RESUMEN
Sacubitril/valsartan has become an important first-line drug for symptomatic heart failure (HF) patients, especially with left ventricular (LV) ejection fraction (LVEF) < 50%. However, the impact of sacubitril/valsartan on cardiovascular outcomes, especially LV reverse remodeling for such patients with low blood pressure, remains uncertain. We retrospectively studied 164 HF patients with LVEF < 50% who were treated with sacubitril/valsartan from two institutions. Echocardiography was performed before and 9.5 ± 5.1 months after initiation of maximum tolerated dose of sacubitril/valsartan. The maximum tolerated dose of sacubitril/valsartan was lower for the low blood pressure group (≤ 100 mmHg in systole) than for the non-low blood pressure group (> 100 mmHg in systole) (165 ± 106 mg vs. 238 ± 124 mg, P = 0.017). As expected, significant LV reverse remodeling was observed in the non-low blood pressure group after initiation of sacubitril/valsartan. It was noteworthy that significant LV reverse remodeling was also observed in the low blood pressure group after initiation of sacubitril/valsartan (LV end-diastolic volume: 177.3 ± 66.0 mL vs. 137.7 ± 56.1 mL, P < 0.001, LV end-systolic volume: 131.6 ± 60.3 mL vs. 94.6 ± 55.7 mL, P < 0.001, LVEF: 26.8 ± 10.3% vs. 33.8 ± 13.6%, P = 0.015). Relative changes in LV volumes and LVEF after initiation of sacubitril/valsartan were similar for the two groups. In conclusion, significant LV reverse remodeling occurred after initiation of sacubitril/valsartan, even in HF patients with LVEF < 50% and systolic blood pressure ≤ 100 mmHg.
Asunto(s)
Aminobutiratos , Compuestos de Bifenilo , Insuficiencia Cardíaca , Hipotensión , Disfunción Ventricular Izquierda , Humanos , Volumen Sistólico/fisiología , Estudios Retrospectivos , Tetrazoles/efectos adversos , Antagonistas de Receptores de Angiotensina/uso terapéutico , Resultado del Tratamiento , Valsartán/uso terapéutico , Insuficiencia Cardíaca/diagnóstico , Insuficiencia Cardíaca/tratamiento farmacológico , Función Ventricular Izquierda/fisiología , Combinación de Medicamentos , Remodelación VentricularRESUMEN
OBJECTIVES: The closure of atrial septal defect (ASD) results in normalized left ventricular (LV) and right ventricular (RV) geometry, and can increase LV stroke volume (LVSV), but the parameters associated with this increase after the closure of ASD remain uncertain. METHODS: Seventy ASD patients, who underwent transcatheter closure, were studied. Their mean age was 57.80 ± 16.88 years, 42 (60%) were female, and LV ejection fraction (LVEF) was 66.76% ± 7.91% (all ≥55%). Transthoracic echocardiography was performed before and 3 months after the procedure. Global longitudinal strain (GLS) was determined as the average peak speckle tracking strain of 18 segments from the 3 standard apical views, LV dispersion was defined as standard deviation of time-to-peak strain from the same views, and RV systolic function was calculated by averaging the 3-regional peak speckle tracking longitudinal strains from the RV free wall. A significant relative increase in LVSV between before and 3 months after the closure was defined as ∆LVSV ≥15%. Twenty age-, gender-, and LVEF-matched controls served as the control group. RESULTS: Global longitudinal strain (GLS) and RV free wall strain were similar for ASD patients and controls, but LV dispersion in ASD patients was significantly larger. Global longitudinal strain (GLS) remained unchanged after transcatheter closure, whereas RV free wall strain and LV dispersion decreased significantly. An important finding of the multivariate logistic regression analysis showed that ∆LV dispersion was the only independent determinant of increased LVSV after the closure (OR 1.023; 95% CI 1.001-1.046; P < .01). CONCLUSIONS: The assessment of LV dispersion may well have clinical implications for better management of ASD patients after transcatheter closure.
Asunto(s)
Cateterismo Cardíaco , Ecocardiografía , Defectos del Tabique Interatrial/cirugía , Ventrículos Cardíacos/diagnóstico por imagen , Dispositivo Oclusor Septal , Función Ventricular Izquierda/fisiología , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
Although right ventricular (RV) pacing is the only effective treatment for patients with symptomatic bradycardia, it creates left ventricular (LV) dyssynchrony, which can induce LV dysfunction and heart failure. The current criterion for consideration of cardiac resynchronization therapy (CRT) is LV ejection fraction (LVEF) ≤ 35%, but indication for CRT in patients required for RV pacing with LVEF > 35% remains unclear.We studied 40 patients, all LVEF ≥ 35%, who had undergone implantable cardioverter-defibrillator implantation with RV pacing < 5%. Echocardiography was performed at baseline and during RV pacing. LV dyssynchrony was defined as anteroseptal-to-posterior wall delay from the mid-LV short-axis view using two-dimensional speckle-tracking radial strain (significant: ≥ 130 ms). Patients were divided into two groups based on baseline LVEF: normal LVEF ( ≥ 50%; n = 20) and mildly reduced LVEF (35-50%; n = 20).LVEF and LV dyssynchrony in patients with mildly reduced LVEF deteriorated significantly during RV pacing compared to those in patients with normal LVEF. Moreover, changes in LV dyssynchrony during RV pacing significantly correlated with changes in LVEF (r = -0.44, P < 0.01). Multivariate logistic regression analysis showed that baseline LVEF was the only independent predictor and baseline LVEF < 48% predictive of significant LV dyssynchrony during RV pacing.The extent of RV pacing-induced LV dysfunction may be associated with baseline LV function. These adverse effects on patients with mildly reduced LVEF of 35-50% and indications for RV pacing due to bradycardia can thus be prevented by CRT.
