non-ICM Patients Research Articles

Optimization of biventricular cardiac resynchronization improves cardiac power and atrial kinetics in patients with systolic heart failure with often hospitalizations for decompensation

Abstract Cardiac resynchronization therapy (CRT) reduces symptoms and improves left ventricular function in patients with heart failure due to left ventricular systolic dysfunction and cardiac dyssynchrony. In this work the biochemical, clinical and echocardiographic outcome of optimizing CRT (optCRT) function by the optimal VTI value of left ventricular outflow track. Methods 80 NYHA III patients (68±10 years; 75% men; 53% ischemic cardiomyopathy-ICM), under optimal tolerated medical therapy, with standard BVP indication, having been implanted with a CRT system. Echocardiographic measurements, including aortoventricular coupling (VAC) calculation, 6-min-walking-test and quality of life (MLHF questionnaire) were measured at baseline, 6 months on optCRT. Cardiac power (CP) was calculated according the equation: CP=Cardiac Output x Mean Aortic Pressure/451. Results End-systolic volume of left ventricle was reduced (p=0.001) in both ischemic and non-ICM; while max left atrial volume was reduced only in non-ICM patients (72.1±32 to 65.8±30, p=0.04). Global longitudinal strain was improved in non ICM patients (p=0.015). Systolic strain of right ventricle was improved in non-ICM (9.4±2.2 to 10.7±2.3 vs. 8.7±3 to 8.9±3.2, p=0.03 for non-ICM); while left atrial function and the ratio E to E TDI of mitral annulus were not improved in either group. Non-ICM patients improved VAC (baseline: 1,36±0,3; CRT: 1.11±0.2; p=0.01) and CP (baseline 660±160 to 782±260, p=0.001); while no significant improvement was detected to ICM patients. 6-min-walk test was improved up to 30% (p=0.05). NtproBNP levels were decreased only in non-ICM patients (1759±1060.9 to 1015±650 vs. 2063,8±1800 to 1950.7±2342, p=0.001). MLHFQ improved in non-ICM patients (p=0.015); while non-significant improvement was detected in ICM patients. Conclusion Optimization of cardiac resynchronization therapy based on stroke volume maximization benefits quality of life and exercise tolerance, mainly in non-ICM. GLPS and aorto-ventricular coupling was improved in non-ischemic patients, reflecting the better adaptation of CRT in this population. Thus, CRT optimization by echocardiographic evaluation may be useful in improve clinical status and quality of life in CRT non-responder patients. Funding Acknowledgement Type of funding sources: None.

Levosimendan Administration May Provide More Benefit for Survival in Patients with Non-Ischemic Cardiomyopathy Experiencing Acute Decompensated Heart Failure.

Background: Acute decompensated heart failure (ADHF) is a life-threatening condition with a high mortality rate. Levosimendan is an effective inotropic agent used to maintain cardiac output and a long-lasting effect. However, only few studies have compared the clinical outcomes, after levosimendan therapy, among etiologies of ADHF. Methods: Between July 2014 and December 2019, 184 patients received levosimendan therapy for ADHF at our hospital. A total of 143 patients had ischemic cardiomyopathy (ICM), and 41 patients had non-ICM (NICM). Data on comorbidities, echocardiographic findings, laboratory findings, use of mechanical devices, consumption of other inotropic or vasopressor agents, frequency of HF hospitalization, cardiovascular (CV) mortality, and all-cause mortality were compared between the ICM and NICM groups. Results: Patients with ICM were older with higher prevalence of diabetes mellitus when compared to patients with NICM. Patients with NICM had a poorer left ventricular ejection fraction (LVEF) and higher left ventricular end-systolic volume when compared to patients with ICM. At the 30 day follow-up period, a lower CV mortality (ICM vs. NICM: 20.9% vs. 5.1%; log-rank p = 0.033) and lower all-cause mortality (ICM vs. NICM: 28.7% vs. 9.8%; log-rank p = 0.018) was observed in the NICM patients. A significantly lower all-cause mortality was noted at 180 day (ICM vs. NICM: 39.2% vs. 22.0%; log-rank p = 0.043) and 1 year (ICM vs. NICM: 41.3% vs. 24.4%; log-rank p = 0.046) follow up in the NICM subgroup. NICM (hazard ratio (HR): 0.303, 95% confidence interval (CI): 0.108–0.845; p = 0.023) and ECMO use (HR: 2.550, 95% CI: 1.385–4.693; p = 0.003) were significant predictors of 30 day all-cause mortality. Conclusions: In our study on levosimendan use for ADHF patients, better clinical outcomes were noted in the NICM population when compared to the ICM population. In the patients with cardiogenic shock or ventilator use, significantly lower incidence of 30 day mortality presented in the NICM population when compared with the ICM population.

