insights on the right ventricle. A cardiovascular magnetic resonance study

OBJECTIVES Pectus excavatum (PE) is often regarded as a cosmetic disease, while its effect on cardiac function is under debate. Data regarding cardiac function before and after surgical correction of PE are limited. We aimed to assess the impact of surgical correction of PE on cardiac function by cardiovascular magnetic resonance (CMR). METHODS CMR at 1.5 T was performed in 38 patients (mean age 21 ± 8.3; 31 men) before and after surgical correction to evaluate thoracic morphology, indices and its relation to three-dimensional left and right ventricular cardiac function. RESULTS Surgery was successful in all patients as shown by the Haller Index ratio of maximum transverse diameter of the chest wall and minimum sternovertebral distance [pre: 9.64 (95% CI 8.18–11.11) vs post: 3.0 (2.84–3.16), P < 0.0001]. Right ventricular ejection fraction (RVEF) was reduced before surgery and improved significantly at the 1-year follow-up [pre: 45.7% (43.9–47.4%) vs 48.3% (46.9–49.5%), P = 0.0004]. Left ventricular ejection fraction was normal before surgery, but showed a further improvement after 1 year [pre: 61.0% (59.3–62.7%) vs 62.7% (61.3–64.2%), P = 0.0165]. Cardiac compression and the asymmetry index changed directly after surgery and were stable at the 1-year follow-up [3.93 (3.53–4.33) vs 2.08 (1.98–2.19) and 2.36 (2.12–2.59) vs 1.38 (1.33–1.44), respectively; P < 0.0001 for both]. None of the obtained thoracic indices were predictors of the improvement of cardiac function. A reduced preoperative RVEF was predictive of RVEF improvement. CONCLUSIONS PE is associated with reduced RVEF, which improves after surgical correction. CMR has the capability of offering additional information prior to surgical correction

results of the prospective observational Berlin Beat of Running study

Objectives: While regular physical exercise has many health benefits, strenuous physical exercise may have a negative impact on cardiac function. The ‘Berlin Beat of Running’ study focused on feasibility and diagnostic value of continuous ECG monitoring in recreational endurance athletes during a marathon race. We hypothesised that cardiac arrhythmias and especially atrial fibrillation are frequently found in a cohort of recreational endurance athletes. The main secondary hypothesis was that pathological laboratory findings in these athletes are (in part) associated with cardiac arrhythmias. Design: Prospective observational cohort study including healthy volunteers. Setting and participants: One hundred and nine experienced marathon runners wore a portable ECG recorder during a marathon race in Berlin, Germany. Athletes underwent blood tests 2–3 days prior, directly after and 1–2 days after the race. Results: Overall, 108 athletes (median 48 years (IQR 45–53), 24% women) completed the marathon in 249±43 min. Blinded ECG analysis revealed abnormal findings during the marathon in 18 (16.8%) athletes. Ten (9.3%) athletes had at least one episode of non-sustained ventricular tachycardia, one of whom had atrial fibrillation; eight (7.5%) individuals showed transient ST-T-segment deviations. Abnormal ECG findings were associated with advanced age (OR 1.11 per year, 95% CI 1.01 to 1.23), while sex and cardiovascular risk profile had no impact. Directly after the race, high-sensitive troponin T was elevated in 18 (16.7%) athletes and associated with ST-T-segment deviation (OR 9.9, 95% CI 1.9 to 51.5), while age, sex and cardiovascular risk profile had no impact. Conclusions: ECG monitoring during a marathon is feasible. Abnormal ECG findings were present in every sixth athlete. Exercise-induced transient ST-T-segment deviations were associated with elevated high-sensitive troponin T (hsTnT) values. Trial registration: ClinicalTrials.gov NCT01428778; Results

Titration to target dose of bisoprolol vs. carvedilol in elderly patients with heart failure: the CIBIS-ELD trial