Asunto(s)
Bradicardia/complicaciones , Estimulación Cardíaca Artificial/métodos , Ventrículos Cardíacos/fisiopatología , Medición de Riesgo/métodos , Disfunción Ventricular Derecha/etiología , Función Ventricular Izquierda/fisiología , Anciano , Bradicardia/fisiopatología , Bradicardia/terapia , Ecocardiografía , Femenino , Estudios de Seguimiento , Ventrículos Cardíacos/diagnóstico por imagen , Humanos , Incidencia , Japón/epidemiología , Masculino , Pronóstico , Estudios Prospectivos , Factores de Riesgo , Volumen Sistólico/fisiología , Disfunción Ventricular Derecha/diagnóstico , Disfunción Ventricular Derecha/epidemiologíaRESUMEN
PURPOSE: Pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH) are the main subgroups of pulmonary hypertension (PH). Despite differences in their etiologies, both diseases are characterized by vascular remodeling, resulting in progressive right heart failure. Noninvasive periodic evaluation of exercise tolerance has become increasingly important. Cardiopulmonary exercise testing (CPET) and a 6-minute walk test (6MWT) are now both recommended for evaluating exercise tolerance, but there is insufficient knowledge about possible differences in the associations of exercise tolerance with right heart catheterization (RHC) data for patients with PAH and CTEPH. METHODS: A retrospective study was performed with 57 patients with PH (24 with PAH and 33 with CTEPH) all of whom underwent echocardiography, CPET, 6MWT, and RHC. RESULTS: For both patients with PAH and CTEPH, peak heart rate during CPET was significantly higher than that from 6MWT, whereas minimum peripheral oxygen saturation during CPET and 6MWT was similar. For patients with PAH, significant correlations were observed between peak (Equation is included in full-text article.)O2 and cardiac index (CI) (r = 0.59; P = .002) and between (Equation is included in full-text article.)E/(Equation is included in full-text article.)CO2 slopes and CI (r =-0.46, P = .02), as well as a nonsignificant correlation tendency for peak (Equation is included in full-text article.)O2 and pulmonary vascular resistance (PVR) and for (Equation is included in full-text article.)E/(Equation is included in full-text article.)CO2 and PVR (r =-0.39; P = .05; and r = 0.39; P = .06, respectively). For patients with CTEPH, however, a significant correlation was observed only between (Equation is included in full-text article.)E/(Equation is included in full-text article.)CO2 slopes and CI (r =-0.38; P = .02). CONCLUSION: PH etiology should be considered when assessing exercise tolerance, whereas CPET can be effective in addition to hemodynamic assessment by means of RHC for periodic evaluation during followup.
Asunto(s)
Prueba de Esfuerzo/métodos , Tolerancia al Ejercicio/fisiología , Hipertensión Pulmonar , Embolia Pulmonar/complicaciones , Prueba de Paso/métodos , Adulto , Anciano , Ecocardiografía/métodos , Femenino , Hemodinámica/fisiología , Humanos , Hipertensión Pulmonar/diagnóstico , Hipertensión Pulmonar/etiología , Hipertensión Pulmonar/fisiopatología , Japón , Masculino , Persona de Mediana Edad , Consumo de Oxígeno/fisiología , Estudios Retrospectivos , Estadística como AsuntoRESUMEN
Left ventricular (LV) diastolic dysfunction and longitudinal systolic dysfunction were identified in patients with diabetes mellitus (DM). This study's aim was to investigate the impact of LV longitudinal systolic function on LV diastolic function in DM patients with preserved LV ejection fraction (LVEF). We studied 177 DM patients with preserved LVEF (all ≥50%), and 82 age-, gender- and LVEF-matched healthy volunteers as control. Global longitudinal strain (GLS) was defined as the average peak strain of 18 segments from standard apical views, GLS <18% as subclinical LV systolic dysfunction (LVSD), and LV dispersion as the standard deviation of time-to-peak strain from the same views. For DM patients with LVSD (n = 74), E/A and E' were lower, and E/E' and isovolumic relaxation time (IVRT) were greater than for DM patients without LVSD (n = 103) and normal controls (n = 82). Moreover, these parameters were lower for DM patients without LVSD than for normal controls. Multivariate analysis revealed that GLS was a strong determinative factor for E' and E/E' (ß = 0.30, p < 0.001 and ß = -0.25, p < 0.001, respectively), as was LV dispersion for E-wave deceleration time and IVRT (ß = 0.21, p = 0.002 and ß = 0.30, p < 0.001, respectively) independently of age. For normal subjects, however, only age was associated with all LV diastolic parameters. In conclusions, in contrast to age-related LV diastolic dysfunction in normal subjects, in DM patients with preserved LVEF, LV diastolic function was associated with LV longitudinal systolic function and LV dispersion independently of age. Our findings have obvious clinical implications for the management of DM patients.
