Effect of left ventricular geometric remodeling on restrictive filling pattern and survival in ischemic cardiomyopathy

Background: To evaluate the effects of Left ventricular remodeling patterns in patients with left ventricular restrictive filling pattern (RFP; E/A>2) in ischemic cardiomyopathy (ICM) on prognosis. Methods: Patient data was retrospectively analyzed over a period of 4.5 years to determine the effect of LV geometry by Echocardiographic parameterson survival and re-admission for heart failure. All patients with previous history of transmural myocardial infarction were studied and all were on guideline directed medical therapy. None underwent device therapy or surgery. The stored 2D Echocardiograms were studied. Left ventricular dimensions were noted, including the relative wall thickness (RWT). The patients were grouped based on RWT<0.34 and _x0001_ 0.34 and were compared for clinical outcomes of mortality and re-admissions for heart failure, over a period of 54 months. Results: There were 102 ICM patients who had baseline RFP. We identified two sub-groups based on geometric phenotypes of left ventricular eccentric remodeling and dilated remodeling based on the relative wall thickness (RWT >0.34 or <0.34). The patients with preserved RWT had significantly more dilated ventricles (LVIDd and LVIDs), greater pulmonary artery systolic pressures (PASP), greater diatolic dysfunction (E/A) and less left ventricular ejection fraction (LVEF); p < 0.001. The number of deaths was higher in the reduced RWT patients, as were the number of re-admissions, although the time to survival and time to re-admission was not significant. Conclusions: In this pilot study on ICM patients in advanced heart failure with baseline RFP, the presence of preserved RWT indicative of eccentric remodelling demonstrated a better clinical outcome

Image-Based Simulative Training for Myectomy in Hypertrophic Cardiomyopathy: An Emerging Necessity

Surgical myectomy was initially advocated only for patients with symptoms refractory to maximal tolerated medical therapy. These were mainly symptoms of cardiac failure. In recent times, there has been a call for revision of guidelines to include patients earlier. As the disease progression cannot be reversed by most currently used drugs which become ineffective with time, this need for earlier myectomy seems mandatory. Presently, surgical expertise in myectomy is limited to specialized centers. The complexity of surgical myectomy is enhanced by the complex and variable anatomic substrate. With the need for earlier myectomy, a vast population of patients with hypertrophic cardiomyopathy will need surgery, predicating a requirement for more skilled cardiac surgeons. Mentoring programs in specialized centers may not be the solution, as is training surgeons using image-guided simulation techniques. Here, we discuss the existing simulative techniques and novel image-based preoperative planning techniques which may help guide myectomy.

Use of coronary hardware in peripheral vascular interventions: Necessity fostered ingenuity-Is it solution enough?

In third world countries like India, where there is a paucity of dedicated interventional radiologists and training fellowships in peripheral interventions, it is the onus of the cardiologist to perform peripheral interventions. This coupled with logistic constraints of unavailability of medical insurance for majority of the population, makes it necessary to modify coronary hardware for use in peripheral interventions. Here, we discuss the modifications and simplifications performed to ensure optimal quality of clinical outcomes.

Impact of left ventricular function on early outcomes after arterial switch for D-transposition of great arteries with intact ventricular septum.

OBJECTIVE: The aim of this study was to assess the utility of tissue Doppler echocardiography in evaluating the pre-operative left ventricular systolic function and in turn its impact on early post-operative outcomes following arterial switch operation for transposition of great arteries with intact ventricular septum. BACKGROUND: Pre-operative left ventricular function is an important determinant of outcomes following arterial switch. METHODS: We studied 19 patients with transposition and intact septum who had undergone one stage arterial switch operation. All had a pre-operative echocardiogram. RESULTS: The left ventricle was adequate in 15 infants as per the dimensions and shape for age. The early outcomes of surgery were assessed on the basis of their pre operative tissue Doppler. There were 7 (40%) patients with reduced S wave velocities (2.62 +/- 0.84 cm/sec) and lower isovolumetric myocardial acceleration (1.2 +/- 0.5 m/sec(2)) reflecting systolic dysfunction. Those patients with reduced S wave velocities and isovolumetric acceleration correlated with poor early surgical outcomes in terms of longer duration of ventilation ( p< 0.001), longer duration of inotropes ( p< 0.00001) and higher mortality ( p < 0.001). CONCLUSION: The tissue Doppler echocardiography is a more sensitive modality to evaluate ventricular performance than the 2D-echo. It can be used as a sensitive predictor of outcomes following arterial switch.

Echocardiographic evaluation of the morphology and function of the right ventricle in Eisenmenger's syndrome and idiopathic pulmonary hypertension.

AIM: The aim of this study was to investigate the reasons for better prognosis in adults with Eisenmenger's syndrome than those suffering from idiopathic pulmonary hypertension. Our hypothesis was that right ventricular function is better preserved in the former case than in the latter. METHODS: We used two-dimensional echocardiography and tissue Doppler imaging to compare right ventricular morphology and function in 24 subjects with Eisenmenger's syndrome and 23 age- and sex-matched subjects with idiopathic pulmonary hypertension. RESULTS: The mean age was 27.4+/-12.2 years for both groups. There were more patients from the idiopathic pulmonary hypertension group in the New York Heart Association Class III than those from the Eisenmenger's syndrome group (48.4% vs 36.3%; p<0.01). Measurements of the right and left ventricular free wall thickness, as well as the internal diameter of the right ventricle were taken, and tissue Doppler imaging was used to assess the function of both ventricles. In the Eisenmenger's group, the mean right ventricular and left ventricular free wall thickness was 10.4+/-2.78 mm and 9.7+/-1.98 mm, respectively. The mean right ventricular internal diameter in diastole and in systole were 20+/-8.64 mm and 18.1+/-9.24 mm, respectively. The mean right ventricular S1 was 10.4+/-3.4 cm/sec and S2, 10.3+/-2.6 cm/sec, while the left ventricular S1 was 7.4+/-1.87 cm/s and S2, 7.5+/-1.05 cm/sec, with a normal biventricular function. In the idiopathic pulmonary hypertension group, the mean right ventricular and left ventricular free wall thickness was 11.3+/-3.24 mm and 9.8+/-1.94 mm, respectively. The mean right ventricular internal diameter in diastole and systole was 36+/-8.9 mm and 30.1+/-9.8 mm, respectively. The mean right ventricular S1 was 6.9+/-3.4 cm/sec and S2, 6.8+/-2.8 cm/sec, while the left ventricular S1 was 7.4+/-1.8 cm/sec and S2, 7.5+/-1.05 cm/sec, reflecting right ventricular systolic dysfunction. CONCLUSIONS: Right ventricular function was better preserved among subjects with Eisenmenger's syndrome than those with idiopathic pulmonary hypertension in a study in which the two groups were matched for age and sex.