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1.
JAMA Netw Open ; 4(1): e2035470, 2021 01 04.
Artigo em Inglês | MEDLINE | ID: mdl-33496796

RESUMO

Importance: Frequent right ventricular (RV) pacing can cause and exacerbate heart failure. Cardiac resynchronization therapy (CRT) has been shown to be associated with improved outcomes among patients with reduced left ventricular ejection fraction who need frequent RV pacing, but the patterns of use of CRT vs dual chamber (DC) devices and the associated outcomes among these patients in clinical practice is not known. Objective: To assess outcomes, variability in use of device type, and trends in use of device type over time among patients undergoing implantable cardioverter defibrillator (ICD) implantation who were likely to require frequent RV pacing but who did not have a class I indication for CRT. Design, Setting, and Participants: This retrospective cohort study used the National Cardiovascular Data Registry (NCDR) ICD Registry. A total of 3100 Medicare beneficiaries undergoing first-time implantation of CRT defibrillator (CRT-D) or DC-ICD from 2010 to 2016 who had a class I or II guideline ventricular bradycardia pacing indication but not a class I indication for CRT were included. Data were analyzed from August 2018 to October 2019. Exposures: Implantation of a CRT-D or DC-ICD. Main Outcomes and Measures: All-cause mortality, heart failure hospitalization, and complications were ascertained from Medicare claims data. Multivariable Cox proportional hazards models and Fine-Gray models were used to evaluate 1-year mortality and heart failure hospitalization, respectively. Multivariable logistic regression was used to evaluate 30-day and 90-day complications. All models accounted for clustering. The median odds ratio (MOR) was used to assess variability and represents the odds that a randomly selected patient receiving CRT-D at a hospital with high implant rates would receive CRT-D if they had been treated at a hospital with low CRT-D implant rates. Results: A total of 3100 individuals were included. The mean (SD) age was 76.3 (6.4) years, and 2500 (80.6%) were men. The 1698 patients (54.7%) receiving CRT-D were more likely than those receiving DC-ICD to have third-degree atrioventricular block (828 [48.8%] vs 432 [30.8%]; P < .001), nonischemic cardiomyopathy (508 [29.9%] vs 255 [18.2%]; P < .001), and prior heart failure hospitalizations (703 [41.4%] vs 421 [30.0%]; P < .001). Following adjustment, CRT-D was associated with lower 1-year mortality (hazard ratio [HR], 0.70; 95% CI, 0.57-0.87; P = .001) and heart failure hospitalization (subdistribution HR, 0.77; 95% CI, 0.61-0.97; P = .02) and no difference in complications compared with DC-ICD. Hospital variation in use of CRT was present (MOR, 2.00), and the use of CRT in this cohort was higher over time (654 of 1351 [48.4%] in 2010 vs 362 of 594 [60.9%] in 2016; P < .001). Conclusions and Relevance: In this cohort study of older patients in contemporary practice undergoing ICD implantation with a bradycardia pacing indication but without a class I indication for CRT, CRT-D was associated with better outcomes compared with DC devices. Variability in use of device type was observed, and the rate of CRT implantation increased over time.


Assuntos
Bradicardia/terapia , Terapia de Ressincronização Cardíaca/métodos , Desfibriladores Implantáveis , Disfunção Ventricular Esquerda/terapia , Idoso , Bradicardia/mortalidade , Feminino , Insuficiência Cardíaca/mortalidade , Hospitalização/estatística & dados numéricos , Humanos , Masculino , Medicare , Sistema de Registros , Estudos Retrospectivos , Estados Unidos/epidemiologia , Disfunção Ventricular Esquerda/mortalidade
3.
Asian Cardiovasc Thorac Ann ; 28(9): 633-637, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32870026

RESUMO

Optimal treatment for patients with ischemic heart disease and severe left ventricular dysfunction is a debatable subject in the literature. The largest and only trial on the subject so far is the Surgical Treatment for Ischemic Heart Failure trial. This trial compared coronary artery bypass grafting with optimal medical treatment in one arm versus coronary artery bypass grafting with surgical ventricular restoration in the second arm. Recently, the 10-year follow-up data of various subsets of the trial have been published. This study reviews various pertinent clinical issues related to the trial and its sub-studies and their relevance in routine modern-day clinical practice.


Assuntos
Ponte de Artéria Coronária , Insuficiência Cardíaca/cirurgia , Isquemia Miocárdica/cirurgia , Ensaios Clínicos Controlados Aleatórios como Assunto , Disfunção Ventricular Esquerda/cirurgia , Ponte de Artéria Coronária/efeitos adversos , Ponte de Artéria Coronária/mortalidade , Insuficiência Cardíaca/diagnóstico por imagem , Insuficiência Cardíaca/mortalidade , Insuficiência Cardíaca/fisiopatologia , Humanos , Isquemia Miocárdica/diagnóstico por imagem , Isquemia Miocárdica/mortalidade , Isquemia Miocárdica/fisiopatologia , Recuperação de Função Fisiológica , Fatores de Risco , Resultado do Tratamento , Disfunção Ventricular Esquerda/diagnóstico por imagem , Disfunção Ventricular Esquerda/mortalidade , Disfunção Ventricular Esquerda/fisiopatologia , Função Ventricular Esquerda
4.
J Card Surg ; 35(8): 1793-1801, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32627240

