Clinical features and outcomes of patients with apical hypertrophic cardiomyopathy

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Abstracts / Cardiovascular Revascularization Medicine 9 (2008) 101–129 Significance of hypertension in hypertophic cardiomyopathy F Aslam Ali, Islamabad, Pakistan

Fig. 1.

mortality was ascertained from the social security master death file. Target vessel revascularization was defined as a repeat intervention on the same vessel (right, left, circumflex, or left main) or death during the study period. Kaplan Meier and Cox proportional hazard survival methods were performed, adjusted for age, sex, diabetes, priority indication, prior coronary artery bypass graft, congestive heart failure, renal function, number of stents implanted, and number of diseased vessels. Results: There was 2.3 years of follow-up (mean, 1.1 years). Target vessel revascularization at 1 (2.7% SES vs 3.8% PES, P=.12) and at 2.3 (3.8% SES vs. 5.4% PES, P=.06) years was similar between the stent platforms. Overall, 2.3-year mortality was 3.0% for SES and 4.3% for PES (P=.08). Target vessel revascularization–free survival at 2.3 years was 91.3% for SES and 86.6% for PES (P=.06) with adjusted hazard ratio of 1.39 (95% CI, 0.99-1.97). Conclusion: Sirolimus-eluting stents and PES platforms had similar outcomes and both performed well in this contemporary, unselected, realworld PCI experience. Fig. 1 doi:10.1016/j.carrev.2008.02.018

Relief of migraine headaches associated with closure of patent foramen ovale F Aslam Ali, Islamabad, Pakistan Objective: The incidence of patent foramen ovale (PFO) in patients with migraine is at least twice that of the general population. However, few reports demonstrate the impact of PFO closure on the relief of migraine headaches. We retrospectively surveyed PFO closure patients to determine if those with migraines were improved after PFO closure. Methods: Between January 2001 and December 2004, 52 PFOs were closed percutaneously using the Cardioseal or Amplatzer devices for patients with a history of prior transient ischemic attack or stroke. At a mean of 28 months post PFO closure, all patients were called to identify the presence, frequency, and type of migraine headache (MH) episode occurring pre- and postprocedure. Migraine headache and associated aura were defined according to the criteria of the International Headache Society. Patients were not informed that PFO closure might have any impact on MH. Results: Among a total of 52 PFO closure patients, 22 (42%) had MH and 12 of 22 had aura. The average age of MH patients was 44 years, and 55% were women. Follow-up transthoracic echocardiography showed complete PFO closure in all patients. Of 22, 8 (36%) had complete relief of MH, and 8 (36%) had partial relief. There was a cumulative reduction in the frequency of MH from 3.06 to 0.05 episodes per patient per month. Conclusion: This observational study demonstrated that PFO closure can reduce, and frequently eliminate, migraine episodes and suggests that, in some patients with MH, PFOs may have a role in the genesis of the headache. doi:10.1016/j.carrev.2008.02.019

Background: Systemic hypertension (SH) and hypertrophic cardiomyopathy (HCM) are important causes of left ventricular hypertrophy. The frequency of coexistence of the 2 conditions increases with age and poses significant diagnostic and management challenges. It is unclear to what extent one disease affects the cardiac phenotypic expression and clinical outcome of the other. The purpose of this study was to compare the echocardiographic and clinical outcome of patients with HCM and with and without SH. Methods: From 1995 to 2005, 196 adults with HCM were evaluated at our institution. Hypertrophic cardiomyopathy was defined as primarily nonuniformly hypertrophied heart with a minimum left ventricular wall thickness of 15 mm. Among these, 122 (62%, group 1) also had SH, defined as blood pressure above 140/90 mm Hg. The clinical presentation, management, outcome, and echocardiographic findings of these patients were compared to 74 (38%, group 2) without SH. Results: Patients in group 1 were older at the time of HCM diagnosis and had higher prevalence of diabetes (28% vs 9%, P=.02) and coronary artery disease (40% vs 25%, P=.03). In addition, echocardiography showed significantly higher prevalence of systolic anterior motion of the anterior mitral valve in association with dynamic left ventricular outflow obstruction (52% vs 19%, P=.02) and mitral annular calcification (27% vs 13%, P=.03) in group 1 patients. Left ventricular wall thickness (17 vs 19 mm), enddiastolic diameter (42 vs 42 mm), resting outflow tract gradient above 30 mm Hg (17% vs 16%), and ejection fraction (65% vs 64%) were similar in the 2 groups. Follow-up (mean months) did not reveal statistically significant difference in angina, syncope, heart failure, atrial fibrillation, or stroke between the 2 groups. Although total mortality was similar (39 vs 15, P=.07), more group 1 patients died of noncardiac causes (30 vs 11, P=.01). Conclusion: Hypertrophic cardiomyopathy frequently coexists with SH in the adult population. Presence of SH in HCM patients is associated with older age and higher risk of diabetes, coronary artery disease, and noncardiac death. Cardiac morphologic findings are largely similar in HCM patients with and without SH. doi:10.1016/j.carrev.2008.02.020

