Degree Of Systolic Dysfunction Research Articles

Echocardiography in the Diagnosis of Cardiomyopathies: Current Status and Future Directions.

Cardiomyopathies are a challenging pathology and echocardiography is essential for diagnosis and prognosis. The most frequent cardiomyopathies are the dilated cardiomyopathy (DCM) and the hypertrophic cardiomyopathy (HCM), followed by the less frequent restrictive (RCM) and arrhythmogenic right ventricle cardiomyopathies (ARVC). Echocardiography can identify diagnostic features, and guide further testing for a definitive diagnosis. Echographic parameters are involved in risk score computing and prognosis assessment. While the most prevalent hallmark of HCM is the asymmetric left ventricular hypertrophy and systolic anterior motion of the mitral valve with the obstructive phenotype, DCM shows dilated left ventricle with different degrees of systolic dysfunction, and RCM is usually characterized by undilated ventricles associated with atrial enlargement. The aim of this review is to display and compare the most frequent cardiomyopathies encountered in clinical practice and highlight their most characteristic features in a useful way for the practicing clinician.

Growth differentiation factor 15 associations with clinical features of chronic heart failure with midrange ejection fraction and preserved ejection fraction depending on the history of myocardial infarction.

Aim To analyze associations between levels of the inflammatory marker, growth differentiation factor 15 (GDF-15), and echocardiographic indexes in CHF patients with mid-range and preserved left ventricular ejection fraction (LV EF) depending on the history of myocardial infarction (MI).Material and methods This study included 34 CHF patients with preserved and mid-range LV EF after MI (group 1, n=19) and without a history of MI (group 2, n=15). Serum concentration of GDF-15 was measured with enzyme immunoassay (BioVendor, Czech Republic). Statistical analysis was performed with STATISTICA 10.0.Results Patients of the study groups were age-matched [62 (58;67) and 64 (60;70) years, p=0.2] but differed in the gender; group 1 consisted of men only (100 %) whereas in group 2, the proportion of men was 53.3 % (p=0.001). Median concentration of GDF-15 was 2385 (2274; 2632.5) and 1997 (1534;2691) pg/ml in groups 1 and 2, respectively (p=0.09). Patients without MI showed a moderate negative correlation between LV EF and GDF-15 concentration (r= - 0.51, p=0.050) and a pronounced correlation between GDF-15 and LV stroke volume (r= -0.722, p=0.002). For patients after MI, a correlation between the level of GDF-15 and the degree of systolic dysfunction was not found (р>0.05).Conclusion Blood concentration of the inflammatory marker, GDF-15, correlates with LV EF and stroke volume in CHF patients with preserved or mid-range LV EF and without a history of MI while no such correlations were observed for patients with a history of MI.

522 Perioperative Echocardiographic Assessment of Malnutrition-Related Cardiomyopathy: A Case Series

Abstract Introduction It is known that systolic dysfunction (dilated cardiomyopathy) may occur in a high percentage of patients with large TBSA burns. The reversible myocardial depression may be due to many factors: thermal injury, sepsis, severe malnutrition. Monitoring nutritional status is an integral part of improving post-burn cardiomyopathy. Perioperative echocardiography can be used to assess the degree of cardiac dysfunction and alter treatment in these patients. Methods Serial echocardiographic parameters were measured (ejection fraction, fractional shortening, pericardial fluid) in 4 patients with evidence of malnutrition (low BMI, low albumin and prealbumin, muscle wasting), delayed wound healing, and a late presentation to the hospital. Initial echocardiography was performed post-injury day 30 -142; follow-up exams were performed in some patients up to 2 years post-injury. Acutely injured or septic patients were excluded. Results Echocardiographic measurements were obtained in 4 patients, ages 7–21. The TBSA ranged from 33–95% and included flame injury and electrical burns. The initial ejection fraction ranged from 12–38% in patients with a BMI range of 10–16. The mean initial albumin was 1.65g/dL; the mean prealbumin was 10.8mg/dL. Selenium deficiency was noted in 1 patient. Dobutamine was required intraoperatively in several patients. Conclusions Patients presenting with malnutrition and impaired wound healing all had evidence of cardiomyopathy of varying degrees. However, the degree of systolic dysfunction varied significantly. Chronic surgical grafting was used to manage burn wounds, while slow nutritional rehabilitation normalized the patient’s BMI with careful avoidance of refeeding syndrome. As exemplified by serial echocardiography, one patient’s EF improved over 1 year from 12% to 50–55% as the nutritional status also improved, demonstrated by the normalization of his BMI. Despite the lower ejection fractions, many patients maintained an adequate cardiac index and required only short-term inotropic agents. Intraoperative and serial echocardiography allowed for continued monitoring and alteration of the heart failure medication regimens if required. With time and adequate nutrition, cardiac function improved, although many remained with mild dysfunction in the first year.