RESUMO

BACKGROUND: This study evaluates the longitudinal impacts of off-pump coronary artery bypass (OPCAB) surgery in patients with reduced left ventricular ejection fraction (LVEF). METHODS: Adults with LVEF ≤ 30% undergoing coronary artery bypass grafting between 2011 and 2020 were included. Patients were stratified based on the utilization of cardiopulmonary bypass into OPCAB or on-pump coronary artery bypass (ONCAB) groups. Primary outcomes included survival and hospital readmissions. Secondary outcomes evaluated postoperative morbidities. Multivariable regression evaluated risk-adjusted mortality and readmission. Propensity score matching was utilized to reduce bias. RESULTS: A total of 660 low LVEF patients were included, of which 28.5% (n = 188) were OPCAB and 71.5% (n = 472) were ONCAB. The rates of complete revascularization were similar between the groups (80.3% vs 82.0%; P = .67). Early survival between the unmatched groups was similar at 1-year follow-up (86.2% vs 87.9%; P = .53); however, at 5 years OPCABs had significantly worse survival compared with ONCABs (71.5% vs 64.2%; P = .02). These findings persisted in the matched cohort where survival at 1 year was comparable (86.8% vs 85.7%; P = .80), but 5-year survival was better for ONCABs (64.1% vs 69.9%; P = .03). The rates of readmission were similar between the unmatched and matched groups at all time intervals, including readmissions for cardiac-related and heart failure-related events (all, P > .05). CONCLUSIONS: In contemporary patients with reduced LVEF, survival after OPCAB was similar at 1 year but lower at 5-year follow-up compared with ONCAB, despite similar rates of complete revascularization. These findings suggest that there may be other factors influencing longitudinal mortality in the low LVEF cohort, beyond the use of cardiopulmonary bypass.


Assuntos
Ponte de Artéria Coronária sem Circulação Extracorpórea , Disfunção Ventricular Esquerda/cirurgia , Seguimentos , Humanos , Estudos Longitudinais , Taxa de Sobrevida , Fatores de Tempo , Disfunção Ventricular Esquerda/mortalidade
5.
Int J Cardiovasc Imaging ; 36(11): 2145-2153, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32621039

RESUMO

Cardiovascular complications have been increasingly detected in patients with sickle cell disease (SCD). Two-dimensional speckle-tracking echocardiography (STE) detects early myocardial changes in a number of pathophysiological processes, which may be useful in SCD. This study was designed to examine the value of STE in predicting clinical outcome in adult patients with SCD. A total of 219 patients, mean age 33 ± 12 years were prospectively enrolled. Several clinical, laboratory and echocardiographic variables including left ventricular global longitudinal strain (LVGLS) by STE were assessed. The endpoint was a composite of the following events: (1) all-cause mortality, (2) three or more acute painful episodes that require hospitalization in one year, (3) acute chest syndrome and (4) hospitalization due to disease complication. The majority of the patients had enlargement of LV and left atrial (LA) with preserved ejection fraction. During the mean follow-up of 30 months, 69 patients (32%) had reached the endpoint, including eight deaths (3.7%). No difference was observed in the parameters of diastolic function comparing the patients with and without events. LVGLS ranged from - 12.25 to - 25.44 (mean - 20.26 ± 2.5), with higher values in the patients who had events compared with those who did not. In the multivariable analysis, higher LVGLS values were associated with adverse events (adjusted OR 1.25; 95% CI 1.04-1.51; p = 0.021), independently of the TR maximal velocity and LV ejection fraction. In patients with SCD, higher LV global longitudinal strain was a predictor of adverse outcome, independently of age, TR velocity and LV function.


Assuntos
Anemia Falciforme/complicações , Ecocardiografia Doppler , Contração Miocárdica , Disfunção Ventricular Esquerda/diagnóstico por imagem , Função Ventricular Esquerda , Adulto , Anemia Falciforme/diagnóstico , Anemia Falciforme/mortalidade , Causas de Morte , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Admissão do Paciente , Valor Preditivo dos Testes , Prognóstico , Estudos Prospectivos , Fatores de Risco , Disfunção Ventricular Esquerda/etiologia , Disfunção Ventricular Esquerda/mortalidade , Disfunção Ventricular Esquerda/fisiopatologia , Adulto Jovem
6.
Int J Cardiovasc Imaging ; 36(10): 2063-2071, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32495064

RESUMO

To compare the left ventricular (LV) phase dyssynchrony parameters obtained from Tc-99m Sestamibi SPECT (GSPECT) and F-18 FDG PET(GPET), as well as the prognostic values in patients with ischemic cardiomyopathy (ICM). Consecutive ICM patients referred for myocardial viability assessment were retrospectively evaluated and were followed-up for 21 ± 5 months. Phase parameter from both GSPECT and GPET were analyzed by QGS software, including histogram bandwidth (BW), standard deviation (SD) and entropy. Independent predictor for cardiac death was analyzed by Cox regression analysis. The estimated cardiac survival curve was analyzed by and was compared with the log-rank test. Eight-eight (mean age 56 ± 10, male 94%, LVEFSPECT23 ± 10%) ICM patients were included for analysis. Moderate correlations were observed for BW (r = 0.65; p < 0.001), SD (r = 0.63; p < 0.001) and entropy (r = 0.73; p < 0.001) between GSPECT and GPET. Among all covariates, the extent of myocardial scar was significantly associated with the differences of SD (r = 0.22; p < 0.05) and entropy (r = - 0.7; p < 0.05), whereas the extent of myocardial viability was not (all p > 0.05). Entropy measured by GSPECT was the predictor for cardiac death (p = 0.037) while QRS duration was not. The cardiac survival of patients with a high entropy (≥ 59%) was significantly lower than that of patients with low entropy (< 59%) (p < 0.05). GSPECT and GPET-derived phase parameters were not interchangeable in ICM patients. Patients with LV dyssynchrony measured by gated SPECT were associated with a worse outcome.