Left Ventricular Assist Device-Mediated Cardiac Recovery: Impact of Diabetes Mellitus and Glycemic Control

<h3>Purpose</h3> Type 2 diabetes mellitus (DM) and poor glycemic control portend a higher risk for cardiovascular morbidity and mortality. We sought to assess their impact on left ventricular assist device (LVAD)-mediated cardiac recovery in chronic advanced heart failure (HF). <h3>Methods</h3> Consecutive patients (N=477) receiving a durable continuous-flow LVAD were prospectively evaluated. After excluding patients with acute HF etiologies or inadequate follow-up after LVAD (<3 months), 396 patients were stratified based on pre-LVAD DM status into non-diabetics (n=121; no history of DM and HbA1c <5.7) and diabetics/prediabetics (n=275; history of DM or HbA1c ≥5.7). Diabetics/prediabetics were further divided into 3 groups: prediabetics, n=106; well-controlled DM (HbA1c <7%), n=90; or not well-controlled DM, n=79. The absolute left ventricular ejection fraction (LVEF) change (ΔLVEF = LVEF post-LVAD - LVEF pre-LVAD) within one year on LVAD support was compared between groups with linear regression. DM is frequently associated with ischemic cardiomyopathy (ICM), so patients were stratified a priori into ICM and non-ICM (NICM). <h3>Results</h3> Compared to non-diabetics, diabetics/prediabetics were older, more likely male, with a higher BMI, and more commonly had an ICM, remote history of hypertension, and a longer HF symptoms duration. The <b>Figure</b> depicts the ΔLVEF between the study groups stratified into ICM or NICM. After adjusting for age, sex, BMI, HF symptoms duration, and history of hypertension, patients with well-controlled DM responded more favorably compared to patients with poor glycemic control. Overall, NICM patients responded more favorably than ICM patients. <h3>Conclusion</h3> DM appears to negatively affect functional cardiac improvement on LVAD support and effective glycemic control seems to be beneficial in enhancing the favorable myocardial functional response. Further research is warranted to investigate the underlying mechanisms driving the differential responses.

Healthcare utilization and clinical outcomes after ablation of atrial fibrillation in patients with and without insertable cardiac monitoring.

BackgroundCompared with short-term electrocardiogram (ECG) monitors, insertable cardiac monitors (ICMs) have been shown to increase atrial fibrillation (AF) detection rates and the opportunity to treat recurrent AF in patients postablation.ObjectiveTo examine healthcare utilization and clinical outcomes following AF ablation, in patients with vs without ICM.MethodsRetrospective analysis pooling Optum Clinformatics and Medicare Fee-for-service 5% Sample claims databases. Patients with an AF ablation between January 1, 2011, and March 31, 2018 who received an ICM implant within 1 year pre-/postablation were propensity score matched 1:3 to patients without ICM. Outcomes included AF-related healthcare utilization, medication use, and occurrence of composite severe cardiovascular events (stroke / transient ischemic attack, major bleeds, systemic embolism, AF- or heart failure–related hospitalization, or death).ResultsA total of 1000 ICM patients and 2998 non-ICM patients were included. During mean follow-up of 33 ± 16 months postablation, ICM patients experienced significantly fewer severe cardiovascular events (1.09 ± 2.22 vs 1.37 ± 4.19, P = .008) and associated costs ($20,757 vs $29,106, P = .0005). ICM patients had a greater number of AF-related clinic visits (16.8 vs 11.6 visits, P < .0001) and were more likely to receive a repeat ablation (38.7% vs 32.4%, P = .0003). Total all-cause costs during follow-up were not statistically different. Discontinuation of oral anticoagulation was higher in ICM patients at 1 year (44% vs 31%, P < .0001) and 2 years (73% vs 64%, P = .0012).ConclusionA shift from acute, reactive care to routine outpatient management was observed in patients with long-term ECG monitoring. Results suggest closer patient management in patients with long-term monitoring after an AF ablation and an improvement in outcomes, at similar overall cost.

