Imaging systolic and diastolic heart murmurs in hypertrophic cardiomyopathy

Muscular obstruction in hypertrophic cardiomyopathy can occur not only in systole, but also in diastole. Here we report a case of hypertrophic cardiomyopathy in a middle-aged lady: echocardiography and cardiovascular magnetic resonance confirmed the diagnosis of hypertrophic cardiomyopathy with significant systolic and diastolic midventricular obstruction, corresponding to the murmurs audible in mid-systole and early-diastole respectively. Moreover, the mid-systolic murmur was clearly distinguishable from the mitral regurgitation murmur, which was audible throughout systole (pan-systolic) and likely related to systolic anterior motion of the mitral chords; similarly, the early-diastolic heart murmur due to diastolic obstruction was better audible at the apex and clearly distinguishable from common diastolic murmurs due to aortic regurgitation. Echocardiography (with Doppler recordings) and magnetic resonance (with turbulence flows at steady state free precession imaging) allowed a detailed visualization of each audible murmur (systolic obstruction, mitral regurgitation, diastolic obstruction). In particular, while systolic obstruction has been extensively studied in hypertrophic cardiomyopathy, only very few reports about diastolic obstruction exist, describing either a normodirected midventricular diastolic obstruction (forward flow) similar to this case or a paradoxical midventricular diastolic obstruction (backward flow) in patients with an apical aneurysm emptying during early diastole into the left ventricular base through a narrow midventricular channel. Whether diastolic obstruction implies worse prognosis or requires specific treatment, deserves further research

High plasma levels of exosomal miR21 and miR133a are associated with LV reverse remodelling after surgical mitral valve repair

Mitral valve regurgitation (MR) is the most common cardiac valvular disease associated with increased morbidity and mortality. Patients are characterized by volume overload and progressive increase of left ventricular (LV) end‐diastolic volume (EDV). Surgery is recommended for patients with substantial loss of global cardiac function (LV ejection fraction, LVEF). A correctly timed surgery for MR can reverse LV remodeling. Identification of patients at high risk of post‐operative LV remodeling may help to act with preventive strategies. In this scenario, microRNAs delivered by plasma exosomes (pEXOs), smallest extracellular nanovesicles, might have a predictive value. Primary MR patients (N=19; 45–71 y.o.) underwent implantation of a prosthetic mitral ring. LV remodeling was assessed by cadiac magnetic resonance imaging and pEXOs were isolated by optimized ultracentrifugation before surgery (T0) and six months after surgery (T1). Isolated pEXOs were quantified by nanoparticle tracking analysis (NanoSight) and miR‐1, miR‐21, miR‐133a and miR‐208a were measured by RT‐qPCR. The same analysis was performed healthy subjects with normal cardiac function (Control, N=8). pEXOs levels at T0 were lower (−32%, p=0.02) in patients with worst postoperative LV function, while they were higher at T1 (+31%, p=0.03) in patients with LV reverse remodeling after surgery. At T1, the increase in pEXOs levels was associated to decreased heart mass index (−13%, p=0.02) and higher levels of exosomal miR‐21 (+78%, p=0.02) and miR‐133a (+69%, p=0.05) were detected in patients with improved LV function. In conclusion, higher postoperative levels of pEXOs and exosomal miR‐21 and 133a mark LV reverse remodeling after mitral valve repair. Combined measurements of circulating exosomes and their microRNAs cargo might represent potential novel perioperative markers in patients with MR

A Prospective Randomized Trial of Thrombectomy Versus No Thrombectomy in Patients With ST-Segment Elevation Myocardial Infarction and Thrombus-Rich Lesions: MUSTELA (MUltidevice Thrombectomy in Acute ST-Segment ELevation Acute Myocardial Infarction) trial