Assuntos
Cardiomiopatias/diagnóstico por imagem , Fluordesoxiglucose F18/administração & dosagem , Isquemia Miocárdica/complicações , Tomografia Computadorizada com Tomografia por Emissão de Pósitrons , Compostos Radiofarmacêuticos/administração & dosagem , Tecnécio Tc 99m Sestamibi/administração & dosagem , Tomografia Computadorizada de Emissão de Fóton Único , Disfunção Ventricular Esquerda/diagnóstico por imagem , Função Ventricular Esquerda , Idoso , Cardiomiopatias/etiologia , Cardiomiopatias/mortalidade , Cardiomiopatias/fisiopatologia , Morte Súbita Cardíaca/etiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Isquemia Miocárdica/diagnóstico , Isquemia Miocárdica/mortalidade , Isquemia Miocárdica/fisiopatologia , Valor Preditivo dos Testes , Prognóstico , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Disfunção Ventricular Esquerda/etiologia , Disfunção Ventricular Esquerda/mortalidade , Disfunção Ventricular Esquerda/fisiopatologia
7.
Cardiovasc Diabetol ; 19(1): 84, 2020 06 13.
Artigo em Inglês | MEDLINE | ID: mdl-32534593

RESUMO

BACKGROUND: Left ventricular (LV) longitudinal dysfunction has been identified in type 2 diabetes mellitus (T2DM) patients with preserved LV ejection fraction (LVEF). However, the impact of T2DM on LV longitudinal function or the association of LV longitudinal function with outcome for dilated cardiomyopathy (DCM) remains unclear. METHODS: We retrospectively studied 206 patients with non-ischemic DCM, mean age of 59 ± 17 years and LVEF of 31 ± 8% (all < 45%). All patients underwent a standard echocardiographic examination, and LV longitudinal function was assessed in terms of global longitudinal strain (GLS). Long-term outcomes were assessed, with a median follow-up period of 6.2 years, as primary endpoints of death from or hospitalization for deteriorating heart failure. RESULTS: GLS of DCM patients with T2DM (n = 55) was significantly lower than that in DCM patients without T2DM (n = 151) in spite of similar conventional LV function (7.0 ± 2.0% vs. 7.8 ± 2.2%, p = 0.03). Kaplan-Meier curves indicated that long-term outcomes for DCM patients without T2DM were better than for those with T2DM (log-rank p = 0.001). Subdividing the two groups into four with by using the median value of GLS (7.9%) showed long-term outcome was worst for DCM patients with T2DM and low GLS. Cox proportional hazards analyses demonstrated an independent association of T2DM, GLS and left atrial volume index with long-term outcome. Moreover, multiple regression analysis for the association of GLS showed that T2DM was the independent determinant parameter for GLS as well as for LVEF and left atrial volume index. CONCLUSION: Management of DCM patients with T2DM may be improved by using GLS guidance.


Assuntos
Cardiomiopatia Dilatada/complicações , Diabetes Mellitus Tipo 2/complicações , Cardiomiopatias Diabéticas/etiologia , Insuficiência Cardíaca/etiologia , Volume Sistólico , Disfunção Ventricular Esquerda/etiologia , Função Ventricular Esquerda , Adulto , Idoso , Cardiomiopatia Dilatada/diagnóstico por imagem , Cardiomiopatia Dilatada/mortalidade , Cardiomiopatia Dilatada/fisiopatologia , Causas de Morte , Diabetes Mellitus Tipo 2/diagnóstico , Diabetes Mellitus Tipo 2/mortalidade , Diabetes Mellitus Tipo 2/fisiopatologia , Cardiomiopatias Diabéticas/diagnóstico por imagem , Cardiomiopatias Diabéticas/mortalidade , Cardiomiopatias Diabéticas/fisiopatologia , Progressão da Doença , Ecocardiografia , Feminino , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/mortalidade , Insuficiência Cardíaca/fisiopatologia , Hospitalização , Humanos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Disfunção Ventricular Esquerda/diagnóstico por imagem , Disfunção Ventricular Esquerda/mortalidade , Disfunção Ventricular Esquerda/fisiopatologia
8.
J Card Surg ; 35(7): 1514-1524, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32485030

RESUMO

INTRODUCTION: Extracorporeal membrane oxygenation (ECMO) is a life-saving technology capable of restoring perfusion but is not without significant complications that limit its realizable therapeutic benefit. ECMO-induced hemodynamics increase cardiac afterload risking left ventricular distention and impaired cardiac recovery. To mitigate potentially harmful effects, multiple strategies to unload the left ventricle (LV) are used in clinical practice but data supporting the optimal approach is presently lacking. MATERIALS & METHODS: We reviewed outcomes of our ECMO population from September 2015 through January 2019 to determine if our LV unloading strategies were associated with patient outcomes. We compared reactive (Group 1, n = 30) versus immediate (Group 2, n = 33) LV unloading and then compared patients unloaded with an Impella CP (n = 19) versus an intra-aortic balloon pump (IABP, n = 16), analyzing survival and ECMO-related complications. RESULTS: Survival was similar between Groups 1 and 2 (33 vs 42%, P = .426) with Group 2 experiencing more clinically-significant hemorrhage (40 vs. 67%, P = .034). Survival and ECMO-related complications were similar between patients unloaded with an Impella versus an IABP. However, the Impella group exhibited a higher rate of survival (37%) than predicted by their median SAVE score (18%). DISCUSSION: Based on this analysis, reactive unloading appears to be a viable strategy while venting with the Impella CP provides better than anticipated survival. Our findings correlate with recent large cohort studies and motivate further work to design clinical guidelines and future trial design.


