Response to Letters Regarding Article, “Myocardial Fibrosis as a Key Determinant of Left Ventricular Remodeling in Idiopathic Dilated Cardiomyopathy: A Contrast-Enhanced Cardiovascular Magnetic Study”

Masci, Pier Giorgio; Schuurman, Robert; Barison, Andrea; Ripoli, Andrea; Coceani, Michele; Chiappino, Sara; Todiere, Giancarlo; Srebot, Vera; Passino, Claudio; Aquaro, Giovanni Donato; Emdin, Michele; Lombardi, Massimo

doi:10.1161/circimaging.113.001217

Cited by 4 publications

(5 citation statements)

References 9 publications

(8 reference statements)

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“…26 In subsequent studies, both the presence and extent of replacement fibrosis were associated with an increased likelihood of all-cause mortality in dilated cardiomyopathy and that this association was independent of LVEF, the initial clinical status, the severity of LV dilatation/dysfunction and other established prognostic factors. [27][28][29] Clinical implications and future directions Our case series study partially reconnects to previous observations confirming that evaluation of cardiac dimensions and EF in patients with VHD could be insufficient to target the best timing for treatment. The best response occurs when surgery is performed before left heart dilation, LV hypertrophy, or LV dysfunction develops.…”

Section: Pathophysiological Role Of Fibrosissupporting

confidence: 81%

“…In addition, patients with fibrosis had a significantly greater incidence of the secondary end point of sudden cardiac death/ventricular tachycardia 26 . In subsequent studies, both the presence and extent of replacement fibrosis were associated with an increased likelihood of all-cause mortality in dilated cardiomyopathy and that this association was independent of LVEF, the initial clinical status, the severity of LV dilatation/dysfunction and other established prognostic factors 27–29 …”

Section: Discussionmentioning

confidence: 98%

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Myocardial fibrosis in asymptomatic patients undergoing surgery for mitral and aortic valve regurgitation

Fragasso¹,

Sanvito²,

Monaca³

et al. 2022

Journal of Cardiovascular Medicine

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BackgroundChronic heart valve regurgitation induces left ventricular (LV) volume overload, leading to the development of hypertrophy and progressive dilatation of the ventricle to maintain physiological cardiac output. In order to prevent potential irreversible LV structural changes, the identification of the best timing for treatment is pivotal.ObjectiveTo assess the presence and extent of fibrosis in myocardial tissue in asymptomatic patients with valvular heart disease (VHD) and preserved LV dimensions and function undergoing cardiac surgery.MethodsThirty-nine patients were enrolled. Sixteen patients were affected by aortic or mitral regurgitation: they were all asymptomatic, undergoing valve surgery according to VHD European Society of Cardiology guidelines. Twenty-three patients with end-stage nonischemic dilated cardiomyopathy (DCM) and severe LV dysfunction undergoing cardiac surgery for implantation of a durable left ventricular assist device (LVAD) served as controls. During surgery, VHD patients underwent three myocardial biopsies at the level of the septum, the lateral wall and LV apex, while in LVAD patients the coring of the apex of the LV was used. For both groups, the tissue samples were analyzed on one section corresponding to the apical area. All slides were stained with hematoxylin and eosin and Masson's trichrome staining and further digitalized. The degree of fibrosis was then calculated as a percentage of the total area.Results Of 39 patients, 23 met the inclusion criteria: 12 had mitral or aortic insufficiency with a preserved ejection fraction and 11 had idiopathic dilated cardiomyopathy. Quantitative analysis of apical sections revealed a myocardial fibrosis amount of 10 ± 6% in VHD patients, while in LVAD patients the mean apical myocardial fibrosis rate was 38 ± 9%. In VHD patients, fibrosis was also present in the lateral wall (9 ± 4%) and in the septum (9 ± 6%).ConclusionOur case series study highlights the presence of tissue remodeling with fibrosis in asymptomatic patients with VHD and preserved LV function. According to our results, myocardial fibrosis is present at an early stage of the disease, well before developing detectable LV dysfunction and symptoms. Since the relationship between the progressive magnitude of myocardial fibrosis and potential prognostic implications are not yet defined, further studies on this topic are warranted.

