Part 2 - News from AHA scientific sessions
By: Lisa Salberg The American Heart Association conducted its annual scientific sessions 2011 in Orlando Florida November 13 -16. The Hypertrophic Cardiomyopathy Association participating in its 14th AHA scientific sessions with an exhibit booth and attendance at sessions related to HCM, sudden cardiac arrest in the young and surveillance systems for identifying those at risk for cardiac disease.
Sleep Disordered Breathing is Associated with Higher Heart Rates in Patients with Hypertrophic Cardiomyopathy Despite Rate Control Therapy
Tomas Konecny1; Peter A Brady1; Ondrej Ludka2; Marek Orban3; Anna Svatikova1; Paul Edelhofer1; Tiffany Shen1; Samuel J Asirvatham1; Bernard J Gersh1; Jamil A Tajik1; Steve R Ommen1; Virend K Somers1
1 Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Rochester, MN
2 Cardiovascular Diseases, ICRC, Brno, Czech Republic
3 Cardiovascular Diseases, ICRC and CKTCH, Brno, Czech Republic
Current guidelines recommend the use of rate control medications for hypertrophic cardiomyopathy (HCM) patients with symptoms of dyspnea and decreased exercise tolerance, based on the rationale that lowering heart rates (HR) of HCM patients may improve these symptoms. Sleep disordered breathing (SDB) is known to increase sympathetic drive and HR in non-HCM patients. Whether the HR of HCM patients with and without SDB differs is not known.
Conclusions: The presence and severity of SDB is associated with higher mean HR despite the use of rate control medications in patients with HCM and could reduce the effectiveness of these agents. Treatment of SDB, which is readily available and has a favorable side effect profile, could improve symptoms by lowering HR in patients with symptomatic HCM.
Effectiveness of Cardiac Resynchronization Therapy in Patients with End-Stage Phase of Hypertrophic Cardiomyopathy: Comparison with Idiopathic Dilated Cardiomyopathy
Methods: We prospectively performed overnight oximetry and 24 hour Holter monitoring on consecutive echocardiographically confirmed HCM patients seen at Mayo Clinic, Rochester. SDB was defined by oxygen desaturation index 5 (number of 4% desaturations per hour of overnight recording). We investigated the relationship between HR (including diurnal variation of HR) and the presence and severity of SDB.
Results: From the 230 HCM patients included in this study (age 54±16 years; 138 male; LVOT pressure gradient at rest 45±39 mmHg), 115 (50%) patients had at least mild SDB (ODI 5). Presence of SDB was associated with higher mean HR (72 bpm vs. 67 bpm; p=0.002, adjusted p<0.001), even though the use of rate control medications was similar in both groups. The figure below demonstrates that the main difference in HR occurred at night (10pm-5am). Severity of SDB was associated with higher HR (p=0.008), and this was particularly pronounced during the nighttime (p<0.001).
Ikutaro Nakajima; Takashi Noda; Koji Miyamoto; Yuko Yamada; Hideo Okamura; Kazuhiro Satomi; Takeshi Aiba; Wataru Shimizu; Naohiko Aihara; Shiro Kamakura
Cardiology, National cardiovascular center Japa, Osaka, Japan
Background: Evolution into dilated-hypokinetic phase of hypertrophic cardiomyopathy (D-HCM) represents an ominous change. Generally, patients with D-HCM were thought to be refractory to intensive medical therapy. Cardiac resynchronization therapy (CRT) is effective in heart failure patients. However effectiveness of CRT in D-HCM patients remains unclear.
Methods: Among our cohort of 170 CRT patients, we identified consecutive 22 D-HCM patients (age 55±14 years, LVEF 27±10%) and 71 patients with idiopathic dilated cardiomyopathy (DCM) (age 56±16 years, LVEF 23±10%). We compared baseline characteristics, response to CRT and subsequent cardiac events between the two groups during a mean follow-up period of 896±511 days after CRT implantation.
Results: The baseline characteristics of D-HCM patients and DCM patients were similar, except for distribution of intra-ventricular conduction delay on the electrocardiogram (D-HCM: 7/22 (32%) vs. DCM: 9/71 (13%), p=0.04). Both groups were improved symptomatically after CRT implantation. However the magnitude of LV reverse remodeling and the proportion of responders (>10% increase in LVEF or >15% reduction of LV end-systolic volume after CRT) were significantly lower than in DCM patients (D-HCM: 8/22 (36%) vs. DCM: 44/71 (62%), p=0.04). Based on the Kaplan-Meier analysis, the extent of CRT benefit associated with all-cause mortality and heart failure hospitalization was similar in the two groups within around two years, however D-HCM patients continuously progressed their morbidity and mortality compared with DCM patients in the long-term period (p=0.30, Figure). No significant difference was observed in terms of subsequent lethal ventricular arrhythmia after CRT.
