Strain predicts left ventricular functional recovery after acute myocardial infarction with systolic dysfunction.

OBJECTIVE: Regional and global longitudinal strain (RLS-GLS) are considered reliable indexes of myocardial viability in chronic ischemic patients and prediction of left ventricular (LV) functional recovery after acute myocardial infarction (MI) with preserved left ventricular ejection fraction (LVEF). We tested in the present study whether RLS and GLS could also identify transmural extent of myocardial scar and predict LV functional recovery and remodeling in patients with reduced LVEF after acute MI. METHODS: Echocardiography and late gadolinium enhancement cardiac magnetic resonance (LGE-CMR) were performed in 71 patients with reduced LVEF (≤45%) after acute MI treated with acute percutaneous coronary intervention. At 8-month follow-up, echocardiography was repeated to determine global LV functional recovery and remodeling. RESULTS: RLS was worse in transmural than in non-transmural infarcted segments (-6.6 ± 6.1% vs -10.3 ± 5.9%, p < 0.0001) and in non-transmural than in normal segments (-10.3 ± 5.9% vs -14.5 ± 6.4%, p < 0.0001). RLS > -12% had sensitivity of 78% and specificity of 69% to identify transmural infarcted segments (AUC = 0.79; 95% CI, 0.77-0.81, p < 0.0001). GLS > -11.3% had sensitivity of 53% and specificity of 100% to predict the absence of LV global functional improvement (AUC = 0.73, CI, 0.55-0.87, p = 0.01) at 8-month follow-up. GLS < -12.5% predicted the absence of adverse LV remodeling with sensitivity of 100% and specificity of 54% (AUC = 0.83; CI, 0.66-0.94, p < 0.0001). GLS > -11.5% was associated with a poor prognosis. CONCLUSIONS: In patients with reduced LVEF after acute MI, RLS and GLS allow: (1) identification of transmural extent of myocardial scar and (2) predict LV global functional recovery and remodeling at 8-month follow-up.

Early exercise training feasibility after aortic valve repair: A multicentre prospective French survey on behalf of the Aortic Valve repair International Registry (AVIATOR).

BACKGROUND: Standardization of aortic valve repair by the external ring annuloplasty approach is an alternative to valve replacement to avoid prosthetic valve-related events. Although the benefit of exercise training to improve postoperative exercise tolerance has been demonstrated in many conditions after cardiac surgery, it has never been described after aortic valve repair. OBJECTIVES: To evaluate the feasibility of an early exercise training programme after aortic valve repair. METHODS: Consecutive patients were prospectively included in 13 postoperative centres. Patients underwent an exercise training programme for approximately 3-5 weeks. Transthoracic echocardiography and a cardiopulmonary exercise test were performed before and after the exercise training programme. RESULTS: Fifty patients (mean±standard deviation [SD] age: 50±13 years) were included a mean of 13.6±12.0 days after aortic valve repair. The preoperative degree of aortic insufficiency was moderate to severe in 35 patients (70%) and the aortic valve was bicuspid in 24 patients (48%). Valve-sparing root replacement and isolated aortic valve repair (including 10% supracoronary aorta replacement) were performed in 64% and 36% of patients, respectively. We found no aortic insufficiency occurrence or worsening and no adverse clinical events after the exercise training programme. Mean left ventricular ejection fraction increased significantly (from 54%±8% to 57%±9%; P=0.0007). Mean peak oxygen consumption and first ventilatory threshold increased from 17.0±5.3 to 22.5±7.8mL/kg/min (32% increase) and from 12.0±3.9 to 14.3±5.2mL/kg/min (19% increase), respectively (both P<0.05). CONCLUSION: Exercise training early after aortic valve repair is safe and seems to significantly improve exercise capacity.

Incidence, diagnostic methods, and evolution of left ventricular thrombus in patients with anterior myocardial infarction and low left ventricular ejection fraction: a prospective multicenter study.