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Section: Pathophysiological Role Of Fibrosissupporting

confidence: 81%

Section: Discussionmentioning

confidence: 98%

Myocardial fibrosis in asymptomatic patients undergoing surgery for mitral and aortic valve regurgitation

Fragasso¹,

Sanvito²,

Monaca³

et al. 2022

Journal of Cardiovascular Medicine

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“…A 10% level of EF improvement was considered clinically significant accordingly to previous studies on reverse remodeling and to our intra-observer variability (3.6%, SD = 3%). Similarly, in consideration of both recent studies on reverse remodeling [ 24 , 25 ] and our intra-observer variability (6.3%, SD = 3.3%), an “EDV improvement” was considered clinically significant if a more-than-10% reduction of baseline levels was noticed. These observations are in line with previous data from the IMPROVE-HF trial that identified non ischemic HF etiology as one of the determinants associated with a >10% improvement in EF [ 26 ].…”

Section: Discussionmentioning

confidence: 96%

“…Other studies have found a reverse remodeling in 25–33% of the patients [ 12 , 25 ], which occurred in the first year after SV began and correlated with the absence of myocardial fibrosis in magnetic resonance imaging (CMR) [ 24 , 26 ]. It appears therefore reasonable that patients with HFrEF of non-ischemic etiology, who typically have a lower LGE extension if compared to ischemic patients, would respond better to optimal medical therapy and benefit more from SV therapy.…”

Section: Discussionmentioning

confidence: 99%

Reverse Remodeling and Functional Improvement of Left Ventricle in Patients with Chronic Heart Failure Treated with Sacubitril/Valsartan: Comparison between Non-Ischemic and Ischemic Etiology

Cemin

Casablanca

Foco

et al. 2023

JCM

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Sacubitril/valsartan (SV) has been demonstrated to reduce cardiovascular mortality, hospitalization for heart failure and to induce reverse ventricular remodeling. The present study was designed to confirm the effects of SV in a selected population of patients with HFrEF and to evaluate the different responses between patients with an ischemic or a non-ischemic etiology. A total of 79 patients with indication of SV were recruited prospectively during a timelapse of 4 years. SV was overall associated to a reduction of end-diastolic and end-systolic volume, of NT-proBNP levels, furosemide dosage and NYHA functional class, together with an increase in EF. These changes were more evident in patients with non-ischemic dilated cardiomyopathy, who showed a significant improvement in ventricular volumes, ejection fraction, TAPSE and blood levels of NT-proBNP. Kaplan–Meier curves confirmed a greater benefit in terms of ejection-fraction improvement in non-ischemic patients compared to the ischemic group. The results of the present study confirm the positive effect of SV on NYHA functional class, NT- proBNP, left ventricular volumes and EF in HFrEF patients, showing evidence of association of SV with ventricular remodeling in patients with dilated cardiomyopathy of non-ischemic etiology compared to the ischemic group.

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“…If a patient missed by guest on http://circimaging.ahajournals.org/ Downloaded from the follow-up visit, telephone contact, review of outpatient clinic or hospital records, and contact with the patient's primary care physician or cardiologist were performed. During follow-up, we recorded the following end points as previously described 16 : (1) long runs of nonsustained ventricular tachycardia defined as ≥10 consecutive ventricular premature beats at >120 bpm or sustained ventricular tachycardia, (2) aborted SCD, defined as an appropriate ICD intervention for ventricular arrhythmias excluding ATP, (3) SCD defined as unexpected death either within 1 hour of cardiac symptom onset in the absence of progressive deterioration, during sleep, or within 24 hours of last being seen alive, (4) hospitalization or cardiac death related to chronic heart failure because of unstable or progressive deterioration of LV function despite active therapy. Major adverse cardiac events (MACE) were defined as a composite end point of long runs of …”

