The Diagnostic and Prognostic Utility of Contemporary Cardiac Magnetic Resonance in Suspected Acute Myocarditis

Cardiovascular magnetic resonance (CMR) is used to investigate suspected acute myocarditis, however most supporting data is retrospective and few studies have included parametric mapping. We aimed to investigate the utility of contemporary multiparametric CMR in a large prospective cohort of patients with suspected acute myocarditis, the impact of real-world variations in practice, the relationship between clinical characteristics and CMR findings and factors predicting outcome. 540 consecutive patients we recruited. The 113 patients diagnosed with myocarditis on CMR performed within 40 days of presentation were followed-up for 674 (504–915) days. 39 patients underwent follow-up CMR at 189 (166–209) days. CMR provided a positive diagnosis in 72% of patients, including myocarditis (40%) and myocardial infarction (11%). In multivariable analysis, male sex and shorter presentation-to-scan interval were associated with a diagnosis of myocarditis. Presentation with heart failure (HF) was associated with lower left ventricular ejection fraction (LVEF), higher LGE burden and higher extracellular volume fraction. Lower baseline LVEF predicted follow-up LV dysfunction. Multiparametric CMR has a high diagnostic yield in suspected acute myocarditis. CMR should be performed early and include parametric mapping. Patients presenting with HF and reduced LVEF require closer follow-up while those with normal CMR may not require it.

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Biomarkers-based personalized follow-up in chronic heart failure improves patient’s outcomes and reduces care associate cost

Health and Quality of Life Outcomes ◽

10.1186/s12955-021-01779-9 ◽

2021 ◽

Vol 19 (1) ◽

Author(s):

Antonio Leon-Justel ◽

Jose I. Morgado Garcia-Polavieja ◽

Ana Isabel Alvarez-Rios ◽

Francisco Jose Caro Fernandez ◽

Pedro Agustin Pajaro Merino ◽

...

Keyword(s):

Heart Failure ◽

Hospital Admissions ◽

Left Ventricular ◽

Left Ventricular Ejection ◽

Secondary Outcome ◽

Ventricular Ejection Fraction ◽

Number Of Patients ◽

Ed Visits ◽

The Impact

Abstract Background Heart failure (HF) is a major and growing medical and economic problem, with high prevalence and incidence rates worldwide. Cardiac Biomarker is emerging as a novel tool for improving management of patients with HF with a reduced left ventricular ejection fraction (HFrEF). Methods This is a before and after interventional study, that assesses the impact of a personalized follow-up procedure for HF on patient’s outcomes and care associated cost, based on a clinical model of risk stratification and personalized management according to that risk. A total of 192 patients were enrolled and studied before the intervention and again after the intervention. The primary objective was the rate of readmissions, due to a HF. Secondary outcome compared the rate of ED visits and quality of life improvement assessed by the number of patients who had reduced NYHA score. A cost-analysis was also performed on these data. Results Admission rates significantly decreased by 19.8% after the intervention (from 30.2 to 10.4), the total hospital admissions were reduced by 32 (from 78 to 46) and the total length of stay was reduced by 7 days (from 15 to 9 days). The rate of ED visits was reduced by 44% (from 64 to 20). Thirty-one percent of patients had an improved functional class score after the intervention, whereas only 7.8% got worse. The overall cost saving associated with the intervention was € 72,769 per patient (from € 201,189 to € 128,420) and €139,717.65 for the whole group over 1 year. Conclusions A personalized follow-up of HF patients led to important outcome benefits and resulted in cost savings, mainly due to the reduction of patient hospitalization readmissions and a significant reduction of care-associated costs, suggesting that greater attention should be given to this high-risk cohort to minimize the risk of hospitalization readmissions.

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The relationship between diastolic blood pressure and the risk of cardiovascular events in patients with atrial fibrillation: the Fushimi AF registry

European Heart Journal ◽

10.1093/ehjci/ehaa946.1168 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

S Ikeda ◽

M Iguchi ◽

H Ogawa ◽

Y Aono ◽

K Doi ◽

...