Assuntos
Oxigenação por Membrana Extracorpórea/efeitos adversos , Coração Auxiliar , Balão Intra-Aórtico , Disfunção Ventricular Esquerda/etiologia , Disfunção Ventricular Esquerda/terapia , Idoso , Feminino , Hemodinâmica , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Taxa de Sobrevida , Resultado do Tratamento , Disfunção Ventricular Esquerda/mortalidade , Disfunção Ventricular Esquerda/fisiopatologia
9.
Circ Heart Fail ; 13(5): e006597, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-32354280

RESUMO

BACKGROUND: Loop diuretics are used for congestion relief, and dose adaptations are usually a consequence of the clinicians' clinical judgement about the congestive status of the patient. In EPHESUS (Eplerenone in Patients With Systolic Dysfunction After Myocardial Infarction), many patients required diuretics for congestion relief. We thus hypothesized that blinded allocation to eplerenone would lead clinicians to reduce loop diuretics, as a consequence of the improvement in patients' status. METHODS: Cox and mixed-effects models were used over a median follow-up of 1.3 years in 6632 patients. RESULTS: A total of 6632 patients were included; at baseline, 3352 (50.5%) did not have diuretics, 2195 (33.1%) had diuretic doses between 1 and 40 mg/day, and 1085 (16.4%) had diuretic doses >40 mg/day. Patients with higher furosemide equivalent doses had a worse clinical status. Both baseline and follow-up incremental loop diuretic doses were associated with worse prognosis. Eplerenone treatment was associated with lower prescribed loop diuretic doses throughout the follow-up; lower doses were observed at 90 days and decreased further at 180 days and beyond. Eplerenone treatment led to a mean furosemide equivalent dose reduction of -2.2 mg/day (-2.9 to -1.6) throughout the follow-up. Eplerenone was effective in reducing morbidity and mortality regardless of the baseline loop diuretic dose used: hazard ratio for the outcome of cardiovascular death or heart failure hospitalization was 0.83 ([95% CI, 0.75-0.92]; P for interaction, 0.54). CONCLUSIONS: Eplerenone treatment led to a loop diuretic dose reduction during follow-up without evidence of treatment effect modification by loop diuretics. These findings suggest that eplerenone reduces congestive signs and symptoms, which enables clinicians to reduce loop diuretic doses.


Assuntos
Eplerenona/administração & dosagem , Insuficiência Cardíaca/tratamento farmacológico , Antagonistas de Receptores de Mineralocorticoides/administração & dosagem , Infarto do Miocárdio/complicações , Inibidores de Simportadores de Cloreto de Sódio e Potássio/administração & dosagem , Disfunção Ventricular Esquerda/tratamento farmacológico , Função Ventricular Esquerda/efeitos dos fármacos , Idoso , Eplerenona/efeitos adversos , Feminino , Insuficiência Cardíaca/etiologia , Insuficiência Cardíaca/mortalidade , Insuficiência Cardíaca/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Antagonistas de Receptores de Mineralocorticoides/efeitos adversos , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/fisiopatologia , Recuperação de Função Fisiológica , Inibidores de Simportadores de Cloreto de Sódio e Potássio/efeitos adversos , Sístole , Fatores de Tempo , Resultado do Tratamento , Disfunção Ventricular Esquerda/etiologia , Disfunção Ventricular Esquerda/mortalidade , Disfunção Ventricular Esquerda/fisiopatologia
10.
Int J Cardiovasc Imaging ; 36(8): 1445-1454, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32297100

RESUMO

Previous studies have focused on only 1 or 2 echocardiographic parameters as prognostic markers in patients with acute ischemic stroke (AIS). A total of 900 patients with AIS who underwent transthoracic echocardiography (72.6 ± 12.0 years and 60% males) were retrospectively reviewed. Composite clinical events, including all-cause mortality, non-fatal stroke, non-fatal myocardial infarction, and coronary revascularization, were assessed during clinical follow-ups. During a median follow-up of 3.3 years (interquartile range 0.6-5.1 years), there were 151 (16.8%) composite events. In the multivariable analyses after controlling for potential confounders, left ventricular ejection fraction (LVEF) < 62% (hazard ratio [HR] 1.62; 95% confidence interval [CI] 1.14-2.30; p = 0.007) and AV sclerosis (AVs) (HR 1.56; 95% CI 1.10-2.21; p = 0.013) were independent prognostic factors associated with composite events. Multivariable analyses showed that HR for composite events gradually increased according to LVEF and AVs: HR was 2.6-fold higher in the highest-risk group than in the lowest group (p < 0.001). Compared with a clinical model (global chi-square = 69.6), LVEF, AVs, and both of them were significantly improved outcome prediction in sequential Cox model analysis (global chi-square = 75.6, 75.7, and 78.8, respectively; p < 0.05 for each) for each. In patients with AIS, LVEF < 62%, and the presence of AV sclerosis can predict future vascular events. Patients with AIS exhibiting reduced LVEF and AV sclerosis may benefit from aggressive secondary prevention.


