- Email: [email protected]
Heart Failure and ECG-gated Single-photon Emission Computed Tomography
S136 Journal of Cardiac Failure Vol. 20 No. 10S October 2014
Symposium Symposium 1 Treatment Strategy of Ischemic Heart Failure, an Overview YUKIHITO SATO Division of Cardiovascular Medicine, Hyogo Prefectural Amagasaki Hospital, Amagasaki, Japan Etiological data showed that coronary artery disease (CAD) is the main leading cause of heart failure (HF) and that the presence of CAD has been shown to be independently associated with a poor prognosis. The therapeutic strategy is aiming prevention from reinfarction, sudden death and left ventricular (LV) remodeling. Recently, large scale clinical trials have documented the pharmacological therapies in patients with post myocardial infarction. ACE inhibitors, beta blockers and aldosterone antagonists has been shown to reduce cardiac death, non-fatal myocardial infarction (MI) and prevent LV remodeling. Besides the pharmacological therapies, device therapy, such as cardiac resynchronization therapy or implantable cardioverter defibrillators (ICD), are effective in certain patients with CAD and HF. However, the impact of inappropriate ICD shock on the HF needs to be determined. Finally, most patients with HF and CAD are in a gray zone without clear evidence of the need for surgical therapy, including revascularization, surgical treatment of mitral regurgitation, and ventricular restoration, even after the STICH trial that compared the strategy 1) medical therapy alone vs. medical therapy +CABG and 2) CABG alone vs. CABG +ventricular reconstruction in patients with severe reduced LVEF patients with CAD. This symposium will review the current understanding of the therapeutic strategies in patients with CAD and HF.
Evaluating the Morphological and Hemodynamic Status in Patients with Ischemic Heart Failure Using Several Imaging Modalities NORIAKI IWAHASHI, TOSHIAKI EBINA, KAZUO KIMURA Division of Cardiology, Yokohama City Univesity Medical Center, Yokohama, Japan The prediction of left ventricular (LV) remodeling is important and preventing its progression to ischemic heartfailure (IHF) is crucial. Two major causes of IHF are well recognized: HF with reduced ejection fraction(EF) (HFrEF) and HF with preserved EF (HFpEF). IHF typically occurs in patients who have not undergone adequate reperfusion therapy, who have large infarct size, or who have histories of myocardial infarction. Infarct size and LV function can be estimated using cardiac MRI (CMR). However, the use of CMR is contraindicated in patients with renal failure or some mechanical devices (e.g., implantable cardioverter-defibrillators and pacemakers). Radioisotopes (Tc or Tl) can be used instead of CMR for patients with these limitations. The resolution of isotope methods is not as high as with CMR; however, the resolution is satisfactory for a large portion of patients so these methods are still useful. Echocardiography (Echo) enables doctors to assess both the systolic and the diastolic function. Strain imaging provides assessments of systolic function with greater accuracy than EF because strain imaging has no tethering effect. Echo provides estimates of diastolic function using various Doppler imaging devices. Hemodynamic status and diastolic function can also be estimated using tissue Doppler imaging (E/e’). Patients with HFpEF can be treated using Echo. Patients with ischemic HF should be treated using these modalities accompanied by appropriate revascularization and medications.