BACKGROUND AND OBJECTIVES: We aimed to assess the incidence and evolution of left ventricular (LV) thrombi in a high-risk population of patients with LV systolic dysfunction after anterior myocardial infarction (ant-MI). We also compared the accuracy of transthoracic echocardiography (TTE) and cardiac magnetic resonance imaging with contrast-delayed enhancement (CMR-DE) in detecting LV thrombi. METHODS: We prospectively included 100 consecutive patients with LV ejection fraction (LVEF) <45% at the first TTE performed <7 days after ant-MI. A second evaluation with TTE and CMR-DE (by blinded examiners) was performed at 30 days. A third TTE and assessment of clinical status were performed between 6 and 12 months after ant-MI. RESULTS: Patients (males 71%; mean age 59.1 ± 12.1 years; mean LVEF 33.5% ± 6.0%) were included at a median of 5.5 days (interquartile range 25th-75th percentile 4.25-6.0 days) after ant-MI. Thrombi were detected among 26 (26%) patients at a median of 12.0 days after ant-MI (7 patients at 1-7 days after MI; 15 at 8-30 days; and 4 after day 30). Sensitivity and specificity for LV thrombi detection were 94.7% and 98.5%, respectively, for TTE as compared with CMR-DE. Most thrombi (n = 24; 92.3%) disappeared after triple antithrombotic therapy (vitamin K antagonist in addition to dual antiplatelet therapy). CONCLUSION: Left ventricular thrombus is a frequent complication after ant-MI with systolic dysfunction. When a search for thrombus is prespecified, the accuracy of TTE is high as compared with CMR-DE. The best antithrombotic strategy is not known.

Exercise training is safe after coronary stenting: a prospective multicentre study.

BACKGROUND: Data on the safety of exercise training after coronary stenting are scarce. DESIGN: This is a prospective cohort study of 3132 patients with coronary stenting within the last 12 months, recruited by 44 cardiac rehabilitation centres; patients were included in a cardiac rehabilitation programme with training sessions 3-5 days a week. Cardiac rehabilitation was defined as early rehabilitation when starting <1 month after coronary stenting and as late rehabilitation when starting later. METHODS: Rate of acute coronary syndrome (ACS) after coronary stenting was estimated according to time to training session. ACS was defined as related to exercise when it occurs during or within the hour after an exercise stress test or a training session. All ACS were documented by an angiographic control. RESULTS: Overall 5016 stents (41.4% drug-eluting stents) were implanted in 3132 patients aged 56.5 ± 12.9 years (84.7% men) with a median of 1 stent (range 1-8) per patient. Indication of coronary senting was ACS (86.4%), angina pectoris (8.6%), and silent ischaemia (5%). Combined antiplatelet treatment was used in 97.2% of the patients. Overall rate of ACS after coronary stenting was 2.9/1000 patients, corresponding to 1.7 complications out of 10(6) patient-hours of exercise. There were four stent thromboses related to exercise (1.2/1000 patients, 0.8/10(6) patient-hours of exercise): two in the early rehabilitation group (days 9 and 11), and two in the late rehabilitation group (days 77 and 228). CONCLUSIONS: Exercise training seems safe and there is no justification to delay cardiac rehabilitation after coronary stenting.

Greater prognostic value of peak VO2 after exercise training program completion in heart failure patients.

BACKGROUND: Exercise capacity, best reflected by peak exercise oxygen consumption (peak VO(2)), is a powerful prognostic factor in patients with chronic heart failure (CHF). However, the optimal time to assess exercise capacity for prognosis remains unclear and whether an exercise training program (ETP) to improve exercise capacity alters the prognostic value of cardiopulmonary exercise (CPX) testing variables in CHF is unknown. METHODS AND RESULTS: CHF patients who underwent an ETP in two cardiac rehabilitation centers between 2004 and 2009 were prospectively included, and CPX testing was performed before and after ETP completion. We included 285 consecutive patients who underwent an ETP (19.4 ± 8.7 training sessions in 4 to 10 weeks), including segmental gymnastics and cycling sessions. During follow-up (12 months), 14 patients died, 6 underwent cardiac transplantation and 15 were hospitalized for acute heart failure. Univariate analysis and receiver operating characteristic (ROC) curve analysis showed that CPX variables, especially peak oxygen consumption and circulatory power (product of peak VO(2) × peak systolic blood pressure) before and after ETP completion predicted prognosis. However, CPX data obtained after ETP completion had the best prognostic value (area under the ROC curve = 0.79 ± 0.03 for peak VO(2) after ETP completion vs 0.64 ± 0.04 before ETP completion, p < 0.0001). The results did not change even when considering only deaths. CONCLUSION: In patients with stable CHF who can exercise, the prognostic value of CPX data seems greater after versus before completion of a hospital-based ETP. Therefore, CPX capacity for prognostic purposes should at best be assessed after cardiac rehabilitation.

Distribution of left ventricular ejection fraction and heart rate values in a cohort of stable coronary patients: the INDYCE registry.

