Goo-Yeong Cho

Left atrial dyssynchrony assessed by strain imaging in predicting future development of atrial fibrillation in patients with heart failure

BACKGROUNDnThe clinical and echocardiographic parameters associated with the risk of developing new onset atrial fibrillation (AF) in congestive heart failure (CHF) have not been studied comprehensively. We determined if dyssynchronous left atrial (LA) lengthening and contraction predicted future development of new onset AF in patients with CHF.nnnMETHODSnOne hundred fifty-eight patients who were admitted for CHF without past or current AF were evaluated. We measured the time to peak velocity and time to peak strain with reference to the QRS complex during ventricular systole (reservoir) and late diastole (atrial contraction) in mid-portion of 4 LA walls. Dyssynchronous atrial lengthening and contraction (atrial dyssynchrony) was defined as the standard deviation of each parameter.nnnRESULTSnNew onset AF developed in 21 patients (13.3%) after a mean follow-up of 43+/-15 months. Based on univariate Cox analysis, older age, larger LA dimension and volume index, lower LA fractional shortening, and the presence of atrial dyssynchrony were associated with new onset AF. In multivariate Cox analysis, atrial dyssynchrony based on strain (>39 ms, HR 10.0, p=0.003) and LA size (> or =45 mm, HR 4.3, p=0.016) were independent predictors of new onset AF in CHF.nnnCONCLUSIONSnWe demonstrated that atrial dyssynchrony based on strain is the strongest univariate and multivariate predictor for new onset AF in hospitalized patients with CHF.

Brain natriuretic peptide levels have diagnostic and prognostic capability for cardio-renal syndrome type 4 in intensive care unit patients.

IntroductionLimited data are available regarding the diagnostic and prognostic utility of brain natriuretic peptide (BNP) in patients with chronic kidney disease (CKD) in the intensive care unit (ICU) setting.MethodsAll patients with CKD and a serum creatinine (Cr) of 2.0 mg/dl or higher admitted to the ICU between January 2006 and September 2007 were enrolled in this study. The CKD group was divided according to the presence or absence of acute decompensated heart failure (ADHF) into CKD + ADHF and CKD - ADHF groups, respectively. Other patients with ADHF having low Cr (<1.2 mg/dl) in the coronary care unit were also recruited as a control group during the same period. BNP levels at the time of admission (admission BNP) were compared amongst these groups. We then sought to determine whether BNP levels could predict the outcome in patients with CKD.ResultsOf 136 patients with CKD for whom data were available, including 58 on dialysis (42.6%), 81 (59.6%) had ADHF and their estimated glomerular filtration rate (eGFR) was 12.8 ± 7.3 ml/min/1.73 m2. BNP levels at admission were 2708.6 ± 1246.9, 567.9 ± 491.7 and 1418.9 ± 1126.5 pg/ml in the CKD + ADHF, CKD - ADHF and control groups (n = 33), respectively (P = 0.000). The optimal cutoff level in patients with CKD was 1020.5 pg/ml (area under the curve = 0.944) to detect ADHF from the receiver operating characteristic (ROC) curve. This level was not associated with in-hospital mortality, all-cause death or a composite event (all-cause death and/or new cardiac event). However, a borderline significant association was observed with new cardiac events (hazard ratio (HR) = 4.551; P = 0.078) during the follow-up period (521.1 ± 44.7 days). Furthermore, continuous variables of BNP and BNP quartiles were significantly associated with new cardiac events in the multivariate Cox model (HR = 1.001, P = 0.041; HR = 2.212, P = 0.018).ConclusionsThe findings suggest that the level of BNP at the time of admission may be a useful marker for detecting ADHF and predicting cardiac events in patients with CKD in the ICU setting.