Symposium 2 Heart Failure and ECG-gated Single-photon Emission Computed Tomography NAOYA MATSUMOTO1, YASUYUKI SUZUKI1, ATSUSHI HIRAYAMA2 1 Nihon University Surugadai Hospital, Department of Cardiology, Tokyo, Japan, 2 Nihon University School of Medicine, Department of Medicine, Division of Cardiology, Tokyo, Japan First of all, myocardial perfusion single-photon emission computed tomography (SPECT) will be used for the differentiation of ischemic cardiomyopathy and non-ischemic cardiomyopathy (DCM). Basically, non-ischemic cardiomyopathy shows essentially normal perfusion and global hypokinesis of the left ventricle with an impaired ejection fraction. ECG-gated SPECT calculates regional wall motion (mm), wall thickening (%) and time to maximum thickening (TTMT: msec) with QGS software. The patients with DCM showed higher maximum difference of TTMT (deltaTTMT) and coefficient of variation of TTMT (CVTTMT) than those in normal control subjects (16.4 vs 7.8, p!0.0001 and 206 vs 103msec, p!0.0001). These indices could be a useful marker for the evaluation of the severity in patientswith left ventricular dyssynchrony. TTMT is also a useful tool to evaluate the effect of cardiac resynchronization therapy (CRT). Dyssynchrony index (DI) which was derived from deltaTTMT may contribute to the evaluation and prediction of CRT. ECG-gated SPECT has a superiority to have those indices without time and effort. Assessment of Myocardial Fibrosis and Prognosis of Non-ischemic Cardiomyopathies by Using Non-contrast T1 Mapping EMI TATEISHI1, YOSHIAKI MORITA2 1 Department of Cardiology, Saiseikai Suita Hospital, Osaka, Japan, 2Department of Radiology, National Cerebral and Cardiovascular Center, Osaka, Japan Myocardial fibrosis is associated with worsening ventricular systolic function, progressive remodeling, and increased ventricular stiffness in patients with heart failure. Late gadolinium enhancement (LGE) on cardiac magnetic resonance (CMR) has been
established as an useful and less invasive method for evaluating myocardialfibrosis, and it plays an important role in the diagnosis of cardiomyopathies and the assessment of prognosis. Moreover, the novel CMR technique, T1 mapping, enables direct quantification of the extracellular volume (ECV) by the measurement of T1 relaxation time before and after gadolinium administration. Since ECV shows good correlation with histological collagen volume fraction, T1 mapping is a promising technique for accurate evaluation of not only focal fibrosis, which can be assessed by LGE, but also diffuse myocardial disorder which cannot be detected by LGE. Recently, several studies have proposed that T1 mapping before gadolinium administration, non-contrast T1 mapping, is potentially valuable for the quantitative assessment of focal and diffuse diseased myocardium. T1 mapping may therefore serve as an effective screening test for the patients with low pre-test likelihood for the presenceof cardiomyopathy and those in whom contrast administration is contraindicated.
Symposium 3 Respiratory Muscle Weakness in Patients with Heart Failure with Preserved Ejection Fraction YOSHIHARU KINUGASA1, KENSAKU YAMADA1, TAKESHI SOTA2, MARI MIYAKI3, SHINOBU SUGIHARA1, MASAHIKO KATO1, KAZUHIRO YAMAMOTO1 1 Division of Cardiovascular Medicine, Department of Molecular, Medicine and Therapeutics, Faculty of Medicine Tottori University, 2Division of Rehabilitation Tottori University Hospital, 3Division of Clinical Laboratory Tottori University Hospital, Yonago, Japan Background: Previous studies have shown that respiratory muscle weakness (RMW) is associated with exercise intolerance in patients with heart failure with reduced ejection fraction. However, in patients with heart failure with preserved ejection fraction (HFpEF), such relationship remains unclear. Methods: The present study enrolled a total of 36 patients with HFpEF (mean age 7722, 52.8% male, EF O 45%) who were hospitalized with HF in our institution. Respiratory muscle strength was assessed by a percent maximum inspiratory pressure to normal predicted value (%MIP), and exercise tolerance was assessed by 6-minute walk distance (6MWD) before hospital discharge. Results: RMW defined as %MIP!70% was prevalent in 36.1% of patients. Patients with RMW had significantly lower percent vital capacity to normal predicted values (%VC) and lower albumin level