Abstract 13895: Machine Learning-based Prediction Model With Contribute the Optimal Recipient Selection for the Regenerative Therapy in ICM and Non-ICM Patients

Background: Although transplantation of patch-shaped autologous skeletal muscle-derived cells has been introduced to ischemic cardiomyopathy (ICM) or non-ICM patients, we found responders or non-responders to this treatment exist and how to predict the responsiveness to this treatment is crucial for the improvement of the effectiveness. In this study, we revealed the clinical features associated with the responders using a machine learning based-model, which was discriminated between the responder and the non-responders in this treatment. Methods and Results: We used the retrospective databases of 23 ICM patients and 23 non-ICM patients undergoing autologous myoblast patch transplantation to develop machine learning models to discriminate 3-year VAD free survival. Sixty-nine pre-transplantation clinical futures were selected to train the models. In ICM models, there were 4 VADs or deaths, and in non-ICM models, there were 10 VADs or deaths during the 3-year follow-up periods. Using these databases, we trained multiple machine learning models and evaluated the models with the leave-one-out method. In ICM, k nearest neighbor demonstrated the best performance, showing the accuracy was 95.7%, and the AUC was 0.95. The features associated with 3-year VAD free survival in ICM were NYHA classification, cardiac index, and left ventricular ejection fraction. In non-ICM, k nearest neighbor demonstrated the best performance among the trained classifiers, demonstrating the accuracy was 95.7%, and the AUC was 0.93. The features associated with 3-year VAD free survival in non-ICM were pulmonary capillary wedge pressure, pulmonary vascular resistance, and albumin. Conclusion: We found the features associated with 3-year VAD free survival in autologous myoblast patch transplantation in ICM and non-ICM. Focusing on these features may facilitate optimal candidate selection in ICM and non-ICM for regenerative therapy.

Healthcare utilization and outcomes in atrial fibrillation ablation patients with and without insertable cardiac monitoring

Abstract Background Atrial fibrillation (AF) is associated with increased risk of stroke and progression to heart failure, and as a result, increased mortality. Catheter ablation can reduce AF burden, potentially allowing discontinuation from anticoagulant medication in some patients. Post ablation, guidelines recommend ECG monitoring in patients discontinuing anticoagulation to monitor potential AF recurrence. Short-term ECG monitors have lower detection rates for AF recurrence, while long-term insertable cardiac monitors (ICM) increase detection rates and the opportunity to manage and treat AF, when it recurs. Whether more intensive monitoring via ICMs translates to improvements in health outcomes or reduced costs is not well understood. Purpose We examined healthcare utilization/costs and anticoagulant discontinuation following AF ablation, in patients with vs. without ICM. Methods Patients with a catheter ablation for AF between January 1, 2011 - March 31, 2018 were identified in a large U.S. administrative claims database. Patients with ICM implant within 1 year pre- or post-ablation were propensity score matched to patients without ICM, based on: demographics, comorbidities, CHAD2S2-VASc score, medication use and healthcare costs in baseline. Results A total of 691 ICM patients were identified and matched 1:3 with 2,073 non-ICM patients. Mean age was 65 years, 38% were female, and mean (SD) CHAD2S2-VASc was 2.29 (1.53). During an average follow-up from ablation discharge of 37 (19) months, ICM patients incurred fewer AF- and HF-related hospitalizations: mean 0.51 (0.91) vs. 0.62 (1.56) AF-related, p=0.018, and 0.14 (0.48) vs. 0.24 (1.30) HF-related hospitalizations per patient, p=0.00. Correspondingly, average per-patient costs for AF- and HF-related hospitalizations were lower in the ICM cohort: $13,041 ($30,831) vs. $17,140 ($55,576), p=0.016 and $3,921 ($17,865) vs. $6,746 ($33,148), p=0.005. The ICM cohort had a greater number of AF-related clinic visits during follow-up: 14.2 (13.0) vs. 10.2 (11.7) visits per patient, p&amp;lt;0.0001. The proportion of patients undergoing a repeat AF ablation during follow-up was higher in the ICM cohort (22.3% vs. 18.3%, P&amp;lt;0.0001), while the proportion with cardioversions was lower (21.0% vs. 25.1%, p=0.031). In patients indicated for anticoagulation (CHAD2S2-VASc≥2), the rate of anticoagulant discontinuation (defined as gap in coverage ≥90 days) was high in both cohorts: 89.5% and 84.6% of patients in ICM and non-ICM groups, respectively. Conclusions AF ablation patients with ICM experienced fewer AF- and HF-related hospitalizations/costs and fewer cardioversions during follow-up. The greater number of AF-related clinic visits and repeat AF ablations observed in ICM patients indicate closer management. Of note, anticoagulant discontinuation was similarly high in the non-ICM cohort despite guidelines recommending rigorous cardiac monitoring for AF recurrence in the context of discontinuation. Funding Acknowledgement Type of funding source: Private company. Main funding source(s): Medtronic

