Prognostic value of left-ventricular hemodynamic forces by echocardiography in patients with non-ischemic dilated cardiomyopathy
Authors: Cesareo M , Rodenas E , Lozano J , Guala A , Casas G , Vallelonga F , Airale L , Milan A , Rodriguez Palomares J F 
Published: June 2023

Abstract

Funding Acknowledgements
Type of funding sources: None.

Background
Dilated cardiomyopathy (DCM) is a non-ischemic heart disease with reduced left-ventricular (LV) ejection fraction (LVEF) bearing high risk for heart failure (HF) and death (1). The evaluation of the LV by transthoracic echocardiography (TTE) is essential for diagnosis, prognosis, and follow-up, but conventional TTE parameters do not allow for proper risk assessment (2). Hemodynamic forces (HDF) by TTE may provide important information on LV mechanics (3), but their prognostic value in DCM is unknown.

Purpose
To test whether HDF provide prognostic value beyond conventional echocardiography parameters in DCM patients.

Methods
In this retrospective longitudinal study, we included patients diagnosed with DCM between 2015 and 2019 who underwent TTE and had coronary artery disease ruled out by coronary angiography. Patients were excluded from this analysis if at first available TTE were hospitalized or symptomatic for HF, had moderate-severe valvular heart disease, had atrial fibrillation during TTE evaluation, and if follow-up was &lt;12 months. Major cardiovascular events (MACE) were considered as a composite of all-cause death, HF hospitalization, and need for ambulatory intravenous diuretic therapy (HF decompensation). LV HDF were analyzed on conventional TTE apical 2-, 3-, and 4-chamber view images with a prototype software (Medis Suite Qstrain, The Netherlands). HDF were decomposed into apex-base (HDFab) and lateral-septal (HDFls) components, and HDF angle (combination of both components, ranging from 0° to 90°) was computed (4).

Results
A total of 109 patients were included, but 12 patients were subsequently excluded for suboptimal TTE image quality. Thus, 97 patients were included in the study: 67 (69%) were males, mean age was 62±14 years, median follow-up was 4.2 [3.1–5.1] years, and mean LVEF was 39.2±8.6%. Mean HDFab, HDFls, and HDF angle were 5.73±1.94%, 1.65±0.53%, and 67.5±5.7°, respectively. MACE occurred in 19 patients (19.6%). Patients experiencing MACE had higher HDF angle (70.8±4.7 vs. 66.8±5.6°, p = 0.006), lower HDFls (1.31±0.41 vs. 1.71±0.53%, p = 0.003) but similar HDFab (5.4±1.7 vs. 5.8±2.0%, p = 0.393) compared with patients without MACE. On Cox univariate analysis age (HR 1.09 [95% CI 1.04–1.15], p&lt;0.001) and HDF angle (HR 1.16 [95% CI 1.04–1.30], p = 0.007) were associated with MACE, while other conventional TTE parameters, including LVEF and LV longitudinal strain, were not. HDF angle was an independent predictor of MACE after adjusting for age, LVEF, and LV longitudinal strain on separate multivariate Cox analyses. HDF angle &gt; 70° was consistently associated with worse prognosis (HR 2.68 [95% CI 1.09–6.60], p = 0.032).

Conclusions
HDF angle is an independent predictor of MACE onset in non-ischemic DCM patients. Higher HDF angle may be a marker of late worsening in myocardial performance in patients with reduced LVEF.