Cardiac Rotational Mechanics As a Predictor of Myocardial Recovery in Heart Failure Patients Undergoing Chronic Mechanical Circulatory Support

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Advanced and chronic dilated cardiomyopathy (NYHA IV) undergoing LVAD implantation (n=63). Intervention: Pre-LVAD peak LV torsion measured by speckle tracking echocardiography vs. Patients not fulfilling criteria for post-LVAD cardiac recovery (Non-Rec Group). Primary outcome: Cardiac recovery post-LVAD implantation (all 3 required: final LVEF >=40%, relative LVEF increase >=50%, and relative LV end-systolic volume index decrease >=50%) (OR 0.65 per 0.1 degrees/cm, 95% CI 0.49-0.87, p=0.014).

Q: What does this research mean for the field?

Pre-implantation peak left ventricular torsion independently predicts myocardial recovery in chronic advanced cardiomyopathy patients undergoing mechanical circulatory support with a left ventricular assist device. Novelty: ClaimNovelty.NOVEL_FINDING. Consensus alignment: ConsensusAlignment.NEUTRAL.

Michael Bonios; Antigone Koliopoulou; Omar Wever‐Pinzon; Iosif Taleb; Josef Stehlik; Weining Xu; James Wever‐Pinzon; Annamaria Catino; Abdallah G. Kfoury; Benjamin D. Horne; José Nativi-Nicolau; Stamatis Adamopoulos; James C. Fang; Craig H. Selzman; Jeroen J. Bax; Stavros G. Drakos

doi:10.1161/circimaging.117.007117

April 1, 2018Circulation Cardiovascular ImagingOpen Access

Cardiac Rotational Mechanics As a Predictor of Myocardial Recovery in Heart Failure Patients Undergoing Chronic Mechanical Circulatory Support

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Key result

Pre-LVAD peak LV torsion is linked to ~35% lower odds of post-LVAD recovery per 0.1°/cm.

OR 0.65 per 0.1 degrees/cm
95% CI 0.49-0.87
P=0.014
n=63

Why the study?

Does pre-implantation left ventricular torsion assessed by speckle tracking echocardiography predict myocardial recovery in patients with chronic advanced dilated cardiomyopathy undergoing LVAD support?

Key Points

To determine whether baseline left ventricular rotational mechanics can predict myocardial recovery in patients with chronic advanced cardiomyopathy undergoing mechanical circulatory support.
Prospectively evaluated 63 patients with advanced chronic dilated cardiomyopathy undergoing left ventricular assist device (LVAD) implantation using speckle tracking echocardiography.
Excluded acute heart failure cases, patients with inadequate echocardiographic imaging (n=67), and those with less than 3 months of post-LVAD follow-up (n=90).
Defined cardiac recovery by meeting all three criteria: final left ventricular ejection fraction ≥40%, relative ejection fraction increase ≥50%, and relative end-systolic volume decrease ≥50%.
Twelve of 63 patients met the recovery criteria, demonstrating significantly less impaired pre-LVAD peak LV torsion than non-recovered patients despite similarly reduced pre-LVAD ejection fractions.
A pre-LVAD peak LV torsion cutoff of 0.35 degrees/cm predicted cardiac recovery with 92% sensitivity and 73% specificity by receiver operating characteristic curve analysis.
Peak LV torsion before LVAD implantation was an independent predictor of cardiac recovery (odds ratio, 0.65 per 0.1 degrees/cm [0.49–0.87]; P =0.014).

Study Design

Type

Cohort (n=63)

Structured PICO

Does pre-implantation left ventricular torsion assessed by speckle tracking echocardiography predict myocardial recovery in patients with chronic advanced dilated cardiomyopathy undergoing LVAD support?

P

Population

63 patients with advanced chronic dilated cardiomyopathy (NYHA IV) undergoing LVAD implantation at the University of Utah, followed with serial echocardiograms for up to 12 months.

E

Exposure

Pre-LVAD left ventricular rotational mechanics (specifically peak LV torsion, apical and basal LV twist) and deformational mechanics (GLS and circumferential strain) assessed via 2D speckle tracking echocardiography (velocity vector imaging)

C

Comparator

Patients not achieving myocardial recovery (Non-Rec Group, n=51) versus those achieving myocardial recovery (Rec Group, n=12); pre-LVAD baseline mechanics also compared to 15 control subjects without structural heart disease

O

Outcome

Cardiac recovery post-LVAD implantation within 12 months, defined as fulfilling all three criteria: (1) final resulting LVEF >=40%, (2) relative LVEF increase >=50%, and (3) relative LV end-systolic volume index (LVESVi) decrease >=50%surrogate

Main Result

Odds Ratio: 0.65 (95% CI 0.49–0.87)

p-value: p=0.014

Pre-LVAD peak LV torsion assessed by speckle tracking echocardiography independently predicts myocardial recovery during chronic mechanical unloading even when baseline LVEF is similarly depressed, offering a potential non-invasive tool to select candidates for targeted recovery protocols.

