Dilated Cardiomyopathy In Sinus Rhythm Research Articles

Comparative prognostic importance of measures of left atrial structure and function in non-ischaemic dilated cardiomyopathy.

To compare the association between measures of left atrial (LA) structure and function, derived from cardiovascular magnetic resonance (CMR), with cardiovascular (CV) death or non-fatal heart failure (HF) events in patients with non-ischaemic dilated cardiomyopathy (DCM). CMR studies of 580 prospectively recruited patients with DCM in sinus rhythm (median age 54 [interquartile range 44-64] years, 61% men, median LVEF 42% [30-51%]) were analysed for measures of LA structure (left atrial maximum volume index [LAVImax], left atrial minimum volume index [LAVImin]) and function (left atrial emptying fraction [LAEF], left atrial reservoir strain [LARS], left atrial conduit strain [LACS] and left atrial booster strain [LABS]). Over median follow-up of 7.4 years, 103 patients (18%) met the primary endpoint. Apart from LACS, each measure of LA structure and function was associated with the primary endpoint after adjusting for other important prognostic variables. The addition of each LA metric to a baseline model containing the same important prognostic covariates improved model discrimination, with LAVImin providing the greatest improvement (C-statistic improvement: 0.702 to 0.738; χ2 test comparing likelihood ratio p < 0.0001; categorical net reclassification index: 0.210 (95% CI 0.023-0.392)). Patients in the highest tercile of LAVImin had similar event rates to those with persistent atrial fibrillation. Measures of LA strain did not enhance model discrimination above LA volumetric measures. Measure of left atrial structure and function offer important prognostic information in patients with DCM and enhance prediction of adverse outcomes. LA strain was not incremental to volumetric analysis for risk prediction.

Combined left and right atrial stiffness index as an independent predictor of rehospitalization in dilated cardiomyopathy

Abstract Background Left atrial stiffness index (LASI) derived from speckle-tracking echocardiography (STE) is a marker of pressure transfer to the pulmonary circulation and a predictor of symptoms in patients with heart failure (HF). However, the role of the right atrial stiffness index (RASI) in the setting of left-sided HF is incompletely understood. Purpose We sought to evaluate the left, right and combined bi-atrial stiffness index (BASI) in a cohort of patients with dilated cardiomyopathy (DCM) and to assess their prognostic role. Methods We prospectively enrolled 60 consecutive patients with DCM in sinus rhythm, who underwent transthoracic echocardiography. As previously described, LASI was defined as the ratio between early diastolic transmitral flow velocity/lateral mitral annulus myocardial velocity (E/e') and left atrial reservoir strain derived from STE. RASI was defined as the ratio between early diastolic tricuspid flow velocity/lateral tricuspid annulus myocardial velocity (Et/e't) and right atrial reservoir strain. BASI was defined as the sum of LASI and RASI. Patients were followed for 19±9 months for an endpoint of HF decompensation requiring hospitalization. Results 29 patients reached the endpoint. Patients with rehospitalization had higher LASI (2.50±2.15 vs. 1.23±1.61, p=0.01), higher RASI (0.76±0.77 vs. 0.36±0.41, p=0.02) and higher BASI (3.25±2.65 vs. 1.59±1.71, p=0.006). In univariate Cox regression, all three stiffness indices were predictors of adverse outcome: HR=2.63 [95% CI, 1.22–5.66], p=0.014 for LASI, HR=2.86 [95% CI, 1.26–6.48], p=0.012 for RASI, HR=3.49 [95% CI, 1.49–8.20], p=0.004 for BASI. A multivariable model was constructed using well-established event predictors in DCM. After adjustment for age, left ventricular ejection fraction and indexed maximal left atrial volume, BASI was the only stiffness index that remained an independent predictor of rehospitalization for HF: HR=2.76 [95% CI, 1.08–7.03], p=0.03. In ROC analysis, a BASI greater than 1.25 had a 75.9% sensitivity and 64.5% specificity for event prediction (AUC=0.716, p=0.004). Conclusion Stiffness of both atria is significantly greater in patients with DCM who get hospitalized for HF decompensation. Combining the left and right atrial stiffness indices provides a better prognostic stratification than left or right atrial stiffness alone, since BASI was the only stiffness index that remained an independent predictor of rehospitalization after adjustment for confounders. Funding Acknowledgement Type of funding sources: None.