Echocardiographic Features of Cardiomyopathy in Emery-Dreifuss Muscular Dystrophy.

Background Emery-Dreifuss muscular dystrophy (EDMD) is a very rare type of muscular dystrophy characterized by musculoskeletal abnormalities accompanied by cardiac defects. Two most common genetic subtypes are EDMD1 due to EMD and EDMD2 caused by LMNA gene mutations. The aim of the study was to characterize and compare the cardiac morphology and function in the two main genetic subgroups of EDMD with the use of echocardiography. Methods 41 patients with EDMD (29 EDMD1 and 12 EDMD2) as well as 25 healthy controls were enrolled in our study. Transthoracic echo with the use of a prescribed protocol was performed. Results Highly statistically significant differences with regard to left ventricle (LV) volumes between the EDMD and the control group were found. 51% of EDMD patients had an enlarged left atrium and as many as 71% had an enlarged right atrium. The LV ejection fraction (LVEF) was significantly lower in EDMD patients than in the control group which corresponded also with a lower systolic velocity of the mitral annulus. 43% of EDMD patients had LVEF below the normal limit. Diastolic dysfunction was detected in 17% of EDMD patients. There were no significant differences between the two types of EDMD in terms of diameters and volumes of any chamber, as well as the systolic function of both left and right ventricles. Conclusions A significant number of EDMD patients present LV dilatation and different degrees of systolic dysfunction. Dilatation of the atria dominates over ventricle dilatation. We did not present any significant differences between EDMD1 and EDMD2 in terms of the morphology and the function of the heart.

Abstract 15108: Phenotypic Associations and Clinical Outcomes of Genetically Predicted Left Ventricular End Systolic Diameter in Prevalent Heart Failure

Introduction: Varying degrees of systolic dysfunction after myocardial injury suggest a genetic basis for cardiac contractile reserve. Left ventricular end systolic dimension (LVESD), acquired by transthoracic echocardiography (TTE), is a proxy for cardiac contractility, and common variation underlying LVESD may offer insight into the underlying biology and clinical manifestations of heart failure (HF) and related phenotypes. Hypothesis: We hypothesized that elevations in genetically predicted LVESD would be associated with prevalent HF with reduced ejection fraction (HFrEF), but not HF with preserved ejection fraction (HFpEF), and with mortality among those with established HF. Methods: LVESD measurements (n = 7,630) were extracted for adults of European ancestry with available genome-wide genotyping who had also undergone clinically indicated TTE at Vanderbilt University Medical Center (VUMC). A polygenic risk score (PRS) for LVESD was created and validated in a separate cohort. HF status was defined using a validated algorithm. Logistic regressions were used to test for association of the PRS with prevalent HFrEF and HFpEF. Cox proportional hazards was used to test for association between PRS and incident death among (2,672) subjects with HF. All models were conducted in R and adjusted for age and sex. Results: A linear model of measured LVESD was significant for PRS (R^2 = 0.092, p < 0.001). The PRS was significantly associated with prevalent HFrEF (OR 1.15 per SD, p < 0.003) but not HFpEF. Genetically predicted LVSD was not associated with mortality among patients with HF (OR 1.01, p = 0.83). Conclusions: Genetically predicted LVESD, assessed by PRS, was associated with risk of prevalent HFrEF but not HFpEF. LVESD PRS was not associated with incident death in subjects with overall HF. These results suggest a potential role of LVSD PRS in HFrEF risk stratification, and further research should explore the relationship between LVESD PRS and incident HF.