Prognostic factors in patients with minor troponin-I elevation but without acute myocardial infarction

Objectives Although cardiac troponin I is widely used as a marker for myocardial infarction, its minor elevations are also observed in other clinical situations, and the prognostic factors in such clinical settings have not been well established. The aim of this study was to identify predictors of mortality in patients with minor troponin elevations without an acute myocardial infarction. Methods We consecutively enrolled 134 patients from the emergency department with a peak troponin I level greater than the lower limit of detectability (0.04u2009ng/ml) but less than the 10% coefficient of variation cutoff value for diagnosis of myocardial infarction (0.26u2009ng/ml). These patients had chest pain or nonspecific symptoms of a circulatory abnormality but lacked the traditional features of an acute myocardial infarction. End point was defined as death from all causes. Cox regression analysis was used to test relations between clinical and biochemical variables and the outcome. Results During the follow-up of 7.6±7.4 months, 12 patients died. Age, log creatine kinase myocardial isoform, and log C-reactive protein were found to be significantly correlated with death. After adjusting for possible confounders in the multivariate model, age (hazard ratio 1.09, confidence interval 1.02–1.16, P=0.012), log creatine kinase myocardial isoform (hazard ratio 13.11, confidence interval 2.01–85.52, P=0.007), and log C-reactive protein (hazard ratio 1.64, confidence interval 1.02–2.56, P=0.041) were identified as independent predictors of mortality. Conclusions Creatine kinase myocardial isoform and C-reactive protein levels and age can be integrated to risk-stratify patients with minor troponin I elevation for reasons other than acute myocardial infarction.

Noncontrast Myocardial T1 Mapping by Cardiac Magnetic Resonance Predicts Outcome in Patients With Aortic Stenosis

OBJECTIVESnThe aim of this study was to evaluate whether native T1 value of the myocardium on cardiac magnetic resonance (CMR) could predict clinical events in patients with significant aortic stenosis (AS).nnnBACKGROUNDnAlthough previous studies have demonstrated the prognostic value of focal fibrosis using late gadolinium enhancement (LGE) by CMR in AS patients, the prognostic implication of diffuse myocardial fibrosis by noninvasive imaging remains unknown.nnnMETHODSnA prospective observational longitudinal study was performed in 127 consecutive patients with moderate or severe AS (68.8 ± 9.2 years of age, 49.6% male) and 33 age- and sex-matched controls who underwent 3-T CMR. The degree of diffuse myocardial fibrosis was assessed by noncontrast mapping of T1 relaxation time using modified Look-Locker inversion-recovery sequence, and the presence and extent of LGE were also evaluated. The AS patients were divided into 3 groups by the native T1 value. Primary endpoint was a composite of all-cause death and hospitalization for heart failure.nnnRESULTSnNative T1 value was higher in AS patients, compared with control subjects (1,232 ± 53 ms vs. 1,185 ± 37 ms; pxa0=xa00.008). During follow-up (median 27.9 months), there were 24 clinical events including 9 deaths (6 pre-operative and 3 post-operative), the majority of which occurred in the patients in the highest T1 tertile group (2.4% vs. 11.6% vs.xa042.9% for lowest, mid-, and highest tertile groups; pxa0< 0.001 by log-rank test). The total number of events for both pre- and post-operative events also occurred more frequently in patients in the highest T1 tertile group. EuroSCORE II, the presence and/or extent of LGE, and the native T1 value were predictors of poor prognosis (adjusted hazard ratio forxa0every 20-ms increase of native T1: 1.28; pxa0= 0.003). In particular, the highest native T1 value provided further risk stratification regardless of the presence of LGE.nnnCONCLUSIONSnHigh native T1 value on noncontrast T1 mapping CMR is a novel, independent predictor of adverse outcome in patients with significant AS.

