Electrocardiographic diagnosis of the left ventricular hypertrophy in patients with left bundle branch block: Is it necessary to verify old criteria?

Background: The diagnosis of left ventricular hypertrophy (LVH) in the presence of the left bundle branch block (LBBB) is difficult. In our study we compared commonly used ECG criteria with left ventricular mass index (LVMI) calculated during cardiac magnetic resonance imaging (CMRI) to verify their clinical value or the need to recalibrate. Methods: CMRI and ECG data of 36 patients were included in this study. Based on the ECG measures we used in our study selected ECG criteria for LVH detection in cases with LBBB: QRS duration, amplitude of S waves in V1, V2, V3; R waves in aVL, V5, V6 and combinations of amplitudes. LVH was defined as LVMI (CMRI) exceeding reference values. Results: LVH was diagnosed in 17 (47%) patients (6 women and 11 men). Following ECG parameters correlated the most prominently with LVMI — RV5: r = 0.5 (p = 0.002), RV6: r = 0.61 (p = 0.0001), SV1+RV5, 6: r = 0.64 (p = 0.001), RaVL+SV3: r = 0.5 (p = 0.002), SV2+RV5, 6: r = 0.71 (p = 0.0001), SV2, 3+RV5, 6: r = 0.75 (p = 0.0001). Based on the results of ROC analysis we proposed new cut points for LVH parameters. The highest diagnostic accuracy achieved S2+SV3 > 6 mV, SV2,V3+RV5,V6 > 4 mV, RaVL+SV3 > 3.5 mV (86–89%). Conclusions: In patients with LBBB the ECG parameters based on the amplitude of S wave in V2 or V3 and R wave in the leads aVL, V5, V6 have the highest clinical value in the prediction of the LVH determined by CMRI. It was necessary to recalibrate these parameters and it is needed to verify them in larger number of LBBB patients

The impact of pulmonary regurgitation on right ventricular size and function in patients with repaired tetralogy of Fallot and additional haemodynamic abnormalities

Purpose: Right ventricular (RV) outflow tract obstruction (RVOTO) was demonstrated to be protective against RV dilatation in patients with repaired tetralogy of Fallot and chronic pulmonary regurgitation (PR). We hypothesised that the presence of additional haemodynamic abnormalities (more than mild tricuspid regurgitation, residual ventricular septal defect) reduces this protective association. Accordingly, we aimed to assess the impact of PR on RV size and function in this population. Material and methods: Consecutive patients with additional haemodynamic abnormalities after tetralogy of Fallot (TOF) repair, who had undergone cardiovascular magnetic resonance, were included. Results: Out of 90 patients studied, 18 individuals (mean age 32.5 ± 10.7 years, 72.2% males) met the inclusion criteria. There were no differences in RV volumes and ejection fraction between patients with and without RVOTO. Neither PR fraction (PRF) nor PR volume (PRV) correlated with RV end-diastolic volume (r = 0.36; p = 0.15 and r = 0.37; p = 0.14, respectively, for PRF and PRV) or RV end-systolic volume (r = 0.2; p = 0.42 and r = 0.19; p = 0.45, respectively, for PRF and PRV). Similarly, no significant correlations were observed between PRF or PRV and RV ejection fraction (r = –0.04; p = 0.87 and r = –0.03; p = 0.9, respectively). Conclusions: Additional haemodynamic abnormalities are associated with the abolition of the protective effect of RVOTO on RV size. There was no significant relationship between measures of PR and RV volumes in patients after TOF repair with concomitant haemodynamic abnormalities. These abnormalities acted as confounding factors in the assessment of the impact of pulmonary regurgitation on RV size and function

Influence of percutaneous pulmonary valve implantation on exercise capacity: Which group of patients benefits most from the intervention?