P969Improvement of left ventricular ejection fraction in the first week post rhythm restoration as a marker of long-term recovery of arrhythmia-induced cardiomyopathy in a latin american population

Abstract Introduction The incidence of Arrhythmia-Induced Cardiomyopathy (AIC) is presumed to be between 8% and 34%. Its outcome is also not well known and may be linked to multiple factors. However, it has been suggested that a 25% improvement of the Left Ventricular Ejection Fraction (LVEF), during the first week after rhythm restoration could be an indicator of long-term and complete recovery. This fact has not been studied in our country or even in Latin America. Purpose To observe the behavior of the LVEF after restoration of sinus rhythm in patients with systolic dysfunction presumably secondary to AIC, at least in one year of follow-up. Methods We evaluated all patients referred for arrhythmia treatment and having any degree of systolic dysfunction (LVEF less or equal to 50%) and functional class deterioration between January 2015 and September 2018. Restoration of sinus rhythm was accomplished in either by pharmacologic or invasive methods aimed to specific arrhythmias. After the treatment, we proceed with the systolic function evaluation starting one week after rhythm control, and then at one, three, six and twelve months. This evaluation consisted in clinical examination, echocardiographic determination of LVEF, as well as NT-ProBNP and troponin measurements. Results We identified twenty one cases with presumed AIC. Sixteen cases were secondary to atrial flutter, with four others being secondary to atrial fibrillation, and the last one being a consequence of frequent ventricular extrasystoles (VES). Fifteen patients (74%) were male, mean age was 51 years old (4-76 years). All cases of tachycardia had a ventricular rate over 100 beats per minute. The patient with VES, had a 58% burden of ectopic beats. Eighteen of these patients were taken to invasive electrophysiological study and radiofrequency ablation; and three patients received antiarrhythmics as rhythm control strategy. All patients had mid-range to severe systolic dysfunction prior to treatment, with a mean LVEF of 38%±7,5%; 63% of them were in NYHA class III-IV. One week after rhythm restoration, mean LVEF was 54± 6,36%. That was an improvement of 45% in LVEF. Mean LVEF at one and three months was 63± 5,43%, 61± 5,23% at six months and 63± 5,43% at one year. All patients improved their functional class, to NYHA I at the first evaluation post rhythm restoration. We found no differences between troponin and NT-ProBNP levels before and after treatment, except for one patient . Conclusion Appropriately treated AIC seems to have a good prognosis and short-term recovery of LVEF could be a useful indicator of complete normalization in the long-term. To our knowledge, here we detail the results of a relatively large time-series of AIC, and is perhaps the first study in the Latin American region that suggests that early LVEF improvement could predict AIC recovery, but controlled trials should be done in order to confirm these results.

ST-segment elevasyonlu akut miyokard infarktüsü ile başvuran hastalarda interatrial ileti bozuklukları

