Degree Of Left Ventricular Remodeling Research Articles

Phenotype of left ventricular remodeling in heart failure with preserved ejection fraction and its impact on all-cause mortality

Abstract Background/Introduction Heart failure with preserved ejection fraction (HFpEF) refers to a heterogeneous group of patients with unexplored subtypes in terms of a guide to treatment or prognosis. Left ventricular (LV) remodeling is very important as not only an index of structural and functional changes, but also a prognosticator in HF patients. Aims To investigate whether patients with HFpEF can be classified into subgroups by degree of LV remodeling and whether it is related to survival. Methods Patients with HFpEF in the China Heart Failure Center Registry (an ongoing large, nationwide, multicenter registry enrolling the admitted HF patients from secondary and above hospitals since 2017) who had data on the in-hospital LV end-diastolic dimension (LVEDD), ejection fraction (LVEF) by echocardiography, and the 1-year survival were recruited. Patients with major structural heart diseases were excluded. The primary endpoint was all-cause mortality during 1 year after discharge. Kaplan-meier survival curve and Cox regression analysis were adopted to compare among the patients stratified by the LVEDD and LVEF. Results A total of 29727 patients with HFpEF (mean age 73±12 years, 51.3% male) were included, of whom 69.8% was in hypertension, 30.4% in diabetes, 37.3% in atrial fibrillation or flutter, and 14.1% in chronic kidney disease. The mean LVEF of the study population was 60±6%. When the patients were divided into 5 groups as every 5% increase in the LVEF, the risk of all-causemortality was increased in the groups of 50-54% [23.3% patients, age- and gender-adjusted hazard ratio (HR)=1.414, p<0.001] and55-59% (28.8%,1.281, p=0.001), while not different in the groups of 60-64% (26.1%,1.056, p=0.493) and 65-69% (14.3%,0.969,p=0.720) when compared with the group of ≥70% (7.6%) as the reference (Figure 1a). The mean LVEDD was 48±7mm. When the patients were divided into 6 groups as every 5mm increase in the LVEDD, the groups of <40mm (7.7% patients, age-and gender-adjusted HR=1.548, p<0.001) and ≥60mm (5.3%, 1.509, p<0.001) had the highest risk ofmortality, followed by the group of 40-44mm (22.2%,1.214, p=0.001), while the groups of 45-49mm (33.0%,0.991, p=0.863) and 55-59mm (10.0%,1.100, p=0.200) had similar risk when compared with the group of 50-54mm (21.7%) as the reference (Figure 1b). Furthermore, the patients were divided into 8 phenotypes of LV remodeling by using the LVEDD (<40mm, 40-44mm, 45-59mm, ≥60mm) and the LVEF divisions (<60%, ≥60%). When the phenotype of LVEDD of 45-59mm and LVEF of ≥60% taken as the reference, all other phenotypes had an increased risk of death by age and sex adjusted Cox regression analysis (Table1). Conclusion(s) Both the LVEF and LVEDD can provide risk stratification for patients with HFpEF. Those patients with a LVEDD of mid-ranged 45-59mm and a high LVEF ≥60% had the lowest risk of mortality. This concept of phenotyping HFpEF by LV remodeling could be considered in future clinical practice and research.KM survival stratified by EF and EDDRisk of death stratified by EF&EDD

Study of the relationship between the severity of alcoholic cardiomyopathy and the level of alcohol consumption in male and female rats in the model of “home drinking”

