Comparison of Mortality Rates and Progression of Left Ventricular Dysfunction in Patients With Idiopathic Dilated Cardiomyopathy and Dilated Versus Nondilated Right Ventricular Cavities

doi:10.1016/S0002-9149(97)00780-7

The American Journal of Cardiology

Volume 80, Issue 12, 15 December 1997, Pages 1583-1587

https://doi.org/10.1016/S0002-9149(97)00780-7 Get rights and content

Abstract

This study assesses the influence of right ventricular (RV) dilation on the progression of left ventricular (LV) dysfunction and survival in patients with idiopathic dilated cardiomyopathy (IDC). Using transthoracic echocardiography, we studied 100 patients with IDC aged 20 to 80 years (mean 55 ± 14); 67% were men. In the apical 4-chamber view, diastolic LV and RV chamber area measurements classified patients into 2 groups: group RV enlargement+ (RV area/LV area >0.5) included 54 patients; group RV enlargement− (no RV enlargement) had RV area/LV area ≤0.5. Echocardiographic studies were repeated in all patients after a mean of 33 ± 16 months. At the time of the initial study, the 2 groups did not differ in age, gender, incidence of atrial fibrillation and diabetes, left ventricular mass, and LV ejection fraction, but the RV enlargement+ group had more severe tricuspid regurgitation and less LV enlargement. After 47 ± 22 months (range 12 to 96), patients in group RV enlargement+ had lower LV ejection fraction (29% vs 34%, p = 0.006) than patients with initial RV enlargement−. At clinical follow-up, mortality was higher (43%) in patients with initial RV enlargement+ than the RV enlargement− patients (15%), p = 0.002. For survivors, the mitral deceleration time averaged 157 ± 36 ms; for nonsurvivors or patients who required transplant, the mitral deceleration time averaged 97 ± 12 ms (p <0.0001). With use of a multivariate Cox model adjusting for LV ejection fraction, LV size, and age, the relative risk ratio of mortality from initial RV enlargement+ was 4.4 (95% confidence limits 1.7 to 11.1) (p = 0.002). Thus, patients with significant RV dilation had nearly triple the mortality over 4 years and more rapidly deteriorating LV function than patients with less initial RV dilation. In IDC, RV enlargement is a strong marker for adverse prognosis that may represent a different morphologic subset.

Section snippets

Patient Selection:

From May 1986 to March 1993, we performed transthoracic echocardiography on 100 patients with global LV dysfunction (LV ejection fraction ≤40%), who subsequently had a second echocardiographic study >1 year later at our institution, and did not have primary valvular disease (stenosed or regurgitant); ischemic heart disease (by clinical, echocardiographic, angiographic, or electrocardiographic evidence for prior myocardial infarction); or uncontrolled hypertensive heart disease (systolic blood

Ventricular Dimensions and Function at Initial Echo Study:

Table I shows comparisons of ventricular dimensions and function at the time of initial and follow-up studies for the 2 subsets of RV enlargement+ and RV enlargement− groups. LV mass index and ejection fraction, and left atrial area did not differ between the 2 groups of patients. In contrast, RV diastolic and systolic chamber areas and right atrial area were larger in the RV enlargement+ than in the RV enlargement− group at the initial study. LV diastolic and systolic cavity areas and RV

Discussion

Lewis et al[11] were the first investigators to study the variability in RV dilatation in IDC relative to LV dilatation. Using the ratio of RV to LV area in the apical 4-chamber view to define patient groups, they found that patients with IDC with predominant dilation of the left ventricle without RV dilation had significantly better survival over the follow-up period than did patients with both LV and RV dilation. Their results suggested that patients with a relatively equal degree of LV and

References (18)

V Fuster et al.
The natural history of idiopathic dilated cradiomyopathy
Am J Cardiol
(1981)
LW Stevenson et al.
The dilated cardiomyopathiesclinical aspects
Cardiol Clin
(1988)
DS Blondheim et al.
Dilated cardiomyopathy with mitral regurgitationdecreased survival despite a low frequency of LV thrombus
Am Heart J
(1991)
JA Franciosa et al.
Survival in men with severe chronic LV failure due to either coronary heart disease or idiopathic dilated cardiomyopathy
Am J Cardiol
(1983)
JP Segal et al.
Idiopathic cardiomyopathyclinical features, prognosis and therapy
Curr Prob Cardiol
(1978)
R Engler et al.
Clinical assessment and follow-up of functional capacity in patients with chronic congestive cardiomyopathy
Am J Cardiol
(1982)
JF Lewis et al.
Discordance in degree of right and left ventricular dilation in patients with dilated cardiomyopathyrecognition and clinical implications
J Am Coll Cardiol
(1993)
RB Devereux et al.
Echocardiographic assessment of left ventricular hypertrophycomparison with necropsy findings
Am J Cardiol
(1986)
K Miyatake et al.
Semiquantitative grading of severity of mitral regurgitation by real-time two dimensional Doppler flow imaging technique
J Am Coll Cardiol
(1986)

There are more references available in the full text version of this article.