compared with those without RMW (all p!0.05). They had also significantly lower quadriceps muscle strength and 6MWD than those without RMW (all p!0.05). Multivariate regression analysis showed that lower %MIP was independently associated with reduced 6MWD as well as higher age and lower quadriceps muscle strength (p!0.05). Conclusions: RMW is a frequent co-morbidity, and is independently associated with exercise intolerance in patients with HFpEF. Further investigations are necessary to clarify the beneficial effect of inspiratory muscle training in these patients. Lack of Inertia Force of Late Systolic Aortic Flow is a Cause of Heart Failure with Preserved Ejection Fraction NOBUYUKI OHTE Department of Cardio-Renal Medicine and Hypertension, Nagoya City University Graduate School of Medical Sciences, Mizuho-ku Nagoya, Japan Inertia force (IF) of late systolic aortic flow is observed in left ventricles with good systolic function. A lack of IF may be related to left ventricular (LV) diastolic dysfunction and the pathogenesis of heart failure (HF) with preserved LV ejection fraction (EF). Accordingly, we examined the relationships between the IF and LV systolic and diastolic functions. IF was calculated from the LV pressure (P)-dP/dt relation. The IF significantly correlated with the LV systolic function parameters such as LVEF and LVend-systolic volume index in patients with preserved LVEF. It also significantly correlated with the parameters of LV early diastolic function, such as the time constant t of LV relaxation and the propagation velocity of LVearly diastolic filling flow. Furthermore, in a retrospective outcome-observational study in which combined subsequent HF and all-cause mortality were set as a study endpoint, fewer patients with IF reached the endpoint in comparison with patients without IF during follow-up. In conclusion, good LV systolic function speeds LV relaxation and enhances LVearly diastolic filling through the IF. A lack of IF causes LVisolated diastolic dysfunction and brings a poorer outcome. One of the causes of HF patients with preserved LVEF is relative or mild systolic dysfunction, although LVEF is more than 50% in this category of patients.
Symposium 4 Characteristics, Management, and Outcomes for Patients during Hospitalization due to Worsening Heart Failure in Japan Versus Europe and US HIROYUKI TSUTSUI Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan Heart failure (HF) is a complex condition with substantial morbidity and mortality and healthcare needs and economic burden for repeated worsening. Current clinical profiles of patients hospitalized with worsening HF have been documented based on large-scale hospital registries such as The EuroHeart Failure survey (EHFS) in
Symposium Symposium 1 Treatment Strategy of Ischemic Heart Failure, an Overview YUKIHITO SATO Division of Cardiovascular Medicine, Hyogo Prefectural Amagasaki Hospital, Amagasaki, Japan Etiological data showed that coronary artery disease (CAD) is the main leading cause of heart failure (HF) and that the presence of CAD has been shown to be independently associated with a poor prognosis. The therapeutic strategy is aiming prevention from reinfarction, sudden death and left ventricular (LV) remodeling. Recently, large scale clinical trials have documented the pharmacological therapies in patients with post myocardial infarction. ACE inhibitors, beta blockers and aldosterone antagonists has been shown to reduce cardiac death, non-fatal myocardial infarction (MI) and prevent LV remodeling. Besides the pharmacological therapies, device therapy, such as cardiac resynchronization therapy or implantable cardioverter defibrillators (ICD), are effective in certain patients with CAD and HF. However, the impact of inappropriate ICD shock on the HF needs to be determined. Finally, most patients with HF and CAD are in a gray zone without clear evidence of the need for surgical therapy, including revascularization, surgical treatment of mitral regurgitation, and ventricular restoration, even after the STICH trial that compared the strategy 1) medical therapy alone vs. medical therapy +CABG and 2) CABG alone vs. CABG +ventricular reconstruction in patients with severe reduced LVEF patients with CAD. This symposium will review the current understanding of the therapeutic strategies in patients with CAD and HF.
