Time course of secondary mitral regurgitation in patients with heart failure receiving cardiac resynchronization therapy: Impact on long-term outcome beyond left ventricular reverse remodelling
Camille BindaAymeric MenetLudovic AppertPierre‐Vladimir EnnezatFrançois DelelisAnne‐Laure CastelCaroline Le GofficYves GuyomarAnne RingléRaphaëlle‐Ashley GuerbaaiP GrauxChristophe TribouilloySylvestre Maréchaux
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Background— Recent studies have demonstrated that a positive response to cardiac resynchronization therapy (CRT) is related to the presence of preimplantation left ventricular (LV) dyssynchrony. The time course and the extent of LV resynchronization after CRT implantation and their relationship to response are currently unknown. Methods and Results— One hundred consecutive patients scheduled for implantation of a CRT device were prospectively included if they met the following criteria: New York Heart Association class III to IV, LV ejection fraction ≤35%, QRS duration >120 ms, and LV dyssynchrony (≥65 ms) on color-coded tissue Doppler imaging. Immediately after CRT implantation, LV dyssynchrony was reduced from 114±36 to 40±33 ms ( P <0.001), which persisted at the 6-month follow-up (35±31 ms; P <0.001 versus baseline; P =0.14 versus immediately after implantation). At the 6-month follow-up, 85% of patients were classified as responders to CRT (defined as >10% reduction in LV end-systolic volume). Immediately after implantation, the responders to CRT demonstrated a significant reduction in LV dyssynchrony from 115±37 to 32±23 ms ( P <0.001). The nonresponders, however, did not show a significant reduction in LV dyssynchrony (106±29 versus 79±44 ms; P =0.08). If the extent of acute LV resynchronization was <20%, response to CRT at the 6-month follow-up was never observed. Conversely, 93% of patients with LV resynchronization ≥20% responded to CRT. Conclusions— LV resynchronization after CRT is an acute phenomenon and predicts response to CRT at 6-month follow-up in patients with echocardiographic evidence of LV dyssynchrony at baseline.
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Abstract Background Re-worsening left ventricular ejection fraction (LVEF) after initial recovery occurs in some patients with dilated cardiomyopathy (DCM). However, prevalence and predictors of re-worsening LVEF in longitudinal follow-up are unclear. Late gadolinium enhancement of cardiovascular magnetic resonance (LGE-CMR) can evaluate the damage of myocardial tissue. Purpose This study sought to evaluate the clinical parameters including LGE-CMR to predict re-worsening LVEF in patients with recent-onset DCM. Methods We included patients with recent-onset DCM who had an LVEF <45% and underwent LGE-CMR at diagnosis. We performed yearly echocardiographc follow-up [median 6 [4–8.3] years]. Initial LVEF recovery defined as patients increased in >5% LVEF from baseline and had an LVEF≥45% after medical therapy. Patients were divided into three groups: (1) Improved: defined as those with sustained LVEF ≥45% after initial LVEF recovery; (2) Re-worse: those with decreased >5% and had an LVEF <45% after initial LVEF recovery. and (3) Not-improved: those with no initial LVEF recovery during follow-up. To evaluate the prognostic factors for Re-worsening LVEF after initial LVEF recovery, multivariate logistic regression analysis performed between the Improved group and the Re-worse group. Cardiac events defined as hospitalization due to heart failure and sudden death. Results Of 138 patents, 82 patients (59%) were the Improved group, 42 patients (30%) were the Re-worse group, and 14 (10%) were the Not-improved group. Loess curves of long-term LVEF trajectories showed that LVEF in the Re-worse group increased first 2 years and declined slowly thereafter (Fig. 1A). Re-worsening LVEF occurred 4.5±2.2 years after initial LVEF recovery. Multivariate logistic regression analysis demonstrated that LGE area at baseline (Odds ratio: 1.09, 95% confidence interval (CI) 1.02–1.18, p=0.014) and Log brain natriuretic peptide (BNP) at initial LVEF recovery (Odds ratio: 1.53, 95% confidence interval (CI) 1.01–2.31, p=0.042) were independent predictors for Re-worsening LVEF. Kaplan Meier analysis demonstrated that the risk of cardiac events in the Re-worse group was significantly higher (hazard ratio: 3.93, 95% CI 1.49–10.36, p=0.006) than in the Improved group and lower risk than in the Not-improved group (hazard ratio: 0.28, 95% CI 0.12–0.62, p=0.002) (Fig. 1B). Conclusion Re-worsening LVEF occurred in 30% of patients in patients with recent-onset DCM. LGE area and BNP at initial LVEF recovery were independently associated with re-worsening LVEF after initial LVEF recovery. Figure 1 Funding Acknowledgement Type of funding source: None
Dilated Cardiomyopathy