Cited by (98)

Refining Severe Tricuspid Regurgitation Definition by Echocardiography with a New Outcomes-Based “Massive” Grade
2020, Journal of the American Society of Echocardiography
Citation Excerpt :
This adaptive RV dilation and systolic dysfunction have been shown to be markers of poor prognosis. In a study of patients with idiopathic LV dilated cardiomyopathy, concomitant RV enlargement is a strong predictor of poor prognosis, with nearly triple the mortality over 4 years.29 In a study of patients with New York Heart Association class II symptoms and heart failure with reduced LV systolic function, RV ejection fraction but not LV ejection fraction was an independent predictor of survival.30
Current echocardiographic guidelines recommend that tricuspid regurgitation (TR) severity be graded in three categories, following assessment of specific parameters. Findings from recent trials have shown that the severity of TR frequently far exceeds the current definition of severe. We postulated that a grading approach that emphasizes outcomes could be useful to identify patients with severe TR at increased risk of mortality.
We identified 284 patients with echocardiograms demonstrating severe functional TR, defined as vena contracta (VC) ≥ 0.7 cm. Demographics and mortality data were obtained from the medical records. Patients were divided into study (n = 122 patients with three-dimensional images) and validation (n = 162) cohorts. The VC was measured in both the right ventricular (RV) inflow and apical four-chamber views and averaged. For the study cohort, tricuspid annular, RV end-diastolic (basal, mid, long axis) dimensions, tricuspid leaflet tenting height and area, RV free-wall longitudinal strain, and RV volumes were measured from two- and three-dimensional data sets. A K-partition algorithm was used in the study cohort to derive a mortality-related cutoff VC value, above which TR was termed “massive.” The ability of this VC cutoff to identify patients at greater mortality risk was then tested in the validation cohort using Kaplan-Meier survival analysis.
In the study cohort, VC > 0.92 cm (massive TR) was optimally associated with worse survival. Tricuspid annular and RV size were larger in the massive group (P < .05), while there were no significant differences in demographics between the TR groups. Importantly, in the independent validation cohort, the above VC cutoff also correlated with increased mortality in the massive group (log-rank P < .05).
Among patients traditionally defined as having severe TR, a subset exists with massive TR, resulting in greater adverse RV remodeling and increased mortality. These patients may derive the greatest benefit from emerging percutaneous therapies.
Cardiac Structural and Functional Consequences of Amyloid Deposition by Cardiac Magnetic Resonance and Echocardiography and Their Prognostic Roles
2019, JACC: Cardiovascular Imaging
Citation Excerpt :
RV dysfunction is common in cardiac amyloidosis (7). Furthermore, RV failure is a well-documented independent predictor of prognosis in patients with primary left heart failure (27–29). However, direct RV subendocardial infiltration is likely to be the principal reason behind the prognostic importance of TAPSE in amyloidosis, rather than RV dysfunction as a consequence of LV impairment.
This cross-sectional study aimed to describe the functional and structural cardiac abnormalities that occur across a spectrum of cardiac amyloidosis burden and to identify the strongest cardiac functional and structural prognostic predictors in amyloidosis using cardiac magnetic resonance (CMR) and echocardiography.
Cardiac involvement in light chain and transthyretin amyloidosis is the main driver of prognosis and influences treatment strategies. Numerous measures of cardiac structure and function are assessed by multiple imaging modalities in amyloidosis.
A total f 322 subjects (311 systemic amyloidosis and 11 transthyretin gene mutation carriers) underwent comprehensive CMR and transthoracic echocardiography. The probabilities of 11 commonly measured structural and functional cardiac parameters being abnormal with increasing cardiac amyloidosis burden were evaluated. Cardiac amyloidosis burden was quantified using CMR-derived extracellular volume. The prognostic capacities of these parameters to predict death in amyloidosis were assessed using Cox proportional hazards models.
Left ventricular mass and mitral annular plane systolic excursion by CMR along with strain and E/e’ by echocardiography have high probabilities of being abnormal at low cardiac amyloid burden. Reductions in biventricular ejection fractions and elevations in biatrial areas occur at high burdens of infiltration. The probabilities of indexed stroke volume, myocardial contraction fraction, and tricuspid annular plane systolic excursion (TAPSE) being abnormal occur more gradually with increasing extracellular volume. Ninety patients (28%) died during a median follow-up of 22 months (interquartile range: 10 to 38 months). Univariable analysis showed that all imaging markers studied significantly predicted outcome. Multivariable analysis showed that TAPSE (hazard ratio: 1.46; 95% confidence interval: 1.16 to 1.85; p < 0.01) and indexed stroke volume (hazard ratio: 1.24; 95% confidence interval: 1.04 to 1.48; p < 0.05) by CMR were the only independent predictors of mortality.