Conclusion: CRT was less effective for D-HCM patients associated with LV reverse remodeling compared with DCM patients. D-HCM had been progressive and the efficacy of CRT for improving their prognosis was limited especially in the long-term period.
Diffuse Myocardial Fibrosis in Hypertrophic Cardiomyopathy Can be Detected by Cardiac MRI and Correlates with Left Ventricular Filling Pressure
Andris H Ellims; Leah Iles; James Hare; David Kaye; Andrew J Taylor
Cardiology, The Alfred Hosp, Melbourne, Australia
Purpose:In patients with hypertrophic cardiomyopathy (HCM) the extent of diffuse myocardial fibrosis and its relationship to diastolic function has not been described. We used a contrast-enhanced cardiac magnetic resonance (CMR) T1 mapping technique to non-invasively determine the extent and location of diffuse myocardial fibrosis in patients with HCM. Furthermore, we evaluated the relationship between diffuse myocardial fibrosis and diastolic function.
Methods:We performed CMR on 44 subjects - 30 with asymmetric septal hypertrophy due to HCM (70% male, mean age 49±13 years) and 14 control patients. Chamber dimensions, wall thickness, systolic function and patterns of regional myocardial fibrosis were evaluated with cine imaging and late gadolinium enhancement (LGE). A prototype T1 mapping sequence was used (excluding areas of regional LGE) to determine the post-contrast myocardial T1 time as an index of diffuse myocardial fibrosis at the basal, mid and apical levels of the left ventricle (LV). Diastolic function (including septal, lateral and mean E/e') was assessed by transthoracic echocardiography.
Results:Regional myocardial fibrosis was observed in 87% of the HCM group. Global post-contrast myocardial T1 times were significantly shorter in patients with HCM compared to controls, consistent with the presence of diffuse myocardial fibrosis (494 ± 92 ms vs. 563 ± 52 ms, p<0.01). This difference was most pronounced at the basal level (436 ± 82 ms vs. 530 ± 87 ms, p<0.01). In HCM patients, the global LV T1 time correlated with mean E/e' (r=-0.47, p=0.01).
Conclusions:Patients with HCM have shorter myocardial T1 times, particularly at the basal level of the LV, consistent with the presence of diffuse myocardial fibrosis. The extent of diffuse fibrosis correlates with LV filling pressure, suggesting a mechanistic link between diffuse myocardial fibrosis and abnormal diastolic relaxation in HCM.
Papillary Muscle Abnormalities in Apical Hypertrophic Cardiomyopathy and Their Association with Mid-Ventricular Obstruction: Insignt from Cardiac Magnetic Resonance Imaging
Chi Young Shim1; Woo-In Yang1; Young Jin Kim2; Min-Kyung Kang1; Namsik Chung1; Seung-Yun Cho3; Jong-Won Ha1
1 Cardiology Div, Yonsei Univ College of Medicine, Seoul, Korea, Republic of
2 Dept of Radiology, Yonsei Univ College of Medicine, Seoul, Korea, Republic of
3 Cardiology Div, CHA Med Univ Hosp, Seongnam, Korea, Republic of
Background Abnormal papillary muscles(PM) are often found in hypertrophic cardiomyopathy(HCM) and the significance relating left ventricular(LV) outflow obstruction has been identified. Mid-ventricular obstruction(MVO) can be found in apical HCM and accompanied by apical aneurysm and ventricular tachycardia. We sought to investigate PM structures including numbers, thickness, insertion site and their association with MVO in apical HCM.
Methods In 44 patients(30 men, age 57±8 yrs) with apical HCM, cardiac magnetic resonsnce was performed to characterize PM morphology. PM numbers, maximal PM thickness in diastole, and their insertion site on LV were evaluated. Patients with isolated asymmetric apical hypertrophy were classified as a pure type, and those with coexistent hypertrophy of the interventricular septum as a mixed type. MVO were examined using Doppler echocardiography and diagnosed when the systolic peak flow velocity at the mid-ventricle was 2.5 m/s. Subjects were divided into 2 groups according to the presence of MVO; Group I(n=28): MVO(-), Group II(n=15): MVO(+).