Why is the clinical response to cardiac resynchronization better in LBBB patients?

AimsThe improved clinical response in patients with left bundle branch block (LBBB) over LBBB‐free patients treated with cardiac resynchronization therapy with a defibrillator (CRT‐D) is commonly attributed to an LBBB abnormality. We aimed to find an alternative explanation.Methods and resultsWe analysed an immediate effect of selecting the LBBB group of patients in a cohort of 63 non‐ischaemic cardiomyopathy (non‐ICM) and 83 ischaemic cardiomyopathy (ICM) patients treated with CRT‐D; 75% of non‐ICM and 51% of ICM patients had an LBBB abnormality on the electrocardiogram, with a significant difference (P = 0.0032 by χ 2). As a result of this difference, the proportion of non‐ICM patients increased from 43% in the primary cohort to 53% in LBBB selection and decreased to 28% in non‐LBBB group. By nonparametric survival analysis, the hazard ratio in non‐ICM patients in the LBBB selection decreased from 0.48 (P = 0.0488) to 0.36 (P = 0.0251) and increased in the non‐LBBB group to 0.75 (P = 0.6496). Any comparison of LBBB and non‐LBBB groups must compare sets with a significantly altered proportion of patients of different aetiologies. Most publications on LBBB patients are erroneous because they compare LBBB with non‐LBBB groups, not taking into account that the groups have been substantially changed by the selection process.ConclusionsThe declared outcome of the LBBB groups reflects inevitably the survival outcome of their non‐ICM patients and not the intended outcome of patients with LBBB. CRT‐D in patients with different aetiologies of cardiomyopathy calls for separate evaluation.

Preoperative Use of Intravenous Contrast Media Is Associated With Decreased Excellent Response Rates in Intermediate-Risk DTC Patients Who Subsequently Receive Total Thyroidectomy and Low-Dose RAI Therapy.

Purpose: To evaluate the impact of preoperative use of intravenous contrast media (ICM) on the excellent response (ER) rates in a cohort of intermediate-risk differentiated thyroid cancer (DTC) patients who received total thyroidectomy (TT) and low-dose radioactive iodine (RAI) therapy.Methods: A total of 683 consecutive patients were retrospectively reviewed in a single center between August 2016 and August 2018. Patients were divided into ICM group (n = 532) and non-ICM group (n = 151). Intravenous contrast media patients were 1:1 propensity matched to non-ICM patients based on T stage, N stage, and urinary iodine. Risk-adjusted logistic regression models were constructed to assess the association between the use of ICM and ER rates.Results: Intravenous contrast media patients had significantly higher T stage (P < 0.001), N stage (P < 0.001), urinary iodine (P < 0.001), and ps-Tg (P = 0.042) than non-ICM patients. Preoperative use of ICM was found to be significantly associated with decreased ER rates in both the primary cohort [odds ratio (OR) = 0.47, 95% confidence interval (CI) = 0.32–0.71; P < 0.001] and the matched cohort (OR = 0.48, 95% CI = 0.25–0.94; P = 0.031). Subgroup analysis on RAI delay time in the primary cohort revealed that ER rates in ICM patients were significantly lower than that of non-ICM patients for 1–2 months (P = 0.0245) and >2–3 months (P = 0.0221) subgroups, but not for >3–4 months, >4–5 months, and >5–6 months subgroups (all P > 0.05). A delay time of >3–4 months exhibited the highest ER rate (63.08%) within the ICM group.Conclusions: Preoperative use of ICM is associated with decreased ER rates in intermediate-risk DTC patients who subsequently receive TT and low-dose RAI therapy. For such patients, if ICM has already been received, an RAI delay time of >3–4 months would seem to be more appropriate to achieve better ER rates.