BACKGROUND: The distribution of left ventricular ejection fraction (LVEF) - a key factor in coronary artery disease (CAD) patient management and prognostication - is poorly documented. OBJECTIVE: To determine LVEF and heart rate (HR) values, and describe the management of stable CAD patients in France. METHODS: The INDYCE survey was a prospective, multicentre registry of consecutive stable CAD outpatients attending a cardiology consultation. The survey focused on LVEF values measured using the echocardiographic Simpson biplane method. Drug therapy, resting HR, blood pressure and symptoms were also recorded. RESULTS: Overall, 3119 patients (68.4 +/- 11.0 years; 80% men) were enrolled. LVEF was 56.1+/-11.8% on average, and was poor (<40%) and moderately impaired (40-50%) in 9.6% (n=298) and 19.8% (n=619) of cases, respectively. Symptomatic angina pectoris was present in 19.2% of cases and only 40.6% of patients were asymptomatic (no angina and NYHA class < or = I) despite relatively aggressive management (79.0% of patients had undergone coronary angioplasty and/or bypass graft). Interestingly, 14.1% of patients with LVEF less than 40% were asymptomatic. In multivariable analysis, LVEF less than 40% was associated most strongly with symptomatic status (odds ratio 3.82; 95% CI 2.59-5.63; P<0.0001), together with female sex, age greater than 75 years, diabetes, HR greater or equal to 70 bpm, sedentariness, obesity and disease duration. CONCLUSION: Only 9.6% of stable CAD patients had severe left ventricular dysfunction; among them, 14.1% were strictly asymptomatic. This could justify regular LVEF measurement in CAD patients. Three potentially reversible factors (HR>or=70 bpm, being overweight and sedentariness) were linked independently to the presence of symptoms.

Nonsteroidal anti-inflammatory drug treatment for postoperative pericardial effusion: a multicenter randomized, double-blind trial.

BACKGROUND: The incidence of asymptomatic pericardial effusion is high after cardiac surgery. Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely prescribed in this setting, but no study has assessed their efficacy. OBJECTIVE: To assess whether the NSAID diclofenac is effective in reducing postoperative pericardial effusion volume. DESIGN: Multicenter randomized, double-blind, placebo-controlled study. (Clinical trials.gov registration number: NCT00247052) SETTING: 5 postoperative cardiac rehabilitation centers. PATIENTS: 196 patients at high risk for tamponade because of moderate to large persistent pericardial effusion (grade 2, 3, or 4 on a scale of 0 to 4, as measured by echocardiography) more than 7 days after cardiac surgery. INTERVENTION: Random assignment at each site in blocks of 4 to diclofenac, 50 mg, or placebo twice daily for 14 days. MEASUREMENTS: The main end point was change in effusion grade after 14 days of treatment. Secondary end points included frequency of late cardiac tamponade. RESULTS: The initial mean pericardial effusion grade was 2.58 (SD, 0.73) for the placebo group and 2.75 (SD, 0.81) for the diclofenac group. The 2 groups showed similar mean decreases from baseline after treatment (-1.08 grades [SD, 1.20] for the placebo group vs. -1.36 (SD, 1.25) for the diclofenac group). The mean difference between groups was -0.28 grade (95% CI, -0.63 to 0.06 grade; P = 0.105). Eleven cases of late cardiac tamponade occurred in the placebo group and 9 in the diclofenac group (P = 0.64). These differences persisted after adjustment for grade of pericardial effusion at baseline, treatment site, and type of surgery. LIMITATION: The sample was not large enough to find small beneficial effects of diclofenac or assess the cardiovascular tolerance of diclofenac. CONCLUSION: In patients with pericardial effusion after cardiac surgery, diclofenac neither reduced the size of the effusions nor prevented late cardiac tamponade. PRIMARY FUNDING SOURCE: French Society of Cardiology.

Benefits of exercise training in chronic heart failure.

Exercise training performed in cardiac rehabilitation centres is an adjuvant therapy in chronic heart failure patients with left ventricular dysfunction; it decreases the deleterious consequences of chronic heart failure. Exercise training attenuates neurohormonal stimulation, the production of proinflammatory cytokines and natriuretic peptide overexpression. Trained patients showed a significant decrease in the peripheral organ injuries encountered in chronic heart failure, with a reduction in vascular resistance and improvements in endothelial dysfunction and the oxidative capacity of peripheral muscles, without a deleterious effect on left ventricular remodelling. Ultimately, exercise training leads to a notable improvement in ventilatory capacity. These beneficial effects are accompanied by improvements in symptoms at rest, exercise capacity and quality of life. Several training programmes are in current use: exercise training sessions always include endurance exercise performed either at a constant load intensity or with interval training, combining periods of exercise performed at high intensity with periods performed at low intensity. Most of the time, training programmes also include resistance training sessions, which improves large muscle strength. Exercise training programmes seem to have a favourable effect on prognosis, even if the results of Heart Failure: a Controlled Trial Investigating Outcomes of Exercise Training (HF-ACTION) remain controversial, emphasizing the difficulty in monitoring observance and the importance of compliance with a long-term exercise training programme. Patients who do not improve their exercise capacity significantly after an exercise training programme have a poorer prognosis.