Background. Earlier, on the translational model of alcoholic cardiomyopathy (ACMP) developed by us in outbred white rats, which reproduces the main clinical diagnostic signs of this disease, it was shown that in rats of both sexes under conditions of constant 24/7 alcoholization for 24 weeks, AСMP is formed.This study purpose is a comparative assessment of the features of the ACM formation in male and female rats depending on the level of ethanol consumption in model experiments simulating "domestic drunkenness" with periodic alcoholization 24/2 for 24 weeks.Materials and methods. Experiments were performed on outbred white rats randomized into 4 groups: group 1 — control male rats (n=18), group 2 — control female rats (n = 18), group 3 — alcoholized male rats (n = 39) and group 4 — alcoholized female rats (n = 19). Control animals received a normal diet and free access to water. Animals of the 3rd and 4th groups weekly, for 24 weeks, from Friday 22.00 to Monday 8.00, received a 10 % ethanol solution as the only source of liquid with unlimited access to standard food, and the usual diet on the remaining days.Results. In animals of both sexes, after 24 weeks from the consumption start of the ethanol solution, ACM is formed, as evidenced by an increase in the end-systolic and end-diastolic sizes of the left ventricle of the heart (p = 0.0001) and a decrease in its ejection fraction (p = 0.0001), while the degree of pathological myocardial remodeling is more pronounced in females. According to cluster analysis, by the consumption of ethanol (CET), animals of both sexes are divided into 3 subgroups: low, medium and high CET, however, in males, the subgroup with an average CET prevails — 56 %, and in females with a high CET — 47 % (p = 0.0286), the low CET subgroup is minimal (16 %). At the same time, if in males in all subgroups, starting from the 8th week of alcoholization, CET dynamically decreases, then how in females in subgroups with medium and high CET, starting from the 16th week, it increases. It was found that the degree of left ventricular remodeling in females with high and moderate CET was almost 2 times higher than in males (p < 0.05).Conclusion. In model experiments imitating “domestic drunkenness”, it was shown that in females the intensity of the left ventricle heart remodeling is significantly higher than in males, which, apparently, is determined by the identified gender-dependent multidirectional trends in the formation of alcoholic behavior characterized by dynamic growth. consumption of ethanol in female rats as the duration of alcoholization increases.

Abstract 12085: Cardiac Structural and Functional Differences Between the Types of Sleep Apnea in Patients With Heart Failure With Reduced Ejection Fraction

Introduction: In patients with heart failure with reduced ejection fraction (HFrEF), sleep-disordered breathing (SDB) may affect, or be affected by cardiac structure and function. We hypothesized that patients with OSA would demonstrate left ventricular (LV) remodeling and impaired LV function intermediate between that of patients with CSA and patients with no SDB. Methods: ADVENT-HF is a multinational randomized trial investigating the effect of adaptive servo ventilation in patients with HFrEF and SDB. Inclusion required LV ejection fraction (LVEF) ≤45%, and a polysomnographic (PSG) apnea-hypopnea index (AHI) ≥15. Subjects with an AHI <15 were excluded from randomization but comprised a no-SDB (NSDB) group. All transthoracic echocardiograms (TTE) and PSGs were analyzed in core laboratories at University Health Network in Toronto. Patients with SDB were subdivided into those with OSA and those with CSA. We then compared baseline demographic and TTE characteristics of the NSDB, OSA and CSA cohorts. Results: Among them, 665 with acceptable TTE were analyzed. As shown in the table, the CSA group was older, more predominantly male, and had a higher AHI than the other groups, and a higher prevalence of atrial fibrillation and a lower minimum arterial oxyhemoglobin saturation level than the NSDB group. The CSA group also had greater LV mass index than the other groups, greater LV volume indices and lower LVEF than the OSA group, and lower cardiac index than the NSDB group. Although the OSA group had no significant differences in TTE findings compared to the NSDB group, the OSA group was older, more predominantly male, and had a greater AHI than the NSDB group and a higher BMI than the CSA group and lower minSaO 2 than the other groups. Conclusion: In patients with HFrEF, the degree of LV remodeling and dysfunction did not differ between the OSA and NSDB groups, but those with CSA had more advanced LV remodeling and dysfunction than the other groups signaling more advanced HF.

Dispersion of repolarization increases with cardiac resynchronization therapy and is associated with left ventricular reverse remodeling

PurposeCardiac resynchronization therapy (CRT) reduces ventricular activation times and electrical dyssynchrony, however the effect on repolarization is unclear. In this study, we sought to investigate the effect of CRT and left ventricular (LV) remodeling on dispersion of repolarization using electrocardiographic imaging (ECGi). Methods11 patients with heart failure and electrical dyssynchrony underwent ECGi 1-day and 6-months post CRT. Reconstructed epicardial electrograms were used to create maps of activation time, repolarization time (RT) and activation recovery intervals (ARI) and calculate measures of RT, ARI and their dispersion. ARI was corrected for heart rate (cARI). ResultsCompared to baseline rhythm, LV cARI dispersion was significantly higher at 6 months (28.2 ± 7.7 vs 36.4 ± 7.2 ms; P = 0.03) but not after 1 day (28.2 ± 7.7 vs 34.4 ± 6.8 ms; P = 0.12). There were no significant differences from baseline to CRT for mean LV cARI or RT metrics. Significant LV remodeling (>15% reduction in end-systolic volume) was an independent predictor of increase in LV cARI dispersion (P = 0.04) and there was a moderate correlation between the degree of LV remodeling and the relative increase in LV cARI dispersion (R = -0.49) though this was not statistically significant (P = 0.12). ConclusionCRT increases LV cARI dispersion, but this change was not fully apparent until 6 months post implant. The effects of CRT on LV cARI dispersion appeared to be dependent on LV reverse remodeling, which is in keeping with evidence that the risk of ventricular arrhythmia after CRT is higher in non-responders compared to responders.

