2 mL; P = .32) between responders and nonresponders, respectively. Percent reduction in QRS duration between the right ventricular-paced and first biventricular-paced waveforms was significantly greater in responders compared with nonresponders (14.4% ± 13.2% vs 7.2%± 14.0%; P = .01). In multivariate analysis, percent reduction in QRS narrowing was the lone factor associated with response (odds ratio 0.02 [0.001-0.42]; P = .01). Reversal of electrical dyssynchrony predicts response to CRT in chronically RV-paced patients upgraded to CRT. Traditional factors associated with a favorable response to CRT in de novo implants (female gender, nonischemic cardiomyopathy, and wider baseline QRS duration) are not significantly associated with response in upgraded patients. Duration of RVP before CRT upgrade is not an important determinant of response.

Prognostic value of reverse left ventricular remodeling after primary angioplasty for STEMI

AimsThus far, the prognostic value of reverse left ventricular (LV) remodeling after ST-elevation acute myocardial infarction (STEMI) has not been fully evaluated. We sought to investigate the incidence, major determinants, and long-term clinical significance of reverse LV remodeling in a large series of STEMI patients successfully treated with primary percutaneous coronary intervention (P-PCI). Methods and resultsSerial complete 2D-echocardiograms were obtained within 24h after P-PCI, and at 1 and 6 months in 512 consecutive reperfused STEMI patients. Reverse remodeling was defined as a reduction >10% in LV end-systolic volume (LVESV) at 6 month follow-up. Reverse LV remodeling occurred in 49% of study population. At follow-up (41.6±23 months), late heart failure (HF) rate was significantly higher among patients without reverse LV remodeling as compared with those with it (32% vs. 11%, P<0.0001). At multivariate analysis, independent predictors of reverse LV remodeling were a small infarct size measured as peak creatine kinase value (P<0.0001), a small functional myocardial damage measured as wall motion score index within the infarct zone (P=0.018) and baseline LVESV (P<0.0001). After adjustment for several clinical, echographic and angiographic variables, Cox analysis identified reverse LV remodeling as the only beneficial independent predictor of long-term heart failure-free survival (HR: 0.44, 95% CI: 0.275–0.722). ConclusionsReverse LV remodeling occurred in half of successfully reperfused STEMI patients. Small structural and functional myocardial damages within the infarct zone are the major determinants of reverse LV remodeling. As expression of effective myocardial salvage by P-PCI, the reverse remodeling is an important predictor of favorable long-term outcome.

Baseline left ventricular function and surgical annular stiffening to predict outcome and reverse left ventricular remodeling after undersized annuloplasty for intermediate-degree ischemic mitral regurgitation

We sought to identify determinants of clinical and functional outcome after myocardial revascularization and associated undersized annuloplasty in patients with intermediate-degree ischemic mitral regurgitation. Fifty-seven patients with 2+ or 3+ ischemic mitral regurgitation underwent coronary bypass surgery and implantation of undersized semirigid or flexible complete ring or autologous pericardial band and were followed up to 8.6 years. Operative mortality was 5%. Baseline left ventricular end-systolic volume index, the strongest multivariable predictor of early postoperative outcome, was correlated with end-systolic volume index (P < .001, R(2) = 0.67) and ejection fraction (P < .001, R(2) = 0.40) after repair. More compromised ejection fraction and end-systolic volume index predicted comparatively greater early functional improvement but higher residual postoperative end-systolic volume index (P < .01). Cox multivariable analysis identified wall motion as the best baseline predictor of late death and heart failure and regional inferoposterior wall motion as the strongest predictor of recurrent mitral regurgitation (P < or = .01). More rigid annuloplasty carried a higher probability of functional recovery in terms of ejection fraction, wall motion, and the occurrence and earlier timing of left ventricular reverse remodeling, expressed by different degrees of end-systolic volume index reduction (P < .001, hazard ratio >6). Combination of undersized mitral annuloplasty and coronary revascularization presents low operative mortality and determines left ventricular unloading in patients with intermediate-degree ischemic mitral regurgitation. Global and regional wall motion are powerful predictors of late outcome. Stiffer mitral annular repair promotes functional recovery and predicts higher probability and earlier timing of reverse remodeling.