Aim: The most significant clinical association of interatrial block (IAB) was found with increased risk of atrial fibrillation and ischemic stroke. In this study, we sought to evaluate P wave duration and interatrial block in patients presented with acute ST-segment-elevation myocardial infarction (STEMI) who underwent primary percutaneous coronary intervention (PCI). Materials and Methods: We performed a retrospective analysis of patients presented with acute STEMI who underwent emergent PCI. Follow-up electrocardiograms were obtained from electronic database system. Echocardiographic data were also obtained from electronic patient records. Electrocardiographic measurements were performed using SEMA Workstation 3.8.1 (Schiller AG). Results: Primary analysis included 200 consecutive patients with STEMI. However, there were 20 in-hospital deaths and 83 patients were lost to follow-up. Remaining 97 patients (80 male, 17 female) were included in the final analysis. Mean age was 57.0212.18 years. There were 48 patients with anterior STEMI and 49 patients with inferior STEMI. Mean duration of follow-up was 11 months and ECGs at the end of the follow up revealed that the frequency of partial and advanced IAB were 13.2% and 7.7% respectively. Statistical analysis showed that neither P wave duration nor IAB showed significant association with the infarct related artery lesion localization. Also, the degree of systolic dysfunction was not associated with IAB. Only male gender and left atrial diameter had significant positive correlation with P wave duration. Conclusion: IAB was not rare in patients with a history of acute coronary syndrome. The infarct related artery does not seem to have a significant correlation with interatrial conduction.

514 Post-burn Malnutrition and Associated Cardiomyopathy

Abstract Introduction It is known that systolic dysfunction (dilated cardiomyopathy) may occur in a high percentage of patients with large TBSA burns. The reversible myocardial depression may be due to many factors: thermal injury, sepsis, severe malnutrition. Malnutrition and delayed wound healing may occur with a combination of primary and secondary protein-energy undernutrition. Methods Serial transthoracic and transesophageal echocardiographic parameters were measured during perioperative care (ejection fraction, fractional shortening, pericardial fluid) in 8 patients with evidence of malnutrition (low BMI, low albumin and prealbumin, muscle wasting) and a delayed presentation to the hospital. Initial echocardiography was performed post-injury day 30 -142; follow-up exams were performed in some patients at 2 years post-injury. Acutely-injured patients or those with sepsis were excluded. Results From 2015–2017, echocardiographic measurements were obtained in 8 patients, ages 7–21. The presenting TBSA ranged from 30–82% and included flame injury, electrical burns, and 1 case of pemphigus vulgaris. The initial ejection fraction ranged from 12–45% in patients with a BMI range of 10–25. The mean initial albumin was 2g/dL; the mean prealbumin was 9.5mg/dL. Two patients had mild to moderate pericardial effusions, which resolved after 1 month of proper nutrition. Selenium deficiency was noted in 1 patient. Four patients required perioperative short-term dobutamine. Conclusions Patients presenting with malnutrition and impaired wound healing all had evidence of cardiomyopathy; however, the degrees of systolic dysfunction varied significantly. BMI, albumin, and prealbumin all had a strong correlation with the degree of myocardial depression. Despite the lower ejection fractions, many patients maintained an adequate cardiac index and did not require inotropic medications. With time and adequate nutrition, cardiac function improved, although many remained with mild dysfunction in the first year. Applicability of Research to Practice This case series demonstrates the continued need for early recognition of malnutrition and cardiomyopathy in this patient population and the need for early intervention. Echocardiographic diagnosis may improve acute perioperative care. In addition, future studies are needed to determine the chronic cardiac effects of reversible dilated cardiomyopathy. Nutrition, refeeding, and perioperative management require a multidisciplinary team.

Increase in cholinergic modulation with pyridostigmine induces anti-inflammatory cell recruitment soon after acute myocardial infarction in rats.

