Depressed Left Ventricular Function Research Articles

Left main coronary artery atresia in an infant with Shone’s complex

A 6-month-old infant with Shone's complex was found to have left main coronary artery atresia during evaluation for recurrent subaortic stenosis with depressed left ventricular function. The ventricular function improved after surgical subaortic resection without coronary re-vascularisation. This case demonstrates first the rare finding of left main coronary artery atresia and second that coronary re-vascularisation is not necessarily required in all cases of left main coronary artery atresia.

Invited Commentary

Invited Commentary

Abstract TP440: Heart Failure is Associated With Elevated von Willebrand Factor (vWF) Antigen but not Factor VIII (FVIII) in Acute Ischemic Stroke (AIS)

Introduction: von Willebrand Factor (vWF) and factor VIII (FVIII) contribute to thrombosis and are important risk factors in acute ischemic stroke (AIS). Elevated vWF has been correlated with depressed left ventricular (LV) function, but has not been examined in a cohort of patients with AIS, particularly with regard to concurrent elevation in FVIII. Hypothesis: We hypothesized that vWF is associated with HF and that combined elevation of vWF and FVIII would strengthen this association. Methods: From our prospective stroke registry, AIS patients >18 years of age admitted from 09/2011 to 01/2015 were included if both FVIII and vWF were measured during hospitalization and an echocardiogram was performed. Comparisons were done between the following groups: patients with normal (-) vs. elevated (+) vWF, patients with (-) vs. (+) FVIII, and patients with (-) vs. (+) levels of both factors. Results: Of 1,091 patients in the study period, 212 patients met inclusion criteria. In all groups, patients differed significantly according to history of DM. +vWF had higher frequency of female gender than -vWF, but did not differ according to any other demographic or baseline characteristics. +vWF patients had higher frequency of HF (p=0.007) and higher frequency of depressed LV function (p=0.028) compared to those with -vWF. vWF level correlated with HF (r=0.189, p=0.006) and reduced LV function (r=0.187, p=0.006). Similar findings were found with dual elevation, but we found no relationship between FVIII and HF. After adjustment for HTN, CAD, and DM, vWF remained an independent predictor of HF (OR 1.003, 95%CI 1.000-1.007, p=0.036). While we found no relationship between LV function and FVIII level, median vWF levels increased with decreasing LV function (p=0.027). Conclusion: The results of our study suggest an association between HF and elevated vWF in the setting of AIS, irrespective of FVIII elevation. These results suggest the potential utility of vWF as an independent biomarker for heart failure in the AIS patient population.

A Novel Approach for Identifying Ischemic Cardiomyopathy.

Refer to the page 41-47 Since Burch et al.1) first introduced the terminology cardiomyopathy (ICM), it has been widely used in clinical practice. The condition may originate from prolonged ischemia, a single large infarct, or repeated micro-infarcts inducing left ventricular dysfunction and remodeling through apoptosis and fibrosis as a result of activation of the endothelin or renin-angiotensin-aldosterone system.2) It can be reversed after successful revascularization in the presence of a viable myocardium. However, there have been several debates about the actual existence of that kind of cardiomyopathy. Because traditionally cardiomyopathy is a result of a genetically or acquired disease-driven myopathic processes, current WHO criteria do not include in the classification of cardiomyopathy.3) But in many clinical practices and studies, an initial classification as or is widely used in patients with severely depressed left ventricular function. Use of the terminology ICM or non-ICM persists in spite of a lack of official guidelines because it can provide a simple and easily communicated understanding of the underlying pathogenesis and treatment options. A myocardium that is malfunctioning from prolonged ischemia can be improved after successful revascularization treatment, such as coronary artery bypass surgery. If a patient is classified as non-ICM, then a search for other causes must be begun. However, the current definition of is vague and cannot fully explain the cause of severely depressed left ventricular dysfunction.4) In addition, as a previous study showed, with post-myocardial infarction has a far different prognosis from without post-myocardial infarction5); the underlying causes of non-post myocardial infarction are very complex and cannot be easily explained by the concept of a hibernating myocardium. This complexity may explain the unexpected dearth of positive outcomes in the Surgical Treatment for Ischemic Heart Failure trial, such as improved survival, according to viability tests, following bypass surgery in patients with ICM.6) In this regard, a study done by Kim et al.7) provides important insight about possible misclassification as or based on the traditional definition using coronary angiography and a history of previous myocardial infarction. According to their observations with delayed hyper-enhancement (DHE)-cardiac magnetic resonance (CMR), some cases classified as had non-ischemic DHE patterns, such as midwall striae, patch, or subepicardial DHE. Also, a small portion of patients had ischemic DHE patterns, such as subendocardial DHE. They suggested that the classification of should be individualized after considering DHE-CMR findings. According to their observations, some patients with showed midwall linear DHE, which is a unique finding related to prognosis in cases.8) It provides new insight into the pathology of left ventricular dysfunction in these patients and also the pathophysiology of midwall DHE, which is believed to be from prior myocarditis or an increase in gadolinium diffusion distance due to high wall stress.9) However, no satisfactory explanation has been proposed because usually the amount of interstitial fibrosis is highest in the subepicardium, not the midwall, in patients.10) The study done by Kim et al.7) has a limitation in that identification of without prior myocardial infarction requires evaluation for the presence of myocardial perfusion defects because DHE only represents replacement fibrosis. Therefore, patients without DHE and with non-DHE regions also need to be characterized to explain severely depressed left ventricular systolic function. To overcome this limitation, inclusion of new parameters such as myocardial flow reserve or extracellular space volume fraction would be helpful. In addition, a large-scale study can provide clarity on the clinical characteristics of this discordant population.