AIMS: Various beta-blockers with distinct pharmacological profiles are approved in heart failure, yet they remain underused and underdosed. Although potentially of major public health importance, whether one agent is superior in terms of tolerability and optimal dosing has not been investigated. The aim of this study was therefore to compare the tolerability and clinical effects of two proven beta-blockers in elderly patients with heart failure. METHODS AND RESULTS: We performed a double-blind superiority trial of bisoprolol vs. carvedilol in 883 elderly heart failure patients with reduced or preserved left ventricular ejection fraction in 41 European centres. The primary endpoint was tolerability, defined as reaching and maintaining guideline-recommended target doses after 12 weeks treatment. Adverse events and clinical parameters of patient status were secondary endpoints. None of the beta-blockers was superior with regards to tolerability: 24% [95% confidence interval (CI) 20-28] of patients in the bisoprolol arm and 25% (95% CI 21-29) of patients in the carvedilol arm achieved the primary endpoint (P= 0.64). The use of bisoprolol resulted in greater reduction of heart rate (adjusted mean difference 2.1 b.p.m., 95% CI 0.5-3.6, P= 0.008) and more, dose-limiting, bradycardic adverse events (16 vs. 11%; P= 0.02). The use of carvedilol led to a reduction of forced expiratory volume (adjusted mean difference 50 mL, 95% CI 4-95, P= 0.03) and more, non-dose-limiting, pulmonary adverse events (10 vs. 4%; P < 0.001). CONCLUSION: Overall tolerability to target doses was comparable. The pattern of intolerance, however, was different: bradycardia occurred more often in the bisoprolol group, whereas pulmonary adverse events occurred more often in the carvedilol group. This study is registered with controlled-trials.com, number ISRCTN34827306

Heart Rate Turbulence and Heart Rate Variability in elderly patients with systolic and diastolic heart failure