Results The mixed type was more prevalent(54 vs 93%, p=0.014) and posterior wall thickness at mid LV was higher(10.2±1.8 vs 12.9±2.1, p<0.001) in group II compared with group I. Apical aneurysm was found in 3 patients in group II. Group II showed higher PM numbers(2.7±0.8 vs 3.3±0.8, p=0.070) and maximal thickness(8.7±0.9 vs 10.8±1.5, p=0.045). PMs were displaced closer to the LV apex(displaced apically: 68 vs 93%, p=0.042) in almost of group II patients. There was no significant difference in heart rate between two groups.
Conclusion In apical HCM, patients with MVO showed different PM structures and displacement than those without MVO. Increased number of PMs and their apical displacement can be one of contributors of MVO. Combined with the LV morphologic type, the assessement of PM morphology would be important to predict the development of MVO and its subsequent outcomes in apical HCM.
Cost-Benefit Analysis of Pre-Participation Screening: How Much is an Athlete's Life?
Federico Migliore1; Alessandro Zorzi1; Cristina Basso2; Maurizio Schiavon3; Maurizio Schiavon3; Gateano Thiene2; Domenico Corrado1
1 Cardio-Thoracic and Vascular sciences, Univ of Padova, Padova, Italy
2 Medico-Diagnostic Sciences and Special Therapies, Univ of Padova, Padova, Italy
3 Social Health, Cntr for Sport Medicine and Physical Activity, Padova, Italy
Background: The Italian preparticipation screening (PPS) by history, physical examination and 12-lead ECG has proven to identify young competitive athletes (YCAs) with at risk-heart diseases (such as hypertrophic and arrhythmogenic right ventricular cardiomyopathy) and to prevent sudden cardiovascular death (SCD) during sports. YCAs identified and disqualified because of such cardiomyopathies have been reported to have an excellent long-term outcome with nearly normal life expectancy.
Methods: We performed a cost-benefit analysis of the Italian PPS program for prevention of SCD in YCAs, based on the estimated mortality rates in the Veneto region of Italy over a 26 year-period, before (1979-1982) and after (1982-2004) screening implementation. In the setting of the Italian mass-screening, the cost of PPS is 30 per each athlete.
Results: Mortality rates were 4.0/100,000 athlete-years in the pre-screening period and 0.4/100,000 athlete-years in the late-screening period, resulting in an estimated mortality reduction of 89%. Accordingly, 36 lives are saved annually by screening 1,000,000 YCAs (40 theoretical SCDs in unscreened YCAs less 4 real SCDs in screened YCAs). The cost to initially screen 1,000,000 YCAs (at 30 each) is 30,000,000 and the estimated cost to further evaluate those with positives findings ( 10% according to Italian data), mostly by echocardiography, is 6,000,000 . Since the estimated total cost of screening (initial cost plus further evaluation cost) is 36,000,000 , the estimated cost for one saved life is 1,000,000 (36,000,000 divided by 36 saved lives). Whether one assumes that former YCAs saved from SCDs because of disqualification from competitive sports will live an additional 20 years, the cost per year of life saved (YLS) is estimated at 50,000 (1,000,000 divided by 20 years); the estimated cost for additional 30 years will be 33,000 per YLS.
Conclusions: The low cost of PPS in the setting of a population based program, the good PPS efficacy and specificity, and the expected large amount of life-years saved in disqualified YCAs, favourably influences the cost-benefit analysis of the Italian PPS, with cost estimates per YLS at or below the threshold to consider a health intervention as cost-effective.
Contributions from Hopkins: Submitted by T. Abraham
16924 - Multimodality Imaging Reveals Decreased Creatine-Kinase Flux and Systolic Strain in Patients with Hypertrophic Cardiomyopathy and Preserved LVEF
M Roselle R Abraham, Johns, Baltimore, MD; Paul Bottomley, Veronica Lea Dimaano, Aurelio Pinheiro, Thomas Traill, Theodore P Abraham, Robert Weiss, Johns Hopkins, Baltimore, MD
We investigated in vivo cardiac creatine kinase (CK) ATP supply and function in a family with HCM who carry an extensively characterized point mutation (R403Q) in the cardiac β-myosin heavy chain gene. Methods: Quantitative phosphorus (31P) saturation transfer MRS was used to noninvasively measure cardiac CK energy transfer-the forward CK flux and the CK rate constant, kf and CK metabolite concentrations (phosphocreatine, [PCr], and [ATP]) in patients with HCM (n=10), and in age-matched healthy controls (n=15). Systolic strain, LV ejection fraction (EF), diastolic function and cardiac morphology were assessed by echocardiography in HCM patients (n=11) and a second group of healthy controls (n=10).