Keyword(s):

Atrial Fibrillation ◽

Blood Pressure ◽

Diastolic Blood Pressure ◽

Cardiovascular Events ◽

Left Ventricular ◽

Cox Proportional Hazards ◽

Left Ventricular Ejection ◽

Ventricular Ejection Fraction ◽

The Impact

Abstract Background Hypertension is one of the major risk factors of cardiovascular events in patients with atrial fibrillation (AF). However, relationship between diastolic blood pressure (DBP) and cardiovascular events in AF patients remains unclear. Methods The Fushimi AF Registry is a community-based prospective survey of AF patients in Japan. Follow-up data were available in 4,466 patients, and 4,429 patients with available data of DBP were examined. We divided the patients into three groups; G1 (DBP<70 mmHg, n=1,946), G2 (70≤DBP<80, n=1,321) and G3 (80≤DBP, n=1,162), and compared the clinical background and outcomes between groups. Results The proportion of female was grater in G1 group, and the patients in G1 group were older and had higher prevalence of heart failure (HF), diabetes mellitus (DM), chronic kidney disease (CKD). Prescription of beta blockers was higher in G1 group, but that of renin-angiotensin system-inhibitors and calcium channel blocker was comparable. During the median follow-up of 1,589 days, in Kaplan-Meier analysis, the incidence rates of cardiovascular events (composite of cardiac death, ischemic stroke and systemic embolism, major bleeding and HF hospitalization during follow up) were higher in G1 group and G3 group than G2 group (Figure 1). When we divided the patients based on the systolic blood pressure (SBP) at baseline (≥130 mmHg or <130 mmHg), the incidence of rates of cardiovascular events were comparable among groups. Multivariate Cox proportional hazards regression analysis including female gender, age (≥75 years), higher SBP (≥130 mmHg), DM, pre-existing HF, CKD, low left ventricular ejection fraction (<40%) and DBP (G1, G2, G3) revealed that DBP was an independent determinant of cardiovascular events (G1 group vs. G2 group; hazard ratio (HR): 1.40, 95% confidence intervals (CI): 1.19–1.64, G3 group vs. G2 group; HR: 1.23, 95% CI: 1.01–1.49). When we examined the impact of DBP according to 10 mmHg increment, patients with very low DBP (<60 mmHg) (HR: 1.50,95% CI:1.24–1.80) and very high DBP (≥90 mmHg) (HR: 1.51,95% CI:1.15–1.98) had higher incidence of cardiovascular events than patients with DBP of 70–79 mmHg (Figure 2). However, when we examined the impact of SBP according to 20 mmHg increment, SBP at baseline was not associated with the incidence of cardiovascular events (Figure 3). Conclusion In Japanese patients with AF, DBP exhibited J curve association with higher incidence of cardiovascular events. Funding Acknowledgement Type of funding source: None

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Clinical Outcomes in Patients with Ischemic versus Non-Ischemic Cardiomyopathy after Angiotensin-Neprilysin Inhibition Therapy

Journal of Clinical Medicine ◽

10.3390/jcm10214989 ◽

2021 ◽

Vol 10 (21) ◽

pp. 4989

Author(s):

Mohammad Abumayyaleh ◽

Christina Pilsinger ◽

Ibrahim El-Battrawy ◽

Marvin Kummer ◽

Jürgen Kuschyk ◽

...

Keyword(s):