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To describe the impact of ejection fraction on the prognosis during 2 years after coronary artery bypass grafting (CABG).All patients in western Sweden who underwent CABG without concomitant valve surgery between June 1988 and June 1991.In all, 2121 patients were operated upon and information on ejection fraction was available for 1961 patients (92%). Of these patients, 178 (9%) had an ejection fraction < 40%, 517 (26%) an ejection fraction of 40-59% and 1266 (65%) an ejection fraction > or = 60%. In these groups the mortalities during the first 30 days after CABG were 5.1, 4.3 and 2.2%, respectively (P < 0.01). The corresponding values for mortalities between 30 days and 2 years were 7.7, 4.3 and 3.3%, respectively (P < 0.01). Patients with a lower ejection fraction were more frequently men and more frequently had a history of cardiovascular disease. In multivariate analysis the preoperative ejection fraction was an independent predictor for total 2-year mortality. Patients with a low ejection fraction died more frequently in association with ventricular fibrillation. Morbidity was, with the exception of that for rehospitalization due to heart failure and infection, not associated significantly with the preoperative ejection fraction.During the 2 years after CABG a low preoperative ejection fraction was associated with a higher mortality, but the association with morbidity was more complex.
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Background: A significant proportion of patients diagnosed as heart failure have preserved ejection fraction. However, the differentiation between heart failure with reduced & preserved ejection fraction is difficult.
Method: The medical records of young patients (20–40 years) admitted during the two years 2014 & 2015 and diagnosed with Heart Failure were scrutinized in an attempt to determine the proportion of patients with preserved vs reduced ejection fraction and to assess the relationship between their Brain-type Natriuretic Peptide (BNP) levels & Left Ventricular Ejection Fraction (LVEF) in both the groups.
Results: After Statistical analysis, it was found that around 36% of heart failure patients had preserved ejection fraction. There was a negative correlation between BNP levels & LVEF in both heart failure with reduced ejection fraction (HFrEF) as well as that with preserved ejection fraction (HFpEF). Majority of patients in HFpEF group were females. Mean BNP level in HFpEF group was significantly lower than that in the HFrEF group.
Conclusion: Around one third of patients had Heart Failure with preserved systolic function, of which majority are females. There is a strong negative correlation between BNP levels and LVEF% in both the groups. Thus. BNP levels can be used in the differentiation of HFpEF and HFrEF.
Keywords: Heart Failure, BNP levels, LVEF, Preserved & reduced ejection fraction
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Diastolic heart failure (DHF) currently accounts for more than 50% of all heart failure patients. DHF is also referred to as heart failure with normal left ventricular (LV) ejection fraction (HFNEF) to indicate that HFNEF could be a precursor of heart failure with reduced LVEF. Because of improved cardiac imaging and because of widespread clinical use of plasma levels of natriuretic peptides, diagnostic criteria for HFNEF needed to be updated. The diagnosis of HFNEF requires the following conditions to be satisfied: (i) signs or symptoms of heart failure; (ii) normal or mildly abnormal systolic LV function; (iii) evidence of diastolic LV dysfunction. Normal or mildly abnormal systolic LV function implies both an LVEF > 50% and an LV end-diastolic volume index (LVEDVI) <97 mL/m(2). Diagnostic evidence of diastolic LV dysfunction can be obtained invasively (LV end-diastolic pressure >16 mmHg or mean pulmonary capillary wedge pressure >12 mmHg) or non-invasively by tissue Doppler (TD) (E/E' > 15). If TD yields an E/E' ratio suggestive of diastolic LV dysfunction (15 > E/E' > 8), additional non-invasive investigations are required for diagnostic evidence of diastolic LV dysfunction. These can consist of blood flow Doppler of mitral valve or pulmonary veins, echo measures of LV mass index or left atrial volume index, electrocardiographic evidence of atrial fibrillation, or plasma levels of natriuretic peptides. If plasma levels of natriuretic peptides are elevated, diagnostic evidence of diastolic LV dysfunction also requires additional non-invasive investigations such as TD, blood flow Doppler of mitral valve or pulmonary veins, echo measures of LV mass index or left atrial volume index, or electrocardiographic evidence of atrial fibrillation. A similar strategy with focus on a high negative predictive value of successive investigations is proposed for the exclusion of HFNEF in patients with breathlessness and no signs of congestion. The updated strategies for the diagnosis and exclusion of HFNEF are useful not only for individual patient management but also for patient recruitment in future clinical trials exploring therapies for HFNEF.