Outcomes in Patients With Hypertrophic Cardiomyopathy Awaiting Heart Transplantation.

Current organ allocation policy and the rapid growth of mechanical support favor heart transplant (HT) candidates on left ventricular assist devices. HT candidates with hypertrophic cardiomyopathy (HCM) are usually not left ventricular assist device candidates and may have a disadvantage compared with dilated forms of cardiomyopathy. Adult HT candidates registered in the Scientific Registry of Transplant Recipients database between 1999 and 2016 were included. HCM candidates were compared with ischemic cardiomyopathy (ICM) and non-ICM patients. Two eras were defined on the basis of the approval date of the first continuous-flow left ventricular assist device for bridge-to-transplant in the United States (2008). Patients outcomes were evaluated while on the waitlist and after HT. The proportion of patients with HCM listed for HT increased by 44% in era 2 compared with era 1. Waitlist mortality in patients with ICM (15.5%-8.7%) and non-ICM (14.2%-8.2%) declined across eras, but minimal decline was observed in HCM patients (11.7%-9.6%; P=0.06). In era 2, the 12-month rate of HT in HCM (64.8%) was comparable to that of ICM (60.9%) and non-ICM (62.7%) patients (P=0.06). Post-transplant survival in HCM patients was the most favorable in the most recent era (1 year: 91.6% and 5 years: 82.5%; P<0.05 for all comparisons). The number of patients with HCM in need of HT is increasing. Although post-transplant survival in HCM is excellent, waitlist mortality is substantial and with minimal decline in the most recent era, despite the frequent use of listing status upgrade by exception in this patient cohort. Different strategies to improve the performance of the organ allocation system in patients with HCM are needed.

Image Integration to Guide Catheter Ablation in Scar‐Related Ventricular Tachycardia

Although multi-detector computed tomography (MDCT) and cardiac magnetic resonance (CMR) can assess the structural substrate of ventricular tachycardia (VT) in ischemic cardiomyopathy (ICM), non-ICM (NICM), and arrhythmogenic right ventricular cardiomyopathy (ARVC), the usefulness of systematic image integration during VT ablation remains undetermined. A total of 116 consecutive patients (67 ICM; 30 NICM; 19 ARVC) underwent VT ablation with image integration (MDCT 91%; CMR 30%; both 22%). Substrate was defined as wall thinning on MDCT and late gadolinium-enhancement on CMR in ICM/NICM, and as myocardial hypo-attenuation on MDCT in ARVC. This substrate was compared to mapping and ablation results with the endpoint of complete elimination of local abnormal ventricular activity (LAVA), and the impact of image integration on procedural management was analyzed. Imaging-derived substrate identified 89% of critical VT isthmuses and 85% of LAVA, and was more efficient in identifying LAVA in ICM and ARVC than in NICM (90% and 90% vs. 72%, P < 0.0001), and when defined from CMR than MDCT (ICM: 92% vs. 88%, P = 0.026, NICM: 88% vs. 72%, P < 0.001). Image integration motivated additional mapping and epicardial access in 57% and 33% of patients. Coronary and phrenic nerve integration modified epicardial ablation strategy in 43% of patients. The impact of image integration on procedural management was higher in ARVC/NICM than in ICM (P < 0.01), and higher in case of epicardial approach (P < 0.0001). Image integration is feasible in large series of patients, provides information on VT substrate, and impacts procedural management, particularly in ARVC/NICM, and in case of epicardial approach.

