Myocardial adaptation after surgical therapy differs for aortic valve stenosis and hypertrophic obstructive cardiomyopathy.
ABSTRACT: Surgical therapies in aortic valve stenosis (AVS) and hypertrophic obstructive cardiomyopathy (HOCM) aim to relief intraventricular pressure overload and improve clinical outcome. It is currently unknown to what extent myocardial adaptation concurs with restoration of intraventricular pressures, and whether this is similar in both patient groups. The aim of this study was to investigate changes in myocardial adaptation after surgical therapies for AVS and HOCM. Ten AVS and ten HOCM patients were enrolled and underwent cardiac magnetic resonance cine imaging and myocardial tagging prior to, and 4 months after aortic valve replacement (AVR) and septal myectomy, respectively. Global left ventricular (LV) analyses were derived from cine images. Circumferential strain was assessed from myocardial tagging images at the septal and lateral wall of the mid ventricle. Pressure gradients significantly decreased in both AVS and HOCM after surgery (p?
Project description:There has been limited data addressing outcomes of extensive septal myectomy in Chinese patients with hypertrophic obstructive cardiomyopathy (HOCM). In this study, the objective was to evaluate the clinical and echocardiographic outcomes of extensive septal myectomy in a relative large number of Chinese HOCM patients over long-term follow-up.We retrospectively studied 139 consecutive HOCM patients (age 43 ± 15 years, 37 % male) who underwent extensive left ventricular septal myectomy. During the perioperative period, all patients were examined by echocardiography. All-cause death and cardiac death were considered as primary endpoints during follow-up. Perioperative data was obtained by retrospective review of institutional surgical databases. Follow-up data of echocardiography and clinical status was recorded through outpatient interview.Perioperative events consisted of arrhythmia, retraction injury to aortic valve leaflets, pleural effusion, and hemodialysis and the use of intra-aortic balloon pump. There was no in-hospital mortality. The follow-up period averaged 5.6 ± 0.9 years and overall survivals were 100.0, 99.3, 99.3, 98.5 and 97.8 % at 1, 2, 3, 4 and 5 years, respectively. Left ventricular outflow tract (LVOT) gradient decreased form preoperative 84 ± 17 mmHg to 12 ± 3 mmHg at 2.5 years after surgery and it further reduced to 6 ± 3 mmHg at 5 years after surgery (P < 0.05). Compared with the preoperative levels, interventricualr septal thickness decreased by 32 % while diastole left ventricular inner diameter approximately increased by 10 % and ejection fraction (EF) was significantly elevated during follow-up (P < 0.05). By echocardiography detection, mitral regurgitation was ameliorated for HOCM patients after surgery. There was significant improvement in New York Heart Association (NYHA) class. The proportion of NYHA III and IV decreased from preoperative 58 to 19 % at 2.5 years after surgery and it reduced to 11 % at 5 years after operation.Extensive septal myectomy offers minimal operative risk and provides long-term relief for LVOT obstruction in Chinese HOCM patients.
Project description:Background:Iatrogenic membranous ventricular septal defects (VSDs) are rare complications of cardiothoracic surgery, such as septal myectomy for hypertrophic obstructive cardiomyopathy (HOCM). Transcatheter closure is considered an appealing alternative to surgery, given the increased mortality associated with repeated surgical procedures, but reports are extremely limited. Case summary:We herein report the case of a 63-year-old woman with HOCM who underwent successful percutaneous closure of an iatrogenic VSD after septal myectomy. Two percutaneous techniques are discussed, namely the 'muscular anchoring' and the 'buddy wire delivery', aimed at increasing support and providing stability to the system during percutaneous intervention. Discussion:Transcatheter closure represents an attractive minimally invasive approach for the management of symptomatic iatrogenic VSDs. The new techniques described could help operators to cross tortuous and tunnelled defects and to deploy closure devices in case of complex VSD anatomy.