The Significance of Shocks in Implantable Cardioverter Defibrillator Recipients.

Large-scale implantable cardioverter defibrillator (ICD) trials have unequivocally shown a reduction in mortality in appropriately selected patients with heart failure and depressed left ventricular function. However, there is a strong association between shocks and increased mortality in ICD recipients. It is unclear if shocks are merely a marker of a more severe cardiovascular disease or directly contribute to the increase in mortality. The aim of this review is to examine the relationship between ICD shocks and mortality, and explore possible mechanisms. Data examining the effect of shocks in the absence of spontaneous arrhythmias as well as studies of non-shock therapy and strategies to reduce shocks are analysed to try and disentangle the shocks versus substrate debate.

Cardiac dyssynchrony and response to cardiac resynchronisation therapy in heart failure: can genetic predisposition play a role?

Cardiac resynchronisation therapy (CRT) is an accepted treatment for heart failure patients with depressed left ventricular (LV) function and dyssynchrony. However, despite better clinical outcome and improved cardiac function after CRT in the majority of eligible heart failure patients, a large proportion of implanted patients do not seem to benefit clinically from this therapy. In this review we consider whether genetic factors may play a role in modulating response to CRT and summarise the few genetic studies that have investigated the role of genetic variation in candidate genes.

Case report: severe reversible cardiomyopathy associated with systemic inflammatory response syndrome in the setting of diabetic hyperosmolar hyperglycemic non-ketotic syndrome

BackgroundThis case study features a woman who presented with clinical and laboratory findings consistent with hyperosmolar hyperglycemic non-ketotic syndrome (HHNS), systemic inflammatory response syndrome (SIRS), and non-thyroidal illness syndrome (NTIS) who was noted to have a transient decrease in myocardial function. To our knowledge, this is the first case discussing the overlapping pathophysiological mechanisms could increase susceptibility to SIRS-induced cardiomyopathy. It is imperative that this clinical question be investigated further as such a relationship may have significant clinical implications for prevention and future treatments, particularly in patients similar to the one presented in this clinical case.Case presentationA 53-year old Caucasian female presented to the Emergency Department for cough, nausea, vomiting and “feeling sick for 3 weeks.” Labs were indicative of diabetic ketoacidosis. Initial electrocardiograms were suggestive of possible myocardial infarction and follow-up echocardiogram showed severely depressed left ventricular systolic function which resolved upon treatment of ketoacidosis.ConclusionWe suggest that her cardiomyopathy could have three synergistic sources: SIRS, HHNS and NTIS. Overlapping mechanisms suggest uncontrolled diabetes mellitus and NTIS could increase susceptibility to SIRS-induced cardiomyopathy as seen in this case. HHNS and SIRS cause cardiac tissue injury through mechanisms including impairment of fatty acid oxidation and formation of reactive oxygen species, as well as modifying the function of membrane calcium channels. As a result, it is conceivable that diabetes may amplify the deleterious effects of inflammatory stressors on cardiac myocytes. This novel case report offers a path for future research into prevention and treatment of SIRS-induced cardiomyopathy in, but not exclusive to, the setting of diabetes.

How should I treat a significant and inoperable left main coronary atherosclerotic disease (LMCAD) in the setting of a severely depressed left ventricular systolic function and severe aorto-iliac atherosclerotic disease?