Heart Failure ◽

Ejection Fraction ◽

Ischemic Cardiomyopathy ◽

Left Ventricular ◽

Left Ventricular Ejection ◽

Ventricular Tachyarrhythmias ◽

Ventricular Ejection Fraction ◽

One Year ◽

The Impact

Background: The angiotensin receptor-neprilysin inhibitor (ARNI) decreases cardiovascular mortality in patients with chronic heart failure with a reduced ejection fraction (HFrEF). Data regarding the impact of ARNI on the outcome in HFrEF patients according to heart failure etiology are limited. Methods and results: One hundred twenty-one consecutive patients with HFrEF from the years 2016 to 2017 were included at the Medical Centre Mannheim Heidelberg University and treated with ARNI according to the current guidelines. Left ventricular ejection fraction (LVEF) was numerically improved during the treatment with ARNI in both patient groups, that with ischemic cardiomyopathy (n = 61) (ICMP), and that with non-ischemic cardiomyopathy (n = 60) (NICMP); p = 0.25. Consistent with this data, the NT-proBNP decreased in both groups, more commonly in the NICMP patient group. In addition, the glomerular filtration rate (GFR) and creatinine changed before and after the treatment with ARNI in both groups. In a one-year follow-up, the rate of ventricular tachyarrhythmias (ventricular tachycardia and ventricular fibrillation) tended to be higher in the ICMP group compared with the NICMP group (ICMP 38.71% vs. NICMP 17.24%; p = 0.07). The rate of one-year all-cause mortality was similar in both groups (ICMP 6.5% vs. NICMP 6.6%; log-rank = 0.9947). Conclusions: This study shows that, although the treatment with ARNI improves the LVEF in ICMP and NICMP patients, the risk of ventricular tachyarrhythmias remains higher in ICMP patients in comparison with NICMP patients. Renal function is improved in the NICMP group after the treatment. Long-term mortality is similar over a one-year follow-up.

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P3118CMR Fast-SENC intramyocardial LV & RV segmental strain detects cardiotoxicity during oncology treatment and impact of cardioprotection therapy before echocardiography

European Heart Journal ◽

10.1093/eurheartj/ehz745.0193 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

H Steen ◽

M Montenbruck ◽

P Wuelfing ◽

S Esch ◽

A K Schwarz ◽

...

Keyword(s):

Breast Cancer ◽

Cancer Therapy ◽

Global Longitudinal Strain ◽

Left Ventricular ◽

Left Ventricular Ejection ◽

Lower Sensitivity ◽

Pharmacological Agents ◽

Ventricular Ejection Fraction ◽

The Impact

Abstract Background The incidence of cardiotoxicity during cancer therapy is underestimated due to limitations of current diagnostic tests. Current biomarkers (BNP, NT-pro-BNP, hs-Troponin, etc.) and imaging calculations (e.g. echocardiography) such as left ventricular ejection fraction (LVEF) are currently included in the guidelines to designate cardiotoxicity during cancer therapy. Unfortunately, these diagnostics identify systemic damage in symptomatic patients after the heart is unable to compensate for regional dysfunction. Fast-SENC segmental intramyocardial strain (fSENC) is a unique cardiac magnetic resonance imaging (CMR) test that regionally detects subclinical intramyocardial dysfunction in 1 heartbeat. Methods This single center, prospective Prefect Study was used to evaluate cardiotoxicity and the impact of cardioprotective therapy in Breast Cancer and Lymphoma patients (NCT03543228). fSENC was acquired with a 1.5T MRI and processed with the software to quantify intramyocardial strain. Segmental strain was measured in three short axis scans (basal, midventricular, apical) with 16 LV/6 RV longitudinal segments & three long axis scans (2-, 3-, 4-chamber) with 21 LV/5 RV circumferential segments. fSENC CMR was performed before chemotherapy, during and after anthracycline/taxane therapy, at 1 year follow-up, and as needed in between designated follow-up periods. Cardioprotective therapy was offered to patients meeting the definition of cardiotoxicity by the ESC Guidelines on Cardiotoxicity and/or ESMO Clinical Practice Guidelines or those observing a substantial decline in cardiac function. Results Two hundred eight (208) CMRs were performed in fifty-two (52) patients (44 female). Patients had an average (± stdev) age of 53 (15) yrs, BMI of 26 (5) kg/m2; 77% had breast cancer, 23% had Lymphoma. fSENC CMRs required 11 (2) min total exam time. The % of normal fSENC (segmental stain <−17%) with a threshold of 65% showed a sensitivity of 87% and specificity of 89% in detecting cardiotoxicity while echocardiography GLS with a threshold of −17% observed a sensitivity of 20% and specificity of 88%. Figure 1 shows receiver operating characteristic curves for fSENC based on the percent of normal myocardium, and echocardiography global longitudinal strain (GLS) respectively. Global fSENC had substantially lower sensitivity than segmental fSENC despite having higher accuracy than the other global metrics. Figure 1 Conclusion Segmental fSENC intramyocardial strain detects subclinical dysfunction due to cardiotoxic response of chemotherapy before other biomarkers and imaging modalities. The ability to detect the subclinical cardiotoxicity of chemotherapy agents, or other pharmacological agents that cause or worsen heart failure, enables proactive prescription of cardioprotective medications to avoid tissue remodeling that precedes systemic cardiac dysfunction and worsening of global measures such as LVEF and current biomarkers.