Objectives: The aim of this study was to evaluate whether thrombectomy during primary percutaneous coronary intervention (pPCI) in patients with high thrombus burden improves myocardial reperfusion and reduces infarct size. Background: Thrombectomy aims at reducing distal thrombotic embolization during pPCI, improving myocardial reperfusion and clinical outcome. Methods: We randomized 208 patients with high thrombus burden in a 1:1 ratio to either pPCI with thrombectomy (Group T) or standard pPCI (Group S). Thrombectomy was performed with either rheolytic or manual aspiration catheters. Three-month magnetic resonance imaging was performed to assess infarct size and transmurality and microvascular obstruction (MVO). The primary endpoints were ST-segment elevation resolution (STR) >70% at 60 min and 3-month infarct size. Results: The baseline profile was similar between groups, except for a higher rate of initial Thrombolysis In Myocardial Infarction flow grade 3 in Group S (p = 0.002). Group T showed a significantly higher rate of STR (57.4% vs. 37.3%; p = 0.004) and of final myocardial blush 3 (68.3% vs. 52.9%; p = 0.03). Group T and Group S did not differ with regard to infarct size (20.4 ± 10.5% vs. 19.3 ± 10.6%; p = 0.54) and transmurality (11.9 ± 12.0% vs. 11.6 ± 12.7%; p = 0.92), but Group T showed significantly less MVO (11.4% vs. 26.7%; p = 0.02) and a higher prevalence of inhomogeneous scar (p < 0.0001). One-year freedom from major adverse cardiac events was similar between groups. Conclusions: Thrombectomy as an adjunct to pPCI in patients with high thrombus load yielded better post-procedural STR and reduced MVO at 3 months but was not associated with a reduction in infarct size and transmurality. Thromboaspiration in Patients With High Thrombotic Burden Undergoing Primary Percutaneous (Coronary Intervention; NCT01472718

Late gadolinium enhancement as a predictor of functional recovery, need for defibrillator implantation and prognosis in non-ischemic dilated cardiomyopathy

Background Aim of the study was to investigate whether late gadolinium enhancement (LGE) at cardiac magnetic resonance (CMR) predict reverse remodeling (RR) in non-ischemic dilated cardiomyopathy (NIDCM). Methods Seventy-one NIDCM patients (age 57 ± 14 years, 43 males, median left ventricular ejection fraction [LVEF] 35%, [interquartile range 27â\u80\u9341%]) with two CMR scans within 5 years were included. RR was defined as â\u89¥ 10% reduction in left ventricular (LV) end-diastolic volume and â\u89¥ 10% LVEF increase. The end-point was a composite of all-cause death, cardiovascular hospitalization or appropriate defibrillator discharge. LGE was assessed both visually and as percentage of LV mass (LGE%). Results LGE was present in 42 patients (59%). During the interval between the 2 CMR scans (median 28 [15â\u80\u9344] months), 22 patients (31%) displayed RR. LGE absence predicted RR irrespectively of baseline LV volumes and LVEF. Over a median 42[15â\u80\u9373]-month follow-up, the endpoint occurred in 36 patients (51%). LGE absence was associated with better prognosis (P = 0.043), with best quantitative LGE cut-point < 7% at ROC analysis (P = 0.017), but RR was the strongest prognostic predictor. Among 35 patients with baseline LVEF < 35%, 25 (69%) crossed the 35% LVEF threshold. Both LGE absence and quantitative LGE < 7% were associated with crossing of the 35% LVEF threshold for defibrillator implantation; patients with either LGE or quantitative LGE â\u89¥ 7% had a worse prognosis. Conclusions In NIDCM, the absence of LGE at baseline CMR is associated with RR. When baseline LVEF is < 35%, LGE absence is associated with more frequent crossing of the 35% LVEF threshold for defibrillator implantation

Regional evidence of modulation of cardiac adiponectin level in dilated cardiomyopathy: pilot study in a porcine animal model

<p>Abstract</p> <p>Background</p> <p>The role of systemic and myocardial adiponectin (ADN) in dilated cardiomyopathy is still debated. We tested the regulation of both systemic and myocardial ADN and the relationship with AMP-activated protein kinase (AMPK) activity in a swine model of non-ischemic dilated cardiomyopathy.</p> <p>Methods and results</p> <p>Cardiac tissue was collected from seven instrumented adult male minipigs by pacing the left ventricular (LV) free wall (180 beats/min, 3 weeks), both from pacing (PS) and opposite sites (OS), and from five controls. Circulating ADN levels were inversely related to global and regional cardiac function. Myocardial ADN in PS was down-regulated compared to control (p < 0.05), yet ADN receptor 1 was significantly up-regulated (p < 0.05). No modifications of AMPK were observed in either region of the failing heart. Similarly, myocardial mRNA levels of PPARγ, PPARα, TNFα, iNOS were unchanged compared to controls.</p> <p>Conclusions</p> <p>Paradoxically, circulating ADN did not show any cardioprotective effect, confirming its role as negative prognostic biomarker of heart failure. Myocardial ADN was reduced in PS compared to control in an AMPK-independent fashion, suggesting the occurrence of novel mechanisms by which reduced cardiac ADN levels may regionally mediate the decline of cardiac function.</p