Asunto(s)
Cardiomiopatías Diabéticas/fisiopatología , Disfunción Ventricular Izquierda/fisiopatología , Función Ventricular Izquierda , Adulto , Anciano , Enfermedades Asintomáticas , Fenómenos Biomecánicos , Estudios de Casos y Controles , Estudios Transversales , Cardiomiopatías Diabéticas/diagnóstico por imagen , Cardiomiopatías Diabéticas/etiología , Diástole , Progresión de la Enfermedad , Ecocardiografía Doppler , Femenino , Humanos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Variaciones Dependientes del Observador , Valor Predictivo de las Pruebas , Estudios Prospectivos , Reproducibilidad de los Resultados , Factores de Riesgo , Factores de Tiempo , Disfunción Ventricular Izquierda/diagnóstico por imagen , Disfunción Ventricular Izquierda/etiologíaRESUMEN
Left ventricular (LV) hypertrophy (LVH) is an independent cardiovascular risk factor for heart failure (HF) patients. The renin-angiotensin system plays a key role in LVH, and since olmesartan increases plasma angiotensin-(1-7) through an increase in angiotensin-converting enzyme-related carboxypeptidase (ACE2) expression, it was hypothesized to reduce LVH, unlike other angiotensin II receptor blockers (ARBs). The objective of this study was therefore to investigate the effects of a changeover from other ARBs to olmesartan on LVH in HF patients. Participants enrolled in this prospective trial were 64 outpatients with stable HF who had received ARBs other than olmesartan for more than 1 year (age: 59 ± 13 years). Transthoracic echocardiography and laboratory tests were performed before and 6 months after administration of olmesartan. Other drugs were not changed during follow-up. The primary end point was defined as a change in LV mass index (LVMI) from baseline up to 6 months after administration of olmesartan. No significant changes were observed in blood pressures and heart rate after administration of olmesartan. LVMI showed a significant decrease from 119 ± 38 to 110 ± 24 g/m2 (p = 0.007) 6 months after administration of olmesartan, and further decreased from 110 ± 24 to 103 ± 35 g/m2 (p = 0.0003) after 12 months. Moreover, this reduction tended to be more prominent in patients with LVH. In conclusions, LVH in HF patients was reduced by the changeover to olmesartan. This finding may well have clinical implications for better management of HF patients.
Asunto(s)
Bloqueadores del Receptor Tipo 1 de Angiotensina II/administración & dosificación , Sustitución de Medicamentos/métodos , Insuficiencia Cardíaca/prevención & control , Hipertrofia Ventricular Izquierda/tratamiento farmacológico , Imidazoles/administración & dosificación , Tetrazoles/administración & dosificación , Relación Dosis-Respuesta a Droga , Ecocardiografía Doppler de Pulso , Femenino , Estudios de Seguimiento , Insuficiencia Cardíaca/etiología , Humanos , Hipertrofia Ventricular Izquierda/complicaciones , Hipertrofia Ventricular Izquierda/fisiopatología , Masculino , Persona de Mediana Edad , Pacientes Ambulatorios , Estudios Prospectivos , Sistema Renina-Angiotensina/efectos de los fármacos , Factores de Riesgo , Volumen Sistólico/efectos de los fármacos , Resultado del TratamientoRESUMEN
BACKGROUND: Diabetic nephropathy is independently associated with longitudinal systolic dysfunction of the left ventricle (LV) in asymptomatic diabetes mellitus (DM) patients with preserved LV ejection fraction (LVEF). However, the effect of diabetic nephropathy on left atrial (LA) function remains unknown. METHODSâANDâRESULTS: We studied 198 asymptomatic DM patients (LVEF ≥50%). Diabetic nephropathy was defined as a protein level higher than for micro-albuminuria. LV global longitudinal strain (GLS) and LA strain were analyzed by 2D speckle-tracking; 69 age-, sex-, and LVEF-matched controls were also studied. GLS and LA strain in systole (LAS-s) decreased significantly from normal controls to DM patients without (n=137) and with nephropathy (n=61), in that order. Furthermore, GLS, LAS-s, and LA strain in late diastole (LAS-a) were significantly lower in DM patients with macro-albuminuria (n=19) than in those with micro-albuminuria (n=42). Although 1 multivariate regression analysis identified albuminuria as an independent determinative factor of LAS-s among other relevant clinical background factors (ß=-0.16, P=0.002), another multivariate regression model for LAS-s+GLS (ß=0.40, P<0.001) showed that albuminuria was not a significant factor (ß=-0.02, P=0.68). Similarly, another multivariate regression model including GLS (ß=0.32, P<0.001) demonstrated that clinical features relevant for LAS-a, except for age, were not independent determinants of LAS-a. CONCLUSIONS: The cross-linked association of LA strain with GLS and albuminuria may be important for better understanding the development of diabetic cardiomyopathy. (Circ J 2016; 80: 1957-1964).