We tested the hypothesis that an increase in the anti-inflammatory cholinergic pathway, when induced by pyridostigmine (PY), may modulate subtypes of lymphocytes (CD4+, CD8+, FOXP3+) and macrophages (M1/M2) soon after myocardial infarction (MI) in rats. Wistar rats, randomly allocated to receive PY (40 mg·kg(-1)·day(-1)) in drinking water or to stay without treatment, were followed for 4 days and then were subjected to ligation of the left coronary artery. The groups-denominated as the pyridostigmine-treated infarcted (IP) and infarcted control (I) groups-were submitted to euthanasia 3 days after MI; the heart was removed for immunohistochemistry, and the peripheral blood and spleen were collected for flow cytometry analysis. Noninfarcted and untreated rats were used as controls (C Group). Echocardiographic measurements were registered on the second day after MI, and heart rate variability was measured on the third day after MI. The infarcted groups had similar MI areas, degrees of systolic dysfunction, blood pressures, and heart rates. Compared with the I Group, the IP Group showed a significant higher parasympathetic modulation and a lower sympathetic modulation, which were associated with a small, but significant, increase in diastolic function. The IP Group showed a significant increase in M2 macrophages and FOXP3(+)cells in the infarcted and peri-infarcted areas, a significantly higher frequency of circulating Treg cells (CD4(+)CD25(+)FOXP3(+)), and a less extreme decrease in conventional T cells (CD25(+)FOXP3(-)) compared with the I Group. Therefore, increasing cholinergic modulation with PY induces greater anti-inflammatory cell recruitment soon after MY in rats.

Quantitative assessment of myocardial extracellular volume fraction in non-ischemic dilated cardiomyopathy and its relation to systolic dysfunction

Background Interstitial myocardial fibrosis is a histological hallmark of non-ischemic dilated cardiomyopathy (DCM), and may play an important role in adverse remodelling and progressive systolic dysfunction. T1-mapping enables noninvasive assessment of diffuse fibrosis by quantification of myocardial extracellular volume fraction (ECV). We hypothesized that CMR would identify a raised ECV in DCM which would correlate with the degree of systolic dysfunction.

Abstract 309: Early Mortality Determinants in Cardiac Arrest Survivors Treated with Therapeutic Hypothermia

Purpose : We hypothesized that advanced circulatory compromise, as manifested by acidosis and hyperkalemia should be associated with worsened clinical outcomes in cardiac arrest patients treated with therapeutic hypothermia. Methods: Results of initial admission laboratory studies, medical history, and echocardiogram in 41 consecutive cardiac arrest patients (13 females, 60+/- 32 years old, 6 with diabetes, 7 with chronic kidney disease, and 8 with history of cardiovascular disease) undergoing therapeutic hypothermia were reviewed. Mortality was ascertained through hospital records and Social Security Death Index. ANOVA, chi-square, Kaplan-Meier, and logistic regression analyses were used. The study was approved by the institutional IRB. Results : Age, gender, medication use, history of CAD, degree of systolic dysfunction by echocardiogram, serum pH, creatinine, sodium, glucose, magnesium, calcium, lactate, BUN, and osmolality were not predictive of mortality in our patient population. However, higher hemoglobin (0.336 per 1 mg/dL, 95% CI 0.138-0.818, p=0.016) and pre-resuscitation ventricular tachycardia or fibrillation (VT-VF vs. pulseless electrical activity or asystole, 0.02, 95% CI 0.002-0.312, p=0.004) were associated with decreased hospital mortality in both univariate and multivariate analyses. Median admission potassium level was 4.0 mEq/L. Unexpectedly, correlation between admission serum potassium and pH was poor (R^2= 0.06). Similarly, actual K requirements were poorly correlated with calculated K deficit (R^2=0.007). VT or VF were more prevalent in patients with K less than 4 (p=0.002). There was also a trend towards improved mortality in patients with lower K levels (72% survival in K≤4 vs. 47% in K>4 mEq/L, p=0.129). Conclusions: Hyperkalemia, pulseless electrical activity, and asystole are predictive of increased hospital mortality in survivors of cardiac arrest. In patients with admission hypokalemia, lack of correlation between admission potassium, pH, and potassium requirements are suggestive for acute event etiology in many cardiac arrests patients. An association between low or low-normal potassium, observed VT-VF, and better outcomes is unexpected and may be used for prognostic purposes. More prospective investigations of mortality predictors in these critically ill patients are needed.

Comparison of the Diagnostic Performance of Three Natriuretic Peptides in Hemodialysis Patients: Which is the Appropriate Biomarker?