Predictors of Spontaneous Echo Contrast in Left Heart Chambers in Patients with Dilated Cardiomyopathy: Slowing Down Might not Always Mean Enjoying Life.

Introduction:Spontaneous echo contrast(SEC) is usually detected in heart chambers as a result of reduced flow velocity in the cavity. The clinical importance of SEC lies in its association with embolic events. The aim of our study was to determine the frequency of SEC in left heart chambers in sinus rhythm patients with dilated cardiomyopathy and predictors for its emergence.Materials and Methods:This was a prospective cross-sectional transesophageal echocardiography study conducted in 101 sinus rhythm patients with dilated heart and mild-to-moderate systolic dysfunction.Results:Moderate-degree SEC was found in the left ventricle(LV) in around 9% of patients, in the left atrium(LA) in 12% and in left atrial appendage(LAA) in 40%. Multiple regression analysis showed that lower heart rate(95% confidence interval[CI]: 0.845–0.978; P = 0.011) and larger LV end-systolic diameter(LVESD)(95% CI: 1.034–1.394; P = 0.017) were independent predictors for LV SEC presence. Lower LV ejection fraction(LVEF) (95% CI: [−0.079]–[−0.037]; P = 0.0001) was the only independent predictor for SEC in the LA. Whereas, independent predictors for SEC in LAA were lower heart rate(95% CI:[−0.030]–[−0.003]; P = 0.018), greater LA indexed diameter (95% CI: 0.016–0.116; P = 0.010), and higher value of C-reactive protein(CRP)(95% CI: 0.0026–0.031; P = 0.027).Conclusions:SEC in left heart chambers is a frequent finding in patients with dilated cardiomyopathy in sinus rhythm. Lower heart rate and LVEF, larger LVESD and LA, as well as higher CRP, predict the presence of SEC in left heart chambers. Lower heart rate might be an essential predictor for SEC presence and severity in these patients.

Spontaneous echo-contrast in LV non-ischemic dilated cardiomyopathy in sinus rhythm. What therapy to prevent cardio-embolic events?

Spontaneous echo-contrast in LV non-ischemic dilated cardiomyopathy in sinus rhythm. What therapy to prevent cardio-embolic events?

Left Ventricular and Left Atrial Thrombi in Sinus Rhythm Patients with Dilated Ischemic Cardiomyopathy

Ischemic dilated cardiomyopathy offers a favorable terrain for left ventricular (LV) thrombus formation; however, left artial appendage (LAA) may be an additional source of thrombi in patients with dilated heart. The main objectives of this study were to determine the prevalence of LV and LAA thrombi in patients with chronic ischemic dilated cardiomyopathy in sinus rhythm, as well as to reveal echocardiographic predictors for thrombus formation. The study included 57 patients with chronic dilated ischemic cardiomyopathy in sinus rhythm, who were not under oral anticoagulation therapy. Exclusion criteria included patients with: swallowing problems, acute myocardial infarction, idiopathic and/or non-ischemic dilated cardiomyopathy, atrial fibrillation/flatter, severe systolic dysfunction. Transthoracic echocardiography and transesophageal echocardiography were obtained for each patient. Mean patient age was 62 +/- 10.5 years, mean LV end diastolic diameter was 67.2 +/- 5.8 mm, whereas mean LV ejection fraction (EF) was 37.1 +/- 4.3%. LV thrombus was detected in 11 (19.3%) patients; while 23 (40.3%) patients had LAA thrombus. In a multiple regression analysis LV size (p = 0.05) and lack of aspirin therapy (p = 0.02) showed to be independent LV thrombus predictors, whereas lower LV EF (p = 0.02) and larger LAA maximal area (p = 0.004) demonstrated to be independent predictors of LAA thrombus. We consider that our study sheds light to the high possibility of LAA thrombi formation in addition to LV thrombi in patients with chronic dilated ischemic cardiomyopathy in sinus rhythm. LV size, LV EF, LAA maximal area and lack of aspirin therapy are shown to be independent predictors of left heart chamber thrombi in this patient category.