Limitations

Large proportion of patients had poor quality echocardiographic images following LVAD implantation, precluding post-LVAD quantification of torsional parameters
Relatively small number of patients (n=12) fulfilled criteria for myocardial recovery, limiting multivariate regression models to up to two explanatory variables
High exclusion rate from the initial screened cohort (67 excluded for inadequate image quality and 90 for <3-month follow-up)
Poor echocardiographic image quality post-LVAD prevented quantification of post-implantation torsional parameters in a large proportion of patients
Small sample size of patients achieving myocardial recovery (n=12), restricting multivariable regression models to two variables
Substantial exclusions from the 220 screened LVAD patients (67 for poor image quality, 90 for <3 months follow-up)

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Implication

May support torsion assessment to identify LVAD recovery candidates; leaves open prospective validation before guiding selection.

Abstract

Background: Impaired qualitative and quantitative left ventricular (LV) rotational mechanics predict cardiac remodeling progression and prognosis after myocardial infarction. We investigated whether cardiac rotational mechanics can predict cardiac recovery in chronic advanced cardiomyopathy patients. Methods and Results: Sixty-three patients with advanced and chronic dilated cardiomyopathy undergoing implantation of LV assist device (LVAD) were prospectively investigated using speckle tracking echocardiography. Acute heart failure patients were prospectively excluded. We evaluated LV rotational mechanics (apical and basal LV twist, LV torsion) and deformational mechanics (circumferential and longitudinal strain) before LVAD implantation. Cardiac recovery post-LVAD implantation was defined as (1) final resulting LV ejection fraction ≥40%, (2) relative LV ejection fraction increase ≥50%, (iii) relative LV end-systolic volume decrease ≥50% (all 3 required). Twelve patients fulfilled the criteria for cardiac recovery (Rec Group). The Rec Group had significantly less impaired pre-LVAD peak LV torsion compared with the Non-Rec Group. Notably, both groups had similarly reduced pre-LVAD LV ejection fraction. By receiver operating characteristic curve analysis, pre-LVAD peak LV torsion of 0.35 degrees/cm had a 92% sensitivity and a 73% specificity in predicting cardiac recovery. Peak LV torsion before LVAD implantation was found to be an independent predictor of cardiac recovery after LVAD implantation (odds ratio, 0.65 per 0.1 degrees/cm [0.49–0.87]; P =0.014). Conclusions: LV rotational mechanics seem to be useful in selecting patients prone to cardiac recovery after mechanical unloading induced by LVADs. Future studies should investigate the utility of these markers in predicting durable cardiac recovery after the explantation of the cardiac assist device.

Discussion

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Cite This Study

Bonios et al. (2018) conducted a cohort in Advanced and chronic dilated cardiomyopathy (NYHA IV) undergoing LVAD implantation (n=63). Pre-LVAD peak LV torsion measured by speckle tracking echocardiography vs. Patients not fulfilling criteria for post-LVAD cardiac recovery (Non-Rec Group) was evaluated on Cardiac recovery post-LVAD implantation (all 3 required: final LVEF >=40%, relative LVEF increase >=50%, and relative LV end-systolic volume index decrease >=50%) (OR 0.65 per 0.1 degrees/cm, 95% CI 0.49-0.87, p=0.014). Pre-LVAD peak LV torsion independently predicted post-LVAD cardiac recovery (OR 0.65 per 0.1 degrees/cm, 95% CI 0.49-0.87; P=0.014), with a cutoff >=0.35 degrees/cm yielding 92% sensitivity.

synapsesocial.com/papers/6a74d27b6a5eb4b8f5092cca https://doi.org/10.1161/circimaging.117.007117

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Cardiac Rotational Mechanics As a Predictor of Myocardial Recovery in Heart Failure Patients Undergoing Chronic Mechanical Circulatory Support

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Cardiac Rotational Mechanics As a Predictor of Myocardial Recovery in Heart Failure Patients Undergoing Chronic Mechanical Circulatory Support

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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