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Steep Left Ventricle to Aortic Root Angle and Hypertrophic Obstructive Cardiomyopathy: Study of a Novel Association using 3-dimensional Multi-modality Imaging
  1. Deborah H Kwon
  1. Cleveland Clinic, United States
    1. Nicholas G Smedira
    1. Cleveland Clinic, United States
      1. Zoran B Popovic
      1. Cleveland Clinic, United States
        1. Bruce W Lytle
        1. Cleveland Clinic, United States
          1. Randolph Setser
          1. Cleveland Clinic, United States
            1. Maran Thamilarasan
            1. Cleveland Clinic, United States
              1. Paul Schoenhagen
              1. Cleveland Clinic, United States
                1. Scott D Flamm
                1. Cleveland Clinic, United States
                  1. Harry M Lever
                  1. Cleveland Clinic, United States
                    1. Milind Y Desai (desaim2{at}ccf.org)
                    1. Cleveland Clinic, United States

                      Abstract

                      Objective: Hypertrophic cardiomyopathy (HCM) patients exhibit difference in left ventricular outflow tract obstruction (LVOTO), independent of basal septal thickness (BST). We observed that some HCM patients have a steeper LV to aortic root angle (LVARA), as compared to controls. Using 3-dimensional imaging, we tested the predictors of LVARA and association between LVARA and LVOTO.

                      Patients: We studied 153 consecutive HCM patients (46±14 years, 68% men) and 62 patients with hypertensive heart disease of the elderly (all > 65 years of age, 73±6 years, 34% men) that underwent whole-heart 3D cardiac magnetic resonance (CMR) angiogram (1.5T Siemens) and Doppler echocardiography. We also studied 42 controls (43±11 years, 38 % men) that underwent contrast-enhanced multi-detector computed tomography (MDCT) and were free of cardiovascular pathology.

                      Main outcomes: LVARA, BST and maximal non-exercise LVOT gradient were measured in HCM and hypertensive-elderly patients. In addition, LVARA and BST were measured in controls.

                      Results: The mean LVARA was significantly different (p< 0.001) in 3 groups as follows: HCM (1340±10), hypertensive-elderly (1280±10) and control (1400±7). There was an inverse correlation between age and LVARA in the 3 groups (all p<0.001): HCM (r=-0.56), hypertensive-elderly (r=-0.35) and control (r=-0.48). On univariate analysis, in the HCM group, LVARA (beta=-0.34, p-value<0.001), age (beta=0.23, p-value=0.01) and end-systolic volume index (beta=-0.20, p-value=0.02); but not BST (beta=0.02, p=0.8), were associated with LVOT gradient. On multivariate analysis, only LVARA was associated with LVOT gradient.

                      Conclusions: HCM patients have a steeper LVARA, compared to controls. In HCM patients, steeper LVARA predicts dynamic LVOTO, independent of BST.

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