Background: Plasma concentrations of natriuretic peptides are often elevated in chronic hemodialysis patients and difficult to interpret due to accumulation, high incidence of cardiac disease and changes in volume status. Mid-regional pro-ANP is a newly developed assay whereas BNP and its fragment NT-pro-BNP are available for a longer time. In this cross-sectional study, we compared the plasma concentration of MR-pro-ANP, BNP and NT-pro-BNP in stable ambulatory hemodialysis patients (n = 239) and investigated their associations with clinical factors such as residual diuresis, cardiac status and interdialytic weight gain and with mortality. Methods and Results: In all patients enrolled, the plasma concentration of all natriuretic peptides were largely elevated with a median concentration of 337 pg/ml (interquartile range 146-684) for BNP, 4435 pg/ml (1687-16228) for NT-proBNP and 907 pmol/L (650-1298) for MR-pro-ANP. Plasma concentration of all natriuretic peptides correlated independently with age, degree of systolic dysfunction and negatively with residual diuresis. Dependency on residual renal clearance was strongest for the fragments MR-pro-ANP and NT-pro-BNP. The plasma concentration of all natriuretic peptides was associated with mortality within 2 years of follow-up. Receiver-operated curves revealed a low sensitivity (32-45%), but high specificity for all natriuretic peptides (85-93%) resulting in a high negative predictive (82-87%). Best cut-off values obtained from were 18 611 pg/ml for NT-pro-BNP, 958 pg/ml for BNP and 1684 pmol/L for MR-pro-ANP. Conclusions: In hemodialysis patients, the fragments NTproBNP and MR-pro-ANP are largely elevated compared to BNP which is explained by accumulation. The prognostic performance of MR-pro-ANP is similar to that of NT-pro-BNP or BNP.

Early and simple detection of diastolic dysfunction during weaning from mechanical ventilation.

Weaning from mechanical ventilation imposes additional work on the cardiovascular system and can provoke or unmask left ventricular diastolic dysfunction with consecutive pulmonary edema or systolic dysfunction with inadequate increase of cardiac output and unsuccessful weaning. Echocardiography, which is increasingly used for hemodynamic assessment of critically ill patients, allows differentiation between systolic and diastolic failure. For various reasons, transthoracic echocardiographic assessment was limited to patients with good echo visibility and to those with sinus rhythm without excessive tachycardia. In these patients, often selected after unsuccessful weaning, echocardiographic findings were predictive for weaning failure of cardiac origin. In some studies, patients with various degrees of systolic dysfunction were included, making evaluation of the diastolic dysfunction to the weaning failure even more difficult. The recent study by Moschietto and coworkers included unselected patients and used very simple diastolic variables for assessment of diastolic function. They also included patients with atrial fibrillation and repeated echocardiographic examination only 10 minutes after starting a spontaneous breathing trial. The main finding was that weaning failure was not associated with systolic dysfunction but with diastolic dysfunction. By measuring simple and robust parameters for detection of diastolic dysfunction, the study was able to predict weaning failure in patients with sinus rhythm and atrial fibrillation as early as 10 minutes after beginning a spontaneous breathing trial. Further studies are necessary to determine whether appropriate treatment tailored according to the echocardiographic findings will result in successful weaning.

Cardiovascular disease in pregnancy

Cardiac disease continues to be an important cause of maternal morbidity and mortality and is now the leading cause of maternal deaths in the United Kingdom. This is largely because of extensive haemodynamic changes which occur during pregnancy, namely the increase in blood volume, fluctuations in cardiac output, fall in systemic vascular resistance and hypercoagulable state. High risk periods include the end of the second trimester, during labour and the immediate postpartum period. Prognosis depends on the specific cardiac condition, the patient's functional class, presence of cyanosis, prior history of cardiac events or arrhythmia and the degree of systolic dysfunction. Conditions where pregnancy should be include Eisenmenger's syndrome, pulmonary hypertension, complex cyanotic congenital heart disease, Marfan syndrome with aortic root dilatation and those with severe left ventricular dysfunction. Women with heart disease should be thoroughly evaluated and counselled before and during pregnancy. Multidisciplinary care is essential for successful maternal and foetal outcomes.