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Minimally Invasive Sutureless Aortic Valve Replacement is Associated With Improved Outcomes in Patients With Left Ventricular Dysfunction

Innovations Technology and Techniques in Cardiothoracic and Vascular Surgery ◽

10.1177/1556984519872990 ◽

2019 ◽

Vol 14 (5) ◽

pp. 445-452

Author(s):

Giovanni Concistrè ◽

Giacomo Bianchi ◽

Francesca Chiaramonti ◽

Rafik Margaryan ◽

Federica Marchi ◽

...

Keyword(s):

Aortic Valve ◽

Aortic Valve Replacement ◽

Minimally Invasive ◽

Valve Replacement ◽

Left Ventricular ◽

Left Ventricular Ejection ◽

Ventricular Ejection Fraction ◽

Lv Dysfunction ◽

The Impact

Objective Patients with severe aortic stenosis and reduced left ventricular ejection fraction (LVEF) have a poor prognosis compared with patients with preserved LVEF. To evaluate the impact of sutureless Perceval (LivaNova, Italy) aortic bioprosthesis on LVEF and clinical outcomes in patients with baseline left ventricular (LV) dysfunction who underwent isolated aortic valve replacement (AVR). Methods Between March 2011 and August 2017, 803 patients underwent AVR with Perceval bioprosthesis implantation. Fifty-two isolated AVR had preoperative LVEF ≤45%. Mean age of these patients was 77 ± 6 years, 24 patients were female (46%), and mean EuroSCORE II was 9.4% ± 4.8%. Perceval bioprosthesis was implanted in 9 REDO operations. In 43 patients (83%), AVR was performed in minimally invasive surgery with an upper ministernotomy ( n = 13) or right anterior minithoracotomy ( n = 30). Results One patient died in hospital. Cardiopulmonary bypass and aortic cross-clamp times were 85.5 ± 26 minutes and 55.5 ± 19 minutes, respectively. At mean follow-up of 33 ± 20 months (range: 1 to 75 months), survival was 90%, freedom from reoperation was 100%, and mean transvalvular pressure gradient was 11 ± 5 mmHg. LVEF improved from 37% ± 7% preoperatively to 43% ± 8% at discharge ( P < 0.01) and further increased to 47% ± 9% at follow-up ( P = 0.06), LV mass decreased from 149.8 ± 16.9 g/m2 preoperatively to 115.3 ± 11.6 g/m2 at follow-up ( P < 0.001), and moderate paravalvular leakage occurred in 1 patient without hemolysis not requiring any treatment. Conclusions AVR with sutureless aortic bioprosthesis implantation in patients with preoperative LV dysfunction demonstrated a significant immediate and early improvement in LVEF.

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Sequential cardiovascular magnetic resonance assessment of left ventricular ejection fraction for prediction of subsequent events in a large multicenter STEMI registry

European Heart Journal - Cardiovascular Imaging ◽

10.1093/ehjci/jeab090.042 ◽

2021 ◽

Vol 22 (Supplement_2) ◽

Author(s):

J Gavara ◽

V Marcos-Garces ◽

C Rios-Navarro ◽

MP Lopez-Lereu ◽

JV Monmeneu ◽

...

Keyword(s):

