Acute effect of nonsurgical septal reduction therapy on regional left ventricular asynchrony in patients with hypertrophic obstructive cardiomyopathy.
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BACKGROUND: Patients with hypertrophic obstructive cardiomyopathy have left ventricular (LV) diastolic dysfunction due, in part, to temporal heterogeneity in regional function. The acute effect of the relief of LV outflow tract obstruction is unknown. Therefore, we investigated the effects of nonsurgical septal reduction therapy (NSRT) on regional function. METHODS AND RESULTS: Twenty-two patients (aged 56+/-17 years) underwent echocardiographic examination, including tissue Doppler imaging, simultaneously with left heart catheterization before and after NSRT. LV regional function was assessed in 12 segments from which myocardial strain was obtained. Asynchrony was calculated as the coefficient of variation of the time interval from the QRS complex to the onset of expansion and to early diastolic strain. After NSRT, a significant reduction in LV outflow tract obstruction (from 57+/-5 to 12+/-3 mm Hg) occurred with shortening of the time constant of LV relaxation (71+/-4 to 61+/-3 ms; both P<0.05). The coefficient of variation of the time interval to onset of regional expansion decreased significantly and related well to the changes in the time constant of LV relaxation (r=0.81, P<0.01). CONCLUSIONS: NSRT has a favorable effect on LV regional asynchrony, which accounts for the acute changes in LV relaxation. (+info)
Role of transcoronary ablation of septal hypertrophy in patients with hypertrophic cardiomyopathy, New York Heart Association functional class III or IV, and outflow obstruction only under provocable conditions.
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BACKGROUND: Transcoronary ablation of septal hypertrophy (TASH) for hypertrophic cardiomyopathy seems to be an effective alternative to surgical myectomy. It remains a point of debate whether an outflow obstruction at rest is a necessary criterion for interventional therapy. METHODS AND RESULTS: TASH was compared in 45 consecutive patients with no resting gradient and a provocable gradient of > or =30 mm Hg (group I) and in 84 consecutive patients with a resting gradient of > or =30 mm Hg (80+/-33 mm Hg) (group II). At baseline, all patients were in NYHA functional class (FC) III or IV, unresponsive to medical treatment. Patients in group I were older (63+/-12 versus 55+/-17 years, P=0.005) and had a lower postextrasystolic gradient (110+/-44 versus 171+/-40 mm Hg, P<0.001). The groups were similar with respect to NYHA FC (3.1+/-0.3 versus 3.1+/-0.3), basal septal thickness (22+/-4 versus 23+/-3 mm), maximal oxygen consumption (13.1+/-4.6 versus 14.5+/-5.0 mL/kg per minute), and pulmonary artery mean pressure at workload (42+/-9 versus 42+/-10 mm Hg) (P>0.05). Median follow-up was 7 months after TASH. The 2 groups showed a significant and similar improvement in provocable obstruction (to 24+/-24 and 56+/-51 mm Hg, respectively), basal septal thickness (to 12+/-3 and 12+/-4 mm, respectively), NYHA FC (to 1.7+/-0.6 and 1.5+/-0.6, respectively), maximal oxygen consumption (to 16.0+/-5.3 and 16.6+/-6.0 mL/kg per minute, respectively), and pulmonary artery mean pressure at workload (to 36+/-9 and 34+/-9 mm Hg, respectively) (P>0.05). CONCLUSIONS: TASH seems to have beneficial clinical and hemodynamic effects in patients with either provocable or resting outflow obstruction. (+info)
Rheology of discrete subaortic stenosis.
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The discrete form of subaortic stenosis is thought to be an acquired lesion, the aetiology of which may be a combination of factors which include an underlying genetic predisposition, turbulence in the left ventricular outflow tract, and various geometric and anatomical variations of the left ventricular outflow tract. A review of hypotheses relating to its aetiology is provided (+info)
Beneficial effect of dual-chamber pacing for a left mid-ventricular obstruction with apical aneurysm.