Strain-based staging classification of left bundle branch block-induced cardiac remodeling predicts reverse remodeling after cardiac resynchronization therapy

Abstract Background Left bundle branch block (LBBB)-induced adverse remodeling is a gradual but largely unknown process, causing a variable degree of left ventricular (LV) dysfunction and response to cardiac resynchronization therapy (CRT). In LBBB patients with septal flash (SF), an electro-mechanical continuum of different speckle-tracking strain patterns was observed, with each pattern tightly correlating with the degree of LV remodeling and dysfunction (1) (Figure 1). Purpose In this study, we investigated the relationship between the staged LBBB strain patterns in CRT-eligible patients and their prediction with respect to reverse remodeling and clinical outcome. Methods This study enrolled CRT patients from the PREDICT-CRT study population (2). Inclusion criteria were LV ejection fraction (LVEF) ≤35%, QRS duration ≥120 ms, NYHA class II–IV, absence of right ventricular pacing and availability of speckle tracking strain imaging. All patients underwent an echocardiographic examination before and 12 months after CRT implant. LV volumes, strain and dyssynchrony were assessed. Mid-septal longitudinal strain curves were classified into 5 patterns (LBBB-0 through LBBB-4; Figure 1). Primary endpoint was all-cause mortality. Results The study involved 250 patients (mean age 64±10 years; 79% men) with a mean LVEF of 26±7%. LBBB was present in 220 (89%) patients and 206 (82%) patients had SF. Prior to CRT implant, a LBBB-0 pattern was observed in 33 (13%), LBBB-1 in 33 (13%), LBBB-2 in 39 (16%), LBBB-3 in 44 (18%) and LBBB-4 in 101 (40%) patients. Patients with LBBB-3 and -4 patterns more frequently had LBBB, lower LVEF, increased mechanical dyssynchrony and more prominent SF (p<0.001 for all) compared with patients with LBBB-0, -1 and -2 patterns. Across the stages, CRT resulted in a gradual volumetric response, ranging from no response in stage LBBB-0 patients (ΔLV end-systolic volume +7±33%; ΔLVEF −2±9%) to super-response in stage LBBB-4 patients (ΔLV end-systolic volume −40±29%; ΔLVEF +15±13%) (p<0.001 for all). Interestingly, following reverse remodeling, the LV function of stage LBBB-2, -3 and -4 patients improved to a similar LVEF of 38% (p=1.000) in this cohort. Patients in stage LBBB-0 had a significantly less favorable five-year outcome compared to those in stage LBBB≥1 (log-rank p=0.003). There was no difference in long-term outcome between stage LBBB-1 to −4 patients (log-rank p=0.510). Conclusion Strain-based LBBB staging predicts the extent of LV reverse remodeling in CRT patients. CRT did not translate into improved absolute survival in the more advanced stages, but the observed gradual volumetric response suggests that CRT corrects the LBBB-induced mortality. Funding Acknowledgement Type of funding sources: None. Figure 1

A comparison of the clinical efficacy of echocardiography and magnetic resonance for chronic aortic regurgitation