Cardiovascular Magnetic Resonance ◽

Magnetic Resonance ◽

Left Ventricular Ejection Fraction ◽

Ejection Fraction ◽

Left Ventricular ◽

Ventricular Ejection ◽

Left Ventricular Ejection ◽

P Value ◽

Ventricular Ejection Fraction

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – EU funding. Main funding source(s): This work was supported by “Instituto de Salud Carlos III” and “Fondos Europeos de Desarrollo Regional FEDER” Background. Cardiovascular magnetic resonance (CMR) is the best tool for left ventricular ejection fraction (LVEF) quantification, but as yet the prognostic value of sequential LVEF assessment for major adverse cardiac event (MACE) prediction after ST-segment elevation myocardial infarction (STEMI) is uncertain. Purpose. We explored the prognostic impact of sequential assessment of CMR-derived LVEF after STEMI to predict subsequent MACE. Methods. We recruited 1036 STEMI patients in a large multicenter registry. LVEF (reduced [r]: <40%; mid-range [mr]: 40-49%; preserved [p]: ≥50%) was sequentially quantified by CMR at 1 week and after >3 months of follow-up. MACE was regarded as cardiovascular death or re-admission for acute heart failure after follow-up CMR. Results. During a 5.7-year mean follow-up, 82 MACE (8%) were registered. The MACE rate was higher only in patients with LVEF < 40% at follow-up CMR (r-LVEF 22%, mr-LVEF 7%, p-LVEF 6%; p-value < 0.001). Based on LVEF dynamics from 1-week to follow-up CMR, incidence of MACE was 5% for sustained LVEF³40% (n = 783), 13% for improved LVEF (from <40 to ³40%, n = 96), 21% for worsened LVEF (from ³40% to <40%, n = 34) and 22% for sustained LVEF <40% (n = 100), p-value < 0.001. Using a Markov approach that considered all studies performed, transitions towards improved LVEF predominated and only r-LVEF (at any time assessed) was significantly related to higher incidence of subsequent MACE. Conclusions. LVEF constitutes a pivotal CMR index for simple and dynamic post-STEMI risk stratification. Detection of reduced LVEF (<40%) by CMR at any time during follow-up identifies a small subset of patients at high risk of subsequent events.

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P450The difference in the prognosis among three categories of the post-procedural left ventricular ejection fraction in patients undergoing atrial fibrillation ablation

EP Europace ◽

10.1093/europace/euaa162.124 ◽

2020 ◽

Vol 22 (Supplement_1) ◽

Author(s):

K Yazaki ◽

K Ejima ◽

M Kanai ◽

S Kataoka ◽

S Higuchi ◽

...

Keyword(s):

Systolic Function ◽

Left Ventricular ◽

Left Ventricular Ejection ◽

Composite Outcome ◽

Ventricular Ejection Fraction ◽

Index Procedure ◽

Af Ablation ◽

One Year ◽

The Impact

Abstract Funding Acknowledgements None Background Atrial fibrillation (AF) ablation has been known to contribute to a good prognosis in heart failure patients and improve their systolic function. However, the impact of the post-procedural systolic function on the prognosis in them remains unclear. Purpose To investigate the impact of the left ventricular ejection fraction (LVEF) following AF ablation in patients with systolic dysfunction. Methods Out of 1078 consecutive patients who underwent AF ablation including extensive pulmonary vein and superior vena cava isolation, 170 with an impaired pre-procedural LVEF (< 50%) were evaluated. They experienced at least one echocardiographic follow-up within one year after the index procedure. The primary outcome was the composite of all-cause death or heart failure hospitalisations (HFHs). In addition, we categorised the patients into three groups according to the post-procedural LVEF within one year to evaluate the outcome: reduced LVEF (rEF, LVEF < 40%), mid-range EF (mrEF, 40% ≤ LVEF < 50%) and preserved LVEF (pEF, LVEF > 50%). Results After the index procedure, the patients’ LVEF improved with an average increase of 8%, and the post-procedural LVEF consisted of an rEF in 27 (16%), mrEF in 41 (24%), and pEF in 102 (60%) patients. During a median follow-up of 31 months, a total of 22 (13%) patients experienced the composite outcome, including 18 (11%) HFHs and 10 (6%) all-cause deaths (5 with cardiac issues, 2 any malignancies, and 3 other issues). In the Kaplan-Meier analysis using a Bonferroni correction, there was a significant difference in achieving the outcome between the rEF and mrEF, and rEF and pEF, but not between the mrEF and pEF groups (Figure). In a univariate analysis, the hazard ratio of the outcome was shown as follows: an age ≥ 65 years (hazard ratio, HR: 3.4 [95% confidence interval, CI: 1.4–8.5], p = 0.006), history of HFHs for AF (HR: 1.7 [95%CI: 0.7–4.0], p = 0.25), known underlying heart disease (HR: 1.9 [95%CI: 0.8–1.2], p = 0.13), pre-procedural LVEF < 40% (HR: 3.1 [95%CI: 1.3–7.5], p = 0.009), atrial tachyarrhythmia recurrence (HR: 3.0 [95%CI: 1.2–7.8], p = 0.01), and the post-procedural LVEF category (mrEF and rEF, compared with pEF) (HR: 2.0 [95%CI: 0.4–7.7], p = 0.34; and HR: 8.6 [95%CI: 2.7–37.5], p < 0.0001). Furthermore, in a multivariate analysis, patients with a rEF was the sole independent predictor of the composite outcome after adjusting for confounders including an age≥65 years and pre-procedural LVEF < 40% (HR: 12.0 [95%CI: 3.9–40.0], p < 0.0001), whereas those with a mrEF was not (HR: 1.8 [95%CI: 0.4–7.3], p = 0.42), as compared to those with a pEF. Conclusions Patients with a mrEF had a comparable prognosis to those with a pEF in a relatively long follow-up, while those with a rEF had the poorest outcome of the three categories, regardless of the pre-procedural LVEF severity. Abstract Figure. The difference in the rate of outcome