Standards for the use of cardiopulmonary exercise testing for the functional evaluation of cardiac patients: a report from the Exercise Physiology Section of the European Association for Cardiovascular Prevention and Rehabilitation.

Cardiopulmonary exercise testing (CPET) is a methodology that has profoundly affected the approach to patients' functional evaluation, linking performance and physiological parameters to the underlying metabolic substratum and providing highly reproducible exercise capacity descriptors. This study provides professionals with an up-to-date review of the rationale sustaining the use of CPET for functional evaluation of cardiac patients in both the clinical and research settings, describing parameters obtainable either from ramp incremental or step constant-power CPET and illustrating the wealth of information obtainable through an experienced use of this powerful tool. The choice of parameters to be measured will depend on the specific goals of functional evaluation in the individual patient, namely, exercise tolerance assessment, training prescription, treatment efficacy evaluation, and/or investigation of exercise-induced adaptations of the oxygen transport/utilization system. The full potentialities of CPET in the clinical and research setting still remain largely underused and strong efforts are recommended to promote a more widespread use of CPET in the functional evaluation of cardiac patients.

French registry of cases of type I acute aortic dissection admitted to a cardiac rehabilitation center after surgery.

BACKGROUND: After surgery for type I acute aortic dissection, the aorta remains partly dissected. This new population of patients is now referred to cardiac rehabilitation centers (CRCs). The feasibility of subsequent physical exercise is unknown. METHODS: Thirty-three consecutive patients (aged 55.1+/-9.3 years) were included in a prospective registry with clinical and radiological follow-up for 1 year after admission to a CRC. Twenty-six patients had undergone standard training sessions with exercise on a bicycle ergometer. Physical training programs included calisthenics, respiratory physiotherapy, walking, and cycling. Seven patients did not perform standard exercise training sessions but only walking and respiratory physiotherapy. RESULTS: For trained patients, the sessions (18+/-10) were carried out at 11.3+/-1.5 on the Borg scale ('light'), with blood pressure monitoring on exercise (<160 mmHg in 75% of patients). Maximum workload during exercise test (bicycle ergometer, 10 watts/min) increased from 62.7+/-11.8 to 91.6+/-16.5 watts (P=0.002). We identified three complications in two patients requiring further thoracic aorta surgery during follow-up. There was also one case of aortic valve replacement after 5 months and three cases of peripheral ischemia. No deaths, cerebral vascular accidents, or myocardial infarctions were recorded. Ten of the 19 patients of working age were able to return to work. CONCLUSION: Physical training of moderate intensity seems feasible and beneficial in postsurgical type I aortic dissection patients.

Determination of exercise training level in coronary artery disease patients on beta blockers.

OBJECTIVES: To compare the intensity of three exercise training regimens. BACKGROUND: During a cardiac rehabilitation program coronary artery disease (CAD) patients should be trained at an intensity as close as possible to the ventilatory threshold (VT) level. The precise way to obtain this intensity of training during the sessions, however, remains unclear. METHODS: In stable beta-blocked CAD patients, heart rate (HR) and workload (WL) at the VT were determined from a cardiopulmonary exercise test. The 3 following days, each patient performed (in a randomized order) one bicycle training session per day at an intensity determined by (i) HR at VT, (ii) WL at VT, (iii) patient's feelings (14 on the Borg scale). HR, WL, systolic blood pressure, oxygen consumption (VO2) and the respiratory exchange ratio were monitored during each session, to compare the intensity of each regimen. RESULTS: Twenty patients, 57+/-10 years old were included. VO2, WL, HR and systolic blood pressure were significantly higher in the sessions driven by feelings and WL, than in the HR-driven sessions. As respiratory exchange ratio remained less than 1, we can assume that there was no important and deleterious participation of anaerobic metabolism. CONCLUSION: Classical training HR prescription could lead to undertrain CAD patients, although a training session prescription driven by the feelings or by the WL observed at VT allows the patients to train at a higher--but still aerobic--intensity.

Absence of exercise capacity improvement after exercise training program: a strong prognostic factor in patients with chronic heart failure.