Timing surgery in chronic aortic regurgitation (AR) relies mostly on echocardiography. However, cardiac magnetic resonance (CMR) may be more accurate for quantifying regurgitation and left ventricular (LV) remodelling. We aimed to compare the technical and clinical efficacies of echocardiography and CMR to account for the severity of the disease, the degree of LV remodelling, and predict AR-related outcomes. We studied 263 consecutive patients with isolated AR undergoing echocardiography and CMR. After a median follow-up of 33 months, 76 out of 197 initially asymptomatic patients reached the primary endpoint of AR-related events: 6 patients (3%) were admitted for heart failure, and 70 (36%) underwent surgery. Adjusted survival models based on CMR improved the predictions of the primary endpoint based on echocardiography: R2 = 0.37 vs. 0.22, χ2 = 97 vs. 49 (P < 0.0001), and C-index = 0.80 vs. 0.70 (P < 0.001). This resulted in a net classification index of 0.23 (0.00-0.46, P = 0.046) and an integrated discrimination improvement of 0.12 (95% confidence interval 0.08-0.58, P = 0.02). CMR-derived regurgitant fraction (<28, 28-37, or >37%) and LV end-diastolic volume (<83, 183-236, or >236 mL) adequately stratified patients with normal EF. The agreement between techniques for grading AR severity and assessing LV dilatation was poor, and CMR showed better reproducibility. CMR improves the clinical efficacy of ultrasound for predicting outcomes of patients with AR. This is due to its better reproducibility and accuracy for grading the severity of the disease and its impact on the LV. Regurgitant fraction, LV ejection fraction, and end-diastolic volume obtained by CMR most adequately predict AR-related events.

Impact of Degree of Left Ventricular Remodeling on Clinical Outcomes From Cardiac Resynchronization Therapy

ObjectivesThis study tested the hypothesis that the extent of left ventricular (LV) eccentric structural remodeling in heart failure with reduced ejection fraction (HFrEF) is directly associated with clinical event responses to cardiac resynchronization therapy (CRT). BackgroundWhether the severity of LV structural remodeling influences CRT treatment effects is unknown. MethodsCOMPANION (Comparison of Medical Therapy, Pacing and Defibrillation in Heart Failure) trial data were analyzed retrospectively. Left ventricular internal dimensions at end diastole indexed by body surface area (LVEDDI) were measured pre-randomization by 2-dimensional echocardiography. LVEDDI values were stratified around the median value of 35 mm/m2, and CRT (including CRT-P [CRT with only pacing capability] and/or CRT-D [CRT with an implantable defibrillator]) treatment effects were assessed and compared by LVEDDI group. Patients assigned to these treatments were compared to those undergoing optimal pharmacologic therapy (OPT) for the outcomes of all-cause mortality (ACM) or ACM and heart-failure hospitalization (ACM/HFH). ResultsIn the LVEDDI ≥35 mm/m2 group (n = 614), CRT vs. OPT was associated with a lower ACM/HFH hazard ratio (HR) (HR: 0.53; 95% confidence interval [CI]: 0.40 to 0.70; p <0.001), whereas in the LVEDDI <35 mm/m2 group, the CRT vs. OPT ACM/HFH hazard ratio was not statistically significant (HR: 0.80; 95% CI: 0.59 to 1.08; p = 0.15). For ACM alone, in the LVEDDI ≥35 mm/m2 group, the hazard ratio for CRT-P was 0.59 (95% CI: 0.39 to 0.90; p = 0.012) and for CRT-D 0.50 (95% CI: 0.32 to 0.77; p = 0.002). Neither of the CRT groups showed a statistically significant reduction in ACM in the LVEDDI <35 mm/m2 group. ConclusionsLarger versus smaller LVEDDIs are associated with a reduction in ACM with CRT-P or CRT-D treatment, and with a more effective reduction in ACM/HFH for the combined CRT treatment groups.

Microvascular Dysfunction in Dilated Cardiomyopathy: A Quantitative Stress Perfusion Cardiovascular Magnetic Resonance Study