Ventricular Mechanical Asynchrony in Patients with Different Degrees of Systolic Dysfunction: Results from AVE Registry by the Italian Society of Cardiovascular Echography (SIEC)

The aim of the study was to compare the prevalence of interventricular and intraventricular asynchrony in patients with different degrees of left ventricular (LV) dysfunction. We enrolled 182 patients (male 79%, mean age 64 +/- 11 years) with LV ejection fraction (EF) < 50% and identified two groups: Group A (n = 79) with mild-to-moderate LV dysfunction (EF between 36% and 49%) and Group B (n = 103) with severe dysfunction (EF <or= 35%). An echocardiogram was performed in all patients and a delay longer than 40 msec in the time difference between the aortic and pulmonary preejection intervals was considered as an index of interventricular asynchrony. The electromechanical delays were assessed by pulsed tissue Doppler technique. A time difference between the earliest and the latest segment greater than 40 msec was considered the cutoff for intraventricular asynchrony. The sum of asynchrony was calculated by adding to the LV intraventricular delay the delay between the lateral basal right ventricular segment and the most delayed LV basal segment. The prevalence of interventricular asynchrony was lower among Group A patients (19.8% vs. 37.9%; P = 0.007) while the prevalence of intraventricular asynchrony did not differ between groups (32.9% vs. 44% in Group A and Group B respectively; P = 0.18). The sum of asynchrony (cutoff >102 msec) did not differ between groups either (29.9% vs. 35.9%; P = 0.39). The prevalence of intraventricular asynchrony is independent of the LV systolic dysfunction severity. This could indicate the potential role of cardiac resynchronization therapy in patients with mild-moderate systolic dysfunction.

Consensus on unsolved issues of left ventricular hypertrabeculation/noncompaction is warranted

Abstract As long as there is no consensus on the definition, diagnostic criteria, and pathogenesis of left ventricular hypertrabeculation (LVHT)/noncompaction misdiagnosis, overreaction, and mistreatment of this abnormality will eventually continue. When considering a therapy for patients presenting with LVHT it has to be taken into account that LVHT is not associated with an increased risk of thrombo-embolism in the absence of atrial fibrillation or systolic dysfunction. There is also no proof that the degree of LVHT correlates with the degree of systolic dysfunction. Secondary prevention of stroke/embolism and sudden cardiac death is indicated in LVHT only if cardiac investigations reveal atrial fibrillation, systolic dysfunction, or ventricular arrhythmias. Up to what we know at the moment LVHT patients should be closely monitored by conventional cardiologic and neurologic diagnostic tools and appropriate measures taken, only if indicated.

Reduced regional systolic function evolved compacted segments in noncompaction

In a recent report about noncompaction Nemes et al. reported that systolic left ventricular (LV) dysfunction assessed using the wall motion score during 2D echocardiography in noncompaction is not confined to noncompacted LV segments. These results confirmed some published reports of our group. Recently we analyzed a population of 238 patients affected by noncompaction, and demonstrated that the number of noncompacted segment is uncorrelated with the degree of systolic dysfunction. It is an attractive hypothesis that the systolic dysfunction could be depend on the fibrosis of the left ventricle, itself a consequence of microcirculatory dysfunction, which has been confirmed by reports that describe microvascular dysfunction using myocardial scintigraphy.