Relationship of Left Ventricular Size to Left Atrial and Left Atrial Appendage Size in Sinus Rhythm Patients with Dilated Cardiomyopathy

Introduction:Thromboembolic events are a frequent cause of mortality in patients with congestive heart failure. The aim of or study was to evaluate the relationship of left ventricular end diastolic diameter (LVEDD) to left atrial (LA) size and left atrial appendage (LAA) size in patients with dilated cardiomyopathy in sinus rhythm, as well as to determine the prevalence of thrombi in LV and LA /LAA.Methods:This was a prospective cross-sectional study, conducted from December 2009 until December 2011. The study included 95 patients with dilated cardiomyopathy in sinus rhythm. Patients with swallowing problems, acute myocardial infarction, atrial fibrillation/flatter, severe systolic dysfunction, and/or patients who were taking oral anticoagulation therapy were excluded.Results:Mean patient age was 58.6 ± 12.2 years and 68.4% were men. Mean LVEDD of our population was 66.5 ± 6.5 mm, while mean LA atrium, LA volume and LAA maximal area were 46 ± 5.1 mm, 87.2 ± 38.7 cm3 and 4.7 ± 1.2 cm2, respectively. LA diameter (p<0.001) and LAA maximal area (p=0.01) showed to be independent predictors of LV size. LV thrombus was detected in 13 (13.7%) patients, while LAA thrombus in 46 (48.4%) patients of our study population.Conclusions:In conclusion, dilated LV size is associated with enlarged LA and LAA size. On the other hand, dilation of LV, LA and LAA is related to high prevalence of left chamber cardiac thrombi.

Exercise-induced hemostatic activation in patients with dilated cardiomyopathy in sinus rhythm

Abnormalities of baseline hemostatic variables have been related to a hypercoagulable state in patients with chronic heart failure (CHF). Given that physical exercise leads to an activation of coagulation physiologically, this study addressed the question of whether the exercise-induced hemostatic activation is enhanced in patients with CHF. Ten patients with dilated cardiomyopathy (ejection fraction < 40%) and 10 healthy individuals (matched for sex, age and body mass index) were subjected to a maximal exercise test on a bicycle ergometer. Healthy subjects performed a second exercise test at a submaximal intensity level, in which oxygen consumption (VO2) was adjusted to the peak oxygen consumption (VO2peak) of the corresponding patient. Exercise testing had only marginal effects on markers of thrombin formation in patients and healthy individuals alike. In patients with CHF, exercise-induced changes in fibrinopeptide A, an index of fibrin formation, paralleled those observed in controls after submaximal exercise whereas most pronounced changes occurred in healthy subjects after maximal exercise. Plasmin-antiplasmin complexes increased almost three-fold with maximal exercise in both groups, thus indicating a marked formation of plasmin. Maximal physical exercise does not induce an exaggerated formation of thrombin and fibrin in CHF patients. The fibrinolytic response to exercise in terms of plasmin formation is not compromised in patients with dilated cardiomyopathy.

Prognostic Value of Pacing-Induced Mechanical Alternans in Patients With Mild-to-Moderate Idiopathic Dilated Cardiomyopathy in Sinus Rhythm

The relation between the occurrence of pacing-induced mechanical alternans and prognosis in patients with mild-to-moderate idiopathic dilated cardiomyopathy (IDCM) in sinus rhythm was investigated prospectively. The myocardial expression of genes for Ca2+-handling proteins in such patients was also examined. Mechanical alternans occurs in some patients with severe heart failure, but the relation between the occurrence of mechanical alternans and prognosis in patients with IDCM has remained unknown. Left ventricular (LV) pressure was measured during atrial pacing, and LV endomyocardial biopsy specimens were collected in 36 IDCM patients and 8 controls. Idiopathic dilated cardiomyopathy patients were divided into two groups consisting of 22 individuals who did not develop mechanical alternans at heart rates up to 140 beats/min (group A) and of 14 individuals who did (group B). The patients were followed up for a mean of 3.7 years. There was no significant difference in LV ejection fraction or the plasma concentration of brain natriuretic peptide between groups A and B. The myocardial abundance of ryanodine receptor 2 messenger ribonucleic acid (mRNA) was significantly lower in groups A and B than in controls, whereas that of sarcoplasmic reticulum Ca2+-ATPase mRNA was significantly lower in group B than in group A or controls. Stepwise multivariate analysis identified pacing-induced mechanical alternans as the strongest predictor of cardiac events. Event-free survival in group A was significantly greater than that in group B. The occurrence of pacing-induced mechanical alternans is a potentially useful indicator of poor prognosis in patients with mild-to-moderate IDCM in sinus rhythm.