ObjectivesThis study sought to quantify myocardial blood flow (MBF) and myocardial perfusion reserve (MPR) in dilated cardiomyopathy (DCM) and examine the relationship between myocardial perfusion and adverse left ventricular (LV) remodeling. BackgroundAlthough regarded as a nonischemic condition, DCM has been associated with microvascular dysfunction, which is postulated to play a role in its pathogenesis. However, the relationship of the resulting perfusion abnormalities to myocardial fibrosis and the degree of LV remodeling is unclear. MethodsA total of 65 patients and 35 healthy control subjects underwent adenosine (140 μg/kg/min) stress perfusion cardiovascular magnetic resonance with late gadolinium enhancement imaging. Stress and rest MBF and MPR were derived using a modified Fermi-constrained deconvolution algorithm. ResultsPatients had significantly higher global rest MBF compared with control subjects (1.73 ± 0.42 ml/g/min vs. 1.14 ± 0.42 ml/g/min; p < 0.001). In contrast, global stress MBF was significantly lower versus control subjects (3.07 ± 1.02 ml/g/min vs. 3.53 ± 0.79 ml/g/min; p = 0.02), resulting in impaired MPR in the DCM group (1.83 ± 0.58 vs. 3.50 ± 1.45; p < 0.001). Global stress MBF (2.70 ± 0.89 ml/g/min vs. 3.44 ± 1.03 ml/g/min; p = 0.017) and global MPR (1.67 ± 0.61 vs. 1.99 ± 0.50; p = 0.047) were significantly reduced in patients with DCM with LV ejection fraction ≤35% compared with those with LV ejection fraction >35%. Segments with fibrosis had lower rest MBF (mean difference: −0.12 ml/g/min; 95% confidence interval: −0.23 to −0.01 ml/g/min; p = 0.035) and lower stress MBF (mean difference: −0.15 ml/g/min; 95% confidence interval: −0.28 to −0.03 ml/g/min; p = 0.013). ConclusionsPatients with DCM exhibit microvascular dysfunction, the severity of which is associated with the degree of LV impairment. However, rest MBF is elevated rather than reduced in DCM. If microvascular dysfunction contributes to the pathogenesis of DCM, then the underlying mechanism is more likely to involve stress-induced repetitive stunning rather than chronic myocardial hypoperfusion.

CARDIOVASCULAR ADAPTATION TO PHYSICAL ACTIVITY IN ETHNICALLY DIFFERENT YOUNG ATHLETES

Objective: Cardiovascular adaptation to intense physical training is determined by many factors including age, gender, body size, load training, ethnicity and blood pressure response to exercise. Our retrospective study aimed to assess secondary left ventricular (LV) remodelling to exercise, in terms of interventricular septum (IVS) and posterior wall (PW) thickness, in young male black soccer players (BP) compared to male white soccer players (WP). Design and method: 77 BP and 53 WP (17.8 years old), trained with the same load and having the same lifestyle, were evaluated with maximal ergometric test, echocardiography and speckle-tracking global longitudinal strain (GLS). 30 younger BP and 27 WP (13.2 years old) were selected and followed up for 4 years. Results: In the older group of athletes blood pressure response to exercise and GLS were comparable in BP and WP, whereas IVS and PW thickness were significantly higher in BP (IVS: 10.04 ± 0.14 and 9.35 ± 0.10 mm, p < 0.001; PW: 9.70 ± 0.20 and 9.19 ± 0.10 mm, p < 0.05; in BP and WP respectively). Considering the younger group of athletes no significant difference was found in blood pressure while a higher LV remodelling was detected (IVS = 9.29 ± 0.3 and 8.53 ± 0.12 mm, p < 0.002; PW = 9.01 ± 0.2 and 8.40 ± 0.20, p = 0.1; in BP and WP respectively). The degree of LV remodelling was proportional with body-size and LV mass during the four years of follow-up (IVS = 10.52 ± 0.17 and 9.03 ± 0.22 mm, p < 0.001; PW: 10.06 ± 0.17 and 8.26 ± 0.19 mm, p < 0.001; in BP and WP respectively). Conclusions: Since no significant difference in blood pressure response to exercise was detected and since all principal determinants of cardiovascular response to exercise were overcome by specific selection of all athletes enrolled, ethnicity seems to remain the principal factor involved in cardiovascular adaptation to physical training.

Efficacy of mitral valve repair versus replacement in severe ischemic mitral regurgitation

