Recovery of left ventricular function in acute nonischemic congestive cardiomyopathy

doi:10.1016/0002-8703(95)90038-1

American Heart Journal

Volume 129, Issue 1, January 1995, Pages 24-30

https://doi.org/10.1016/0002-8703(95)90038-1 Get rights and content

Abstract

The extent and time course of recovery of left ventricular function were investigated in 29 patients with no previous symptoms who had acute nonischemic congestive cardiomyopathy and left ventricular ejection fraction of 0.22 ± 0.07. Improvement in left ventricular ejection fraction by at least 0.05 was observed in 24 of the 29 patients and was achieved within 6 months after the initial evaluation. Progressive improvement was seen, with a maximum ejection fraction of 0.45 ± 0.17 being achieved within approximately 18 months. The degree of ejection fraction recovery was not related to the initial clinical or hemodynamic variables. However, the extent of fibrosis detected on endomyocardial biopsy correlated inversely with subsequent changes in ejection fraction (r = −0.65, p = 0.0003). Thus significant recovery is likely after an acute episode of nonischemic cardiomyopathy and may be progressive during the first year. Recovery is related to the extent of myocardial fibrosis detected on endomyocardial biopsy but cannot be predicted from the initial clinical or hemodynamic presentation.

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The aim of this study was to test the hypothesis that patients with reverse-remodeled dilated cardiomyopathy (DCM), whose ejection fractions (EFs) were normalized after optimal pharmacologic therapy, had subclinical myocardial dysfunction.
Thirty-two patients with reverse-remodeled DCM, defined as having an initial EF ≤ 35%, which then recovered to ≥50% after optimal pharmacologic therapy, and 11 normal controls with preserved EFs were retrospectively studied. Averaged peak systolic and early diastolic radial, circumferential, and longitudinal speckle-tracking strain rates were assessed from an 18-segment left ventricular model. Similarly, averaged peak systolic radial, circumferential, and longitudinal speckle-tracking strain was obtained.
Peak systolic and early diastolic longitudinal strain rates, peak systolic and early diastolic circumferential strain rates, and peak circumferential and longitudinal strain in patients with reverse-remodeled DCM were significantly lower than those in normal controls, but peak systolic and early diastolic radial strain rates and peak radial strain in patients with reverse-remodeled DCM were similar to those in normal controls. Isometric handgrip stress testing showed a significant decrease in EF from 56 ± 5% to 51 ± 5% (P < .001). Of note, the increase of afterload resulting from isometric handgrip stress testing was associated with a decrease in peak systolic circumferential and longitudinal strain rates and peak circumferential strain in patients with reverse-remodeled DCM.
The circumferential and longitudinal myocardial function of patients with reverse-remodeled DCM is lower compared with that of normal controls with preserved EFs. Furthermore, the increase in afterload was associated with the decrease in circumferential and longitudinal myocardial systolic function. These findings suggest that in treated patients with DCM with reverse remodeling, left ventricular mechanics may not be normal, even when EFs are normal.
The Impact of Exercise-Induced Changes in Intraventricular Dyssynchrony on Functional Improvement in Patients with Nonischemic Cardiomyopathy
2008, Journal of the American Society of Echocardiography
Citation Excerpt :
The biologic function of ventricular myocardium has been emphasized as a main target of pharmacologic treatment for attenuating ventricular remodeling.11 Our data can be explained by a previously proposed theory that the myocardial contractile reserve reflecting the myocardial biologic function affects the functional recovery.12-14 The precise role of impaired myocardial contractile reserve and mitral closing force in the development of dynamic MR has been emphasized in patients with heart failure.15,16
The assessment of dynamic intraventricular dyssynchrony has been reported to be feasible in a clinical setting. However, its prognostic implication in functional improvement has not yet been investigated.
Symptom-limited, supine bicycle exercise was performed on 41 patients with nonischemic cardiomyopathy (52 ± 12 years, ejection fraction < 40%). Using Doppler tissue imaging, the average of peak systolic velocities at 6 basal segments was obtained at rest and peak exercise. Dyssynchrony index (Ts-SD12) was defined as the SD of the time to peak systolic velocities at 12 left ventricular segments. The percent change of end-systolic volume (%ΔESV) was calculated at follow-up. A 15% or greater reduction in end-systolic volume (%ΔESV < −15%) was considered as functional improvement.
During exercise, changes in dyssynchrony (ΔTs-SD12) were individually variable. Average of peak systolic velocities (V) at 6 basal segments at peak exercise independently correlated with Ts-SD12 at peak exercise (β = −0.541, P < .001). Follow-up echocardiography was performed on 35 patients after medical treatment for 13.0 ± 4.9 months. There was significant association of %ΔESV with the change in mitral regurgitation (r = 0.434, P = .009), disease duration (r = 0.343, P = .045), QRS interval (r = 0.347, P = .041), and ΔTs-SD12 (r = 0.511, P = .002). Multivariate analysis identified Ts-SD12 measured at peak exercise as the strongest predictor for functional improvement (%ΔESV: β = 0.577, P < .001; and Δejection fraction: β = −0.563, P < .001).