Left Atrial Mechanical Function and Global Strain in Hypertrophic Cardiomyopathy

Background Atrial fibrillation is the most common arrhythmia and is associated with adverse outcomes in hypertrophic cardiomyopathy (HCM). Although left atrial (LA) remodeling and dysfunction are known to associate with the development of atrial fibrillation in HCM, the changes of the LA in HCM patients remain unclear. This study aimed to evaluate the changes in LA size and mechanical function in HCM patients compared to control subjects and to determine the characteristics of HCM associated with LA remodeling and dysfunction. Methods Seventy-nine HCM patients (mean age, 54 ± 11 years; 76% were men) were compared to 79 age- and sex-matched controls (mean age, 54 ± 11 years; 76% were men) and 20 young healthy controls (mean age, 33 ± 5 years; 45% were men). The LA diameter, volume, and mechanical function, including global strain (ε), were evaluated by 2D-speckle tracking echocardiography. The phenotype of HCM, maximal left ventricular (LV) wall thickness, LV mass, and presence and extent of late gadolinium enhancement (LGE) were evaluated with cardiac magnetic resonance imaging. Results HCM patients showed increased LA volume index, impaired reservoir function, and decreased LA ε compared to the control subjects. When we divided the HCM group according to a maximal LA volume index (LAVImax) of 38.7 ml/m2 or LA ε of 21%, no significant differences in the HCM phenotype and maximal LV wall thickness were observed for patients with LAVImax >38.7 ml/m2 or LA ε ≤21%. Conversely, the LV mass index was significantly higher both in patients with maximal LA volume index >38.7 ml/m2 and with LA ε ≤21% and was independently associated with LAVImax and LA ε. Although the LGE extent was increased in patients with LA ε ≤21%, it was not independently associated with either LAVImax or LA ε. Conclusions HCM patients showed progressed LA remodeling and dysfunction; the determinant of LA remodeling and dysfunction was LV mass index rather than LV myocardial fibrosis by LGE-magnetic resonance imaging.

Myocardial Strain in Prediction of Outcomes After Surgery for Severe Mitral Regurgitation

OBJECTIVESnWe investigated whether global longitudinal strain (GLS) is a better predictor of clinical events after surgery for mitral regurgitation (MR) than conventional parameters.nnnBACKGROUNDnThe optimal timing for surgery is guided by left ventricular (LV) dimension or left ventricular ejection fraction (LVEF), even though normal LVEF can mask depressed LV systolic function in severe mitral MR.nnnMETHODSnFrom 2006 to 2016, 506 patients (age 58.5 ± 13.7 years, 54.3% male) with severe primary MR who underwent mitral valve surgery were included. We measured GLS and global circumferential strain. Cardiac events included admission for worsening heart failure (HF), reoperation for failure of MV surgery, and cardiac death.nnnRESULTSnDuring a median follow-up period of 3.5 years, 56 (11.1%) patients died, 41 (8.1%) were hospitalized for HF, and 10 (2.0%) underwent reoperation. In univariate analysis, LVEF, atrial fibrillation, left atrial dimension, age, previous ischemia, concomitant coronary artery bypass graft, and both GLS and global circumferential strain were predictive of cardiac events. On multivariate Cox models, age (hazard ratio [HR]: 1.429, 95% confidence interval [CI]: 1.116 to 1.831; pxa0= 0.005), left atrial dimension (HR: 1.034, 95% CI: 1.006 to 1.063; pxa0= 0.019) and GLS (HR: 1.229, 95% CI: 1.135 to 1.331; pxa0< 0.001) were independent predictors of cardiac events. In subgroup analysis, LV GLS was a significant predictor of cardiac outcome, regardless of the presence of LV dysfunction, the presence of atrial fibrillation, and the type of surgery. Impaired GLS was associated with all-cause mortality (HR: 1.068, 95% CI: 1.003 to 1.136; pxa0= 0.040).nnnCONCLUSIONSnGLS appears to be a better predictor of cardiac events all-cause death than conventional parameters. Measuring preoperative GLS is helpful to predict post-operative outcome and determine optimal timingxa0for surgery in patients with severe primary MR.

Impact of a Telehealth Program With Voice Recognition Technology in Patients With Chronic Heart Failure: Feasibility Study