Abstract 2386: Asymptomatic Left Ventricular Systolic Dysfunction as a Predictor of Incident Heart Failure and Mortality in the Elderly: The Cardiovascular Health Study

Left ventricular systolic dysfunction (LVSD) is an important predictor of outcomes in heart failure (HF) patients. Adverse effects of LVSD in individuals without heart failure, also known as asymptomatic LVSD (ALVSD), are not well established in the elderly. This study reports outcomes and evaluates the impact of LVSD in elderly subjects with ALVSD. The Cardiovascular Health Study is a multicenter longitudinal cohort study designed to assess cardiac risk factors and outcomes in a community-based population 65 years and older. The incidence of HF and mortality was evaluated in those with ALVSD with a median follow-up of 11.9 years. Cox regression was used, adjusting for demographics and cardiac risk factors, and stratified by severity of LVSD. Incident HF occurred in 39.2% of those with ALVSD vs. 22.8% in those without LVSD (RR = 1.51, CI = 1.25–1.84). Impaired ejection fraction (EF) (&lt; 45%) was associated with more than twice the risk of incident HF than normal systolic function (RR = 2.21; CI 1.67–2.91). Individuals with borderline EF (45–55%) did not have an increased risk of incident HF (RR = 1.21; CI 0.94–1.56). The severity of LVSD was also predictive of mortality: borderline LVSD RR = 1.23 (CI 1.04–1.47) for all-cause mortality and 1.60 (CI 1.26–2.03) for cardiac death; impaired LVSD RR = 1.54 (CI 1.24–1.92) for all-cause mortality and RR = 2.12 (CI 1.60–2.81) for cardiac death. ALVSD is associated with increased risk of heart failure, death, and cardiac death when compared to normal systolic function. Furthermore, the degree of systolic dysfunction has a significant impact in predicting these outcomes in elderly individuals with ALVSD.

Cardiovascular disease in pregnancy

Heart disease continues to be an important cause of maternal morbidity and mortality. This is largely because of the extensive haemodynamic changes that occur during pregnancy, namely the increase in blood volume, fluctuations in cardiac output, fall in systemic vascular resistance and the hypercoagulable state. High-risk periods include the end of the second trimester, during labour and the immediate postpartum period. Prognosis depends on the specific cardiac condition, the patient's functional class, presence of cyanosis, history of cardiac events or arrhythmia and the degree of systolic dysfunction. Pregnancy is contraindicated in women with Eisenmenger's syndrome, pulmonary hypertension, complex cyanotic congenital heart disease, Marfan's syndrome with aortic root dilatation, and those with severe left ventricular dysfunction. Women with heart disease should be thoroughly evaluated and counselled before and during pregnancy. Multidisciplinary care is essential for successful maternal and fetal outcomes.

Extensive myocardial infiltration by hemopoietic precursors in a patient with myelodysplastic syndrome

BackgroundAlthough myocardial infiltration with leukemic blasts is a known finding in patients with acute leukemia, this phenomenon in myelodysplasia is not reported in the literature. Cardiac symptoms in patients with myelodysplasia are often due to anemia and may be due to iron overload and side effects of therapy.Case presentationHerein we report the first case of neoplastic infiltration of the heart with associated myocardial necrosis in a patient with myelodysplasia. It was associated with unicellular and multifocal geographic areas of necrosis in the left ventricle and the interventricular septum. It is likely that cardiac compromise in our patient was due to a combination of restrictive cardiomyopathy due to leukemic infiltration, concomitant anemia, cardiac dilatation, conduction blocks and myocardial necrosis. Myocardial necrosis was most likely due to a combination of ischemic damage secondary to anemia and prolonged hypotension and extensive leukemic infiltration. Markedly rapid decrease in ejection fraction from 66% to 33% also suggests the role of ischemia, since leukemic infiltration is not expected to cause this degree of systolic dysfunction over a 24-hour period. The diagnosis was not suspected during life due to concomitant signs and symptoms of anemia, pulmonary infections, and pericardial and pleural effusions. The patient succumbed to cardiac failure.ConclusionHemopoietic cell infiltration was not considered in the differential diagnosis and contributed to this patient's morbidity and mortality. This case highlights the clinical importance of considering myocardial infiltration in patients with myelodysplasia and cardiac symptoms.