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Background: A significant proportion of patients diagnosed as heart failure have preserved ejection fraction. However, the differentiation between heart failure with reduced & preserved ejection fraction is difficult. The objectives of the study include: To assess the BNP levels in both patients with Heart failure with preserved LV ejection fraction and those with reduced LV ejection fraction. To study the correlation between the BNP levels and LVEF in both the groups and to ascertain whether BNP can be an useful tool in diagnosis of Heart failure with preserved LV ejection fraction]. Methods: The medical records of young patients (20–40 years) admitted during the two years 2014 & 2015 and diagnosed with Heart Failure were scrutinized in an attempt to determine the proportion of patients with preserved vs reduced ejection fraction and to assess the relationship between their Brain-type Natriuretic Peptide (BNP) levels & Left Ventricular Ejection Fraction (LVEF) in both the groups. Results: After Statistical analysis, it was found that around 36% of heart failure patients had preserved ejection fraction. There was a negative correlation between BNP levels & LVEF in both heart failure with reduced ejection fraction (HFrEF) as well as that with preserved ejection fraction (HFpEF). Majority of patients in HFpEF group were females. Mean BNP level in HFpEF group was significantly lower than that in the HFrEF group. Conclusion: Around one third of patients had Heart Failure with preserved systolic function, of which majority are females. There is a strong negative correlation between BNP levels and LVEF% in both the groups. Thus BNP levels can be used in the differentiation of HFpEF and HFrEF.
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Discordant and concordant left bundle branch block (dLBBB/cLBBB) are characterized by negative or positive T waves, respectively, in lateral leads. We assessed if the two morphologies are associated with different clinical status and prognosis in patients with heart failure (HF) and current indication to Cardiac Resynchronization Therapy (CRT)/CRT-Defibrillator (CRT-D). Baseline electrocardiograms of 1270 patients with LBBB in the Multicenter Automatic Defibrillator Implantation Trial–Cardiac Resynchronization Therapy cohort were analysed to identify dLBBB and cLBBB. The two groups were compared with respect to baseline clinical characteristics, primary endpoint (HF event or death), and secondary endpoint (ventricular tachycardia, ventricular fibrillation, or death) over a 3.5-year period, and benefit of CRT-D over implantable cardioverter defibrillator (ICD). dLBBB was identified in 909 (72%) patients, and cLBBB in 361 (28%). Patients with dLBBB were older, had more severe symptoms and systolic dysfunction, as well as higher brain natriuretic peptide. CRT-D was superior to ICD in patients with both LBBB morphologies. The occurrence of the primary outcome was significantly more frequent in patients with dLBBB than in those with cLBBB, both in the entire cohort (P = 0.005), and in the CRT-D arm (P = 0.002). There was a trend towards more frequent occurrence of the secondary endpoint in patients with dLBBB than in those with cLBBB, but statistical significance was not reached in the whole population or in the subgroup undergoing CRT-D. Among patients receiving CRT-D, dLBBB was an independent predictor of the primary endpoint. dLBBB morphology is associated with more severe HF clinical status and worse prognosis, even in patients receiving CRT-D, compared with cLBBB morphology.
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