Relationship between Fragmented QRS Complexes and Implantable Cardioverter Defibrillator Use in Patients with Structural Heart Disease

Background: Fragmented QRS complexes (fQRS) is one of risk stratifications for arrhythmic events, although, its relationship with appropriate/inappropriate discharges of implantable cardioverter defibrillator (ICD) remains unknown. Methods: Of 98 patients treated with ICD, 20 ischemic cardiomyopathy (ICM) and 45 non-ICM (NICM) patients were enrolled. fQRS was defined as QRS with more than 2 notches in the R wave or the S wave present on more than 2 contiguous leads of inferior, lateral or anterior segments. All patients were classified into the fQRS or non-fQRS group; appropriate/inappropriate ICD discharges were retrospectively investigated. Results: Of the ICM patients, 3 had appropriate shocks and 3 had inappropriate shocks in the fQRS group (n=13), whereas 1 had appropriate shocks and 1 had inappropriate shocks in the non-fQRS group (n=7). No differences in appropriate shocks were found between the fQRS group and non-fQRS group (p=0.89). Of the NICM patients, 11 had appropriate shocks and 7 had inappropriate shocks in the fQRS group (n=31), whereas 1 had appropriate shocks and 1 had inappropriate shocks in the non-fQRS group (n=14). Appropriate shocks was more frequently used in the NICM patients in the fQRS group than those in the non-fQRS group (p=0.04, the hazard ratio 3.56). Conclusions: fQRS is a useful predictor for risk stratification in NICM patients treated with ICD.

Response to preventive cardiac resynchronization therapy in patients with ischaemic and nonischaemic cardiomyopathy in MADIT-CRT

There are no data regarding the differential response to cardiac resynchronization therapy with defibrillator (CRT-D) by the aetiology of cardiomyopathy in mildly symptomatic patients. We evaluated the outcome of patients enrolled in MADIT-CRT by ischaemic and non-ischaemic aetiology of cardiomyopathy (ICM and non-ICM, respectively). The clinical response to CRT-D was assessed among ICM (n = 1046) and non-ICM (n = 774) patients enrolled in MADIT-CRT during an average follow-up of 2.4 years, and echocardiographic response was assessed at 1 year. Cardiac resynchronization therapy with defibrillator vs. ICD therapy was associated with respective 34% (P = 0.001) and 44% (P = 0.002) reductions in the risk of heart failure or death among ICM and non-ICM patients (P for interaction = 0.455). In the ICM group, CRT-D was associated with mean (±SD) 29 ± 14% and 18 ± 10% reductions in left ventricular end-systolic volume (LVESV) and left ventricular end-diastolic volume (LVEDV), respectively. In the non-ICM group, CRT-D was associated with significantly greater volume reductions compared with the ICM group [37 ± 16% and 24 ± 12% reductions in LVESV and LVEDV, respectively (P < 0.001 for all)]. Risk subsets in the ICM group that showed a favourable clinical response to CRT-D included patients with QRS ≥150 ms, systolic blood pressure <115 mmHg, and left bundle branch block (LBBB), whereas in the non-ICM group females, patients with diabetes mellitus, and LBBB, displayed a favourable clinical response. Mildly symptomatic ICM and non-ICM patients show significant differences in the echocardiographic response to CRT-D and in the clinical benefit within risk subsets suggesting that risk assessment for CRT-D in this population should be aetiology-specific.

Impact of scar burden by single-photon emission computed tomography myocardial perfusion imaging on patient outcomes following cardiac resynchronization therapy

Ischaemic heart disease negatively impacts response to cardiac resynchronization therapy (CRT), yet the impact of infarct scar burden on clinical outcomes and its interaction with mechanical dyssynchrony have not been well described. We studied 620 NYHA classes III-IV heart failure patients with ejection fraction (EF) ≤ 35% and QRS duration ≥120 ms referred for CRT. Included were 190 ischaemic cardiomyopathy (ICM) CRT recipients with scar burden quantified by rest-redistribution Tl(201) myocardial perfusion imaging using a 17-segment (0 = normal to 4 = absence of uptake) summed rest score (SRS). Non-ICM (NICM) CRT recipients (n = 380) and 50 patients referred for CRT with unsuccessful LV lead implant comprised the comparison groups. Echocardiographic dyssynchrony analysis was performed in a subgroup of 150 patients. Follow-up left ventricular EF (LVEF) and volumes were examined at 7 ± 3 months in 143 patients. The outcome of death, cardiac transplant, or mechanical circulatory support was assessed in all. Over 2.1 ± 1.6 years, ICM patients had significantly worse survival and less LVEF improvement than NICM patients (P < 0.01). Ischaemic cardiomyopathy patients with low scar burden (SRS < 27) had favourable survival and LVEF improvement, similar to NICM patients. A high scar burden (SRS ≥ 27) was associated with reduced survival and lack of LV functional improvement (P ≤ 0.01), similar to those with unsuccessful LV lead implant, whereas baseline dyssynchrony was not predictive of outcome in these patients. Extensive scar burden in ICM patients unfavourably affected clinical and LV functional outcomes after CRT, regardless of baseline dyssynchrony measures. Patients with ICM and lower scar burden had significantly better outcomes, similar to NICM patients.