Asunto(s)
Nefropatías Diabéticas , Ecocardiografía , Ventrículos Cardíacos , Volumen Sistólico , Adulto , Anciano , Nefropatías Diabéticas/diagnóstico por imagen , Nefropatías Diabéticas/fisiopatología , Atrios Cardíacos/diagnóstico por imagen , Atrios Cardíacos/fisiopatología , Ventrículos Cardíacos/diagnóstico por imagen , Ventrículos Cardíacos/fisiopatología , Humanos , Persona de Mediana EdadRESUMEN
BACKGROUND: Right ventricular (RV) systolic function is one of the most important determinants of outcome for pulmonary hypertension (PH) patients, but the factors influencing prognosis vary widely. Elevated right atrial (RA) pressure is reported to be one of these prognostic factors, but its functional importance has scarcely been assessed. METHODS: Eighty-two PH patients, all of whom underwent echocardiography and right heart catheterization, were recruited. RV function was assessed by two-dimensional speckle tracking longitudinal strain from RV-focused apical four-chamber view and calculated by averaging the three regional peak strains from the RV free wall (RV-free). RA function was determined as the sum of three peak strain values comprising reservoir, conduit, and contractile function (sum of RA strain). RESULTS: Sum of RA strain correlated significantly with hemodynamic parameters such as mean right atrial pressure (r = -0.35, P = 0.002) and end-diastolic RV pressure (r = -0.29, P = 0.008). Patients with sum of RA strain ≥30.2% experienced more favorable outcomes than those with sum of RA strain <30.2% (log-rank P = 0.001). Furthermore, patients with impaired RV systolic function (RV-free <20%) and RA function (sum of RA strain <30.2%) showed the worst outcome (P = 0.001). A sequential Cox model based on clinical variables (χ(2) = 5.8) was improved by addition of RV-free (χ(2) = 8.7; P < 0.05) and further improved by addition of sum of RA strain (χ(2) = 12.0; P < 0.01). CONCLUSION: Right atrial strain appears to be a valuable additive factor for predicting outcomes for PH patients, and comprehensive functional assessment of right-sided heart using speckle tracking strain may have potential clinical implications for better management of PH patients.
Asunto(s)
Ecocardiografía/métodos , Diagnóstico por Imagen de Elasticidad/métodos , Hipertensión Pulmonar/diagnóstico por imagen , Hipertensión Pulmonar/fisiopatología , Disfunción Ventricular Derecha/diagnóstico por imagen , Disfunción Ventricular Derecha/fisiopatología , Femenino , Humanos , Hipertensión Pulmonar/complicaciones , Interpretación de Imagen Asistida por Computador/métodos , Masculino , Persona de Mediana Edad , Reproducibilidad de los Resultados , Sensibilidad y Especificidad , Volumen Sistólico , Disfunción Ventricular Derecha/etiología , Función Ventricular DerechaRESUMEN
AIMS: Current guidelines recommend implantation of prophylactic implantable cardioverter-defibrillators (ICD) in patients with left ventricular (LV) ejection fraction (EF) <35%. We explored the prognostic factors of fatal ventricular arrhythmias for heart failure (HF) patients with LVEF ≥35%. METHODS AND RESULTS: We retrospectively studied 72 patients with LVEF of 52 ± 12% (all ≥35%) who had undergone ICD implantation. Heterogeneity of LV regional myocardial contraction was defined as standard deviation of peak strain (dyssynergy index) and time-to-peak strain (dispersion index) from 18 LV segments determined by speckle tracking. Fatal ventricular arrhythmias with appropriate ICD therapy occurred in 34 patients (47%) during a median follow-up of 17 months. Receiver operating characteristic curve analysis identified dispersion index ≥101 ms and dyssynergy index ≥6.1% as predictors of fatal ventricular arrhythmias (P = 0.004 and P = 0.0001, respectively). In addition, the combination of dispersion index ≥101 ms and dyssynergy index ≥6.1% was the most predictive of fatal ventricular arrhythmias with a sensitivity of 77%, specificity of 79%, and area under the curve of 0.795 (P < 0.0001). A sequential Cox model based on clinical and conventional echocardiographic variables including age, gender, HF aetiology, and LVEF (χ(2) = 4.8) was improved, but not statistically significant (χ(2) = 4.9; P = 0.82), by addition of global longitudinal strain, whereas improvement by the addition of the dispersion index (χ(2) = 8.9; P = 0.04) and further improvement by the addition of the dyssynergy index (χ(2) = 20.2; P < 0.005). CONCLUSION: Combined assessment of LV dyssynergy and dispersion can enhance predictive capability for fatal ventricular arrhythmias in patients with LVEF ≥35% and may have potential for better management of such patients.
Asunto(s)
Arritmias Cardíacas/mortalidad , Arritmias Cardíacas/fisiopatología , Desfibriladores Implantables , Disfunción Ventricular Izquierda/mortalidad , Disfunción Ventricular Izquierda/fisiopatología , Ecocardiografía , Determinación de Punto Final , Femenino , Sistema de Conducción Cardíaco/fisiopatología , Humanos , Interpretación de Imagen Asistida por Computador , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Factores de Riesgo , Volumen SistólicoRESUMEN
BACKGROUND: Transcatheter closure is a well-established treatment for patients with atrial septal defect (ASD), but long-term outcome prognostic factors for adults have not been fully identified yet. METHODS: Forty-nine consecutive patients (age 57 ± 17 years, 59% female), who underwent transcatheter closure of ASD, were the subjects of this study. Transthoracic echocardiography was performed before and midterm after the procedure (6 ± 1 months). Isovolumic contraction peak velocity (IVV) was measured at the lateral site of the tricuspid annulus using spectral tissue Doppler imaging, and ΔIVV was determined as the absolute change at midterm follow-up. Long-term unfavorable outcome events, tracked for 19 ± 9 months, were prespecified as primary end points comprising newly developed atrial fibrillation, cerebral infarction, and heart failure. RESULTS: Symptomatic improvement, defined as an improvement in New York Heart Association functional class by one grade or more at midterm after the procedure, was observed in 24 patients (49%), and the remaining 25 (51%) were classified as not symptomatically improved. ΔIVV was significantly larger for patients with symptomatic improvement than for those without (from 11.5 ± 4.3 cm/s to 14.2 ± 3.7 cm/s vs. from 11.8 ± 4.1 cm/s to 12.5 ± 2.9 cm/s; P = 0.045). An important finding of the multivariate Cox proportional-hazards analysis was that only ΔIVV was independently associated with cardiovascular events (HR: 0.701; 95% CI 0.537-0.916; P = 0.01). Kaplan-Meier analysis showed that more patients with enhanced ΔIVV presented with favorable long-term outcome than those with diminished ΔIVV (log-rank P = 0.0001). CONCLUSIONS: IVV, which is a less volume-sensitive parameter, can be useful for comprehensive evaluation of ASD patients referred for transcatheter closure.