Evaluating the Morphological and Hemodynamic Status in Patients with Ischemic Heart Failure Using Several Imaging Modalities NORIAKI IWAHASHI, TOSHIAKI EBINA, KAZUO KIMURA Division of Cardiology, Yokohama City Univesity Medical Center, Yokohama, Japan The prediction of left ventricular (LV) remodeling is important and preventing its progression to ischemic heartfailure (IHF) is crucial. Two major causes of IHF are well recognized: HF with reduced ejection fraction(EF) (HFrEF) and HF with preserved EF (HFpEF). IHF typically occurs in patients who have not undergone adequate reperfusion therapy, who have large infarct size, or who have histories of myocardial infarction. Infarct size and LV function can be estimated using cardiac MRI (CMR). However, the use of CMR is contraindicated in patients with renal failure or some mechanical devices (e.g., implantable cardioverter-defibrillators and pacemakers). Radioisotopes (Tc or Tl) can be used instead of CMR for patients with these limitations. The resolution of isotope methods is not as high as with CMR; however, the resolution is satisfactory for a large portion of patients so these methods are still useful. Echocardiography (Echo) enables doctors to assess both the systolic and the diastolic function. Strain imaging provides assessments of systolic function with greater accuracy than EF because strain imaging has no tethering effect. Echo provides estimates of diastolic function using various Doppler imaging devices. Hemodynamic status and diastolic function can also be estimated using tissue Doppler imaging (E/e’). Patients with HFpEF can be treated using Echo. Patients with ischemic HF should be treated using these modalities accompanied by appropriate revascularization and medications.
Symposium 2 Heart Failure and ECG-gated Single-photon Emission Computed Tomography NAOYA MATSUMOTO1, YASUYUKI SUZUKI1, ATSUSHI HIRAYAMA2 1 Nihon University Surugadai Hospital, Department of Cardiology, Tokyo, Japan, 2 Nihon University School of Medicine, Department of Medicine, Division of Cardiology, Tokyo, Japan First of all, myocardial perfusion single-photon emission computed tomography (SPECT) will be used for the differentiation of ischemic cardiomyopathy and non-ischemic cardiomyopathy (DCM). Basically, non-ischemic cardiomyopathy shows essentially normal perfusion and global hypokinesis of the left ventricle with an impaired ejection fraction. ECG-gated SPECT calculates regional wall motion (mm), wall thickening (%) and time to maximum thickening (TTMT: msec) with QGS software. The patients with DCM showed higher maximum difference of TTMT (deltaTTMT) and coefficient of variation of TTMT (CVTTMT) than those in normal control subjects (16.4 vs 7.8, p!0.0001 and 206 vs 103msec, p!0.0001). These indices could be a useful marker for the evaluation of the severity in patientswith left ventricular dyssynchrony. TTMT is also a useful tool to evaluate the effect of cardiac resynchronization therapy (CRT). Dyssynchrony index (DI) which was derived from deltaTTMT may contribute to the evaluation and prediction of CRT. ECG-gated SPECT has a superiority to have those indices without time and effort. Assessment of Myocardial Fibrosis and Prognosis of Non-ischemic Cardiomyopathies by Using Non-contrast T1 Mapping EMI TATEISHI1, YOSHIAKI MORITA2 1 Department of Cardiology, Saiseikai Suita Hospital, Osaka, Japan, 2Department of Radiology, National Cerebral and Cardiovascular Center, Osaka, Japan Myocardial fibrosis is associated with worsening ventricular systolic function, progressive remodeling, and increased ventricular stiffness in patients with heart failure. Late gadolinium enhancement (LGE) on cardiac magnetic resonance (CMR) has been
established as an useful and less invasive method for evaluating myocardialfibrosis, and it plays an important role in the diagnosis of cardiomyopathies and the assessment of prognosis. Moreover, the novel CMR technique, T1 mapping, enables direct quantification of the extracellular volume (ECV) by the measurement of T1 relaxation time before and after gadolinium administration. Since ECV shows good correlation with histological collagen volume fraction, T1 mapping is a promising technique for accurate evaluation of not only focal fibrosis, which can be assessed by LGE, but also diffuse myocardial disorder which cannot be detected by LGE. Recently, several studies have proposed that T1 mapping before gadolinium administration, non-contrast T1 mapping, is potentially valuable for the quantitative assessment of focal and diffuse diseased myocardium. T1 mapping may therefore serve as an effective screening test for the patients with low pre-test likelihood for the presenceof cardiomyopathy and those in whom contrast administration is contraindicated.