Elevation of plasma placental growth factor in the patients with ischemic cardiomyopathy

Background Placental growth factor (PlGF), which is a member of the vascular endothelial growth factor family, stimulates angiogenesis and collateral growth in ischemic tissues. In addition, PlGF has been known to be a useful biomarker of vascular inflammation. This study was undertaken to examine whether plasma PlGF levels were increased in patients with congestive heart failure (CHF). Methods Ninety-eight patients with systolic heart failure (ejection fraction < 40%) and twenty control subjects were enrolled. The patients were divided into four subgroups according to the criteria of NYHA functional class. Plasma PlGF, tumor necrosis factor (TNF)-α, brain natriuretic peptide (BNP), norepinephrine, high-sensitive C-reactive protein (hs-CRP) were determined. Results In analysis of all the subjects, there was no significant difference in plasma PlGF levels among the subgroups of NYHA classes and the controls. In the ischemic cardiomyopathy (ICM) patients, however, plasma PlGF levels were significantly increased according to the severity of NYHA class; control: 8.9 ± 0.5; NYHA I: 9.4 ± 1.1, NYHA II: 9.7 ± 1.9, NYHA III: 14.6 ± 1.2, NYHA IV: 17.9 ± 1.9 pg/ml ( p = 0.0006). Plasma PlGF levels correlated positively with BNP ( r = 0.53, p = 0.0003) and hs-CRP ( r = 0.23, p = 0.02) in the ICM patients, whereas there was not any correlation between plasma PlGF levels and other variable values in the non-ICM patients. Conclusions In the ICM patients, plasma PlGF levels are increased according to the severity of heart failure. These results may indicate that augmented release of PlGF is involved in the pathogenesis of cardiomyopathy derived from chronic myocardial ischemia.

The echocardiographic determinants of functional mitral regurgitation differ in ischemic and non-ischemic cardiomyopathy

Background Functional mitral regurgitation (MR) is one of the common and severe complications in patients with dilated cardiomyopathy. The detailed mechanisms that cause functional MR remain to be elucidated. Using two-dimensional transthoracic echocardiography, we investigated the differences in major determinants of MR severity between ischemic cardiomyopathy (ICM) and non-ICM patients. Methods We enrolled 103 patients (91 males; age 64 ± 12 years) with significant left ventricular (LV) dilatation. They were divided into ICM group ( n = 69) with significant coronary disease, and non-ICM ( n = 34) group without coronary disease. We devised a novel and simple parameter; the short-axis sphericity index (SI), to evaluate global LV remodeling, and used coaptation depth (CD) and tenting area (TA) to evaluate mitral deformity. Results In all cases, CD, TA and left atrium diameter (LAD) correlated positively with maximum regurgitation area (MRA) ( r = 0.54, 0.57, 0.57; P < 0.0001). A negative correlation was observed between MRA and SI ( r = −0.33, P = 0.0008). There was no significant relationship between MRA and LV ejection fraction (EF). In non-ICM cases, SI tended to be lower with reduced EF. Multivariate stepwise linear regression analysis showed the following equations; ICM: MRA = −9.4 +0.81CD + 0.21LAD ( r 2 = 0.47, P < 0.0001), non-ICM: MRA = −7.2 + 0.17LVDs (LV end systolic diameter) −8.7SI + 0.27LAD ( r 2 = 0.63, P < 0.0001). Conclusions The strongest determinants of functional MR severity differ in ICM and non-ICM. While LV diameter and SI (global LV remodeling index) mainly determine the severity in non-ICM, CD that reflects mitral deformity is the major determinant in ICM.