Asunto(s)
Cateterismo Cardíaco , Defectos del Tabique Interatrial/diagnóstico por imagen , Defectos del Tabique Interatrial/cirugía , Complicaciones Posoperatorias/diagnóstico por imagen , Complicaciones Posoperatorias/fisiopatología , Dispositivo Oclusor Septal , Velocidad del Flujo Sanguíneo/fisiología , Ecocardiografía Doppler , Femenino , Estudios de Seguimiento , Defectos del Tabique Interatrial/fisiopatología , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Resultado del TratamientoRESUMEN
BACKGROUND: Current guidelines recommend the routine use of tricuspid annular plane systolic excursion (TAPSE) as a simple method for estimating right ventricular (RV) function. However, when ventricular apical longitudinal rotation (apical-LR) occurs in pulmonary hypertension (PH) patients, it may result in overestimated TAPSE. METHODS: We studied 105 patients with PH defined as mean pulmonary artery pressure >25 mmHg at rest measured by right heart cardiac catheterization. TAPSE was defined as the maximum displacement during systole in the RV-focused apical four-chamber view. RV free-wall longitudinal speckle tracking strain (RV-free) was calculated by averaging 3 regional peak systolic strains. The apical-LR was measured at the peak rotation in the apical region including both left and right ventricle. The eccentricity index (EI) was defined as the ratio of the length of 2 perpendicular minor-axis diameters, one of which bisected and was perpendicular to the interventricular septum, and was obtained at end-systole (EI-sys) and end-diastole (EI-dia). Twenty age-, gender-, and left ventricular ejection fraction-matched normal controls were studied for comparison. RESULTS: The apical-LR in PH patients was significantly lower than that in normal controls (-3.4 ± 2.7° vs. -1.3 ± 1.9°, P = 0.001). Simple linear regression analysis showed that gender, TAPSE, EI-sys, and EI-dia/EI-sys were associated with apical-LR, but RV-free was not. Multiple regression analysis demonstrated that gender, EI-dia/EI-sys, and TAPSE were independent determinants of apical-LR. CONCLUSIONS: TAPSE may be overestimated in PH patients with clockwise rotation resulting from left ventricular compression. TAPSE should thus be evaluated carefully in PH patients with marked apical rotation.
Asunto(s)
Ventrículos Cardíacos/diagnóstico por imagen , Ventrículos Cardíacos/fisiopatología , Hipertensión Pulmonar/complicaciones , Disfunción Ventricular Derecha/diagnóstico por imagen , Disfunción Ventricular Derecha/fisiopatología , Femenino , Humanos , Hipertensión Pulmonar/fisiopatología , Masculino , Persona de Mediana Edad , Reproducibilidad de los Resultados , Sístole , Disfunción Ventricular Derecha/complicacionesRESUMEN
AIMS: The purpose of this study was to investigate the prognostic impact of the changes in ventriculo-arterial (VA) coupling during dobutamine stress on the cardiovascular events for patients with dilated cardiomyopathy (DCM). METHODS AND RESULTS: For this study, 89 DCM patients with ejection fractions of 32 ± 10% and 30 normal controls were recruited. Ees was estimated with the non-invasive single-beat method using three-dimensional echocardiography at rest and during dobutamine stress (20 µg/kg/min). Effective arterial elastance (Ea) was calculated as left ventricular (LV) end-systolic pressure divided by stroke volume, and VA coupling was calculated as Ea/Ees. Event-free survival was then tracked for 32 months. At baseline, VA coupling was far from optimal in patients with DCM compared with controls (Ea/Ees: 2.49 ± 1.02 vs. 1.04 ± 0.21, P < 0.001). During the follow-up period, 22 patients developed adverse cardiovascular events. During dobutamine stress, VA coupling was significantly improved in patients without cardiovascular events (from 2.47 ± 1.09 to 1.59 ± 0.68, P < 0.001), but remained unchanged in those with cardiovascular events. A multivariate Cox proportional-hazards analysis revealed that age, NYHA functional class (>II), and the change in VA coupling during dobutamine stress were the independent determinants of cardiovascular events (P < 0.05, <0.01, and <0.001, respectively). When patients were divided into two subgroups based on the finding of receiver operating characteristic curve analysis, patients with good VA coupling reserve (cut-off: change in VA coupling> 0.29) showed significantly favourable event-free survival than those with poor VA coupling reserve (P < 0.001). CONCLUSIONS: Improvement in VA coupling during dobutamine stress is an important determinant of cardiovascular outcome for patients with DCM.
