The prognostic value of biventricular long axis strain using standard cardiovascular magnetic resonance imaging in patients with hypertrophic cardiomyopathy
Introduction
Hypertrophic cardiomyopathy (HCM), the most common hereditary cardiovascular disease, is characterized by a thickened left ventricular (LV) wall and normal chamber size. The prevalence of HCM is approximately 1:500 people in the general population [1]. HCM causes heart failure (HF) and death at any age, and is the main explanation for sudden cardiac death (SCD) in young people [2,3]. Recently, the SHaRe study of 4591 patients with HCM showed that 8% of patients died, 3% of patients experienced resuscitated cardiac arrest, and up to 20% of patients suffered from HF during the mean follow-up of 5.4 years [4]. Therefore, early identification of high-risk patients with HCM is critical to guide individualized treatment and management.
Cardiovascular magnetic resonance (CMR) is recognized as the gold standard for non-invasive diagnosis and evaluation of ventricular function in patients with HCM [5]. Late gadolinium enhancement (LGE) and ventricular dysfunction are associated with adverse prognosis in patients with HCM [[6], [7], [8]]. Recently, long axis strain (LAS), a new parameter that can be derived rapidly from CMR cine images without additional pulse sequences and special post-processing software, has proven to be feasible and has shown good inter- and intra-observer agreement in patients with different cardiomyopathies [9,10]. LV-LAS was reported as a powerful predictor of cardiovascular disease and congestive HF occurrence in the Multi-Ethnic Study of Atherosclerosis [11]. Subsequent studies demonstrated that reduced LV-LAS and right ventricular (RV)-LAS values were associated with increased risk of cardiac death, transplant, aborted SCD caused by appropriate implantable cardioverter defibrillator (ICD) shock, and hospitalization because of HF in patients with non-ischemic dilated cardiomyopathy [[12], [13], [14]]. However, there is no data on the prognostic value of biventricular LAS in patients with HCM. Therefore, the present study aimed to investigate whether CMR LV-LAS and RV-LAS have prognostic value in patients with HCM.
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Research population and design
This study comprised healthy volunteers from our database [15,16] and consecutive patients with HCM who underwent a baseline CMR assessment from August 2011 to October 2017 at West China Hospital, Sichuan University. We collected clinical data retrospectively from our electronic medical records, including basic information, clinic history, and cardiac medication. The study was approved by the Institutional Ethics Committee of West China Hospital, Sichuan University. All patients with HCM and
Baseline characteristics
A total of 386 patients with HCM and 150 healthy volunteers were enrolled. Two patients were excluded from the study because of poor 4-chamber images. All baseline characteristics and CMR data of the patients with HCM and healthy volunteers are presented in Table 1. In terms of CMR functional parameters, the mean values for the patients were significantly different from those of the volunteers (all p < 0.05). The mean values of max LVT and LGE in the patients were 22.5 (SD 5.7) mm and 8.6 (SD
Discussion
This study investigated the relationship between the outcome of patients with HCM and biventricular global longitudinal function using standard CMR cine sequences. The results confirmed that RV-LAS is an independent prognostic factor for patients with HCM.
Kaplan–Meier survival analysis and univariate Cox regression analysis showed that a lower LV-LAS increased the risk of achieving the primary and secondary endpoints. However, LV-LAS was not retained in the multivariate Cox regression analysis
Conclusions
Right ventricular-LAS is a more sensitive indicator of RV dysfunction than RVEF and TAPSE, and can be quickly obtained from standard CMR images without the need for contrast agents and special post-processing software. Impaired RV-LAS is an independent prognostic marker of adverse outcomes in patients with HCM, and adds value to RVEF and TAPSE.
Contributors
Conception and drafting the article: FY and JW. Data collection, analysis, and interpretation: FY, JW, YL, WL, YX, KW, JS, YH, and YC. Revising the article: FY, JW, WL, YX, YH, and YC. Final approval of the manuscript to be published: all authors.
Acknowledgement of grant support
This study was supported by the National Natural Science Foundation of China (contract grant numbers: 81571638 and 81271531) and 1·3·5 project for disciplines of excellence, West China Hospital, Sichuan University (No: ZYJC18013).
Conflicts of interest
No.
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- 1
Both authors contributed equally to this study.
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All author takes responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.