Ziel der Arbeit war die Heart Rate Turbulence (HRT), ein starker Risikoprädiktor bei Postinfarktpatienten, erstmalig gesondert an einem älteren Patientenkollektiv zu erheben und zusammen mit einer Serie von etablierten Parametern im Zusammenhang mit der Art der Herzinsuffizienz gegen ein gesundes Kontrollkollektiv zu vergleichen. Methoden: Bei Patienten höheren Lebensalters (>65 J) mit systolischer (n=33) oder diastolischer (n=40) Herzinsuffizienz sowie bei gesunden Probanden (n=26) wurde eine körperliche Untersuchung, ein 6 -Minuten-Gehtest, ein 12-Kanal-Ruhe-EKG, ein 24-Stunden-12-Kanal-LZ-EKG und eine echokardiographische Untersuchung durchgeführt. Für die Untersuchung, ob abnorme HRT-Parameter diejenigen Patienten identifizieren können, die ein erhöhtes Risiko für schwerwiegende ventrikuläre Ereignisse haben, wurde das Patientenkollektiv in Abhängigkeit von An- oder Abwesenheit nichtanhaltender ventrikulärer Tachykardien (nsVT) im Aufnahme-LZ-EKG (definiert als >4 aufeinander folgende VPB, RR-Intervall ≤400ms) in zwei Gruppen eingeteilt. Ergebnisse: Das mittlere Alter der Untersuchten betrug 73±6 Jahre für Patienten mit diastolischer Herzinsuffizienz, 72±6 Jahre für diejenigen mit systolischer Herzinsuffizienz und 70±4 Jahre für die herzgesunde Kontrollpopulation (p=ns). Die mittlere linksventrikuläre Pumpfunktion betrug 60,2±7%; 38,7±8% und 64,5±6% entsprechend den drei oben genannten Gruppen. Von den HRT-Werten zeigte sich der Turbulence slope (TS) signifikant abgeschwächt bei Patienten mit systolischer Herzinsuffizienz (4,5±4 ms/RRI, p<0,001) im Vergleich zu denjenigen mit diastolischer Herzinsuffizienz (9,5±8 ms/RRI) und zur Kontrollpopulation (11,4±8 mm/RRI). Außerdem konnte eine positive Korrelation mit der linksventrikulären Auswurffraktion (r= 0,30 p<0,05) und den SDANN-Werten (r=0,42, p<0,001) nachgewiesen werden. Im Gegensatz dazu waren die Verhältnisse des Turbulence onset (TO) sowohl zwischen den Gruppen, als auch zu anderen elektrokardiographischen und echokardiographischen Parametern nicht signifikant unterschiedlich. Des Weiteren zeigten sich die TS-Werte signifikant niedriger bei Patienten mit nsVT im Vergleich zu denjenigen ohne dieses Ereignis im LZ-EKG (2,9±2,2 vs. 7,8±7; p <0,001). Hinsichtlich des TO zeigte sich eine nur leichte Tendenz zu erhöhten Werten bei Patienten mit nsVT im Vergleich zu denjenigen ohne nsVT (0,5±2,5% vs -1,3±2,5% p=ns). Eine Kombination beider pathologischer HRT-Werte war mit erhöhtem Risiko für das Auftreten schwerwiegender ventrikulärer Ereignisse assoziiert. Bei der Hälfte der Patienten mit der oben genannten Kombination traten nichtanhaltende ventrikuläre Tachykardien auf, was sich im Vergleich mit anderen HRT-Gruppen als signifikant erwies (p<0,01 für den χ²-Test). Hieraus wird ersichtlich, dass eine Erhebung der HRT-Parameter auch bei Patienten im fortgeschrittenen Alter zur Identifizierung derjenigen mit erhöhtem Risiko für schwerwiegende ventrikuläre Ereignisse einen Nutzen bringen kann. Es ist denkbar, dass auch ältere Patientenkollektive von einer Erhebung der HRT-Parameter (besonders des TS) bezüglich Therapiewahl, Risikostratifizierung und Prognosestellung profitieren können.Aim: The aim of this study was to evaluate heart rate turbulence (HRT) in elderly heart failure (HF) patients with systolic or diastolic HF and in comparison with coeval healthy individuals. Methods: In patients with systolic HF (n=33) and diastolic HF (n=40), and healthy volunteers (n=26) aged ≥ 65 years, clinical examination, 6-min-walking test, transthoracal echocardiography, 12-lead surface electrocardiography (ECG) and 24-hour 12-lead electrocardiography were performed. To investigate whether HRT can predict ventricular arrhythmias, patients were divided into two groups by presence or absence of ventricular tachycardia (VT) (>4 consecutive VPB, RR≤ 400ms) documented during baseline Holter examination. Results: Mean age of patients with diastolic HF, systolic HF and healthy volounters was 73±6y, 72±6y, and 70±4y, respectively. Mean left ventricular ejection fraction was 60,2±7%, 38,7±8%, and 64,5±6%, respectively. HRT values and especially turbulence slope (TS) were significantly blunted in patients with systolic HF (4,49±3,46ms/RRI, p<0,001) compared to patients with diastolic HF (9,53±8,25ms/RRI) and healthy controls (11,4±8,02mm/RRI), and also correlated positively with left ventricular ejection fraction (r= 0,30 p<0,05) and SDANN values (r=0,42, p<0,001). In contrast, no significant differences or correlations were found among the three groups between turbulence onset (TO) and other echocardiographic or electrocardiographic parameters. TS was also significantly blunted in patients with non-sustained VT compared to patients without non-sustained VT in baseline Holter examination (2,9±2,2 vs 7,8±7; p <0,001). TO showed only a slight tendency to higher values in patients with non-sustained VT in comparison to patients without non-sustained VT (0,5±2,5% vs -1,3±2,5% p=ns), and patients with both, pathological TS and TO, presented more often with non-sustained VT (50%) than the other groups (p<0.01 for χ² test). Conclusions: TS was significantly reduced in elderly patients with systolic heart failure compared to patients with diastolic heart failure and healthy volunteers, and significantly correlated with echocardiographic and electrocardiographic parameters. There was no difference between the groups in other parameters and no correlations with TO. It appears that pathological TS, together with pathological TO, identify patients with an increased risk for ventricular arrhythmia. These results emphasize the importance of the physiological properties of HRT when using it for risk stratification, especially in elderly patients

Assessment of diastolic dysfunction: comparison of different cardiovascular magnetic resonance techniques.