Asunto(s)
Cardiomiopatía Dilatada/diagnóstico por imagen , Cardiomiopatía Dilatada/fisiopatología , Ecocardiografía de Estrés/métodos , Ecocardiografía Tridimensional/métodos , Volumen Sistólico/efectos de los fármacos , Función Ventricular Izquierda/efectos de los fármacos , Cardiomiopatía Dilatada/mortalidad , Estudios de Casos y Controles , Femenino , Humanos , Estimación de Kaplan-Meier , Masculino , Contracción Miocárdica/efectos de los fármacos , Contracción Miocárdica/fisiología , Variaciones Dependientes del Observador , Valor Predictivo de las Pruebas , Pronóstico , Curva ROC , Estudios Retrospectivos , Medición de Riesgo , Estadísticas no Paramétricas , Volumen Sistólico/fisiología , Análisis de Supervivencia , Función Ventricular Izquierda/fisiologíaRESUMEN
Worsening of mitral regurgitation (MR) is sometimes observed after closure of an atrial septal defect (ASD). However, since the mechanism of this deterioration remains unclear, the aim of our study was to investigate the effect of left (LV) and right ventricular (RV) geometry on MR after transcatheter closure of ASD.We studied 27 patients with ASD who underwent transcatheter closure. Echocardiography was performed before and 6 ± 2 months after the procedure. In addition to conventional echocardiographic parameters, full volume data of the whole LV and RV heart was obtained with 3-dimensional echocardiography. MR was quantified by measuring the width of the vena contracta, and was graded as mild (< 3.0 mm), moderate (3.0 to 6.9 mm), or severe (≥ 7.0 mm).Ten patients (37%) were classified as having worsening MR and the remaining 17 (63%) as not having worsening MR. The two groups showed similar baseline characteristics, except for patients with worsening MR being more likely to be older (P = 0.009) and having a larger left-to-right shunt of pulmonary and systemic blood flow ratio (P = 0.02). It is noteworthy that the horizontal-to-vertical ratio of basal-RV at end-systole for patients with worsening MR was significantly smaller than that for patients without worsening MR (1.0 ± 0.2 versus 1.4 ± 0.2, P < 0.0001). Furthermore, multivariate analysis showed that the horizontal-to-vertical ratio of basal-RV at end-systole was the independent predictor of worsening MR during follow-up (P < 0.001).RV geometry may affect MR after closure of ASD. The pre-operative horizontal-to-vertical ratio of basal-RV is considered useful for predicting worsening of MR after closure of ASD.
Asunto(s)
Cateterismo Cardíaco/efectos adversos , Ventrículos Cardíacos/diagnóstico por imagen , Insuficiencia de la Válvula Mitral , Complicaciones Posoperatorias , Adulto , Anciano , Cateterismo Cardíaco/métodos , Progresión de la Enfermedad , Ecocardiografía/métodos , Femenino , Defectos del Tabique Interatrial/complicaciones , Defectos del Tabique Interatrial/diagnóstico , Defectos del Tabique Interatrial/cirugía , Ventrículos Cardíacos/fisiopatología , Humanos , Masculino , Persona de Mediana Edad , Insuficiencia de la Válvula Mitral/diagnóstico , Insuficiencia de la Válvula Mitral/etiología , Insuficiencia de la Válvula Mitral/fisiopatología , Evaluación de Resultado en la Atención de Salud , Complicaciones Posoperatorias/diagnóstico , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/fisiopatología , Implantación de Prótesis/efectos adversos , Implantación de Prótesis/instrumentación , Implantación de Prótesis/métodos , Dispositivo Oclusor SeptalRESUMEN
BACKGROUND: Subclinical left ventricular (LV) longitudinal myocardial systolic dysfunction occurs in patients with diabetes mellitus (DM) and preserved LV ejection fraction (LVEF), and is closely related to DM-related complications. However, the association of diabetic neuropathy (DN) with subclinical LV systolic longitudinal dysfunction in such patients has not been fully clarified. METHODS: The subjects of this study were 112 consecutive DM patients with preserved LVEF (all ≥50%) without coronary artery disease and overt heart failure (aged 59 ± 14 years; 60 women, 52 men). Global longitudinal strain (GLS) was determined as the average peak strain of 18 segments from the three standard apical views, and was expressed as an absolute value. DN was diagnosed by experienced diabetologists. Median, ulnar, and sural nerves were subjected to motor and sensory nerve conduction studies. F-wave latency was defined as the minimum F-wave latency after a total of 16 stimulations of the tibial nerve. RESULTS: Forty-one (37%) patients were clinically diagnosed with DN. LV functions of DM patients with and without DN were similar except for GLS being significantly smaller in patients with than in patients without DN (18 ± 2% vs. 20 ± 2%, p < 0.001). It was noteworthy that, of the parameters for the nerve conduction study, only F-wave latency correlated with GLS (r = -0.34, p < 0.001), and also was identified as an independent determinative value of GLS in a multivariate linear regression model (ß = -0.25, p = 0.001) even after adjustment for other closely related GLS factors. CONCLUSIONS: Monitoring of F-wave latency may aid early detection of not only DN but also subclinical LV dysfunction. Joint planning of assessment by diabetologists and cardiologists is therefore advisable for better management of DM patients.