Clinical features and outcomes of patients with apical hypertrophic cardiomyopathy F Aslam Ali, Islamabad, Pakistan Background: The apical hypertrophic cardiomyopathy (ApHCM) is a relatively rare form of hypertrophic cardiomyopathy (HCM) in which the hypertrophy of myocardium predominantly involves the apex of left ventricle. The characteristic feature of ApHCM is the presence of deep symmetrical T-wave inversion on electrocardiogram (ECG) and a spadelike configuration of the left ventricular cavity at end diastole on echo. Aim: The aim of this study was to analyze clinical characteristics and outcome of patients with ApHCM. Methods: We analyzed 196 patients with echocardiographically documented HCM at our tertiary care center from 1995 to 2005. Among them, there were 14 patients with ApHCM. All patients were assessed on at least 2 occasions, and data were collected retrospectively on demographic characteristics, symptoms, ECG and results of transthoracic echocardiography (TTE). Results: There were 5 male patients with a mean age of 65 years. Symptoms on initial presentation included chest pain (35%), palpitation (35%), and heart failure (14%). On ECG, 9 patients had T-wave inversion. Transthoracic echocardiography revealed a mean apical wall thickness of 15.3 mm, and mean ratio of apical to posterior wall thickness was 1.6. There was no case of apical aneurysm in our study population. During the mean follow-up of 3±2 years, 3 patients died, 1 of cardiac and 2 of noncardiac causes. One

Abstracts / Cardiovascular Revascularization Medicine 9 (2008) 101–129 patient was managed by defibrillator; 2 patients, with pacemaker; and the rest, medically managed. Conclusion: Apical hypertrophic cardiomyopathy constitutes a small population among patients with hypertrophic cardiomyopathy. Characteristic findings such as deep symmetrical T-wave inversion and echocardiographic features can help to differentiate this variant of HCM. doi:10.1016/j.carrev.2008.02.021

Inflammatory response of endocannabinoid system to oxidative stimulation of oxidized low-density lipoprotein J Lisheng Sr. Medical College of Shanghai Jiaotong University, Shanghai, China Background: Atherosclerosis is a chronic disease in which oxidized lowdensity lipoprotein (oxLDL) plays important roles. There has recently been marked interest in endocannabinoid system in terms of its response to some inflammatory diseases including atherosclerosis. In this study, we observed inflammatory response of endocannabinoid system to oxidative stimulation of oxLDL in RAW264.7 murine macrophages. Methods: RAW264.7 murine macrophages were cultured in Dulbcco's modified eagle medium containing 10% fetal bovine serum. Secretion of anandamide (AEA) and 2-arachidonoylglycerol (2-AG), members of endocannabinoids, were analyzed with API 4000 LC/MS/MS system (Applied Biosystems, Foster City, CA). Expression of CB1 and CB2 receptors was measured by Western blot. The level of tumor necrosis factor-α in cell culture supernates was assessed by enzyme-linked immunosorbent assay. Results: Secretion of AEA and 2-AG and expression of CB1 and CB2 receptors were observed in RAW264.7 murine macrophages. Following stimulation with oxLDL (3 μg/mL), secretions of AEA and 2-AG were significantly increased (Pb.01), together with up-regulated CB1 and CB2 receptors. R (+) WIN 55,212-2 (1-20 μM), a synthetic nonselective CB1/ CB2 cannabinoid receptor agonist, reduced markedly release of tumor necrosis factor-α produced by oxLDL (Pb.01), whereas this reduced release was blocked by AM630 (1-20 μM), an antagonist of the CB2 receptor (Pb.01). Conclusions: Inflammation-protective responses of endocannabinoid system are produced by oxidative stimulation of oxLDL in vitro. These data also suggest that activation of CB2 receptors may contribute to the antiinflammatory response of macrophages and might be a novel pharmaceutical target against oxidative stimulation of oxLDL. doi:10.1016/j.carrev.2008.02.022