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Genotype–phenotype correlation in arrhythmogenic right ventricular cardiomyopathy—risk of arrhythmias and heart failure

Journal of Medical Genetics ◽

10.1136/jmedgenet-2021-107911 ◽

2021 ◽

pp. jmedgenet-2021-107911

Author(s):

Alex Hørby Christensen ◽

Pyotr G Platonov ◽

Henrik Kjærulf Jensen ◽

Monica Chivulescu ◽

Anneli Svensson ◽

...

Keyword(s):

Right Ventricular ◽

Arrhythmogenic Right Ventricular Cardiomyopathy ◽

Left Ventricular ◽

Left Ventricular Ejection ◽

Carrier Status ◽

Ventricular Cardiomyopathy ◽

Ventricular Ejection Fraction ◽

Male Sex ◽

The Impact

BackgroundArrhythmogenic right ventricular cardiomyopathy (ARVC) is predominantly caused by desmosomal genetic variants, and clinical hallmarks include arrhythmias and systolic dysfunction. We aimed at studying the impact of the implicated gene(s) on the disease course.MethodsThe Nordic ARVC Registry holds data on a multinational cohort of ARVC families. The effects of genotype on electrocardiographic features, imaging findings and clinical events were analysed.ResultsWe evaluated 419 patients (55% men), with a mean follow-up of 11.2±7.4 years. A pathogenic desmosomal variant was identified in 62% of the 230 families: PKP2 in 41%, DSG2 in 13%, DSP in 7% and DSC2 in 3%. Reduced left ventricular ejection fraction (LVEF) ≤45% on cardiac MRI was more frequent among patients with DSC2/DSG2/DSP than PKP2 ARVC (27% vs 4%, p<0.01). In contrast, in Cox regression modelling of patients with definite ARVC, we found a higher risk of arrhythmias among PKP2 than DSC2/DSG2/DSP carriers: HR 0.25 (0.10–0.68, p<0.01) for atrial fibrillation/flutter, HR 0.67 (0.44–1.0, p=0.06) for ventricular arrhythmias and HR 0.63 (0.42–0.95, p<0.05) for any arrhythmia. Gene-negative patients had an intermediate risk (16%) of LVEF ≤45% and a risk of the combined arrhythmic endpoint comparable with DSC2/DSG2/DSP carriers. Male sex was a risk factor for both arrhythmias and reduced LVEF across all genotype groups (p<0.01).ConclusionIn this large cohort of ARVC families with long-term follow-up, we found PKP2 genotype to be more arrhythmic than DSC2/DSG2/DSP or gene-negative carrier status, whereas reduced LVEF was mostly seen among DSC2/DSG2/DSP carriers. Male sex was associated with a more severe phenotype.

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Abstract 5936: Can Apoptosis Predict Functional Recovery in Acute Myocarditis?

Circulation ◽

10.1161/circ.118.suppl_18.s_1033-c ◽

2008 ◽

Vol 118 (suppl_18) ◽

Author(s):

Antonio Abbate ◽

Gianfranco Sinagra ◽

Rossana Bussani ◽

Nicholas N Hoke ◽

Stefano Toldo ◽

...