Asunto(s)
Neuropatías Diabéticas/diagnóstico , Neuropatías Diabéticas/fisiopatología , Conducción Nerviosa , Nervios Periféricos/fisiopatología , Disfunción Ventricular Izquierda/diagnóstico , Disfunción Ventricular Izquierda/fisiopatología , Anciano , Neuropatías Diabéticas/epidemiología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Conducción Nerviosa/fisiología , Disfunción Ventricular Izquierda/epidemiologíaRESUMEN
BACKGROUND: Right ventricular (RV) dysfunction in pulmonary hypertension (PH) is linked to adverse outcomes, but this response is considered heterogeneous because it can be associated with multiple factors. METHODS: RV function of 51 PH patients was calculated by averaging peak speckle-tracking longitudinal strain from RV free-wall (RV-free), and the cutoff for RV dysfunction was predefined as RV-free ≤ 19%. Right-sided heart remodelling was assessed in terms of RV end-systolic area (RVESA) and right atrial (RA) area (RA-area). Midterm reverse remodelling was defined as a relative decrease in RVESA (ΔRVESA) and RA-area (ΔRA-area) of at least 15% at 5.7 ± 4.0 months after introduction of pulmonary artery hypertension-specific drugs. Long-term outcome was tracked for 3.0 ± 2.0 years. RESULTS: Patients with midterm RV and RA reverse remodelling showed more favourable long-term outcomes than those without (P = 0.01, P = 0.047, respectively). Sequential Cox models showed that a model based on hemodynamic parameters (χ(2) = 0.3) was improved by the addition of RV-free (χ(2) = 6.4; P = 0.01), and further improved by addition of ΔRVESA and ΔRA-area (χ(2) = 28.2; P < 0.001). Furthermore, preservation of baseline RV function and midterm reverse remodelling in right-sided heart was associated with an optimal outcome: a survival rate of 100%. In contrast, absence of midterm reverse remodelling in the right-sided heart of patients with impaired baseline RV function was associated with significantly worse outcome with a survival rate of 33% (P = 0.01). CONCLUSIONS: RV function and echocardiographic right-heart reverse remodelling with therapy improves the prediction of long-term outcomes for PH patients over standard hemodynamic indices.
Asunto(s)
Antihipertensivos/uso terapéutico , Ecocardiografía Doppler en Color/métodos , Endarterectomía/métodos , Ventrículos Cardíacos/diagnóstico por imagen , Hipertensión Pulmonar/diagnóstico por imagen , Función Ventricular Derecha/fisiología , Remodelación Ventricular/fisiología , Anciano , Femenino , Estudios de Seguimiento , Ventrículos Cardíacos/fisiopatología , Humanos , Hipertensión Pulmonar/fisiopatología , Hipertensión Pulmonar/terapia , Masculino , Persona de Mediana Edad , Reproducibilidad de los Resultados , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Disfunción Ventricular Derecha/diagnóstico por imagen , Disfunción Ventricular Derecha/etiología , Disfunción Ventricular Derecha/fisiopatologíaRESUMEN
AIMS: Right ventricular (RV) as well as left ventricular (LV) function has been recognized as an important prognostic factor for heart failure patients. Our objective was thus to investigate the prognostic significance of combined assessment of bi-ventricular functional reserve for patients with dilated cardiomyopathy (DCM). METHODS AND RESULTS: We studied 104 DCM patients with ejection fractions (EF) of 32 ± 9%, and speckle-tracking echocardiography was used to assess both RV and LV contractile reserve under dobutamine stress (20 µg/kg/min). RV contractile function was measured as peak global longitudinal strain (GLS) from the RV free wall (RV-free), and LV function as global circumferential strain (GCS) and GLS, respectively. Event-free survival was then tracked for 17 months. Twenty-one patients (20%) developed cardiovascular events. A multivariate Cox proportional-hazards analysis revealed that the baseline EF, E/A, and the relative change in EF (ΔEF), in GCS (ΔGCS), and in RV-free (ΔRV-free) during dobutamine stress were the independent predictors of cardiovascular events (P < 0.001, <0.05, <0.01, <0.05, and <0.01, respectively). A Cox model based on baseline clinical and echocardiographic variables (χ(2) = 23.6) was improved by the addition of LV contractile reserve parameters (plus ΔGCS and ΔEF) (χ(2) = 49.1; P < 0.001) and further improved by adding RV contractile reserve (plus ΔRV-free) (χ(2) = 60.3, P < 0.001). CONCLUSION: Assessment of RV contractile reserve during dobutamine stress offers a significantly better prognostic value for patients with DCM. Bi-ventricular contractile reserve may be required for a favourable outcome, so that estimation of RV contractile reserve should be considered part of a comprehensive functional assessment of these patients.
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Cardiomiopatía Dilatada/diagnóstico por imagen , Cardiomiopatía Dilatada/fisiopatología , Ventrículos Cardíacos/diagnóstico por imagen , Ecocardiografía de Estrés , Femenino , Humanos , Masculino , Persona de Mediana Edad , Contracción Miocárdica/fisiología , Pronóstico , Volumen Sistólico/fisiología , Tasa de SupervivenciaRESUMEN
BACKGROUND: Left ventricular (LV) longitudinal systolic dysfunction has been identified even in asymptomatic patients with diabetes mellitus (DM) and preserved LV ejection fraction (LVEF). However, its relevant clinical features have not been fully evaluated. METHODS: We studied 144 asymptomatic DM patients without coronary artery disease. Their mean age was 57 ± 15 years, 79 (55%) were female, and mean LVEF was 66 ± 4% (all ≥50%). Global longitudinal strain (GLS) was determined as the average peak strain of 18 segments from the three standard apical views, and was expressed as an absolute value. With the pre-defined cutoff for subclinical LV systolic dysfunction in DM patients with preserved LVEF set at GLS < 18%, this dysfunction was detected in 53 patients (37%). RESULTS: Multivariate logistic regression analysis revealed that type 2 DM, hypertriglyceridemia, overweight/obesity, nephropathy and neuropathy were independently associated with GLS < 18%, with nephropathy being the highest risk factor (OR: 5.26; 95% CI 2.111-13.12, p < 0.001). For sequential logistic regression models, a model based on clinical variables including gender, type 2 DM and DM duration (χ(2) = 24.1) was improved by addition of overweight/obesity and hypertriglyceridemia (χ(2) = 45.6, p < 0.001), and further improved by addition of nephropathy and neuropathy (χ(2) = 70.2, p < 0.001) as variables. Furthermore, albuminuria significantly correlated with GLS (r = -0.51, p < 0.001), and a multivariate regression model showed it to be the factor most closely associated with GLS (ß = -0.33, p < 0.001). CONCLUSIONS: Diabetic complications, hypertriglyceridemia and overweight/obesity were closely associated with early stage of LV systolic longitudinal myocardial dysfunction in asymptomatic DM patients with preserved LVEF. Our findings can be clinically noticeable for the management of DM patients.