Background: The aim of the study was to evaluate the role of cardiopulmonary exercise testing (CPET) parameters in assessing exercise capacity improvement after percutaneous pulmonary valve implantation (PPVI). Additionally, it aimed to determine if there are any baseline characteristics influencing that change. Methods and results: The study comprised 32 patients (mean age 26 ± 9); 53% males; diagnosis: tetralogy of Fallot (n = 18), pulmonary atresia (n = 6), Ross procedure (n = 4), other (transposition of great arteries, pulmonary stenosis, double outlet right ventricle, common arterial trunk type II — n = 4) who underwent successful PPVI due to right ventricular out­flow tract dysfunction (predominant pulmonary regurgitation — n = 17, predominant pulmo­nary stenosis — n = 15). Treadmill CPET was performed before and a year after PPVI along with clinical evaluation, cardiac magnetic resonance and transthoracic echocardiography. Twelve months post successful PPVI (pulmonary valve competence restoration and pulmonary gradient reduction from 58.8 ± 47.1 to 26.6 ± 10.8 mm Hg) there was a significant decrease in the ventilatory equivalent for CO2 at peak exercise (EQCO2) (25.3 ± 3.3 to 24.3 ± 3.0, p = 0.04) and oxygen consumption at peak exercise (pVO2) (20.4 ± 5.0 to 22.6 ± 5.3 mL/kg/min, p = 0.04). Improved EQCO2 correlated with an increase in right and left ventricular ejection fraction (respectively R = –0.57, p = 0.002; R = –0.56, p = 0.002). In this study, no baseline factors that might affect improvement in exercise function were found. Conclusions: Successful PPVI leads to an improvement in exercise capacity and hemodynamic response to exercise. The correlation between the improvement in EQCO2 or peak VO2 and baseline characteristics was too weak to reliably identify the group of patients that will benefit from the procedur

Late percutaneous coronary intervention for an occluded infarct-related artery in patients with preserved infarct zone viability: A pooled analysis of cardiovascular magnetic resonance studies

Background: The results of clinical trials assessing the effect of late opening of infarct-related artery (IRA) on left ventricular ejection fraction (LVEF) and size in stable patients are equivocal, which may be related to the fact that the presence of viability was not a requirement for randomization in these trials. The aim of the study was to assess the influence of late percutaneous coronary intervention (PCI) with optimal medical therapy (OMT) vs. OMT alone on cardiac function and remodeling in patients presenting infarct zone with preserved viability on cardiovascular magnetic resonance (CMR).Methods: The analysis included pooled data of 43 patients from 3 randomized studies. All patients underwent CMR before randomization, but only in 1 previously unpublished study was preserved viability required for randomization to treatment. Follow-up CMR was performed after 6–12 months.Results: Late PCI with OMT led to improved LVEF (+5 ± 7% vs. –1 ± 6%, p = 0.005), decreased left ventricular end-systolic volume (–11 ± 19 mL vs. 12 ± 40 mL, p = 0.02) and a trend towards a decrease in end-diastolic volume (–7 ± 27 mL vs. 15 ± 47 mL, p = 0.07) in comparison to OMT alone. Increased LVEF and decreased left ventricular volumes were observed after the analysis was restricted to patients with left anterior descending artery (LAD) occlusion.Conclusions: In patients with the presence of infarct zone viability, OMT with late PCI for an occluded IRA (particularly LAD) is associated with improvement of left ventricular systolic function and size over OMT alone

Reduction of left ventricular mass, left atrial size, and N-terminal pro–B-type natriuretic peptide level following alcohol septal ablation in patients with hypertrophic obstructive cardiomyopathy

Background: Alcohol septal ablation (ASA) is an alternative to surgical treatment in patients with hypertrophic obstructive cardiomyopathy (HOCM). Through alcohol-induced necrosis, ASA leads to an increase in left ventricular outflow tract (LVOT) diameter and a decrease in LVOT pressure gradient. Aims: We sought to assess the effect of ASA on left ventricular (LV) wall thickness and mass, left atrial (LA) size, and N-terminal pro–B-type natriuretic peptide (NT-proBNP) level. Methods: The study cohort consisted of 50 patients with HOCM (30 in the ASA group, 20 in the optimal pharmacotherapy group [OPG]). Transthoracic echocardiography (TTE), cardiac magnetic resonance (CMR), and NT-proBNP level analysis were performed at baseline and at six months. Results: All parameters are presented as means. In the ASA group, the maximal LVOT pressure gradient decreased from 122.7 to 54.8 mmHg directly after ASA and to 37.2 mmHg after a further six months (p < 0.0001). The NT-proBNP level decreased from 2174.4 to 1103.4 pg/mL (p < 0.001). On TTE, the interventricular septum (IVS) thickness decreased to from 23.6 to 19.4 mm (p < 0.0001) and the lateral wall (LW) thickness decreased from 15.9 to 14.2 mm (p < 0.007). On CMR, basal IVS thickness decreased from 23.7 to 18.0 mm (p < 0.0001) and the LW thickness decreased from 13.2 to 12.2 mm (p = 0.02). IVS mass reduced from 108.9 to 91.5 g (–16%; p < 0.001). All of the above parameters remained unchanged in the OPG. Conclusions: Successful ASA reduces LV hypertrophy and improves parameters of the LV overload, resulting in LV wall hy­pertrophy regression, and LA size and NT-proBNP level reduction. The above parameters may be as useful in assessing the efficacy of ASA as the LVOT gradient itself