Assuntos
Valva Aórtica/diagnóstico por imagem , Isquemia Encefálica/terapia , Ecocardiografia Doppler em Cores , Doenças das Valvas Cardíacas/diagnóstico por imagem , Acidente Vascular Cerebral/terapia , Disfunção Ventricular Esquerda/diagnóstico por imagem , Idoso , Idoso de 80 Anos ou mais , Valva Aórtica/fisiopatologia , Isquemia Encefálica/diagnóstico por imagem , Isquemia Encefálica/mortalidade , Causas de Morte , Feminino , Doenças das Valvas Cardíacas/mortalidade , Doenças das Valvas Cardíacas/fisiopatologia , Doenças das Valvas Cardíacas/terapia , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Esclerose , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/mortalidade , Volume Sistólico , Fatores de Tempo , Resultado do Tratamento , Disfunção Ventricular Esquerda/mortalidade , Disfunção Ventricular Esquerda/fisiopatologia , Disfunção Ventricular Esquerda/terapia , Função Ventricular Esquerda
11.
Am J Cardiol ; 125(10): 1543-1549, 2020 05 15.
Artigo em Inglês | MEDLINE | ID: mdl-32273053

RESUMO

Patients with low gradient severe aortic stenosis (LG-AS) often exhibit significant limitations in functional status and quality of life. We aimed to evaluate the clinical effect of transcatheter aortic valve implantation (TAVI) on LG-AS patients compared to those with high transvalvular gradients and similar left ventricular dysfunction. Retrospective analysis of records for all patients with a left ventricular ejection fraction <50% who underwent TAVI at our institution was performed. Patients were grouped according to their transvalvular gradient. Data were collected from The Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry. Clinical benefit endpoints included improvements in left ventricular ejection fraction and changes in the Kansas City Cardiomyopathy Questionnaire. Additional outcomes analyzed included 1-year all-cause mortality, stroke rates, rates of rehospitalization, need for a permanent pacemaker, and hospital length of stay. Two hundred three patients met our inclusion criteria. one hundred one LG-AS patients (mean transvalvular gradient <40 mm Hg) were compared to 102 patients with high transvalvular gradients (mean transvalvular gradient >40 mm Hg). LG-AS patients yielded similar improvements in left ventricular ejection fraction (43.5% ± 63.7 vs 37.7% ± 58.7; p = 0.525) and Kansas City Cardiomyopathy Questionnaire scores (423.51% ± 1257.02 vs 266.56% ± 822.81; p = 0.352). There were no differences between the groups with respect to 1-year mortality (16.8% vs 12.7%; p = 0.412), stroke rates, hospital length of stay, need for permanent pacemaker implantation or hospital readmissions. In conclusion, we found that TAVI is associated with comparable improvement in clinical and echocardiographic outcomes in LG-AS patients as compared to those with high gradient severe aortic stenosis.


Assuntos
Estenose da Valva Aórtica/fisiopatologia , Estenose da Valva Aórtica/cirurgia , Substituição da Valva Aórtica Transcateter , Disfunção Ventricular Esquerda/fisiopatologia , Idoso de 80 Anos ou mais , Estenose da Valva Aórtica/mortalidade , Ecocardiografia , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Marca-Passo Artificial , Readmissão do Paciente/estatística & dados numéricos , Estudos Retrospectivos , Acidente Vascular Cerebral/epidemiologia , Volume Sistólico , Inquéritos e Questionários , Disfunção Ventricular Esquerda/mortalidade
12.
Pediatr Cardiol ; 41(5): 925-931, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32157397

RESUMO

Duchenne muscular dystrophy (DMD) is characterized by myocardial fibrosis and left ventricular (LV) dysfunction. Implantable cardioverter defibrillator (ICD) use has not been characterized in this population but is considered for symptomatic patients with severe LV dysfunction (SLVD) receiving guideline-directed medical therapy (GDMT). We evaluated ICD utilization and efficacy in patients with DMD. Retrospective cohort study of DMD patients from 17 centers across North America between January 2, 2005 and December 31, 2015. ICD use and its effect on survival were evaluated in patients with SLVD defined as ejection fraction (EF) < 35% and/ or shortening fraction (SF) < 16% on final echocardiogram. SLVD was present in 57/436 (13.1%) patients, of which 12 (21.1%) died during the study period. Of these 12, (mean EF 20.9 ± 6.2% and SF 13.7 ± 7.2%), 8 received GDMT, 5 received steroids, and none received an ICD. ICDs were placed in 9/57 (15.8%) patients with SLVD (mean EF 31.2 ± 8.5% and SF 10.3 ± 4.9%) at a mean age of 20.4 ± 6.3 years; 8/9 received GDMT, 7 received steroids, and all were alive at study end; mean ICD duration was 36.1 ± 26.2 months. Nine ICDs were implanted at six different institutions, associated with two appropriate shocks for ventricular tachycardia in two patients, no inappropriate shocks, and one lead fracture. ICD use may be associated with improved survival and minimal complications in DMD cardiomyopathy with SLVD. However, inconsistent GDMT utilization may be a significant confounder. Future studies should define optimal indications for ICD implantation in patients with DMD cardiomyopathy.


Assuntos
Desfibriladores Implantáveis , Distrofia Muscular de Duchenne/complicações , Disfunção Ventricular Esquerda/cirurgia , Adolescente , Adulto , Ecocardiografia , Feminino , Humanos , Masculino , Distrofia Muscular de Duchenne/terapia , Estudos Retrospectivos , Disfunção Ventricular Esquerda/etiologia , Disfunção Ventricular Esquerda/mortalidade , Adulto Jovem
13.
Open Heart ; 7(1): e001199, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32153792