Objective: To compare the mortality, survival rate and the therapeutic efficacy between mitral valve repair and replacement as treatment for severe ischemic mitral regurgitation (IMR), and explore the middle- and long-term outcomes. Methods: Between January 2000 and January 2016, 378 patients with severe IMR underwent coronary artery bypass grafting (CABG) combined with mitral valve repair (n=162) or mitral valve replacement (n=216) in the Department of Cardiovascular Surgery of Nanjing First Hospital. Clinical data, in-hospital morbidity and mortality of patients were retrospectively reviewed. The patients were followed up for the long term survival rate, heart function and re-admission. Results: No statistically significant differences of baseline data and operation details were found between the two groups except for left ventricular end-diastolic diameter[(61.3±10.2)mm in replacement group vs (56.2±9.0)mm in repair group, P<0.001]. Seven patients died during the perioperative period, with a total operation mortality of 1.9%.No significant difference of mortality was found between the two groups (5 cases in the replacement group and 2 cases in the repair group). The early outcome after the surgery showed that the rate of low cardiac output and ventricular arrhythmia of patients were significantly higher in the replacement group compared with the repair group (both P<0.05). The mortality of patients received mitral valve replacement was better than who received mitral valve repair when left ventricular end-diastolic diameter was over 65 mm (5.9% vs 10.0%, P=0.036). No significant differences were observed between the two groups in the middle- and -long term survival rate (87% for replacement group vs 85% for repair group, P=0.568). The follow-up time was 1-85 (52.8±21.5) months and the follow-up rate was 93%. The rate of valve-related complications was significantly higher in the repair group compared with the replacement group (8.82% vs 3.82%, P=0.003). Conclusions: We should choose the surgical methods carefully (replacement or repair) for severe IMR patients according to degree of left ventricular remodeling and pathological changes of mitral valve. Mitral valve replacement with preservation of the subvalvular apparatus is a safe and effective surgical alternative for mitral valve repair, especially for patients with complications or complex reflux.

Chronic ischemic mitral regurgitation – adiagnostic and therapeutic challenge

Chronic ischemic mitral regurgitation (IMR) is a valvular disorder caused by left ventricular dysfunction due to chronic coronary artery disease. It represents a valvular consequence of left ventricular contractile dysfunction and/or pathologic remodeling that indirectly impairs appropriate closing of the mitral valve. IMR is not caused by a structural change of the mitral valve. Acute postinfarction mitral regurgitation is also differentiated from chronic IMR. Chronic IMR occurs in the chronic stage of myocardial infarction in 20–50 % of the patients; its prevalence in the population is increasing. In patients after myocardial infarction, impaired contractility and mitral regurgitation are the most important negative prognostic factors. Furthermore, regurgitation that would be considered mild in patients with organic mitral valve disease already has a negative prognostic implication in patients with IMR. Echocardiogram is the fundamental tool for diagnostic evaluation and treatment planning in patients with IMR. The key parameters that have to be assessed include left ventricular contractile dysfunction, degree of left ventricular remodeling, pathologic changes in mitral valve geometry and quantification of regurgitation severity. In some patients, significant IMR can only be identified by stress echocardiography. Although IMR has an important negative impact on prognosis, indications for treatment and best treatment options have still not been well defined. According to the European and American guidelines, significant IMR should be treated, particularly in patients who are candidates for surgical coronary artery revascularisation. However, there is still no conclusive evidence that any surgical or percutaneous treatment of IMR improves patients’ prognosis.

Editorial Comment: Secondary mitral regurgitation in patients undergoing aortic valve replacement