Specific functional and structural abnormalities characterize different burdens of cardiac amyloid deposition. In a multimodality imaging assessment of a large cohort of amyloidosis patients, CMR-derived TAPSE and indexed stroke volume are the strongest prognostic cardiac functional markers.
Right ventricular enlargement predicts responsiveness to tolvaptan in congestive heart failure patients with reduced ejection fraction
2018, IJC Heart and Vasculature
Citation Excerpt :
First, RV dilatation itself may be a reliable maker of venous congestion because RV dilatation was proven to represents right-sided volume overload and elevated filling pressure [28,29]. Second, patients with RV dilatation may tend to show RV diastolic dysfunction similar to that seen in constrictive pericarditis, and may have more severe venous congestion [24,30–35]. Since our study population consisted of patients with RV dilatation with coexistence of LV and left atrial dilatation, the thin-walled RV is expected to result in less dilatation because of crowding within the limited pericardial space or diastolic ventricular interdependence.
Tolvaptan is a vasopressin type 2 receptor antagonist used in heart failure (HF) with refractory diuretic resistance. However, since tolvaptan is also ineffective in some HF patients with reduced ejection fraction (HFrEF), the identification of responders is important.
The study population consisted of 51 HFrEF patients who were administered tolvaptan (EF, 28 ± 7%). We defined responders as patients with a ≥50% increase in urine volume during the 24-hours after administration of tolvaptan. All patients underwent comprehensive transthoracic echocardiography before administration of tolvaptan. Patients were followed for 120 days to ascertain secondary events (cardiac death and rehospitalization for HF).
Multiple regression analysis indicated that right ventricular (RV) enlargement (defined as basal RV diameter > 41 mm and midlevel RV diameter > 35 mm, according to guidelines) remained a predictor of response after adjustment for age, sex, starting dosage of tolvaptan, and estimated glomerular filtration rate (odds ratio, 4.88; 95%-confidence interval, 1.26–18.9; P < 0.05), whereas left ventricular parameters and RV dysfunction were not. Kaplan-Meier curves indicated responsiveness to tolvaptan was associated with better prognosis among the overall population (P < 0.05); similar trends were observed among patients with RV dilatation (P = 0.056).
These findings suggest that RV enlargement, which represents right-sided volume overload, elevated filling pressure, and diastolic dysfunction similar to that seen in constrictive pericarditis, predicts responsiveness to tolvaptan in patients with HFrEF. Moreover, administration of tolvaptan may have the potential to improve the reportedly poor prognosis for HFrEF patients with RV dilatation.
Assessment of right ventricular function by echocardiography in patients with chronic heart failure
2018, Egyptian Heart Journal
The main focus of most of the studies in heart failure (HF) is the assessment of the left ventricular functions, while the right ventricle was much less studied. Much of this neglect is due to the complexity of anatomy and physiology of the right ventricle which are considered challenges during assessment of RV.
[1] To review the alterations of right ventricular dimensions & function associated with chronic heart failure. [2] To predict the prevalence of right ventricular systolic dysfunction in patients with chronic heart failure, based on echocardiographic parameters.
100 chronic left sided heart failure patients with LVEF less than 40% were evaluated in Ain Shams University hospitals from April 2015 to March 2016. All patients were subjected to full history taking & clinical evaluation. ECG was done mainly to exclude presence of ischemic heart disease. Complete trans-thoracic echocardiography study was done for assessment of [B] Left ventricular dimensions, systolic and diastolic functions [B] Assessment of the right side of the heart: [1] Measurement of the right ventricular dimensions [basal – mid cavity and the longitudinal diameters]. [2] Right ventricular area and calculation of the fractional area change (FAC). [3] Tricuspid annular plane systolic excursion (TAPSE). [4] Tissue Doppler derived tricuspid lateral annular systolic velocity (S′ wave velocity). [5] Tissue Doppler derived Myocardial Performance Index (MPI) (Tei index). [6] Grading of tricuspid regurgitation severity, and assessment of right ventricular systolic pressure.
Right ventricle was dilated at the basal level in 36% of the studied patients & at the mid cavity level in 23% of the patients. Longitudinal RV diameter was enlarged in 20% of the patients.
Right ventricular systolic dysfunction was found in 36% of patients with DCM in the current study. Patients who had right ventricular systolic dysfunction had significantly higher incidence of elevated JVP, significantly lower EF and significantly higher grade of LV Diastolic dysfunction. They showed significantly larger RV dimensions at different levels, significantly worse degree of TR and significantly higher mean value of RVSP.