Asunto(s)
Diabetes Mellitus Tipo 2/complicaciones , Cardiomiopatías Diabéticas/etiología , Disfunción Ventricular Izquierda/etiología , Función Ventricular Izquierda , Adulto , Anciano , Enfermedades Asintomáticas , Distribución de Chi-Cuadrado , Estudios Transversales , Diabetes Mellitus Tipo 2/diagnóstico , Cardiomiopatías Diabéticas/diagnóstico , Cardiomiopatías Diabéticas/fisiopatología , Ecocardiografía Doppler en Color , Femenino , Humanos , Hipertrigliceridemia/complicaciones , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Obesidad/complicaciones , Oportunidad Relativa , Pronóstico , Factores de Riesgo , Volumen Sistólico , Sístole , Disfunción Ventricular Izquierda/diagnóstico , Disfunción Ventricular Izquierda/fisiopatologíaRESUMEN
Although impaired right ventricular (RV) performance has been associated with adverse outcomes for pulmonary hypertension (PH) patients, the relationship between bi-ventricular interdependence and outcomes is not yet fully understood. We studied 96 PH patients. RV systolic function was assessed by means of RV free-wall longitudinal speckle-tracking strain (RV-free), and left ventricular (LV) filling as early diastolic transmitral flow velocity (TMF-E). RV-free ≤19 % and TMF-E <60 cm/s were adopted as pre-defined cut-offs for RV systolic dysfunction and LV under-filling, respectively, associated with worse outcomes. Long-term outcome was tracked over 2.2 years. RV-free correlated significantly with TMF-E (r = 0.57, p < 0.001).TMF-E and RV-free were significantly lower in patients with than in those without cardiac events. RV systolic dysfunction and LV under-filling was observed in 35 patients. These features were associated with worse long-term survival compared to other sub-groups (log-rank p = 0.012). A sequential Cox model based on clinical variables including world health organization functional class IV and brain natriuretic peptide >150 pg/dl (χ(2) = 1.2) was improved by the addition of RV-free (χ(2) = 5.5, p = 0.04) as well as of TMF-E (χ(2) = 11.5, p = 0.01). In conclusions, RV systolic function was shown to correlate significantly with LV filling in PH patients. In addition, not only assessment of RV systolic function, but also of a combined bi-ventricular parameter comprising RV systolic function and LV filling may well have clinical implications for more successful management of PH patients.
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Hipertensión Pulmonar/fisiopatología , Sístole , Disfunción Ventricular Izquierda/fisiopatología , Disfunción Ventricular Derecha/fisiopatología , Función Ventricular Izquierda , Función Ventricular Derecha , Anciano , Distribución de Chi-Cuadrado , Supervivencia sin Enfermedad , Ecocardiografía Doppler de Pulso , Femenino , Humanos , Hipertensión Pulmonar/diagnóstico por imagen , Hipertensión Pulmonar/mortalidad , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Pronóstico , Modelos de Riesgos Proporcionales , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Disfunción Ventricular Izquierda/diagnóstico por imagen , Disfunción Ventricular Izquierda/mortalidad , Disfunción Ventricular Derecha/diagnóstico por imagen , Disfunción Ventricular Derecha/mortalidadRESUMEN
BACKGROUND: Identification of heart failure (HF) symptoms in patients with severe aortic stenosis (AS) and preserved left ventricular (LV) ejection fraction (EF) is clinically important, but assessment of HF symptoms is challenging. It was recently reported that resting left atrium (LA) functions are related to exercise performance and are also important prognostic markers for patients with HF. The aim of this study was to assess the association of the HF symptoms with LA function in patients with severe AS and preserved LVEF. METHODS: We retrospectively studied 40 patients with severe AS and preserved LVEF (all ≥50%) who were referred for aortic valve replacement (AVR). LA reservoir (SR-LAs), conduit (SR-LAe), and booster-pump (SR-LAa) functions were determined as the averaged global LA speckle tracking longitudinal strain rate from apical four- and two-chamber views. Twenty patients were symptomatic and 20 asymptomatic. RESULTS: Aortic stenosis severity was similar for the 2 groups. Symptomatic status was associated with age, LV mass index, hemoglobin, B-type natriuretic peptide, LV end-systolic volume index, LVEF, LA volume index, SR-LAs, SR-LAe, and SR-LAa. Importantly, multivariate logistic regression analysis revealed that SR-LAa was the only independent determinant of symptomatic status (OR = 0.242, P = 0.002). Furthermore, significant improvement of SR-LAa was observed along with the reduction in LA volume index and LV mass index after AVR. CONCLUSIONS: SR-LAa was found to be associated with the HF symptoms. Characterization of LA booster-pump function may be useful for the assessment of the symptomatic status in patients with severe AS patients and limited physical activity.