BACKGROUND: Exercise training is established as adjuvant therapy for chronic heart failure, but the prognostic value of improvement in exercise capacity after exercise training has never been evaluated. METHODS AND RESULTS: In this prospective bicentric study, all chronic heart failure patients with left ventricular ejection fraction <45% who underwent an exercise training program in a cardiac rehabilitation center between January 2004 and September 2006 were consecutively included. Improvement in exercise capacity was assessed by change in peak oxygen consumption (deltaPVo(2)) and in PVo(2) expressed as a percentage of predicted PVo(2) (delta%PPVo(2)) measured before and after the training program. We included 155 patients (54+/-12 years old, male 81%, left ventricular ejection fraction=29.5+/-7.1%). Patients underwent 20 (10-30) training sessions. PVo(2) and %PPVo(2) were significantly increased after the training program (14% and 13%, respectively, P<0.001 for both). After 16+/-6 months follow-up, 27 patients had a cardiac event (death [n=12], cardiac transplantation [n=5], hospitalization for acute heart failure [n=10]). Univariate analysis revealed that among 17 significant predictors of cardiac events, the 2 more powerful ones were level of B-type natriuretic peptide at baseline (P<0.0001) and improvement in exercise capacity as assessed by deltaPVo(2) and delta%PPVo(2) (P<0.0001). Multivariate analysis revealed B-type natriuretic peptide level and delta%PPVo(2) as only independent predictive factors of outcome (P=0.01). The risk ratio of cardiac events for nonresponse versus response to the training program (defined as median delta%PPVo(2)<6%) was 8.2 (P=0.0006). CONCLUSIONS: Among patients with chronic heart failure, the lack of improvement in exercise capacity after an exercise training program has strong prognostic value for adverse cardiac events independent of classical predictive factors such as left ventricular ejection fraction, New York Heart Association class, and B-type natriuretic peptide level.

Thromboembolic events early after mitral valve repair: incidence and predictive factors.

BACKGROUND AND OBJECTIVES: The incidence of thromboembolic events (TE) in the early period following mitral valve repair (MV repair) is poorly documented. The aim of this prospective study was to evaluate it, and to determine predictive factors. METHODS AND RESULTS: In this prospective multicenter non-randomized study, 350 consecutive patients were included after MV repair and monitored until post-operative day 44+/-6. 65.7% received Vitamin K antagonists (VKA), 18.8% aspirin (ASA), 5.4% ASA+VKA and 10% received no antithrombotic therapy (AT). All patients with AF received VKA or VKA+ASA. Twelve patients had a cerebral TE during follow-up:14.3% among untreated patients, 3.0% in the VKA group, and 0% in the ASA and in the ASA+VKA groups (p=0.03 for comparison no AT group versus the three other combined groups; p=NS for VKA versus ASA). In univariate analysis, only the absence of post-operative AT was related to the risk of TE (HR=6.7, CI 95%[2.1-21], p=0.0002). In a prespecified subgroup (n=185) of patients with sinus rhythm and without concomitant cardiac surgery (in which the choice of AT is not influenced by these associate conditions), only the absence of post-operative AT remained related to the risk of TE (HR=10.0, CI 95%[2.45-40], p=0.001). CONCLUSION: In the first six weeks following MV repair, the incidence of thromboembolic events is far from negligible (3.5%), even in patients with sinus rhythm. The main predictive factor for thromboembolic event determined in this study is the absence of an antithrombotic therapy.

Role of B-type natriuretic peptide and echocardiographic indices in predicting the development of acute heart failure following beta-blocker uptitration in chronic heart failure patients with left ventricular systolic dysfunction.

We evaluated the role of clinical, BNP and echocardiographic left ventricular (LV) indices in predicting the development of acute heart failure (HF) following beta-blocker initiation and uptitration in 50 stable CHF patients with LVEF < 40% and creatininemia < 250 micromol/l. Use of NYHA class alone predicted the development of acute HF decompensation in only 56% and the absence of this event in 93% of patients. Use of echocardiographic indices (systolic PAP < 40 mmHg or E/A ratio < 1.4 or EDT > 145 ms) predicted the absence of acute HF decompensation in 100% of patients. Use of NYHA > 3 combined with BNP > 398 pg/ml or with echocardiographic indices (i.e. systolic PAP > 40 mmHg or E/A > 1.4 or EDT < 145 ms) predicted the development of acute HF decompensation in 100% of patients. In conclusion use of BNP and echocardiographic LV filling pressure indices in combination with NYHA class may predict beta-blocker tolerance more accurately than clinical indices alone in patients with LV systolic dysfunction (LVEF < 40%).