Project description:<h4>Background</h4>The aim of this study was to assess the impact of septal thickness on long-term outcomes of surgical treatment for hypertrophic obstructive cardiomyopathy (HOCM) and correction of mitral subvalvular anomalies.<h4>Methods</h4>Sixty-six consecutive patients (58 ± 12 years, 56% female) undergoing extended septal myectomy and subvalvular mitral apparatus remodeling from 2007 to 2021 were retrospectively reviewed. Patients were divided into 2 groups according to septal thickness: moderate [< 18 mm, 29 patients (44%)] and severe [≥ 18 mm, 37 patients (56%)]. End points included survival, symptom improvement, reduction of left ventricle outflow tract (LVOT) gradient, resolution of mitral regurgitation (MR), and reoperation.<h4>Results</h4>The mean interventricular septal thickness was 19 ± 3 mm, 15.8 ± 0.8 mm in patients with moderate and 21.4 ± 3.2 mm in those with severe hypertrophy. Preoperative data, intraoperative variables, postoperative complication rates, pre-discharge echocardiographic and clinical parameters did not differ between the two study groups [except for procedures involving the posterior mitral leaflet (<i>p</i> = 0.033) and septal thickness after myectomy (<i>p</i> = 0.0001)]. Subvalvular apparatus remodeling (secondary chordae of mitral valve resection and papillary muscle and muscularis trabecula procedures including resection, splitting, and elongation) was invariably added to septal myectomy (100%). Four (6%) procedures involved the posterior mitral leaflets. Mitral valve replacement was carried out in two patients (3%, <i>p</i> = 0.4). Reoperation for persistent MR was necessary in one patient (1%, <i>p</i> = 0.4). Neither iatrogenic ventricular septal defect nor in-hospital mortality occurred. During follow-up (mean 4.8 ± 3.8 years), two deaths occurred. NYHA class was reduced from 2.9 ± 0.7 to 1.6 ± 0.6 (<i>p</i> < 0.0001), the LVOT gradient from 89.7 ± 34.5 to 16.3 ± 8.8 mmHg (<i>p</i> < 0.0001), mitral valve regurgitation grade from 2.5 ± 1 to 1.2 ± 0.5 (<i>p</i> < 0.0001), and septal thickness from 18.9 ± 3.7 to 13.9 ± 2.7 mm (<i>p</i> < 0.0001).<h4>Conclusions</h4>Regardless of septal thickness, subvalvular apparatus remodeling with concomitant septal myectomy can provide satisfactory long-term outcomes in terms of symptom improvement, LVOT obstruction relief, and MR resolution (without mitral valve replacement in most cases) in patients with HOCM.
Project description:<h4>Background</h4>Segment length in cine (SLICE) strain analysis on standard cardiovascular magnetic resonance (CMR) cine images was recently validated against gold standard myocardial tagging. The present study aims to explore predictive value of SLICE for cardiac resynchronization therapy (CRT) response.<h4>Methods and results</h4>Fifty-seven patients with heart failure and left bundle branch block (LBBB) were prospectively enrolled in this multi-center study and underwent CMR examination before CRT implantation. Circumferential strains of the septal and lateral wall were measured by SLICE on short-axis cine images. In addition, timing and strain pattern parameters were assessed. After twelve months, CRT response was quantified by the echocardiographic change in left ventricular (LV) end-systolic volume (LVESV). In contrast to timing parameters, strain pattern parameters being systolic rebound stretch of the septum (SRS<sub>sep</sub>), systolic stretch index (SSI<sub>sep-lat</sub>), and internal stretch factor (ISF<sub>sep-lat</sub>) all correlated significantly with LVESV change (R - 0.56; R - 0.53; and R - 0.58, respectively). Of all strain parameters, end-systolic septal strain (ESS<sub>sep</sub>) showed strongest correlation with LVESV change (R - 0.63). Multivariable analysis showed ESS<sub>sep</sub> to be independently related to LVESV change together with age and QRS<sub>AREA</sub>.<h4>Conclusion</h4>The practicable SLICE strain technique may help the clinician to estimate potential benefit from CRT by analyzing standard CMR cine images without the need for commercial software. Of all strain parameters, end-systolic septal strain (ESS<sub>sep</sub>) demonstrates the strongest correlation with reverse remodeling after CRT. This parameter may be of special interest in patients with non-strict LBBB morphology for whom CRT benefit is doubted.