Results: LV mass was higher in HCM patients than controls (307.21 ± 12.37 vs 167.63 ± 42.53; p=0.0037). [PCr] was significantly decreased by 22% in HCM patients (7.36 ± 2.29µmol/g wet weight) as compared to controls (9.41 ± 1.2µmol/g; p=0.005), but PCr/ATP ratio was not significantly altered (1.54 ± 0.4 in HCM vs. 1.69 ± 0.29, p=0.26). The pseudo-first-order rate-constant for the CK reaction, kf was reduced by 26% (0.266 ± 0.14 vs. 0.36 ± 0.08, p<0.04) and the forward CK flux was reduced by 43% (1.94 ± 1.27 vs 3.39 ± 0.96, p<0.003) in HCM patients when compared to controls. Diastolic function (E/A) was impaired (0.90 ± 0.31 in HCM vs 1.48 ± 0.27 controls; p=0.0003) and peak systolic strain (longitudinal; εL) was significantly decreased in HCM patients (-13.40 ± 5.32 vs -18.93 ± 2.46; p=0.0076). Peak longitudinal strain and diastolic function (E/A) correlated with NYHA class (R²=0.50; p=0.0007); E/A <1 correlated with NYHA class progression over 5 years of follow up (R2=0.6, p=0.024).
Conclusions: PCr, kfor and CK flux are significantly reduced in patients compared to age-matched healthy control subjects, indicating impaired CK ATP energy supply even at rest, consistent with prior work on a HCM (R403Q) mouse model. However, only systolic strain and diastolic function were correlated with NYHA class and progression respectively, suggesting that while bioenergetic alterations are associated with the underlying mutation, other downstream molecular effects contribute to the severity of dysfunction and clinical status of these patients
Hypertrophic cardiomyopathy (HCM) is associated with patchy fibrosis seen by histology and by delayed enhancement (DE) using gadolinium-enhanced magnetic resonance (CMR). The etiology of fibrosis remains unclear. The aim of our study was to examine whether there is a relationship between fibrosis and microvascular ischemia. Methods/Results: Symptomatic HCM patients (n=22) without obstructive coronary anatomy underwent CMR for assessment of DE. Presence of DE was defined as a signal 6 standard deviations above mean signal intensity for normal remote myocardium. All patients also had
Hypertrophic cardiomyopathy (HCM) is associated with patchy fibrosis seen by histology and by delayed enhancement (DE) using gadolinium-enhanced magnetic resonance (CMR). The etiology of fibrosis remains unclear. The aim of our study was to examine whether there is a relationship between fibrosis and microvascular ischemia. Methods/Results: Symptomatic HCM patients (n=22) without obstructive coronary anatomy underwent CMR for assessment of DE. Presence of DE was defined as a signal 6 standard deviations above mean signal intensity for normal remote myocardium. All patients also had 13N-ammonia positron emission tomography (PET) to quantify myocardial blood flow (MBF) and myocardial flow reserve (MFR), and determine a summed difference score(SDS), left ventricular ejection fraction (LVEF) and transient ischemic dilatation (TID) index. Patients with no DE (n=7) were compared to patients with DE (n=15). Clinical and PET characteristics were similar in both groups: age (52±17 vs. 53±16yrs; P=0.9), heart rate (59±4 vs. 62±11bpm;P=0.6), mean blood pressure (91±9 vs. 87±10mmHg; P=0.3), rest LVEF (56±6 vs. 58±7%; P=0.6), and resting MBF (0.85±0.13 vs. 0.93±0.22 ml/min/g; P=0.4). Wall thickness was significantly larger in HCM in the DE group (2.2±0.3 vs1.6±0.1 cm,respectively, p=0.001). After vasodilator stress, peak MBF (2.14±0.35 vs.1.73±0.39 ml/min/g; P=0.03), MFR (2.55±0.29 vs. 1.90±0.48; P=0.004) and LVEF (57± 13 vs. 47±8%;P=0.03) were significantly lower, and SDS (0.4±1.1 vs. 8.5±5.0, P< 0.0001) and TID index (1.0±0.13 vs. 1.16 ± 0.10; P=0.006) significantly higher in patients with than without DE.