Symposium 3 Respiratory Muscle Weakness in Patients with Heart Failure with Preserved Ejection Fraction YOSHIHARU KINUGASA1, KENSAKU YAMADA1, TAKESHI SOTA2, MARI MIYAKI3, SHINOBU SUGIHARA1, MASAHIKO KATO1, KAZUHIRO YAMAMOTO1 1 Division of Cardiovascular Medicine, Department of Molecular, Medicine and Therapeutics, Faculty of Medicine Tottori University, 2Division of Rehabilitation Tottori University Hospital, 3Division of Clinical Laboratory Tottori University Hospital, Yonago, Japan Background: Previous studies have shown that respiratory muscle weakness (RMW) is associated with exercise intolerance in patients with heart failure with reduced ejection fraction. However, in patients with heart failure with preserved ejection fraction (HFpEF), such relationship remains unclear. Methods: The present study enrolled a total of 36 patients with HFpEF (mean age 7722, 52.8% male, EF O 45%) who were hospitalized with HF in our institution. Respiratory muscle strength was assessed by a percent maximum inspiratory pressure to normal predicted value (%MIP), and exercise tolerance was assessed by 6-minute walk distance (6MWD) before hospital discharge. Results: RMW defined as %MIP!70% was prevalent in 36.1% of patients. Patients with RMW had significantly lower percent vital capacity to normal predicted values (%VC) and lower albumin level compared with those without RMW (all p!0.05). They had also significantly lower quadriceps muscle strength and 6MWD than those without RMW (all p!0.05). Multivariate regression analysis showed that lower %MIP was independently associated with reduced 6MWD as well as higher age and lower quadriceps muscle strength (p!0.05). Conclusions: RMW is a frequent co-morbidity, and is independently associated with exercise intolerance in patients with HFpEF. Further investigations are necessary to clarify the beneficial effect of inspiratory muscle training in these patients. Lack of Inertia Force of Late Systolic Aortic Flow is a Cause of Heart Failure with Preserved Ejection Fraction NOBUYUKI OHTE Department of Cardio-Renal Medicine and Hypertension, Nagoya City University Graduate School of Medical Sciences, Mizuho-ku Nagoya, Japan Inertia force (IF) of late systolic aortic flow is observed in left ventricles with good systolic function. A lack of IF may be related to left ventricular (LV) diastolic dysfunction and the pathogenesis of heart failure (HF) with preserved LV ejection fraction (EF). Accordingly, we examined the relationships between the IF and LV systolic and diastolic functions. IF was calculated from the LV pressure (P)-dP/dt relation. The IF significantly correlated with the LV systolic function parameters such as LVEF and LVend-systolic volume index in patients with preserved LVEF. It also significantly correlated with the parameters of LV early diastolic function, such as the time constant t of LV relaxation and the propagation velocity of LVearly diastolic filling flow. Furthermore, in a retrospective outcome-observational study in which combined subsequent HF and all-cause mortality were set as a study endpoint, fewer patients with IF reached the endpoint in comparison with patients without IF during follow-up. In conclusion, good LV systolic function speeds LV relaxation and enhances LVearly diastolic filling through the IF. A lack of IF causes LVisolated diastolic dysfunction and brings a poorer outcome. One of the causes of HF patients with preserved LVEF is relative or mild systolic dysfunction, although LVEF is more than 50% in this category of patients.
Symposium 4 Characteristics, Management, and Outcomes for Patients during Hospitalization due to Worsening Heart Failure in Japan Versus Europe and US HIROYUKI TSUTSUI Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan Heart failure (HF) is a complex condition with substantial morbidity and mortality and healthcare needs and economic burden for repeated worsening. Current clinical profiles of patients hospitalized with worsening HF have been documented based on large-scale hospital registries such as The EuroHeart Failure survey (EHFS) in