How should I treat a significant and inoperable left main coronary atherosclerotic disease (LMCAD) in the setting of a severely depressed left ventricular systolic function and severe aorto-iliac atherosclerotic disease?

Treatment of acute heart failure

Acute heart failure is a symptom complex of heterogeneous etiology. Clinically, it comprises a broad spectrum ranging from hypertensive pulmonary edema in patients with preserved left ventricular systolic function up to cardiogenic shock in patients with severely depressed left ventricular function. The pathophysiology of acute heart failure is based on a mismatch between myocardial pump function and afterload. Besides causal measures, vasodilators and diuretics are the mainstay of therapy. Catecholamines are indicated only when other drugs are unsuccessful. Opioids are often used in clinical practice but should be used cautiously as they are associated with a negative prognosis. Further adjunctive treatment consists of thromboembolism prophylaxis, non-invasive ventilation and in some cases mechanical circulatory support and renal replacement therapy. This article discusses the differential use of these treatment modalities.

Successful Treatment of a Giant Left Atrial Mass Stemming from Pulmonary Vein after Chemotherapy-radiotherapy Combination in a Patient with Lung Adenocarcinoma

A 66-year-old male presented with fatigue, weakness, haemoptysis and severe dyspnoea for two weeks. On physical examination, heart rate was 80 beats/min, blood pressure was 110/80 mmHg and bilateral crepitant rales up to the mid zone of the lungs. Surface ECG showed sinus rhythm. Transthoracic echocardiography revealed moderate depression of left ventricular function (ejection fraction: 40%) and left atrial mass. To confirm the diagnosis, we also performed a transoesophageal echocardiography and demonstrated a lobulated mass with a diameter of 30x25 mm in the left atrium and compression of the mass to superior vena cava (Figure 1A, 1B). Cardiac magnetic resonance imaging (CMRI) confirmed the findings in the transoesophageal echocardiography (Figure 1C). Thoracic computed tomography demonstrated a mass with a diameter of 52x36 mm in the

Reassessing noninducibility as ablation endpoint of post-infarction ventricular tachycardia: the impact of left ventricular function.

Noninducibility is frequently used as procedural end point of ventricular tachycardia (VT) ablation after myocardial infarction. We investigated the influence of left ventricular (LV) function on the predictive value of noninducibility for VT recurrence and cardiac mortality. Ninety-one patients (82 men, 67±10 years) with post-myocardial infarction VT underwent ablation between 2009 and 2012. Fifty-nine (65%) had an LV ejection fraction (EF) >30% (mean 41±7) and 32 (35%) an LVEF≤30% (mean 20±5). Thirty patients (51%) with EF>30% and 13 (41%) with EF≤30% were noninducible after ablation (P=0.386). During a median follow-up of 23 (Q1-Q3 16-36) months, 35 patients (38%) experienced VT recurrences and 17 (18%) cardiac death. At 1 year follow-up, survival free from VT recurrence and cardiac death for patients with LVEF>30% was 80% (95% confidence interval [CI], 70-90) compared with 42% (95% CI, 33-51) for those with LVEF≤30% (P=0.001). Noninducible patients with LVEF>30% had a recurrence-free survival from cardiac death of 90% (95% CI, 71-100) compared with 65% (95% CI, 47-83) for inducible patients (P=0.015). In the subgroup of patients with LVEF≤30%, the survival free from VT recurrence and cardiac death was 31% (95% CI, 0%-60%) for noninducible compared with 39% (95% CI, 27-52) for those who remained inducible (P=0.842). Noninducible patients with moderately depressed LV function have a favorable outcome compared with patients who remained inducible after ablation. On the contrary, patients with severely depressed LV function have a poor prognosis independent of the acute procedural outcome.

Cardiac resynchronization therapy: past, present, and future.

Cardiac resynchronization therapy (CRT), or biventricular pacing, has become a standard therapeutic modality for patients with symptomatic heart failure (HF), depressed left ventricular (LV) function, and electrical dyssynchrony. Despite the overall success of CRT in improving morbidity and mortality in selected patients with HF, a significant minority demonstrates nonresponse. This review describes the electrical and physiologic rationale for biventricular pacing therapy, summarizes landmark clinical trials assessing CRT efficacy, highlights strategies to optimize the response to CRT, and frames future challenges in the use, delivery, and care of patients undergoing CRT.