RESUMO

Objectives: The physiological determinants of left ventricular (LV) mechanical dispersion (MD) are not fully explored. We aimed to investigate the impact of afterload reduction and changes in ventricular conduction on LV MD after transcatheter aortic valve implantation (TAVI). Methods: Patients with severe aortic stenosis (AS) were examined in a prospective, repeated measures observational cohort study before and after an uncomplicated transfemoral TAVI in a single tertiary centre. LV MD was assessed by speckle tracking echocardiography. Valvulo-arterial impedance (ZVA) was used as a measure of global afterload. Results: We included 140 consecutive patients (83±8 years old, 49% women, logistic EuroSCORE 16±10) with severe AS (valve area 0.7±0.2 cm2, mean transvalvular gradient 54±18 mm Hg) and a relatively preserved LV ejection fraction (52%±11%). After TAVI, we observed favourable changes in transvalvular gradients and ZVA in all patients. Compared with baseline, postprocedural MD was significantly lower in 108 patients with unchanged ventricular conduction (55±17 ms vs 51±17 ms, p=0.02) and higher in 28 patients with TAVI-induced left bundle branch block (51±13 ms vs 62±19 ms, p≤0.001). During 22±9 months observation, 22 patients died. Postprocedural MD was associated with mortality in a univariate Cox regression model (HR=1.24 (1.01-1.52), p<0.04, per 10 ms increase). Conclusions: Isolated afterload reduction was associated with reduction of MD, while concomitant impairment of ventricular conduction resulted in a more pronounced MD after TAVI, indicating that loading conditions and conduction should be considered when evaluating MD. A pronounced postprocedural LV MD was associated with mortality.


Assuntos
Potenciais de Ação , Estenose da Valva Aórtica/cirurgia , Valva Aórtica/cirurgia , Bloqueio de Ramo/etiologia , Frequência Cardíaca , Substituição da Valva Aórtica Transcateter/efeitos adversos , Disfunção Ventricular Esquerda/etiologia , Função Ventricular Esquerda , Idoso , Idoso de 80 Anos ou mais , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/fisiopatologia , Estenose da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/mortalidade , Estenose da Valva Aórtica/fisiopatologia , Bloqueio de Ramo/diagnóstico , Bloqueio de Ramo/mortalidade , Bloqueio de Ramo/fisiopatologia , Ecocardiografia , Eletrocardiografia , Feminino , Próteses Valvulares Cardíacas , Humanos , Masculino , Estudos Prospectivos , Fatores de Risco , Índice de Gravidade de Doença , Fatores de Tempo , Substituição da Valva Aórtica Transcateter/instrumentação , Substituição da Valva Aórtica Transcateter/mortalidade , Resultado do Tratamento , Disfunção Ventricular Esquerda/diagnóstico por imagem , Disfunção Ventricular Esquerda/mortalidade , Disfunção Ventricular Esquerda/fisiopatologia
15.
Sci Rep ; 10(1): 1736, 2020 02 03.
Artigo em Inglês | MEDLINE | ID: mdl-32015449

RESUMO

To compare in-hospital outcomes between left ventricular myocardial infarction (LVMI) patients with and without right ventricular myocardial infarction (RVMI). Patients with acute ST-segment elevation MI (STEMI) undergoing primary percutaneous coronary intervention (PCI) were enrolled and divided into LVMI with and without RVMI groups. Between-group differences and in-hospital outcomes were compared. Compared to patients without RVMI, patients with RVMI were more likely to be male, have higher body mass index, serum levels of C-reactive protein (8.9 ± 2.4 vs 6.2 ± 2.1 mg/dL), B-type natriuretic peptide (1295 ± 340 vs 872 ± 166 pg/mL) and cardiac troponin-I (8.6 ± 2.9 vs 5.2 ± 2.1 ng/mL), and have diabetes (36.3% vs 3.4%) and dyslipidemia (53.4% vs 48.1%). Patients with RVMI had lower left and right ventricular ejection fraction (50.5 ± 5.6% vs 53.4 ± 3.8% and 33.6 ± 2.9% vs 45.7 ± 2.0%), but had higher mean pulmonary artery pressure (30.6 ± 3.3 vs 23.8 ± 3.1 mm Hg). Compared to patients without RVMI, patients with RVMI had higher odds of in-hospital all-cause mortality (4.1% vs 1.0%) and new onset acute heart failure (3.4% vs 1.0%). After adjusted for confounding factors, LVMI with RVMI remained independently associated with composite outcomes, with odds ratio 1.66 (95% confidence interval 1.39-2.04). Compared to isolated LVMI patients, those with concomitant RVMI have higher odds of in-hospital complications, particularly all-cause mortality and new onset acute heart failure.


Assuntos
Infarto do Miocárdio/terapia , Intervenção Coronária Percutânea , Disfunção Ventricular Esquerda/terapia , Disfunção Ventricular Direita/terapia , Adulto , Idoso , Índice de Massa Corporal , Proteína C-Reativa/metabolismo , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/complicações , Infarto do Miocárdio/mortalidade , Peptídeo Natriurético Encefálico/sangue , Análise de Sobrevida , Resultado do Tratamento , Disfunção Ventricular Esquerda/complicações , Disfunção Ventricular Esquerda/mortalidade , Disfunção Ventricular Direita/complicações , Disfunção Ventricular Direita/mortalidade
16.
J Am Coll Cardiol ; 75(3): 304-316, 2020 01 28.
Artigo em Inglês | MEDLINE | ID: mdl-31976869

