Frank van Buuren

Alcohol septal ablation in patients with hypertrophic obstructive cardiomyopathy: low incidence of sudden cardiac death and reduced risk profile

Background The infarction induced by alcohol septal ablation (ASA) may predispose to arrhythmia and sudden cardiac death (SCD). Objective To assess survival, incidence of SCD after ASA and effects of ASA on the traditional risk factors (RFs) for SCD. Design An observational cohort-study (follow-up 8.4±4 years). Setting A dual-centre cohort. Patients 470 consecutive patients (age 56±14 years) with obstructive hypertrophic cardiomyopathy (HCM) (1996–2010). Interventions Clinically applied echo-contrast-guided ASA treatments. Main outcome measures All-cause mortality, SCD and RFs for SCD before and after ASA. Results The 10-year survival was 88% (annual all-cause death rate 1.2%) after ASA compared with 84% (p=0.06) in a matched background population. The 10-year survival free of SCD was 95% (annual SCD rate 0.5%). ASA reduced the prevalence of abnormal blood pressure response (from 23% to 9%, p<0.001), syncope (26% to 2%, p<0.001), non-sustained ventricular tachycardia (NSVT) (23% to 17%, p<0.05) and maximal wall thickness ≥30 mm (7% to 2%, p<0.001). There was a family history of SCD in 19% of the patients. The proportion of patients at high risk—that is, two or more RFs (n=89), was reduced from 25% to 8% (p<0.001). A RF score ≥2 before ASA was not associated with SCD (n=361, p=0.31). Conclusions Survival in ASA-treated patients was similar to that in the background population. The number of RFs, including the prevalence of NSVT, was markedly reduced by ASA and the incidence of SCD was correspondingly low. Thus, clinically applied ASA was safe.

Myocardial fibrosis severity on cardiac magnetic resonance imaging predicts sustained arrhythmic events in hypertrophic cardiomyopathy.

BACKGROUND The purpose of our study was to correlate the incidence of adequate implantable cardioverter-defibrillator (ICD) interventions in hypertrophic cardiomyopathy (HCM) patients with risk markers (RMs) for sudden cardiac death (SCD) plus myocardial fibrosis as detected by late gadolinium-enhanced cardiac magnetic resonance (LGE-CMR) imaging. METHODS In all, 87 patients with HCM underwent LGE-CMR imaging prior to ICD implantation, performed for secondary (n = 2; 2%) or primary SCD prophylaxis (n = 85; 98%). Fibrosis was graded with a 17-segment left ventricular model (0 = absent, 1 = point-shaped, 2 = limited to 1 left ventricular segment, 3 = involving ≥ 2 segments). During follow-up, ICD memories were read out by a physician blinded to the individual patient data. RESULTS The number of RMs per patient was 1.9 ± 0.8. Myocardial fibrosis was present in 78 patients (90%); 26 (30%) had a fibrosis score of 3. During follow-up (3.5 ± 2.6 [range, 0.2-11.4 years]), 15 patients had 50 appropriate ICD interventions. Episodes of atrial fibrillation were found in 28 patients. Fibrosis severity correlated with occurrence of ventricular tachycardia (Cramérs V, or φc = 0.4, P < 0.001) and atrial fibrillation (φc = 0.6, P < 0.001). On multivariate regression analysis, an independent association between myocardial fibrosis (ß = 0.6, P < 0.01) and sustained ventricular tachycardia was found. CONCLUSIONS In HCM patients treated with ICD implantation because of a high SCD risk by traditional RM assessment, a high rate of arrhythmic events was observed during long-term follow-up. In a cohort of patients with clinical markers for high risk of SCD, severity of myocardial fibrosis as detected by an easy LGE-CMR scoring system was associated with future arrhythmic events and appropriate ICD therapies.

Consensus document regarding cardiovascular safety at sports arenas

Mass gathering events in sports arenas create challenges regarding the cardiovascular safety of both athletes and spectators. A comprehensive medical action plan, to ensure properly applied cardiopulmonary resuscitation, and wide availability and use of automated external defibrillators (AEDs), is essential to improving survival from sudden cardiac arrest at sporting events. This paper outlines minimum standards for cardiovascular care to assist in the planning of mass gathering sports events across Europe with the intention of local adaptation at individual sports arenas, to ensure the full implementation of the chain of survival.

Recommendations for the management of individuals with acquired valvular heart diseases who are involved in leisure-time physical activities or competitive sports:

Physical check-ups among athletes with valvular heart disease are of significant relevance. In athletes with mitral valve stenosis the extent of allowed physical activity is dependant on the size of the left atrium and the severity of the valve defect. Patients with mild-to-moderate mitral valve regurgitation can participate in all types of sport associated with low and moderate isometric stress and moderate dynamic stress. Patients under anticoagulation should not participate in any type of contact sport. Asymptomatic athletes with mild aortic valve stenosis can take part in all types of sport, as long as left ventricular function and size are normal, a normal response to exercise at the level performed during athletic activities is present and there are no arrhythmias. Asymptomatic athletes with moderate aortic valve stenosis should only take part in sports with low dynamic and static stress. Aortic valve regurgitation is often present due to connective tissue disease of a bicuspid valve. Athletes with mild aortic valve regurgitation, with normal end diastolic left ventricular size and systolic function can participate in all types of sport. A mitral valve prolapse is often associated with structural diseases of the myocardium and endocardium. In patients with mitral valve prolapse Holter-ECG monitoring should also be performed to detect significant arrhythmias. All athletes with known valvular heart disease, a previous history of infective endocarditis and valve surgery should receive endocarditis prophylaxis before dental, oral, respiratory, intestinal and genitourinary procedures associated with bacteraemia. Sport activities have to be avoided during active infection with fever.