The occurrence of right ventricular systolic dysfunction in patients with DCM is common [Approaching 40% in this study] and is independent of age and sex, and is proportionate to the degree of LV dilatation, and EF impairment.
Relation of High Serum Bilirubin to Short-Term Mortality Following a Myocardial Infarction Complicated by Left Ventricular Systolic Dysfunction (from the High-Risk Myocardial Infarction Database Initiative)
2018, American Journal of Cardiology
Citation Excerpt :
Our study showed that elevated bilirubin values are relatively frequent in the studied population and are independently associated with dismal prognosis. Both hemodynamic and echocardiographic data suggest that elevated “right-sided pressures” (which are transmitted directly to the hepatic veins) may contribute to cholestatic liver function abnormalities and to a dismal outcome8,12,29–31 In our analysis, the prevalence of abnormally elevated bilirubin concentrations was relatively high (14.1%) despite the exclusion of patients with significant liver disease at the time of enrollment and the low proportion of patients with a history of alcohol abuse. The proportion of patients with an elevated bilirubin concentration in the present study was consistent with that of previous reports of patients with chronic HF (≈15%),31 but lower than that of reports of patients with acute HF (≈26%).32
Higher serum bilirubin has been associated with poorer prognosis in patients with heart failure (HF). We examined the association between serum bilirubin and clinical outcomes in patients with clinical signs of HF and/or left ventricular systolic dysfunction after acute myocardial infarction (MI). A total of 7,467 patients from the High-Risk Myocardial Infarction Database Initiative with an available baseline total bilirubin concentration were studied. The association between baseline bilirubin concentrations and the composite outcome of cardiovascular mortality (CVM), nonfatal stroke, nonfatal MI or hospitalization for HF, CVM, and all-cause mortality were assessed using Cox proportional hazards models. An interaction with time was observed with associations present only in the first 90 days after randomization. The median (percentile_25-75) baseline total bilirubin concentration was 11 (8 to 14) µmol/L and was above the “normal” range (>17.1 µmol/L) in 1,053 (14.1%) patients. In multivariable analysis, with adjustment for baseline characteristics (demographic, co-morbidities, Killip score, left ventricular ejection fraction, and laboratory variables), patients with a bilirubin concentration of >17.1 µmol/L had a significantly higher risk of all the studied outcomes at 90 days (e.g., CVM: adjusted hazard ratio 1.45, 95% confidence interval 1.14 to 1.86, p = 0.003). The addition of bilirubin to a validated survival model modestly improved the risk reclassification to predict 90-day events (continuous net reclassification improvement for CVM 6.4%, 95% confidence interval 0.7% to 9.6%, p = 0.04). In patients with MI complicated with HF and/or systolic dysfunction, bilirubin concentration is an independent predictor of mortality and may improve risk stratification.
Long-Term Survival in Patients Receiving a Continuous-Flow Left Ventricular Assist Device
2018, Annals of Thoracic Surgery
Long-term survivors after implantation of left ventricular assist devices (LVADs) are increasing in prevalence. We describe the characteristics and outcomes in patients surviving longer than 4 years on LVAD support.
We performed a multicenter, retrospective analysis of patients surviving at least 4 years on continuous-flow LVAD (CF-LVAD) support with a HeartMate II at centers participating in the Evolving Mechanical support Research Group.
Between 2005 and 2010, 156 long-term survivors were identified with a mean survival of 7.1 years (95% confidence interval: 6.7 to 7.5 years). The mean age was 58.2 ± 15.2 years and 30.1% were women. Readmission rate was low at 1.1 events per patient per year with the most common reasons leading to readmission being infection (0.10 readmissions per patient per year) and gastrointestinal bleeding (0.07 readmissions per patient per year). Two years after implantation, 97% of patients were either New York Heart Association functional class I or II, with 92% at 4 years.
Patients surviving 4 years on CF-LVAD support can anticipate ongoing long-term survival with sustained improvements in functionality and low rates of rehospitalization.

View all citing articles on Scopus

View full text

CardiomyopathyComparison of Mortality Rates and Progression of Left Ventricular Dysfunction in Patients With Idiopathic Dilated Cardiomyopathy and Dilated Versus Nondilated Right Ventricular Cavities

Abstract

Section snippets

Patient Selection:

Ventricular Dimensions and Function at Initial Echo Study:

Discussion

Am J Cardiol

Cardiol Clin

Am Heart J

Am J Cardiol

Curr Prob Cardiol

Am J Cardiol

J Am Coll Cardiol

Am J Cardiol

J Am Coll Cardiol

Cardiomyopathy
Comparison of Mortality Rates and Progression of Left Ventricular Dysfunction in Patients With Idiopathic Dilated Cardiomyopathy and Dilated Versus Nondilated Right Ventricular Cavities