Project description:Hypertrophic cardiomyopathy is a genetically determined disorder resulting in left ventricular hypertrophy. In a majority of the estimated 20 million people affected worldwide, left ventricular outflow obstruction is present at rest or with provocation. The presence and degree of obstruction influence the symptomatic presentation, treatment strategies and prognosis of affected individuals. Pharmacologic therapy with beta-adrenergic blocking drugs and calcium channel blockers is the principal treatment strategy in symptomatic patients with left ventricular outflow obstruction but is ineffective in many patients. When symptoms of exertional shortness of breath, chest pain and/or syncope prove refractory to medical therapy and there is persisting left ventricular outflow obstruction, or when there is drug intolerance, septal reduction strategies (surgical myectomy and alcohol septal ablation) are quite effective. Selection of the optimal septal reduction strategy for a given patient has become controversial and is determined largely by the medical system providing treatment strategies for the patient. Regretably, there are no randomized trials comparing myectomy and ablation and none are anticipated. The comprehensive Hypertrophic Cardiomyopathy Guideline Statements published in 2011 and 2014 differ significantly with the earlier statement favoring surgical myectomy and the more recent statement giving equal class I status to the two septal reduction strategies in adult patients with drug-refractory symptoms. Recently published studies of long-term follow-up of patients after alcohol septal ablation in Europe, where surgical myectomy is rarely performed, confirm long-term safety and effectiveness with survival free of cardiac events exceeding 96% at 15 years. The lesser degree of discomfort and more rapid recovery associated with the minimally invasive catheter-based alcohol ablation procedure coupled with the recently published long-term safety data favor an increased use of this strategy in symptomatic adult patients with hypertrophic obstructive cardiomyopathy (HOCM).
Project description:AIMS:Left ventricular hypertrophy (LVH) in aortic stenosis (AS) varies widely before and after aortic valve replacement (AVR), and deeper phenotyping beyond traditional global measures may improve risk stratification. We hypothesized that machine learning derived 3D LV models may provide a more sensitive assessment of remodelling and sex-related differences in AS than conventional measurements. METHODS AND RESULTS:One hundred and sixteen patients with severe, symptomatic AS (54% male, 70?±?10?years) underwent cardiovascular magnetic resonance pre-AVR and 1 year post-AVR. Computational analysis produced co-registered 3D models of wall thickness, which were compared with 40 propensity-matched healthy controls. Preoperative regional wall thickness and post-operative percentage wall thickness regression were analysed, stratified by sex. AS hypertrophy and regression post-AVR was non-uniform-greatest in the septum with more pronounced changes in males than females (wall thickness regression: -13?±?3.6 vs. -6?±?1.9%, respectively, P?<?0.05). Even patients without LVH (16% with normal indexed LV mass, 79% female) had greater septal and inferior wall thickness compared with controls (8.8?±?1.6 vs. 6.6?±?1.2?mm, P?<?0.05), which regressed post-AVR. These differences were not detectable by global measures of remodelling. Changes to clinical parameters post-AVR were also greater in males: N-terminal pro-brain natriuretic peptide (NT-proBNP) [-37 (interquartile range -88 to -2) vs. -1 (-24 to 11) ng/L, P?=?0.008], and systolic blood pressure (12.9?±?23 vs. 2.1?±?17?mmHg, P?=?0.009), with changes in NT-proBNP correlating with percentage LV mass regression in males only (ß 0.32, P?=?0.02). CONCLUSION:In patients with severe AS, including those without overt LVH, LV remodelling is most plastic in the septum, and greater in males, both pre-AVR and post-AVR. Three-dimensional machine learning is more sensitive than conventional analysis to these changes, potentially enhancing risk stratification. CLINICAL TRIAL REGISTRATION:Regression of myocardial fibrosis after aortic valve replacement (RELIEF-AS); NCT02174471. https://clinicaltrials.gov/ct2/show/NCT02174471.