EFFECT OF BETA-BLOCKADE ON CARDIOVASCULAR EVENT RATES IN PATIENTS WITH ASYMPTOMATIC AORTIC STENOSIS

Beta-blockers (BB) are frequently avoided in aortic stenosis (AS) patients because of fear of depression of left ventricular function. We evaluated if BB increased the risk of cardiovascular events in patients with mild to moderate AS. Post-hoc analysis from the Simvastatin and Ezetimibe in Aortic

Inappropriate use of digoxin in patients presenting with digoxin toxicity.

BackgroundDigoxin remains widely used today despite its narrow therapeutic index and toxicity. The objective of this study was to investigate the percentage of inappropriate use of digoxin and long-term outcomes of elderly patients hospitalized for digoxin toxicity.MethodsThe study included 99 consecutive patients hospitalized for digoxin toxicity. The other study criteria for the inappropriate use of digoxin was regarded if participants having depressed left ventricular systolic function (ejection fraction < 45%) who were not on optimal medical therapy including beta-blocker and angiotensin-converting-enzyme inhibitor therapy or if participants having permanent AF who were not on optimal beta-blocker therapy.ResultsAppropriate digoxin usage was confirmed in 33 of patients in spite of its narrow therapeutic index. A total of 16 of 99 patients died, with a mean follow-up time of 22.1 ± 10.3 months.ConclusionsContrary to popular belief, the rate of inappropriate digoxin usage remains high. On account of its narrow therapeutic index and toxicity, digoxin should be used more carefully according to the current evidence and guidelines.

Oral Abstract session: Stress echo in clinical practice: Friday 5 December 2014, 08:30-10:00 * Location: Agora

Oral Abstract session: Stress echo in clinical practice: Friday 5 December 2014, 08:30-10:00 * Location: Agora

Individualized cardiac resynchronization therapy: current status

Individualized cardiac resynchronization therapy: current status Martin H Ruwald,1,2 Niels E Bruun1,3 1Department of Cardiology, Gentofte Hospital, Hellerup, Denmark; 2Heart Research Follow-up Program, Division of Cardiology, University of Rochester Medical Center, Rochester, NY, USA; 3Clinical Institute, Aalborg University, Aalborg, Denmark Abstract: Cardiac resynchronization therapy (CRT) has shown a substantial reduction in heart failure patient morbidity and mortality, with improvement in quality of life as well as symptoms. The therapy is, however, limited to approximately 10%&ndash;15% of heart failure patients and, typically, 30% do not derive benefit from the device. For optimal outcomes with CRT, the correct selection of patients is of paramount importance. The first parameter is depressed left ventricular systolic function, and the second is a wide QRS complex. Different nuances among clinical trials have rendered guidelines pragmatic and compromising, but also conflicting and confusing. A large proportion of real-life CRTs are implanted in patients where the evidence for benefit is scarce or not present. Further, for optimal benefit, patients require evidence-directed medical therapy at maximal doses, effective placement of ventricular leads, and high biventricular pacing percentages, along with optimized atrioventricular (AV) and interventricular interval device programming. These items, as well as specific clinical characteristics, such as AV block and atrial fibrillation, in the context of CRT indications, are discussed. This review focuses on these issues to guide the clinician through guidelines, with an evidence-based update on the current status of CRT. Keywords: Cardiac resynchronization therapy, prognosis, review, biventricular pacing, guideline, indications&nbsp;

Transapical aortic valve implantation in patients with poor left ventricular function and cardiogenic shock

In line with our institutional no exclusion policy we accept patients with very poor left ventricular performance and cardiogenic shock for transcatheter aortic valve implantation (TAVI). The purpose of our study was to analyze outcome in these patients and to identify what happens to the left ventricular function after TAVI in patients with failing ventricles. Between April 2008 and August 2013, 730 patients underwent transapical TAVI at our institution. The study group consisted of all 104 patients who presented with severely depressed left ventricular function, defined as left ventricular ejection fraction (LVEF) ≤ 30%. Based on the Society of Thoracic Surgeons predicted risk of mortality, the arithmetic risk for surgery in the study cohort was 23% ± 19% (2%-90%), and 23 patients (22%) were in cardiogenic shock. Excluding patients in cardiogenic shock, the survival rates in the study group at 1, 2, and 4 years were 81% ± 5%, 65% ± 6%, and 45% ± 8%, respectively. Patients in cardiogenic shock showed significantly worse outcome (P = .048). Improvement in LVEF of 50% or more was found in 74 patients (71%) and 100% or more improvement in 45 patients (43%). Early improvement in LVEF was significantly (P = .049) greater in patients with preoperative values of LVEF ≤ 20%. In the majority of patients with failing ventricles, left ventricular function is quickly restored after TAVI and elimination of aortic stenosis. Without the additional trauma of cardioplegic arrest, TAVI is the potentially superior treatment option in patients with poor and very poor left ventricular performance.