Improved coronary vasodilatatory capacity by H.E.L.P. apheresis: comparing initial and chronic treatment.

Abstract:  Hypercholesterolemia impairs endothelial function and subsequently decreases coronary vasodilatatory capacity. We examined the quantitative effects of one single LDL apheresis on vasodilatatory capacity. Using N‐13 ammonia as a tracer for dynamic quantitative positron emission tomography (PET), mean myocardial perfusion measurements were carried out before and 20 h later after LDL apheresis, both under resting conditions and after pharmacological vasodilatation with dipyridamole. LDL apheresis was carried out using the heparin induced extracorporeal LDL precipitation (H.E.L.P.) procedure. We examined 47 patients (12 women and 35 men), with angiographically‐proven coronary artery disease. All of them suffered from hypercholesterolemia. Of the patients, 35 received a chronic weekly H.E.L.P. procedure (group A), while H.E.L.P. procedure treatment was started for the first time in 12 patients, who were subsequently enrolled in a chronic apheresis program (group B). H.E.L.P. apheresis was combined with cholesterol lowering drugs in all patients. Both groups underwent positron emission tomography twice (prior to LDL apheresis and 20 h later). In group A, LDL cholesterol levels decreased from 175 ± 50 mg/dL to 60 ± 21 mg/dL immediately after H.E.L.P. (77 ± 25 mg/dL before the second PET). Corresponding values for fibrinogen levels were 287 ± 75 mg/dL to 102 ± 29 mg/dL (155 ± 52 mg/dL), minimal coronary resistance dropped from 0.56 ± 0.20 to 0.44 ± 0.17 mm Hg × 100 g × min/mL (P < 0.0001). Plasma viscosity decreased by 7.8%. In group B, LDL cholesterol decreased from 187 ± 45 mg/dL to 75 ± 27 mg/dL (85 ± 29 mg/dL) and fibrinogen from 348 ± 65 mg/dL to 126 ± 38 mg/dL (168 ± 45 mg/dL). Minimal coronary resistance was reduced from 0.61 ± 0.23 to 0.53 ± 0.19 mm Hg × 100 g × min/mL (P < 0.01). Plasma viscosity was observed to decrease by 7.6%. The strong LDL drop in patients under chronic H.E.L.P. treatment has a significant impact on coronary vasodilatatory capacity within 20 h leading to an improved overall cardiac perfusion. Nearly the same effect can be seen in patients after their first H.E.L.P. treatment. 

The importance of training in echocardiography: a validation study using pocket echocardiography.

Aims To investigate the training effect in echocardiography by using recent hand-held ultrasound scanners (HANDs). Methods In this prospective study, 320 consecutive patients were scanned with HAND by an inexperienced ultrasonographer over a period of 8 weeks. Imaging studies were compared with high-end echocardiography as gold standard. Segmental endocardial border delineation was scored to describe image quality. Assessment of left ventricular dimensions, regional/global left ventricular function and grading of valve disease were compared. Results A significant reduction in examination duration, improvement in image quality, substantial agreement in functional assessment (&kgr; > 0.61, P < 0.01) and wall motion scoring (&kgr;=0.67, P < 0.01) could be observed over time. The correlation in left ventricular measurements was excellent (r > 0.98, P < 0.01). The detection of valve diseases and pericardial effusions was sufficient, but the grading only moderate (&kgr; < 0.6). Conclusion Well-grounded training in echocardiography leads to a rapid improvement in image acquisition and interpretation over a period of a few weeks. Basic diagnostic findings could be interpreted with high accuracy after short training. Interpretation of complex findings remained difficult. The time needed to carry out an examination using pocket echocardiography could not be reduced to less than 3–4 min per patient. New educational concepts are warranted.