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Sustained ventricular tachycardia (VT) developed in a 63-year-old woman. The 2-dimensional echocardiogram revealed left mid-ventricular obstructive hypertrophy and a discrete apical chamber. A continuous wave Doppler signal across the mid-ventricular narrowing exhibited early systolic ejection flow and diastolic paradoxical jet flow from the apex to the basal chamber, implying a significant systolic and diastolic intraventricular gradient with a high apical pressure. The left ventriculogram confirmed a mid-ventricular obstruction with an apical aneurysm. Invasive assessment of intraventricular pressure showed a peak-to-peak gradient greater than 100 mmHg. Treatment with antiarrhythmic agents could not prevent the VT, but dual-chamber pacing reduced the intraventricular pressure gradient and suppressed the VT completely. Continuous wave Doppler showed that the early systolic ejection flow from the apex had disappeared, that there was isovolumetric relaxation flow toward the apex and that there was attenuation of the diastolic paradoxical jet flow toward the basal chamber. Such findings by continuous wave Doppler can be useful in pacing therapy for evaluating changes in the severity of mid-ventricular obstruction. (+info)
Shoshin beriberi with vasospastic angina pectoris possible mechanism of mid-ventricular obstruction: possible mechanism of mid-ventricular obstruction.
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A 73-year-old heavy drinker was admitted to hospital in a state of shock. He had been suffering from frequent angina at rest, causing him to drink more heavily in an effort to overcome his anginal chest pain. He had been drinking hard each day and had not eaten for 4 weeks. His hemodynamic state on admission showed high-output heart failure. Echocardiography revealed hyperkinesis of the left ventricle and mid-ventricular obstruction with peak intraventricular gradients of 30 mmHg. Although no improvement was seen despite administering the maximal dose in catecholamine therapy, his condition improved rapidly after vitamin B(1) was administered. Cardiac catheterization revealed mid-ventricular obstruction with an apical aneurysm. Coronary artery spasm was induced by injecting acetylcholine in the distal site of the left anterior descending artery, which perfused the area of the apical aneurysm. In the present case, both left ventricular hyperkinesis caused by shoshin beriberi and apical myocardial infarction caused by frequent coronary spasms produced mid-ventricular obstruction with an apical aneurysm. (+info)
Risk associated with pregnancy in hypertrophic cardiomyopathy.
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OBJECTIVES: We sought to assess mortality and morbidity in pregnant women with hypertrophic cardiomyopathy (HCM). BACKGROUND: The risk associated with pregnancy in women with HCM is an important and increasingly frequent clinical issue for which systematic data are not available and a large measure of uncertainty persists. METHODS: Maternal mortality in 91 consecutively evaluated families with HCM was compared with that reported in the general population. The study cohort included 100 women with HCM with one or more live births, for a total of 199 live births. Morbidity related to HCM during pregnancy was investigated in 40 women evaluated within five years of their pregnancy. RESULTS: Two pregnancy-related deaths occurred, both in patients at a particularly high risk. The maternal mortality rate was 10 per 1,000 live births (95% confidence interval [CI] 1.1 to 36.2/1,000) and was in excess of the expected mortality in the general Italian population (relative risk 17.1, 95% CI 2.0 to 61.8). In the 40 patients evaluated within close proximity of their pregnancy, 1 (4%) of the 28 who were previously asymptomatic and 5 (42%) of the 12 with symptoms progressed to functional class III or IV during pregnancy (p < 0.01). One patient had atrial fibrillation and one had syncope, both of whom had already experienced similar and recurrent events before their pregnancy. CONCLUSIONS: Maternal mortality is increased in patients with HCM compared with the general population. However, absolute maternal mortality is low and appears to be principally confined to women at a particularly high risk. In the presence of a favorable clinical profile, the progression of symptoms, atrial fibrillation, and syncope are also uncommon during pregnancy. (+info)
Abnormal postexercise cardiovascular recovery and its determinants in patients after right ventricular outflow tract reconstruction.