Background Despite the advances in the diagnosis and treatment of heart failure (HF), the current hospital-oriented framework for HF management does not appear to be sufficient to maintain the stability of HF patients in the long term. The importance of self-care management is increasingly being emphasized as a promising long-term treatment strategy for patients with chronic HF. Objective The objective of this study was to evaluate whether a new information communication technology (ICT)–based telehealth program with voice recognition technology could improve clinical or laboratory outcomes in HF patients. Methods In this prospective single-arm pilot study, we recruited 31 consecutive patients with chronic HF who were referred to our institute. An ICT-based telehealth program with voice recognition technology was developed and used by patients with HF for 12 weeks. Patients were educated on the use of this program via mobile phone, landline, or the Internet for the purpose of improving communication and data collection. Using these systems, we collected comprehensive data elements related to the risk of HF self-care management such as weight, diet, exercise, medication adherence, overall symptom change, and home blood pressure. The study endpoints were the changes observed in urine sodium concentration (uNa), Minnesota Living with Heart Failure (MLHFQ) scores, 6-min walk test, and N-terminal prohormone of brain natriuretic peptide (NT-proBNP) as surrogate markers for appropriate HF management. Results Among the 31 enrolled patients, 27 (87%) patients completed the study, and 10 (10/27, 37%) showed good adherence to ICT-based telehealth program with voice recognition technology, which was defined as the use of the program for 100 times or more during the study period. Nearly three-fourths of the patients had been hospitalized at least once because of HF before the enrollment (20/27, 74%); 14 patients had 1, 2 patients had 2, and 4 patients had 3 or more previous HF hospitalizations. In the total study population, there was no significant interval change in laboratory and functional outcome variables after 12 weeks of ICT-based telehealth program. In patients with good adherence to ICT-based telehealth program, there was a significant improvement in the mean uNa (103.1 to 78.1; P=.01) but not in those without (85.4 to 96.9; P=.49). Similarly, a marginal improvement in MLHFQ scores was only observed in patients with good adherence (27.5 to 21.4; P=.08) but not in their counterparts (19.0 to 19.7; P=.73). The mean 6-min walk distance and NT-proBNP were not significantly increased in patients regardless of their adherence. Conclusions Short-term application of ICT-based telehealth program with voice recognition technology showed the potential to improve uNa values and MLHFQ scores in HF patients, suggesting that better control of sodium intake and greater quality of life can be achieved by this program.

Intracardiac bronchogenic cyst: report of a growing lesion.

Intracardiac bronchogenic cyst is a rare congenital malformation that is a remnant from abnormal budding of the embryonic foregut. Among the intracardiac cases, bronchogenic cysts of the interatrial septum account for three-fourths of the reported cases.1 Because most of the intracardiac cysts are surgically removed promptly after detection, the natural course of intracardiac bronchogenic cyst is unknown. Here, we report the case of a growing interatrial bronchogenic cyst incidentally detected during the postoperative surveillance of gastric cancer.nnA 35-year-old male patient was referred to the cardiology department for an incidentally detected intracardiac mass. The patient had been diagnosed with advanced gastric cancer 14 months before referral, had undergone total gastrectomy, and was receiving adjuvant chemotherapy. The mass was first noted by his surveillance abdominal computed tomography (CT) scan, which covered his heart. Retrospective review of his preoperative stomach CT scan and follow-up abdomen CT scan revealed that the cyst had increased up to 6-fold in volume over a period of 13 months (Figure 1 and Figure I in the online-only Data Supplement).nnnnFigure 1. nRapidly growing intracardiac mass incidentally detected during abdomen CT follow-up. Top left , At diagnosis of gastric cancer (13 months before referral). Top right , 7-month follow-up (6 months before referral). Bottom left , 12-month follow-up (1 month before referral). Bottom right , 13-month CT angiography (at referral). Scale …

Global Left Atrial Strain as a Predictor of Silent Atrial Fibrillation Following Dual Chamber Cardiac Implantable Electronic Device Implantation

Silent atrial fibrillation (SAF) detected by cardiac implantable electronic device (CIED) is known to increasexa0the risk of death, stroke, and heart failure (HF), which is comparable to overt atrial fibrillation (AF) [(1)][1]. Left atrial (LA) strain, an emerging parameter of LA function, was found

Left Ventricular Longitudinal Strain and Strain Rate Values According to Sex and Classifications of Sports in the Young University Athletes Who Participated in the 2015 Gwangju Summer Universiade

Left ventricular (LV) strain values measured by 2-dimensional speckle tracking echocardiography (2DSTE) represent global and regional myocardial functions. These values can give prognostic information, detect subclinical LV changes, and distinguish physiologic adaptation from pathologic hypertrophy