Diagnostic Performance of Handheld Echocardiography for the Assessment of Basic Cardiac Morphology and Function: A Validation Study in Routine Cardiac Patients

Aims: To investigate the intra‐ and interrater variability of expert users in the interpretation of handheld echocardiographic studies (HAND). Methods: We scanned 320 consecutive patients with both HAND and high‐end (HIGH) scanners. Images were interpreted independently by two blinded level III echocardiographers. Readings from the HIGH scanner served as the gold standard. Segmental endocardial‐border delineation was scored to describe image quality. Assessment of left ventricular (LV) dimensions and regional/global LV function, and grading of valve disease were compared. Results: We obtained correlations of r > 0.8 (P < 0.01) for intrarater variability for both expert readers when they analyzed HAND and HIGH images in relation to image quality, wall‐motion abnormalities, and LV measurements. For intrarater variability of LVEF assessment, the correlations were at least moderate (r > 0.6, P < 0.01). Interrater variability for HIGH images was r = 0.9 (P < 0.01) for all parameters. Interrater variability for HAND images was less favorable for all parameters, but was at least moderate (r > 0.6, P < 0.01). All cases of pericardial effusion were detected. The agreement for the detection and grading of mitral and aortic regurgitation was at least moderate (κ > 0.6, P < 0.01). Detection of tricuspid regurgitation was less favorable, but only cases of mild regurgitation were missed. All cases of aortic stenosis were detected by both echocardiographers. Conclusions: In relation to the basic assessment of cardiac morphology and function, the interpretation by experienced echocardiographers of images obtained using handheld echocardiographic devices showed a moderate to very good correlation with standard echocardiography.

Time for action regarding cardiovascular emergency care at sports arenas: a lesson from the arena study

Sudden cardiac arrest (SCA) is a common cause of death worldwide, most often triggered by ventricular fibrillation or asystole.1 The estimated prevalence in adult individuals (>35 years) is about 1 in 1000 per year in the USA.2 The major determinant for survival in such instances is the time to defibrillation,1 with the critical interval from the onset of a lethal arrhythmia to subsequent shock, to restore sinus rhythm, being 3–5 min.2 The efficacy of automated external defibrillators (AEDs) to prevent SCAs has been demonstrated in large public settings, such as airports and casinos3,4 and their implementation in other crowded venues has also been advocated.5 Large sports arenas typically gather several thousands of spectators, including adult and senior individuals with risk factor for cardiac events, repeatedly exposed to intense emotion.6 Although much attention is put on the athletes on the field, most cases of SCA in this setting will occur among spectators, and simply watching (emotional) sports events has been demonstrated to trigger cardiac events.7 The National Association of Emergency Medical Services Physicians (NAEMSP) recommends a medical action plan (MAP), including AEDs, as a blue-print for delivering emergency medical care at mass gathering events (e.g. more than 1000 persons).8 In the USA, moreover, AEDs are recommended in large sports facilities and gyms, and also in the school setting when the time to defibrillation exceeds the critical threshold of 5 min.9,10 On the contrary, no recommendations regarding acute cardiovascular care at sports arenas exist at present in Europe, and the current implementation of medical action plans (including AEDs) in major continental sports arenas is largely unknown. We sought to investigate the existing cardiovascular safety procedures of major sports arenas in Europe, with special attention to the availability of …

Systolic and early diastolic left ventricular velocities assessed by tissue Doppler imaging in 100 top-level handball players

Background and objective Echocardiographic tissue Doppler imaging (TDI) has been proposed for the differentiation of physiologic left ventricular hypertrophy and pathologic left ventricular hypertrophy in athletes. In addition, cutoff values for systolic (S’ < 9 cm/s) and early diastolic (E’ < 9 cm/s) myocardial velocities had been defined. The aim of our study was the analysis of the morphologic cardiac changes by standard echocardiography, and the myocardial velocities S’ and E’ by TDI in top-level handball players with respect to the predefined cutoff values. Patients and methods Pulsed-wave TDI of the systolic and early diastolic velocities was performed at the lateral and septal mitral annulus (MA) in the four-chamber view in 100 athletes (100 Caucasian men; professional handball players of the first German handball league and the German national team; mean age 25.8 ± 4.8 years). Results Global and regional left ventricular systolic function was normal in all athletes. They showed an eccentric hypertrophy of the left ventricle (LV), which was characterized by an increased mass of the LV (287.3 ± 58.4 g), and an increased end diastolic diameter of the LV (LVEDD: 58 ± 5.9 mm), but no echomorphologic signs of pathologic hypertrophy or hypertrophic cardiomyopathy. TDI showed a systolic velocity S’ of the MA of 9.3 ± 1.5 cm/s at the septal and 10.5 ± 2.1 at the lateral MA. Ten of the 100 athletes showed a S’ <9 cm/s at both sides of the MA. TDI showed an early diastolic velocity E’ of the MA of 13.2 ± 2.8 cm/s at the septal and of 16.6 ± 3.4 cm/s at the lateral MA. None of the 100 athletes showed reduced systolic or early diastolic velocities below the proposed cutoff values (S’ and E’ < 9 cm/s) at any sides of the MA. Conclusion Our study provides further insights into systolic and diastolic function as assessed by TDI in top-level handball players. Owing to the large cohort of individuals, our findings might be helpful as reference values for the echocardiographic assessment of handball players, who are performing a moderate static and high dynamic sport. Eur J Cardiovasc Prev Rehabil 17:342-348

Athlete Screening for Occult Cardiac Disease: No Risk, No Fun?⁎

Regular physical exercise promotes health and longevity. Young, well-conditioned competing athletes are believed to be one of the healthiest segments of society and a brilliant example of the beneficial effects of sport. Therefore, sudden cardiac death (SCD) in such persons is not only devastating