In patients with heart failure, dynamic dyssynchrony can be assessed during exercise. Ts-SD12 at peak exercise may be an independent predictor for reverse remodeling with medical treatment.
Myocardial contractile reserve determined by dobutamine stress Tc-99m tetrofosmin quantitative gated SPECT predicts late spontaneous improvement in cardiac function in patients with recent-onset dilated cardiomyopathy
2003, Journal of Nuclear Cardiology
We evaluated whether dobutamine stress technetium 99m tetrofosmin (DSTF) quantitative gated single photon emission computed tomography (QGS) could predict late spontaneous improvement of cardiac function in patients with idiopathic dilated cardiomyopathy (DCM).
The study included 26 patients with recently diagnosed (<2 months) idiopathic DCM and a left ventricular ejection fraction (LVEF) lower than 45%. DSTF-QGS was performed in all patients to measure LVEF at rest and during dobutamine infusion (10 μg · kg⁻¹ · min⁻¹). LVEF and left ventricular end-diastolic volume (LVEDV) were determined by echocardiography, and New York Heart Association (NYHA) functional class was estimated at baseline and after 1 year. After 1 year of treatment, the echocardiographic LVEF improved by greater than 5% in 13 patients (group A) but did not improve in the remaining 13 patients (group B). At baseline, the echocardiographic LVEF, LVEDV, and NYHA functional class were similar in both groups. However, there was a greater increase in the LVEF during the dobutamine infusion portion of the DSTF-QGS (ΔLVEF) in group A than in group B (13.1% ± 5.9% vs 2.6% ± 4.1%, P < .0001). If a critical value for the ΔLVEF of 7.0% was used to predict improvement in LVEF after treatment, the sensitivity was 84.7% and the specificity was 84.7%. LVEDV and NYHA functional class improved to a greater extent in group A than in group B.
DSTF-QGS can be used to predict late spontaneous improvement in cardiac function and symptoms after treatment in patients with idiopathic DCM.
Prognostic implications derived from ultrasonic tissue characterization with myocardial integrated backscatter in patients with dilated cardiomyopathy
2002, International Journal of Cardiology
Background: Various clinical parameters have been reported to predict survival in patients with dilated cardiomyopathy (DCM). Myocardial ultrasonic integrated backscatter (IB) imaging has a potential to perform in vivo tissue characterization. The present study was performed to examine whether myocardial IB analysis can predict the prognosis of DCM patients. Methods and results: We prospectively carried out echocardiographic examinations with IB analysis in 43 patients with DCM (31 males, 12 females) under the standard treatment. IB analysis was performed in the left ventricular wall and the calibrated (subtracting pericardial data) myocardial IB intensity (IBI) was obtained from the interventricular septum and the left ventricular posterior wall. After the follow-up (8–39 months), 31 followed a good clinical course, but eight had cardiac death, one had partial left ventriculectomy for uncontrolled heart failure and three were hospitalized for worsening heart failure. β-Blocker responded in 27 (87%) of the 31 with good clinical course, but it did not respond in 11 among the 12 with poor course. In these 12 DCM, left ventricular fractional shortening (LVFS) was lower (good: 18±5%, poor: 14±4, P<0.03) and calibrated IBI was higher in both the septum (good: −16.4±5.6 dB, poor: −11.1±4.2 dB, P<0.006) and the posterior wall (good: −19.5±3.6 dB, poor: −13.8±5.6 dB, P<0.004). On the Cox proportional hazard model analysis, only calibrated IBI in the septum >−17 dB, the cut-off score of calibrated IBI discriminating non-responders to β-blocker therapy in our previous report, was related to the poor outcome (χ²=4.43, P=0.035). The stepwise multivariate analysis revealed that both calibrated IBI in the septum>−17 dB (χ²=4.43, P=0.035) and LVFS<15% (χ²=3.89, P=0.049) were useful to predict the poor clinical outcome. The event free rate assessed by the Kaplan–Meier method was also significantly reduced in patients with calibrated IBI in the septum >−17 dB (χ²=6.594, P=0.01) and calibrated IBI in the posterior wall>−17 dB (χ²=4.215, P=0.04). However, LVFS<15% (χ²=3.576, not significant) did not contribute to discriminating the event free rate in the clinical course. Conclusions: The present study demonstrated that myocardial IB intensity was higher in DCM patients who followed a poor clinical course rather than in those with a good outcome. Therefore, it is clarified that myocardial ultrasonic tissue characterization in DCM patients is useful for assessing their clinical outcome after receiving not only the standard treatment but also β-blocker therapy.
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2016, Heart and Vessels

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^☆: Supported in part by National Research Service Award grant HL07101-17 from the National Institutes of Health.

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Recovery of left ventricular function in acute nonischemic congestive cardiomyopathy☆

Abstract

Am J Cardiol

Am J Cardiol

J Am Coll Cardiol

Am J Cardiol

Am J Cardiol

Am Heart J

Am J Med

J Am Coll Cardiol

Am J Cardiol

Am J Cardiol

J Am Coll Cardiol

Am Heart J

J Am Coll Cardiol

Am J Med

J Am Coll Cardiol

Am J Cardiol

The natural history of congestive heart failure: the Framingham Study

N Engl J Med

Plasma norepinephrine as a guide to prognosis in patients with chronic congestive heart failure

N Engl J Med

Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure

N Engl J Med

A comparison of enalapril with hydralazine-isosorbide dinitrate in the treatment of chronic congestive heart failure

N Engl J Med