Conclusions: Presence of DE in HCM is associated with myocardial perfusion abnormalities and depressed MFR by PET in the setting of non-obstructive epicardial coronary arteries indicating microvascular disease. Our data suggest that microvascular ischemia is a contributor to fibrosis in HCM.
Introduction: HCM is often characterized by marked repolarization abnormalities. However the significance of repolarization changes in these patients has not been investigated.
Aim: We investigated the prevalence and significance of ECG repolarization patterns on sensitive measures of systolic and diastolic function in a cohort of 110 patients (mean age 52± 17 yrs, male 65%, Caucasian 73%) with HCM.
17364 - Abnormal Repolarizations in Electrocardiogram Correlate with Abnormal Diastolic Mechanics in Patients with Hypertrophic Cardiomyopathy
Xiaoping Lin, Hsin-Yueh Liang, Aurelio Pinheiro, Lea Dimaano, Lars Sorensen, Larisa Tereshchenko, Theodore Abraham, Roselle Abraham, Johns Hopkins hospital, Baltimore, MD
Method: We performed echocardiography and ECG evaluation in 110 HCM patients. ECG repolarization parameters including strain pattern, early repolarization pattern, ST elevation, ST depression and T wave inversion were measured. Conventional and longitudinal tissue Doppler- derived tissue velocity and strain were analyzed off-line.
Result: The mean left ventricular mass index was 141± 48 g/m,2 LVEF was 69± 10% and left ventricular outflow tract gradient was 27±29 mmHg. ECG analysis revealed mean QTc of 451± 34 ms; 45/110 had strain pattern , 17/110 had early repolarization pattern and 14/110 had deeply inverted T waves. Patients with strain pattern on ECG, demonstrated decreased early diastolic velocity (lateral: -3.7± 2.2 vs. -4.6± 2.3 cm/s, p= 0.044, anterior: -2.6± 1.5 vs. -3.4± 1.4 cm/s, p= 0.04 and inferior:-2.7± 1.4 vs. -3.9± 1.6 cm/s, p= 0.005 regions), and late diastolic velocity (lateral:-1.2+- 0.76 vs -2.3+- 1.6, p= 0.001, anterior: -1.6+- 0.7, -2.7+- 1.3, p= 0.0006 and inferior: -2.7+- 1.8 vs -4.1 +- 1.7, p= 0.0003) in the corresponding regional myocardium, when compared to HCM patients without strain pattern. Patients who exhibited deeply inverted T waves on ECG exhibited decrease in late diastolic strain rate in the corresponding regional myocardium (lateral: 0.44± 0.32 vs. 0.84±0.48 s-1, p= 0.001 and anterior: 0.56±0.19 vs. 1.0± 0.56 s-1, p= 0.005), when compared to HCM patients without this finding. In contrast, early diastolic strain rate was increased in the corresponding regional myocardium (lateral: 1.75± 0.6 vs. 1.1± 0.62 s-1, p= 0.015 and anterior: 1.17± 0.3 vs. 0.87± 0.5 s-1, p= 0.01) in patients with evidence of early repolarization on ECG, when compared to patients without this feature.
Conclusion: Strain pattern and deeply inverted T waves are markers for abnormal diastolic mechanics in patients with hypertrophic cardiomyopathy.
13828 - Safety During Treadmill Exercise in Patients With High Gradient Hypertrophic Cardiomyopathy.
Lars L Sorensen
, Gentofte Hosp, Copenhagen, Denmark; Aurelio Pinheiro, Hsin-Yueh Liang, Miguel S Tomas, Hagit Shatkay, Raimond Winslow, Veronica Dimaano, Blaid Mbiyangandu, Johns Hopkins Hosp, Baltimore, MD; Kristian Eskesen, Niels T Olsen, Thomas Fritz-Hansen, Peter Sogaard, Gentofte Hosp, Copenhagen, Denmark; Theodore P Abraham, Johns Hopkins Hosp, Baltimore, MD
Exercise echocardiography is a well established imaging modality in the evaluation of hypertrophic cardiomyopathy (HCM), providing valuable information about risk stratification, treatment options and symptoms. However, HCM patients with high left ventricular outflow gradients (LVOTG) i.e.> 30 mmHg are often excluded from exercise testing. We report the safety and clinical profile of exercise testing in 211 HCM patients with and without LVOT obstruction.