Mitral regurgitation (MR) is frequently found in patients scheduled for aortic valve replacement (AVR). The aetiology of concomitant MR can be organic or functional. Organic MR is the result of rheumatic or myxomatous degeneration or, particularly in the elderly, calcification of the mitral apparatus. Functional MR, on the other hand, is secondary to increased left ventricular (LV) afterload and/or variable degree of LV remodelling and is the most common form of mitral insufficiency in patients requiring AVR. The evidence is clear to not surgically intervene if associate functional MR is only mild. Similarly, there is a general agreement that mitral valve (MV) surgery, possibly repair, should be performed when severe functional MR exists. On the other hand, the question is often raised of whether additional MV surgery is required in patients submitted to AVR who do have concomitant less than severe functional MR [1–3]. Indeed, no randomized trials have been conducted in this setting and the scattered information available is the result of observational studies with small sample sizes, retrospective analyses, heterogeneous populations and different aetiologies of MR. In addition, the presence of concomitant procedures like myocardial revascularization and the use of different echocardiographic parameters in grading preoperative MR further limits direct comparison between studies. In this scenario, not surprisingly, even the last 2012 European Guidelines on the management of Valvular Heart Disease [4] do not specifically address this issue and simply suggest that, as long as there are no significant organic abnormalities of the mitral apparatus, surgical intervention on the MV is generally not necessary at the time of AVR because non-severe secondary MR usually improves after the aortic valve is treated. The prognostic significance of ‘less than severe’ functional MR in patients undergoing isolated AVR is still debated. Some studies have shown no difference in survival in patients with moderate or moderate-to-severe functional MR vs no (or mild MR) after isolated AVR [2, 5]. Other reports, on the other hand, have demonstrated significantly poorer survival in patients with at least moderate MR submitted to isolated AVR. Organic MV disease and severe degree of MR, however, were usually included in this second group of studies [6, 7]. Those controversial findings explain why some authors have recommended an aggressive approach in operating on the MV [7, 8], whereas others continue to support a more conservative strategy, believing that functional non-severe MR is likely to decrease after the surgical correction of aortic valve disease [2]. Most of the data available demonstrate a general trend towards an improvement of the grade of less-than-severe functional MR after isolated AVR. This is usually due to the postoperative reduction in LV systolic pressure (aortic stenosis) or to the decrease in LV dimensions (aortic regurgitation). Only in about one-third of the patients, preoperative functional MR remains unchanged and in a minority of them it further deteriorates [7]. Whether persistence or worsening in MR severity following AVR directly correlates with mortality remains unclear. The study by Coutinho et al. [9] provides some more light in this controversial field showing that, in the great majority of patients, secondary MR decreases early after isolated AVR and, in 67% of them, this improvement persists in the medium to long term. This finding confirms a relatively benign evolution of secondary MR in patients submitted to isolated AVR. The second important message emerging from this series is that functional MR, in the context of AVR, can be treated with a high rate of repair and with low mortality and morbidity if simple procedures are used. In the study by Coutinho, MV surgery mainly consisted of suture or ring annuloplasty, which required an extra aortic cross-clamp time of <20 min and had no negative impact on the postoperative course of the patients. Those annuloplasty techniques provided satisfactory long-term results in this specific setting, although one might speculate on whether a larger adoption of ring prostheses would have further decreased the recurrence of late MR without significantly prolonging the duration of the cardioplegic arrest. Ten-year survival was not significantly different between patients with or without concomitant MV surgery, but those who had concomitant MR correction experienced less congestive heart failure symptoms at the follow-up, more pronounced reverse LV remodelling and a trend (although not statistically significant) towards improved late survival. If the option not to intervene on the MV did not influence overall and event-free survival, early persistence of MR greater than 2+ did. This means that patients who still had an important degree of MR by the first month after AVR, remained at risk of

Pattern and degree of left ventricular remodeling following a tailored surgical approach for hypertrophic obstructive cardiomyopathy.

Background The role of a tailored surgical approach for hypertrophic cardiomyopathy (HCM) on regional ventricular remodelling remains unknown. The aims of this study were to evaluate the pattern, extent and functional impact of regional ventricular remodelling after a tailored surgical approach. Methods From 2005 to 2008, 44 patients with obstructive HCM underwent tailored surgical intervention. Of those, 14 were ineligible for cardiac magnetic resonance (CMR) studies. From the remainder, 14 unselected patients (42±12 years) underwent pre- and post-operative CMR studies at a median 12 months post-operatively (range 4–37 months). Regional changes in left ventricular (LV) thickness as well as global LV function following surgery were assessed using CMR Tools (London, UK). Results Pre-operative mean echocardiographic septal thickness was 21±4 mm and mean LV outflow gradient was 69±32 mmHg. Following surgery, there was a significant degree of regional regression of LV thickness in all segments of the LV, ranging from 16% in the antero-lateral midventricular segment to 41% in the anterior basal segment. Wall thickening was significantly increased in basal segments but showed no significant change in the midventricular or apical segments. Globally, mean indexed LV mass decreased significantly after surgery (120±29g/m2 versus 154±36g/m2; p<0.001). There was a trend for increased indexed LV end-diastolic volume (70±13 mL versus 65±11 mL; p=0.16) with a normalization of LV ejection fraction (68±7% versus 75±9%; p<0.01). Conclusion Following a tailored surgical relief of outflow obstruction for HCM, there is a marked regional reverse LV remodelling. These changes could have a significant impact on overall ventricular dynamics and function.