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BACKGROUND: Abnormal responses of heart rate (HR) and oxygen uptake (VO2) during exercise characterize patients after right ventricular outflow tract reconstruction (RVOTR) for congenital heart defects. However, little is known about the postexercise dynamics. METHODS AND RESULTS: We evaluated postexercise cardiovascular dynamics in 52 patients after closure of an atrioventricular septal defect (group A), 79 patients after RVOTR (group B), and 44 control subjects. HR variability, arterial baroreflex sensitivity (BRS), plasma norepinephrine, and hemodynamics were measured. Although there was no difference between group A and control subjects, declines in HR and VO2 after light and peak exercise and in systolic blood pressure (SBP) after peak exercise were delayed in group B. Age, low-frequency component of HR variability, and plasma norepinephrine were independent determinants of early HR decline. Peak SBP and VO2 had a great impact on the corresponding recoveries. When the peak values were excluded, body weight, BRS, and right ventricular ejection fraction were independent determinants of early SBP decline. BRS and the pulmonary artery resistance were independent determinants of VO2 decline throughout recovery, and age and right systolic ventricular pressure also determined the early VO2 decline. BRS and low-frequency component of HR variability were determined independently by the number of surgical procedures. CONCLUSIONS: In RVOTR patients, in addition to metabolic and autonomic maturation, surgery-related abnormal cardiac autonomic nervous activity and impaired hemodynamics have a great impact on delayed postexercise cardiovascular recovery. (+info)
Right ventricular function in adults with repaired tetralogy of Fallot assessed with cardiovascular magnetic resonance imaging: detrimental role of right ventricular outflow aneurysms or akinesia and adverse right-to-left ventricular interaction.
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OBJECTIVES: We examined the relationship among biventricular hemodynamics, pulmonary regurgitant fraction (PRF), right ventricular outflow tract (RVOT) aneurysm or akinesia, and baseline and surgical characteristics in adults with repaired tetralogy of Fallot (rTOF). BACKGROUND: The precise relationship of pulmonary regurgitation with biventricular hemodynamics has been hampered by limitations of right ventricular (RV) imaging. METHODS: We assessed 85 consecutive adults with rTOF and 26 matched healthy controls using cardiovascular magnetic resonance imaging. RESULTS: Patients had higher right ventricular end-diastolic volume index (RVEDVi) (p < 0.001), right ventricular end-systolic volume index (RVESVi) (p < 0.001), right ventricular mass index (RVMi) (p < 0.001), and lower right ventricular ejection fraction (RVEF) (p < 0.001) and left ventricular ejection fraction (LVEF) (p = 0.002) compared to controls. The PRF (range 0% to 55%) independently predicted RVEDVi (p < 0.01) and the latter predicted RVESVi (p < 0.01) and RVMi (p < 0.01). The RVOT aneurysm/akinesia was present in 48/85 (56.9%) of patients and predicted RV volumes (RVEDVi, p = 0.01, and RVESVi, p = 0.03). There was a negative effect of RVOT aneurysm/akinesia and RVMi on RVEF (p < 0.01 and p = 0.02, respectively). There was only a tendency among patients with transannular or RVOT patching toward RVOT aneurysm/akinesia (p = 0.09). The LVEF correlated with RVEF (r = 0.67, p < 0.001). CONCLUSIONS: Pulmonary regurgitation and RVOT aneurysm/akinesia were independently associated with RV dilation and the latter with RV hypertrophy late after rTOF. The RVOT aneurysm/akinesia was common but related only in part to RVOT or transannular patching. Both RV hypertrophy and RVOT aneurysm/akinesia were associated with lower RVEF. Left ventricular systolic dysfunction correlated with RV dysfunction, suggesting an unfavorable ventricular-ventricular interaction. Measures to maintain or restore pulmonary valve function and avoid RVOT aneurysm/akinesia are mandatory for preserving biventricular function late after rTOF. (+info)