Elsevier

International Journal of Cardiology

Volume 294, 1 November 2019, Pages 43-49
International Journal of Cardiology

The prognostic value of biventricular long axis strain using standard cardiovascular magnetic resonance imaging in patients with hypertrophic cardiomyopathy

https://doi.org/10.1016/j.ijcard.2019.08.010Get rights and content

Highlights

  • Long axis strain is a new parameter that is easily derived from CMR imaging.

  • RV-long axis strain is an independent prognostic factor in HCM.

  • RV-long axis strain may provide incremental value beyond RVEF in HCM.

Abstract

Background

Long axis strain (LAS) is a parameter derived from standard cardiovascular magnetic resonance imaging. However, the prognostic value of biventricular LAS in hypertrophic cardiomyopathy (HCM) is unknown.

Methods

Patients with HCM (n = 384) and healthy volunteers (n = 150) were included in the study. Left ventricular (LV)-LAS was defined as the percentage change in the length measured from the epicardial border of the LV apex to the midpoint of a line connecting the mitral annulus at end-systole and end-diastole. Right ventricular (RV)-LAS represented the percentage change of length between epicardial border of the LV apex to the midpoint of a line connecting the tricuspid annulus at end-systole and end-diastole. The primary endpoint was a combination of all-cause death and sudden cardiac death aborted by appropriate implantable cardioverter-defibrillator discharge and cardiopulmonary resuscitation after syncope. The secondary endpoint was a combination of the primary endpoint and hospitalization for congestive heart failure.

Results

Twenty-nine patients (7.6%) achieved the primary endpoint, and the secondary endpoint occurred in 66 (17.2%) patients. In multivariate Cox regression analysis, RV-LAS was an independent prognostic factor for the primary (hazard ratio (HR), 1.13) and secondary (HR, 1.11) endpoints. In the subgroup of patients with a normal RV ejection fraction (EF) (>45.0%, n = 345), impaired RV-LAS was associated with adverse outcomes and might add incremental prognostic value to RVEF and tricuspid annular plane systolic excursion (TAPSE) (p < 0.01).

Conclusions

RV-LAS is an independent predictor of adverse prognosis in HCM in addition to RVEF and TAPSE.

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.

Section snippets

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.

    2

    All author takes responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.

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