Biomarkers in pediatric heart failure: Their role in diagnosis and evaluating disease progression

Biomarkers have established an important role in the diagnosis and prognosis of heart failure in adults. Several biomarkers of different classes have also demonstrated a practical or potential role in managing patients with heart failure. In the pediatric population, objective assessment of severity and disease progression is apt to be more difficult. Therefore, biomarkers may represent an objective tool to confirm functional status and echocardiographic indices of left ventricular dysfunction in children with heart failure. Since early detection of remodeling is vital to preemptive management, biomarkers may also serve to gauge the severity of the ventricular remodeling process in several different diseases. Thus far, B-type natriuretic peptide levels have been found to be associated with the severity and outcome of heart failure in children, correlating with symptom severity, functional status and degree of left ventricular remodeling. They have been found to predict cardiovascular events, and may guide medical treatment decisions in symptomatic heart failure. High-sensitivity C reactive protein, cytokines, cytokine receptors, cardiac troponins and gene expression profiling are all emerging as a useful assessment tools in adults with heart failure. Further study is required to validate the role of these measures in children with cardiomyopathies and with heart failure.

Early abciximab administration before primary percutaneous coronary intervention improves infarct-related artery patency and left ventricular function in high-risk patients with anterior wall myocardial infarction: A randomized study

Early abciximab administration before primary percutaneous coronary intervention (PPCI) for ST-segment elevation myocardial infarction (STEMI) is recommended in practice guidelines. However, the evidence supporting abciximab use before and during transfer for PPCI is limited. We investigated the effect of early abciximab administration on early reperfusion, ST-segment resolution, enzymatic infarct size, and left ventricular function in patients with first anterior wall STEMI. A total of 59 nonshock patients with STEMI admitted <12 hours to remote hospitals with anticipated delay to PPCI of <90 minutes were randomly assigned to 2 study groups: 27 patients received abciximab before transfer to catheterization laboratory (Early group), and 32 patients received abciximab immediately before PPCI (Late group). Angiography revealed more frequent infarct-related artery patency in the Early group than in the Late group (TIMI 2 + 3: 48% vs 20%, P = .04). Better ST-segment resolution of >50% 60 minutes after PPCI was found in Early group than in the Late group (84% vs 56.7%, P = .04). The area under the curve for creatine kinase-MB indicated a significantly greater extent of myocardial injury in the Late group versus the Early group (8324 +/- 4185 vs 5938 +/- 3949 U/L . h, P = .04). There was a significant difference in the 30-day left ventricular end-systolic volume index (P = .02) and end-diastolic volume index (P = .05) in the echocardiography favoring the Early group. Early abciximab administration before transfer for PPCI in patients with first anterior wall STEMI results in more frequent infarct-related artery patency before PPCI, better myocardial tissue perfusion after PPCI, with lower enzymatic infarct size and lower degree of left ventricular remodeling during 30-day follow-up.

Relation of initial infarct size to extent of left ventricular remodeling in the year after acute myocardial infarction

This study attempted to determine the relation between infarct size after acute myocardial infarction and subsequent left ventricular remodeling using precise clinical measurements. Animal studies have demonstrated that the degree of left ventricular remodeling after myocardial infarction is linearly related to infarct size. Clinical studies have not clearly replicated these results because of imprecise measurements and failure to adjust for patency of the infarct-related artery. Infarct size was measured from technetium-99m (Tc-99m) sestamibi perfusion images in 14 patients (12 with an anterior, 2 with an inferior infarction) by a threshold method previously described and expressed as percent of the left ventricle (32 +/- 17% left ventricle [mean +/- SD], range 6% to 58%). Absolute end-systolic volume, end-diastolic volume and ejection fraction were determined by electron beam computed tomographic images performed at discharge and at 6 weeks, 6 months and 1 year after myocardial infarction. All patients had documented infarct-related artery patency after reperfusion therapy. At hospital discharge, there was no correlation between infarct size and end-systolic and end-diastolic volumes or ejection fraction. There was significant left ventricular dilation in the study group over the next year. As remodeling progressed, there was closer correlation between infarct size and ejection fraction and end-systolic volume measures (infarct size vs. end-systolic volume, from r = 0.43 at discharge to r = 0.80 at 1 year; infarct size vs. ejection fraction, from r = -0.39 at discharge to r = -0.84 at 1 year). There was a strong inverse correlation between infarct size at discharge and subsequent changes over the next year in end-systolic volume (r = 0.63, p = 0.02) and ejection fraction (r = -0.66, p = 0.01). Infarct size as measured by Tc-99m sestamibi at hospital discharge after an index infarction is predictive of subsequent change in left ventricular volume and function in the year after myocardial infarction. Patients with a large infarct demonstrated the greatest degree of dilation in the setting of patency of the infarct-related artery.