Section: Follow-up and End Pointsmentioning

confidence: 99%

Prognostic Benefit of Cardiac Magnetic Resonance Over Transthoracic Echocardiography for the Assessment of Ischemic and Nonischemic Dilated Cardiomyopathy Patients Referred for the Evaluation of Primary Prevention Implantable Cardioverter–Defibrillator Therapy

Pontone

Guaricci

Andreini

et al. 2016

Circ: Cardiovascular Imaging

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S udden cardiac death (SCD) is the most common cause of cardiovascular death in ischemic cardiomyopathy (ICM) and nonischemic dilated cardiomyopathy (NIDCM) patients, averaging 300 000 deaths in the United States annually.1-6 Implantable cardioverter-defibrillator (ICD) demonstrated to be the most effective SCD prophylactic strategy adopted for both primary Background-The aim of this study was to determine the prognostic benefit of cardiac magnetic resonance (CMR) over transthoracic echocardiography (TTE) in ischemic cardiomyopathy and nonischemic dilated cardiomyopathy patients evaluated for primary prevention implantable cardioverter-defibrillator therapy. Methods and Results-We enrolled 409 consecutive ischemic and dilated cardiomyopathy patients (mean age: 64±12 years; 331 men). All patients underwent TTE and CMR, and left ventricle end-diastolic volume, left ventricle end-systolic volume, and left ventricle ejection fraction (LVEF) were evaluated. In addition, late gadolinium enhancement was also assessed. All patients were followed up for major adverse cardiac events (MACE) defined as a composite end point of long runs of nonsustained ventricular tachycardia, sustained ventricular tachycardia, aborted sudden cardiac death, or sudden cardiac death. The median follow-up was 545 days. CMR showed higher left ventricle end-diastolic volume (mean difference: 43±22.5 mL), higher left ventricle endsystolic volume (mean difference: 34±20.5 mL), and lower LVEF (mean difference: −4.9±10%) as compared to TTE (P<0.01). MACE occurred in 103 (25%) patients. Patients experiencing MACE showed higher left ventricle end-diastolic volume, higher left ventricle end-systolic volume, and lower LVEF with both imaging modalities and higher late gadolinium enhancement perpatient prevalence as compared to patients without MACE. At multivariable analysis, CMR-LVEF ≤35% (hazard ratio=2.18 [1.3-3.8]) and the presence of late gadolinium enhancement (hazard ratio=2.2 [1.4-3.6]) were independently associated with MACE (P<0.01). A model based on CMR-LVEF ≤35% or CMR-LVEF ≤35% plus late gadolinium enhancement detection showed a higher performance in the prediction of MACE as compared to TTE-LVEF resulting in net reclassification improvement of 0.468 (95% confidence interval, 0.283-0.654; P<0.001) and 0.413 (95% confidence interval, 0.23-0.63; P<0.001), respectively. Conclusions-CMR provides additional prognostic stratification as compared to TTE, which may have direct impact on the indication of implantable cardioverter-defibrillator implantation. (Circ Cardiovasc Imaging. 2016;9:e004956.

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Response to Letters Regarding Article, “Myocardial Fibrosis as a Key Determinant of Left Ventricular Remodeling in Idiopathic Dilated Cardiomyopathy: A Contrast-Enhanced Cardiovascular Magnetic Study”

Cited by 4 publications

References 9 publications

Myocardial fibrosis in asymptomatic patients undergoing surgery for mitral and aortic valve regurgitation

Myocardial fibrosis in asymptomatic patients undergoing surgery for mitral and aortic valve regurgitation

Reverse Remodeling and Functional Improvement of Left Ventricle in Patients with Chronic Heart Failure Treated with Sacubitril/Valsartan: Comparison between Non-Ischemic and Ischemic Etiology

Prognostic Benefit of Cardiac Magnetic Resonance Over Transthoracic Echocardiography for the Assessment of Ischemic and Nonischemic Dilated Cardiomyopathy Patients Referred for the Evaluation of Primary Prevention Implantable Cardioverter–Defibrillator Therapy

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