Methods: Data were abstracted from patients evaluated at the Johns Hopkins HCM clinic. All HCM patients undergo treadmill exercise testing unless excluded per following criteria: high fall risk, BP >220/120 mmHg, active angina, recent myocardial infarction, decompensated heart failure, active arrhythmias. Patients were monitored closely for symptoms and complications.
Results: The cohort was separated according to resting gradients into non-obstructive (<30 mmHg) and obstructive (>30 mmHg). The baseline characteristics of the patients are shown in table 1. Patients with obstruction were older, had higher LV mass index, slightly higher LVEF and higher gradients. Symptoms and arrhythmic events during treadmill testing are presented in table 2. Patients with obstruction had a lower work capacity and more frequently developed ECG changes. But we observed no differences in arrhythmic events. We observed no syncope or VF and all arrhythmias resolved without intervention.
Conclusion: The results of this study suggest that treadmill testing in high gradient HCM patients is safe. Given the important information the exercise test provides it should be part of the standard evaluation of all HCM patients.
13695 - Prevalence of Mechanical Dyssynchrony in Hypertrophic Cardiomyopathy
Aurelio Pinheiro, Veronica Dimaano, Miguel Santaularia-Tomas, Lars Sorensen, Hsin-Yueh Liang, Sivajothi Kanagalingam, Blaid Mbiyangandu, Sourabh Verma, Roselle Abraham, Theodore Abraham, Johns Hopkins Univ, Baltimore, MD
Dyssynchrony has been extensively studied in LV systolic dysfunction, properly selecting patients for CRT. The present study has the objective to analyze the prevalence of dyssynchrony in a hypertrophic cardiomyopathy (HCM) population and its correlation with left ventricular mass related measurements and diastolic function parameters by echocardiography. METHODS/RESULTS. We included 160 patients, being 120 HCM patients and 40 controls. HCM patients had higher LV mass (286.6±106g vs 144±36g,p<0.001), septum thickness (2.0±0.5cm vs 0.9±0.1cm, p<0.001), and septum/posterior thickness ratio (1.8±0.4 vs 1.0±0.1, p<0.001). Resting LVOT gradient was 31±35mmHg in HCM patients. Derived from Doppler method, time delay (Δt) between 2 opposing walls and standard deviation of time to peak (SD) were taken from all 3 apical plane views (A4C, A2C and A3C) on basal and mid wall regions for systolic velocities (Sm) and systolic strain rate (sSR). Differences were found between all indexes originated from A4C and A3C views with higher values for HCM patients for Sm (A4C-ΔtSmMid: 41±27.3ms vs 59.6±53.7ms, p=0.009; A3C-ΔtSmBasal: 20.5±13.4ms vs 36.8±40.0ms, p=0.001; A3C-ΔtSmMid: 30.5±30.8ms vs 47.4±51.2ms, p=0.031) and for sSR (A4C-ΔtsSRBasal: 39.3±31.3ms vs 68.8±61.7ms, p = 0.001; A3C-ΔtsSRBasal: 30.0±37.6ms vs 59.3±58.1ms, p =0.002), this last variable only on the mid wall region. The SDSm index was also higher in HCM patients (25.0±11.6ms vs 31.2±20.0ms, p =0.021). Multivariate regression with all conventional systolic and diastolic echocardiography, A3C-ΔtSmBasal showed the most significant correlation with E/e’ (p=0.0004). No significant correlations were found with left ventricular mass variables. CONCLUSION. An increased Δt between two opposing walls was found in HCM patients, mainly from apical 4 and 3 chamber plane views and they were significantly associated with the diastolic dysfunction.
Delayed Enhancement in Hypertrophic Cardiomyopathy Is Related to Perfusion Abnormalities: An Ischemia-Fibrosis Connection
Paco E Bravo, Miguel Santaularia, Stefan Zimmerman, Aurélio Pinheiro, Takahiro Higuchi, Richard L. Wahl, Roselle M. Abraham, Johns Hopkins Univ, Baltimore, MD; Frank M. Bengel, Hannover Medical Sch, Hannover, Germany; Theodore Abraham, Johns Hopkins Univ, Baltimore, MD