RESUMO

BACKGROUND: Myocardial fibrosis is a key mechanism of left ventricular decompensation in aortic stenosis and can be quantified using cardiovascular magnetic resonance (CMR) measures such as extracellular volume fraction (ECV%). Outcomes following aortic valve intervention may be linked to the presence and extent of myocardial fibrosis. OBJECTIVES: This study sought to determine associations between ECV% and markers of left ventricular decompensation and post-intervention clinical outcomes. METHODS: Patients with severe aortic stenosis underwent CMR, including ECV% quantification using modified Look-Locker inversion recovery-based T1 mapping and late gadolinium enhancement before aortic valve intervention. A central core laboratory quantified CMR parameters. RESULTS: Four-hundred forty patients (age 70 ± 10 years, 59% male) from 10 international centers underwent CMR a median of 15 days (IQR: 4 to 58 days) before aortic valve intervention. ECV% did not vary by scanner manufacturer, magnetic field strength, or T1 mapping sequence (all p > 0.20). ECV% correlated with markers of left ventricular decompensation including left ventricular mass, left atrial volume, New York Heart Association functional class III/IV, late gadolinium enhancement, and lower left ventricular ejection fraction (p < 0.05 for all), the latter 2 associations being independent of all other clinical variables (p = 0.035 and p < 0.001). After a median of 3.8 years (IQR: 2.8 to 4.6 years) of follow-up, 52 patients had died, 14 from adjudicated cardiovascular causes. A progressive increase in all-cause mortality was seen across tertiles of ECV% (17.3, 31.6, and 52.7 deaths per 1,000 patient-years; log-rank test; p = 0.009). Not only was ECV% associated with cardiovascular mortality (p = 0.003), but it was also independently associated with all-cause mortality following adjustment for age, sex, ejection fraction, and late gadolinium enhancement (hazard ratio per percent increase in ECV%: 1.10; 95% confidence interval [1.02 to 1.19]; p = 0.013). CONCLUSIONS: In patients with severe aortic stenosis scheduled for aortic valve intervention, an increased ECV% is a measure of left ventricular decompensation and a powerful independent predictor of mortality.


Assuntos
Estenose da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/fisiopatologia , Líquido Extracelular/fisiologia , Volume Sistólico/fisiologia , Disfunção Ventricular Esquerda/diagnóstico por imagem , Disfunção Ventricular Esquerda/fisiopatologia , Idoso , Idoso de 80 Anos ou mais , Estenose da Valva Aórtica/mortalidade , Feminino , Seguimentos , Humanos , Estudos Longitudinais , Imagem Cinética por Ressonância Magnética/métodos , Masculino , Pessoa de Meia-Idade , Mortalidade/tendências , Miocárdio/patologia , Estudos Prospectivos , Disfunção Ventricular Esquerda/mortalidade
17.
Am J Cardiol ; 125(6): 924-930, 2020 03 15.
Artigo em Inglês | MEDLINE | ID: mdl-31954508

RESUMO

The prevalence of coexisting coronary artery disease (CAD) is high in patients who underwent transcatheter aortic valve implantation (TAVI). Our objective was to first determine if the severity of CAD before TAVI had an important impact on post-TAVI outcomes and second, if revascularization with percutaneous coronary intervention (PCI) before TAVI modified this relation. In this retrospective population-based study in Ontario, Canada, we identified all patients with obstructive CAD who underwent TAVI from April 1, 2012 to March 31, 2017. Our primary outcomes of interest were all-cause mortality within 30-day and 1-year post-TAVI procedure. Secondary outcomes included 30-day and 1-year all-cause readmissions. We developed multivariable Cox proportional hazard models, with a robust sandwich-type variance estimator to account for clustering within TAVI centers. These models included an interaction term between severity of CAD and PCI before TAVI. The study cohort included 888 of whom 444 (50%) patients underwent PCI before TAVI procedure. In the Cox models, we found that severity of CAD before TAVI was not significantly associated with post-TAVI outcomes. The only exception was 1 to 2 vessel/s disease which was a significant predictor of 1-year readmission. Pre-TAVI PCI was not significantly associated with outcomes, nor did it modify the relation between severity of CAD pre-TAVI and outcomes. In conclusion, we did not find a consistent relation between severity of CAD and revascularization with post-TAVI outcomes.


Assuntos
Doença da Artéria Coronariana/diagnóstico , Hemorragia/etiologia , Revascularização Miocárdica , Substituição da Valva Aórtica Transcateter , Disfunção Ventricular Esquerda/diagnóstico , Idoso , Causas de Morte , Estudos de Coortes , Doença da Artéria Coronariana/mortalidade , Doença da Artéria Coronariana/fisiopatologia , Correlação de Dados , Feminino , Hemorragia/mortalidade , Hemorragia/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Revascularização Miocárdica/mortalidade , Ontário , Avaliação de Processos e Resultados em Cuidados de Saúde , Estudos Retrospectivos , Fatores de Risco , Taxa de Sobrevida , Substituição da Valva Aórtica Transcateter/mortalidade , Disfunção Ventricular Esquerda/mortalidade , Disfunção Ventricular Esquerda/fisiopatologia
18.
J Korean Med Sci ; 35(4): e24, 2020 Feb 03.
Artigo em Inglês | MEDLINE | ID: mdl-31997614

RESUMO

BACKGROUND: The impact of myocardial damage on the prognosis of patients with septic shock is not clearly elucidated because complex hemodynamic changes in sepsis obscure the direct relationship. We evaluated left ventricular (LV) conditions that reflect myocardial damage independently from hemodynamic changes in septic shock and their influence on the prognosis of patients. METHODS: We retrospectively enrolled 208 adult patients who were admitted to the intensive care unit and underwent echocardiography within 7 days from the diagnosis of septic shock. Patients who were previously diagnosed with structural heart disease or coronary artery disease were excluded. Left ventricular ejection fraction (LVEF) was divided into four categories: normal, ≥ 50%; mild, ≥ 40%; moderate, ≥ 30%; and severe dysfunction, < 30%. Wall motion impairment was categorized into the following patterns: normal, diffuse, ballooning, and focal. RESULTS: There were 141 patients with normal LVEF. Among patients with impaired LV wall motion, the diffuse pattern was the most common (34 patients), followed by the ballooning pattern (26 patients). Finally, 102 patients died, and in-hospital mortality was significantly higher in patients with severe LV systolic dysfunction (hazard ratio [HR], 1.97; 95% confidence interval [CI], 1.04-3.75; P = 0.039) and in patients with diffuse pattern of LV wall motion impairment (HR, 2.28; 95% CI, 1.19-4.36; P = 0.013) than in those with a normal LV systolic function. CONCLUSION: Severe LV systolic dysfunction and diffuse pattern of LV wall motion impairment significantly affected in-hospital mortality in patients with septic shock. Conventional echocardiographic evaluation provides adequate information on the development of myocardial damage and accurately predicts the prognosis of patients with septic shock.