Keyword(s):

Functional Recovery ◽

Cardiac Dysfunction ◽

Acute Myocarditis ◽

Left Ventricular ◽

Left Ventricular Ejection ◽

Causal Association ◽

Double Positive ◽

Cytokeratin 18 ◽

Ventricular Ejection Fraction

Background. Acute myocarditis is characterized by acute cardiac dysfunction followed by a variable recovery over time. Recent data have shown the presence of apoptosis in acute myocarditis. We hypothesized that the presence and extent of apoptosis evaluated at endomyocardial biopsy (EMB) could predict functional recovery in patients with acute myocarditis, with more apoptosis predicting less recovery. Methods. Sixteen patients with acute myocarditis were studied with EMB. Baseline and follow up echocardiography was obtained in all cases. The patients were retrospectively divided in 2 groups according to the final left ventricular ejection fraction (LVEF): LVEF>40% [recovery] and LVEF≤40% [no recovery]. Co-staining for DNA fragmentation (TUNEL) and caspase-cleaved cytokeratin-18 (CytoDeath) were performed to quantify the cardiomyocyte apoptosis in EMB specimens. Four subjects dying of non-cardiac causes were selected as control hearts at time of autopsy. Results. Six patients showed functional recovery (38%) while 8 did not (62%). The apoptotic rate (AR, expressed as % of double positive cardiomyocytes on total number per field) was significantly higher in the hearts of patients with acute myocarditis (1.1%[0.7–2.2] vs 0.01%[0.01–0.01] in control hearts, p<0.001). Unexpectedly, patients with functional recovery had a significantly higher AR than patients without recovery (3.2%[1.1–8.0] vs 0.5%[0.3–1.0], p=0.001), and the AR correlated with follow-up LVEF (R=+0.54, p=0.030). Six of the 8 patients (75%) with AR above average showed functional recovery vs 0 of the 8 patients (0%) with AR below average (p=0.007). Conclusions. This study surprisingly shows that the presence of greater apoptosis at EBM in patients with acute myocarditis predicts functional recovery at 12 months. Whether this represents a true cause-effect association or it simply represents a non-causal association remains unclear and warrants further studies.

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Impact of pulmonary hypertension on outcome in patients with moderate or severe tricuspid regurgitation

Open Heart ◽

10.1136/openhrt-2019-001104 ◽

2019 ◽

Vol 6 (2) ◽

pp. e001104 ◽

Cited By ~ 1

Author(s):

Sahrai Saeed ◽

Jenna Smith ◽

Karine Grigoryan ◽

Stig Urheim ◽

John B Chambers ◽

...

Keyword(s):

Pulmonary Hypertension ◽

Tricuspid Regurgitation ◽

Left Ventricular ◽

Right Atrial ◽

Left Ventricular Ejection ◽

Systolic Pulmonary Artery Pressure ◽

Ventricular Ejection Fraction ◽

Cox Regression Analysis ◽

The Impact

ObjectivesThe true prevalence and disease burden of moderate or severe (significant) tricuspid regurgitation (TR) in patients undergoing routine echocardiography remains unknown. Our aim was to explore the prevalence of significant TR and the impact of pulmonary hypertension (PH) on outcome in a less selected cohort of patients referred to echocardiography.MethodsFrom 12 791 echocardiograms performed between January and December 2010, a total of 209 (1.6%) patients (72±14 years, 56% men) were identified with significant TR; 123 (0.96%) with moderate and 86 (0.67%) with severe TR. Median follow-up time was 80 months (mean 70±33 months). Systolic pulmonary artery pressure was derived from peak velocity of tricuspid regurgitant jet plus the right atrial pressure and considered elevated if ≥40 mm Hg (PH).ResultsDuring follow-up there were 123 (59%) deaths with no difference in mortality between moderate and severe TR (p=0.456). The death rates were 93 (67%) in patients with PH versus 30 (42%) without PH (p<0.001). PH was associated with lower event-free survival in moderate (log-rank, p<0.001), but not in severe TR (log-rank, p=0.133). In a multivariate Cox regression analysis adjusted for age, smoking, coronary artery disease, reduced right ventricle S′, lower left ventricular ejection fraction at baseline, right atrium size and mitral valve replacement, PH remained a significant predictor of all-cause mortality (HR 2.22; 95% CI 1.41 to 3.47, p=0.001).ConclusionsModerate or severe TR was found in 1.6% of patients attending for routine echocardiograms. PH identified a high-risk subset of patients with moderate TR but not with severe TR.

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