Influence of diabetes on long-term survival after rapamycin and paclitaxel-eluting stent implantation in a nonselected sample JM Nogales-Asensio Sr., JR López-Mínguez Sr., R González-Fernández, A Merchán-Herrera Sr., G Martínez, J Doncel, C Palanco, A Morales Hospital Infanta Cristina, Badajoz, Spain Introduction: Diabetes mellitus (DM) is a bad prognosis factor between patients (pts) undergoing percutaneous coronary intervention (PCI). The appearance of drug-eluting stents (DES) has improved long-term prognosis for these pts. Objectives: To study long-term survival of pts undergoing PCI with DES implantation, Cypher (Cordis Corp, Miami Lakes, FL) or Taxus (Boston Scientific, Natick, MA), in our catheterization laboratory. Methods: Six hundred twenty consecutive pts with a clinical follow-up were analyzed. Results: Five hundred seventy-one pts (92.4%) completed follow-up. Mean follow-up time was 23.5±11.5 months. Mean age was 62.7±11.5 years; 73% were men, and 34% were diabetic (a mean of 1.8 vessel disease per pt). A mean of 1.5 treated lesions per pt with a mean of 1.3 stents per lesion were implanted. Influence of DM and type of DM on the survival were analyzed in this sample.

Age (y) No. of diseased vessels Death on follow-up MACE Stent diameter New PCI

107

Non-DM (378 pts)

NIDDM (121 pts)

IDDM (74 pts)

P

60.6±12 1.7±0.8 7 (2%) 20 (5%) 2.9±0.4 46 (13%)

65.8±9.5 2±0.9 8 (7%) 13 (11%) 2.8±0.3 22 (20%)

66.8±8.4 2.2±0.8 12 (16%) 15 (20%) 2.7±0.3 16 (24%)

b.001 b.001 b.001 b.001 b.001 .03

Independent predictors of death (multivariant Cox regression analysis) were DM (HR, 6; Pb.001), age (HR, 1.1; P=.03), and stent diameter (HR, 0.2; P=.01). DM, diabetes melitus; NIDDM, non-insulin dependent diabetes mellitus; IDDM, insulin dependent diabetes mellitus; MACE, major adverse cardiac events; PCI, percutaneous coronary intervention. Conclusion: Diabetes mellitus still continues to be the main factor prognosis after intracranial pressure, even in the era of the DES. doi:10.1016/j.carrev.2008.02.023

N-terminal pro-B-type natriuretic peptide predicts impaired functional capacity in chronic mixed heart valve disease N Bissessor, R Jayasinghe, A Mishra, J Sedgwick, R Batra Gold Coast Hospital, Gold Coast, Australia Background: Impaired functional capacity is an important determinant of the decision to operate, surgical risk, and prognosis in patients with mixed heart valve disease (MVD). The presence of symptoms is a clear indication for surgical valve replacement. Patients with chronic valve disease are known to tailor physical activities to avert the onset of symptoms and regress to a sedentary lifestyle. Symptoms may be vague or overlooked by sedentary patients. Peak oxygen consumption (peak VO2) is the gold standard of cardiovascular exercise capacity and provides an objective evaluation of aerobic functional capacity. The cardiac-specific marker NTproBNP is a simple blood test that has shown to predict onset of symptoms and prognosis in valve disease. Aim: To examine the relationship between NTproBNP and functional capacity (peak VO2) in MVD. To assess the factors associated with impaired functional capacity in these patients. Methods: In a prospective study, we recruited 45 patients with mixed moderate-severe stenosis/regurgitation referred for the timing of surgery. Factors associated with impaired peak VO2 on formal cardiopulmonary exercise testing were assessed. These included demographics, New York Heart Association class, cardiac and echocardiographic parameters of valve disease severity, respiratory function, and serum NTproBNP measurement. Results: Mean age was 56 (16) years, N=45, and New York Heart Association class I:II was 28:17. There was a strong correlation between peak VO2 and NTproBNP (r=−0.71). Serum NTproBNP level of 84 pmol/L had 77% sensitivity and 70% specificity to predict peak VO2 b60% (age- and sex–match-predicted), area under the curve=0.80. In the multivariate analysis Log, NTproBNP (β=−9.3, SE=1.9, Pb.0001) and lean body weight (β=.59, SE=0.22, P=.01) were dominant independent predictors of peak VO2. Conclusion: Resting NTproBNP is the best predictor of peak VO2 while symptoms are sometimes a less reliable guide. Impaired respiratory function and lower lean body weight, possibly due to deconditioning, also contribute significantly to impaired peak VO2 in MVD. doi:10.1016/j.carrev.2008.02.024

Prevalance of aspirin resistance and its impact on angiographic and clinical outcomes post–elective percutaneous coronary intervention S Shaheen, M Abd El Zaher, S Sabet, L Tawfeek, A Gamal, A Abd El Rahman Ain Shams University, Cairo, Egypt