Assuntos
Sepse , Choque Séptico , Disfunção Ventricular Esquerda , Idoso , Ecocardiografia , Feminino , Mortalidade Hospitalar , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Prognóstico , Sepse/complicações , Sepse/mortalidade , Choque Séptico/complicações , Choque Séptico/mortalidade , Disfunção Ventricular Esquerda/complicações , Disfunção Ventricular Esquerda/diagnóstico por imagem , Disfunção Ventricular Esquerda/mortalidade , Função Ventricular Esquerda
19.
Am J Cardiol ; 125(6): 948-955, 2020 03 15.
Artigo em Inglês | MEDLINE | ID: mdl-31928719

RESUMO

Computed tomography plays a central role in the evaluation of patients with severe aortic stenosis who underwent transcatheter aortic valve implantation (TAVI). Advances in left ventricular (LV) analysis with multidetector row computed tomography (MDCT) permit measurement of LV global longitudinal strain (GLS). The present study aimed at evaluating the association between feature tracking (FT) MDCT derived LV GLS and all-cause mortality in patients treated with TAVI. A total of 214 patients with severe aortic stenosis (51% male, 80 ± 7 years) who underwent TAVI and with dynamic MDCT data allowing LV GLS measurement with novel FT algorithm were included. LV GLS was measured at baseline and were divided according to a previously published cut-off value of LV GLS associated with all-cause mortality (≤-14% [more preserved LV systolic function] vs >-14% [more impaired LV systolic function]). Patients were followed for the occurrence of all-cause mortality. Mean FT MDCT-derived LV GLS was -12.5 ± 4%. During a median follow-up of 45 months (interquartile range: 29 to 62 months), 67 (31%) patients died. The cumulative rate of all-cause mortality for the patients with FT MDCT-derived LV GLS ≤-14% was 15% versus28% for the patients with FT MDCT-derived LV GLS >-14%, Log rank p = 0.001). FT MDCT-derived LV GLS was independently associated with all-cause mortality (hazard ratio: 0.851; 95% confidence interval: 0.772 to 0.937; p = 0.001). In conclusion, impaired FT MDCT-derived LV GLS is independently associated with all-cause mortality in patients treated with TAVI. Besides aortic valve area and calcification, FT MDCT-derived LV GLS is an important prognostic marker.


Assuntos
Estenose da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/cirurgia , Tomografia Computadorizada Multidetectores , Complicações Pós-Operatórias/diagnóstico por imagem , Disfunção Ventricular Esquerda/diagnóstico por imagem , Remodelação Ventricular/fisiologia , Idoso , Idoso de 80 Anos ou mais , Estenose da Valva Aórtica/mortalidade , Causas de Morte , Feminino , Seguimentos , Ventrículos do Coração/diagnóstico por imagem , Ventrículos do Coração/fisiopatologia , Humanos , Masculino , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/fisiopatologia , Prognóstico , Disfunção Ventricular Esquerda/mortalidade , Disfunção Ventricular Esquerda/fisiopatologia
20.
Am J Cardiol ; 125(6): 916-923, 2020 03 15.
Artigo em Inglês | MEDLINE | ID: mdl-31928720

RESUMO

The pulse amplitude ratio (PAR), the ratio of pulse pressure at the end of the Valsalva maneuver to before the onset, correlates with cardiac filling pressure. We have developed a handheld device that uses finger photoplethysmography to measure PAR and estimate left ventricular end diastolic pressure (LVEDP). Patients hospitalized with heart failure (HF) performed three 10-second trials of a standardized Valsalva maneuver (at 20 mm Hg measured via pressure transducer), while photoplethysmography waveforms were recorded, at admission and discharge. Combined primary outcome was 30-day HF hospitalization, intravenous diuresis, or death. Fifty-two subjects had discharge PAR testing; 12 met the primary outcome. Median PAR on admission was 0.55 (interquartile range: 0.40 to 0.70, n = 48) and on discharge was 0.50 (interquartile range: 0.36 to 0.69). Mean PAR-estimated LVEDP was significantly higher in subjects that had an event (20.2 vs 16.9 mm Hg, p = 0.043). Subjects with PAR-estimated LVEDP >19.5 mm Hg had an event rate hazard ratio of 4.57 (95% confidence interval 1.37, 15.19, p = 0.013) compared with patients with LVEDP 19.5 mm Hg or below, with significantly lower 30-day event-free survival (log-rank p = 0.006). In conclusion, noninvasively estimated LVEDP using the pulse amplitude response to a Valsalva maneuver in patients hospitalized for HF changes with diuresis and identifies patients at high risk for 30-day HF events. Detection of elevated filling pressures before hospital discharge may be useful in guiding HF management to reduce HF events.


Assuntos
Pressão Sanguínea/fisiologia , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/fisiopatologia , Determinação da Frequência Cardíaca/instrumentação , Hospitalização/estatística & dados numéricos , Fotopletismografia/instrumentação , Manobra de Valsalva/fisiologia , Desenho de Equipamento , Insuficiência Cardíaca/mortalidade , Humanos , Intervalo Livre de Progressão , Modelos de Riscos Proporcionais , Medição de Risco , Disfunção Ventricular Esquerda/diagnóstico , Disfunção Ventricular Esquerda/mortalidade , Disfunção Ventricular Esquerda/fisiopatologia
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