AIMS Heart failure with preserved ejection fraction is still a diagnostic and therapeutic challenge, and accurate non-invasive diagnosis of left ventricular (LV) diastolic dysfunction (DD) remains difficult. The current study aimed at identifying the most informative cardiovascular magnetic resonance (CMR) parameters for the assessment of LVDD. METHODS AND RESULTS We prospectively included 50 patients and classified them into three groups: with DD (DD+, n = 15), without (DD-, n = 26), and uncertain (DD±, n = 9). Diagnosis of DD was based on echocardiographic E/E', invasive LV end-diastolic pressure, and N-terminal pro-brain natriuretic peptide. CMR was performed at 1.5 T to assess LV and left atrial (LA) morphology, LV diastolic strain rate (SR) by tissue tracking and tagging, myocardial peak velocities by tissue phase mapping, and transmitral inflow profile using phase contrast techniques. Statistics were performed only on definitive DD+ and DD- (total number 41). DD+ showed enlarged LA with LA end-diastolic volume/height performing best to identify DD+ with a cut-off value of ≥0.52 mL/cm (sensitivity = 0.71, specificity = 0.84, and area under the receiver operating characteristic curve = 0.75). DD+ showed significantly reduced radial (inferolateral E peak: DD-: -14.5 ± 6.5%/s vs. DD+: -10.9 ± 5.9%/s, P = 0.04; anterolateral A peak: DD-: -4.2 ± 1.6%/s vs. DD+: -3.1 ± 1.4%/s, P = 0.04) and circumferential (inferolateral A peak: DD-: 3.8 ± 1.2%/s vs. DD+: 2.8 ± 0.8%/s, P = 0.007; anterolateral A peak: DD-: 3.5 ± 1.2%/s vs. DD+: 2.5 ± 0.8%/s, P = 0.048) SR in the basal lateral wall assessed by tissue tracking. In the same segments, DD+ showed lower peak myocardial velocity by tissue phase mapping (inferolateral radial peak: DD-: -3.6 ± 0.7 ms vs. DD+: -2.8 ± 1.0 ms, P = 0.017; anterolateral longitudinal peak: DD-: -5.0 ± 1.8 ms vs. DD+: -3.4 ± 1.4 ms, P = 0.006). Tagging revealed reduced global longitudinal SR in DD+ (DD-: 45.8 ± 12.0%/s vs. DD+: 34.8 ± 9.2%/s, P = 0.022). Global circumferential and radial SR by tissue tracking and tagging, LV morphology, and transmitral flow did not differ between DD+ and DD-. CONCLUSIONS Left atrial size and regional quantitative myocardial deformation applying CMR identified best patients with DD

HCM patient with myocardial crypts in the anteroseptal region.

<p>Upper row: 3-chamber view with different techniques, Bottom row: short axis view using the same techniques, A and B CINE images at 3.0T, C and D Late Gadolinium Enhancement at 3.0T, E and F CINE images at 7.0T, G and H CINE images at 1.5 T CMR, I and J Fat-Water images, Single arrows indicates LGE at 3.0T, Double arrow displays myocardial crypt at 7.0T.</p

Feasibility of CMR in HCM patients at 7.0T.

<p>High Resolution CINE images of each patient (slice thickness 2.5 mm) All images were evaluable as shown by these two-chamber views, but the quality scoring revealed differences. A-H) Examples with a good images quality and mild artifacts. I-M) Images with different types of artifacts</p

Distribution and prevalence of fibrosis and crypts.

<p>Myocardial crypts were only located in the regions with fibrosis as identified by LGE at 3.0T</p

Comparison of left ventricular function between the different field strengths.

<p>The comparison of left ventricular function revealed no ignificant differences between the field strengths, Top: Left ventricular function at 3.0 T (biplanar versus short axis). Bottom: Left ventricular function at 7.0 T compared to 3.0 T (both biplanar).</p