Assessing the interaction of respiration and heart rate in heart failure and controls using ambulatory Holter recordings

Breathing is a critical component of cardiopulmonary function, but few tools exist to evaluate respiration in ambulatory patients. Holter monitoring allows accurate diagnosis of a host of cardiac issues, and several investigators have demonstrated the ability to detect respiratory effort on the electrocardiogram. In this study we introduce a myogram signal derived from 12-lead, high frequency Holter as a means of detecting respiratory effort. Using the combined myogram and ECG signal, four novel variables were created: total number of Cheyne–Stokes episodes; the BWRatio, the ratio of power (above baseline) measured one second after peak-to-peak respiratory power, an assessment of the “shape” of the respiratory effort; DRR, the change in RR interval centering around peak inspiration; and minutes of synchronized breathing, a fixed ratio of heart beats to respiratory cycles. These variables were assessed in 24-hour recordings from three cohorts: healthy volunteers (n=33), heart failure subjects from the GISSI HF trial (n=383), and subjects receiving implantable defibrillators with severely depressed left ventricular function enrolled in the M2Risk trial (n=470). We observed a statistically significant 6-fold increase in the number of Cheyne–Stokes episodes (p=0.01 by ANOVA), decreases in BWRatio (p<0.001), as well as decrease in DRR in heart failure subjects; only minutes of synchronized breathing was not significantly decreased in heart failure. This study provides “proof of concept” that novel variables incorporating Holter-derived respiration can distinguish healthy subjects from heart failure. The utility of these variables for predicting heart failure, arrhythmia, and death risk in prospective studies needs to be assessed.

Prevalence of myocardial infarction in congestive heart failure patient at emergency room of Rajavithi Hospital

Background: Congestive heart failure is a common condition and along with myocardial ischemia is a global public health problem. In the emergency room, myocardial infarction and uncontrolled hypertension are also found among patients who present with dyspnea from congestive heart failure. Therefore, the researchers chose to study the prevalence of acute myocardial infarction in congestive heart failure patients who presented at the emergency room of Rajavithi Hospital. Improving the screening of patients presenting at the emergency room with congestive heart failure will produce better treatment in the future. Objectives: To determine the prevalence of acute myocardial infarction and prevalence of preserved left ventricular function of patients who present at the emergency room of Rajavithi Hospital. Method: The study enrolled 91 heart failure patients who presented at the emergency room of Rajavithi Hospital from 1 July 2011 to 31August 2012. A cross-sectional descriptive study was conducted to determine the prevalence of acute myocardial infarction based on universal definition of myocardial infarction and prevalence of heart failure with preserved left ventricular function. The data were collected from medical records of patients. Statistics and data analysis included percentage, mean and standard deviation using the SPSS version 11.5. Results: Of the patients, 91 were female (53.8%), mean age was 66.406±12.52 years, main underlying diseases were hypertension and diabetes mellitus. The prevalence of myocardial infarction in this study was 14.13% (13 patients), and patients with an acute myocardial infarction association were male. The overall body height was higher than in subjects having diabetic mellitus with chronic kidney disease. Patients and CK-MB enzyme level elevations were higher compared with those without myocardial infarction. Mean left ventricular ejection fraction was 44.996±18.894%, and preserved left ventricular function was 51.6% (47 patients). Therefore, depressed left ventricular function was significantly found among male patients when compared with the preserved left ventricular function group. Conclusion: The prevalence of myocardial infarction in congestive heart failure patients was studied. Male patients having diabetes mellitus or chronic kidney disease should be more concerned about myocardial infarction than other population groups. Preserved left ventricular function was associated with a few heart failure cases. Males require earlier detection of the left ventricular function than females.

Nuclear cardiology: 2014 innovations and developments.

Nuclear cardiac imaging is acknowledged as a robust technique for clinically assessing patients with a wide spectrum of cardiac illnesses. Recent technical, radiotracer, and stressor advancements continue to expand the role of nuclear cardiology for the accurate diagnosis and prognostication of patients with known or suspected coronary artery disease. The introduction of I-123 MIBG represents another advance for assessing risk in patients with congestive heart failure and depressed left ventricular (LV) function. Software and hardware innovations and recent shifts in acquisition protocols have greatly improved image quality, reduced cost and radiation exposure, and continue to promote patient and physician satisfaction. The following article will highlight recent achievements in the field that continue to foster a patient-centered imaging approach.