Doppler-derived mitral and pulmonary venous flow variables are predictors of pulmonary hypertension in dilated cardiomyopathy.

This study assessed whether Doppler-derived mitral and pulmonary venous flow parameters were predictors of pulmonary artery hypertension in patients with left ventricular dysfunction. Doppler echocardiographic examinations were performed in patients (n = 100) with dilated cardiomyopathy in sinus rhythm either symptomatic or asymptomatic before and after optimized therapy with ACE inhibitors, diuretics, and vasodilators. In case of weak or poor Doppler signals, measurable tricuspid regurgitation and pulmonary venous flow tracings were obtained after intravenous administration of 2.5 grams of Levovist at 400 mg/ml. At baseline, left ventricular ejection fraction was 30% +/- 7% and pulmonary artery systolic pressure was 48 +/- 14 mmHg. At the follow-up study carried out after 6 +/- 2 months, reversibility of pulmonary artery hypertension was apparent only in those patients exhibiting favorable changes of mitral flow curve from the restrictive or pseudonormal to impaired relaxation pattern (53 +/- 7 mmHg vs 38 +/- 8 mmHg; P < 0.0001). Numerous variables correlated significantly with pulmonary artery systolic pressure at baseline, while the correlations were generally weaker at the follow-up study. The closest correlations were found with E wave deceleration rate (r = 0.73) at baseline and with the systolic fraction of pulmonary venous flow forward peak velocities (r = -0.67) at follow-up. The stepwise regression model showed that the E wave deceleration rate and the degree of mitral regurgitation were the strongest independent predictors of pulmonary hypertension at baseline, while the ratio between pulmonary venous flow reverse and mitral wave velocities at atrial systole and ejection fraction added minor contributions, leading to a cumulative r value of 0.81. The systolic fraction was the strongest at the follow-up study, with minor contributions provided by the E wave deceleration rate and the left atrial dimension index, leading to a cumulative r value of 0.71.

Prognostic value of mechanical efficiency in ambulatory patients with idiopathic dilated cardiomyopathy in sinus rhythm

ObjectivesThe purpose of this study was to determine, by analyzing the pressure-volume relationship, the prognostic value of parameters related to myocardial energetics for predicting mortality in patients with dilated cardiomyopathy (DCM) in sinus rhythm. BackgroundThe relationship between the myocardial energetics and the prognosis of patients with DCM in sinus rhythm remains unclear. MethodsWe followed 114 ambulatory patients with nonischemic DCM in sinus rhythm for a mean period of 5.8 ± 3.9 years. Over 70% of our patients were in New York Heart Association functional class I and class II. Pressure-volume data were obtained by the conductance method, and myocardial oxygen consumption per beat (Vo2) measurements were obtained. ResultsThe 3-, 5-, and 10-year cumulative survival rates were 88.6%, 80.0%, and 73.9%, respectively. Of the 114 patients, 47 were selected randomly to assess their myocardial energetics. By univariate analysis, the mechanical efficiency (ME, external work/Vo2), left ventricular (LV) ejection fraction and the LV end-diastolic pressure were statistically associated with cardiac death. The ME was the strongest predictor of survival in a Cox proportional-hazards analysis (p = 0.011). The best cutoff point of ME identified by the receiver-operating curve was 11%. This value had a sensitivity of 100%, a specificity of 87% and an overall predictive accuracy of 88% to distinguish survivors from nonsurvivors. ConclusionsThis study clearly demonstrates that ME is a powerful clinical predictor for cardiac death in patients with mild to moderate heart failure and with sinus rhythm. Whether these conclusions apply to patients with more severe heart failure requires further investigations.