Project description:Hypertrophic cardiomyopathy (HCM) is a complex, underestimated, multifaceted disease frequently associated with left ventricular outflow tract (LVOT) obstruction. It is clearly demonstrated that this is due not only to septal hypertrophy but also to systolic anterior motion (SAM) of mitral valve leaflets secondary to mitral valve/subvalvular apparatus abnormalities. Surgical treatment involves performing an extended septal myectomy, eventually followed by ancillary procedures to those structures responsible for maintaining LVOT obstruction, if necessary. In this review, we describe the spectrum of possible surgical techniques beyond septal myectomy and their pathophysiologic rationale.
Project description:A total of 373 subjects [367 service persons and 6 civilians) with ECG abnormality were evaluated with maximal TMT exercise, 86 (23%) of them showing positivity. Subsequent assessment including radionuclide ventriculography and coronary arteriography wherever necessary revealed coronary artery disease in 31 (8.3%). The remaining 55 were further evaluated by 2D and M-Mode echocardiography for exclusion of any other cardiac disease responsible for the ECG abnormality as well as for assessment of LV performance. Seven subjects showed minor structural cardiac anomalies - MVP in 5 and HOCM in 2. The remaining 48 showed no significant difference in the measurements of LV posterior wall and IV septal wall thickness, mitral septal separation, mitral valve excursion velocities, LV end-systolic/end-diastolic internal diameters and calculated percent fractional shortening, LV end-diastolic, end-systolic and stroke volumes as well as ejection fraction, on comparison with 20 age matched controls. These 48 service persons, thus evaluated were considered to have no organic heart disease or cardiac function impairment and were cleared for all strenuous duties including flying of sophisticated aircrafts or posting to high altitudes.
Project description:<h4>Objectives</h4>Although B-type natriuretic peptide (BNP) and highly sensitive cardiac troponin T (cTnT) are useful for the evaluation of clinical features in various cardiovascular diseases, there are comparatively few data regarding the utility of these parameters in patients with hypertrophic obstructive cardiomyopathy (HOCM). The goal of this study was to assess the association between BNP, cTnT and clinical parameters in patients with HOCM.<h4>Design</h4>Cross-sectional survey<h4>Settings</h4>The relationship between BNP, cTnT and clinical end points and echocardiographic data was investigated.<h4>Participants</h4>This study included 102 consecutive outpatients with HOCM who were clinically stable.<h4>Results</h4>BNP was significantly associated with both maximum left ventricular (LV) wall thickness (r=0.28; p=0.003), and septal peak early transmitral filling velocity/peak early diastolic mitral annulus velocity (r=0.51; p=0.0001). No statistically significant associations were seen between cTnT and any echocardiographic parameters, but the presence of atrial fibrillation (AF) was associated with a high level of cTnT (p=0.01).<h4>Conclusions</h4>BNP is useful for monitoring clinical parameters and as a reflection of both LV systolic/diastolic function and increased LV pressure in patients with HOCM. A high level of serum cTnT is associated with the presence of AF.
Project description:We investigated the effectiveness of soluble Receptor for Advanced Glycation Endproducts (sRAGE) in attenuating angiotensin II (AngII)-induced left ventricular hypertrophy (LVH) using in vivo 9.4T cine-magnetic resonance imaging (CINE-MRI). Mice were divided into four groups: AngII (n = 9), saline (n = 10), sRAGE (n = 10), and AngII + sRAGE (n = 10). CINE-MRI was performed in each group after administration of the AngII or sRAGE, and CINE-MR images were analyzed to obtain parameters indicating cardiac anatomical and functional changes including end-diastolic and end-systolic blood volume, end-diastolic and end-systolic myocardial volume, ejection fraction, end-diastolic and end-systolic myocardial mass, and LV wall thickness. LVH observed in AngII group was significantly attenuated by sRAGE. These trends were also observed in histological analysis, demonstrating that cardiac function tracking using in vivo and real-time 9.4T MR imaging provides valuable information about the cardiac remodeling induced by AngII and sRAGE in an AngII-induced LV hypertrophy mice model.