Clinicopathological profiles of progressive heart failure in hypertrophic cardiomyopathy.
OBJECTIVE
Hypertrophic cardiomyopathy (HCM) is an important cause of heart failure-related disability over a wide range of ages. Profiles of severe progressive heart failure symptoms and death, or heart transplantation deserve more complete definition within large patient cohorts.


RESULTS
Clinical and morphological features of heart failure were assessed in 293 consecutive HCM patients over a median follow-up of 6 (inter-quartile range 2-11) years. Gross and histopathological features were analysed in 12 patients for whom the heart was available for inspection. Of the 293 patients, 50 (17%) developed severe progressive heart failure, including 18 who died or were transplanted. Three profiles of heart failure were identified predominantly associated with: (i) end-stage systolic dysfunction (ejection fraction <50%) (15; 30%); (ii) left ventricular (LV) outflow obstruction at rest (11; 22%); and (iii) non-obstructive with preserved systolic function (24; 48%). Overall, atrial fibrillation (AF) contributed to heart failure in 32 patients (64%) among the three profiles. Compared with other patients, those non-obstructive with preserved systolic function had earlier onset of heart failure symptoms mainly due to diastolic dysfunction, and the most accelerated progression to advanced heart failure and adverse outcome (P = 0.04). Thrombi were identified in the left atrial appendage of five gross heart specimens all belonging to patients with AF, including three of which were unrecognized clinically and had previously embolized. Extensive myocardial scarring with LV remodelling was evident in all end-stage patients; no or only focal scars were present in other patients.


CONCLUSIONS
Profiles of advanced heart failure in HCM are due to diverse pathophysiological mechanisms, including LV outflow obstruction and diastolic or global systolic ventricular dysfunction. Atrial fibrillation proved to be the most common disease variable associated with progressive heart failure. Recognition of the heterogeneous pathophysiology of heart failure in HCM is relevant, given the targeted management strategies necessary in this disease.
Department of Cardiac, Thoracic and Vascular Sciences, University of Padua Medical School, Via Giustiniani 2, 35100 Padova, Italy. paola.melacini@unipd.it
Paola
P
Melacini
Cristina
C
Basso
Annalisa
A
Angelini
Chiara
C
Calore
Fabiana
F
Bobbo
Barbara
B
Tokajuk
Nicoletta
N
Bellini
Gessica
G
Smaniotto
Mauro
M
Zucchetto
Sabino
S
Iliceto
Gaetano
G
Thiene
Barry J
BJ
Maron
D000328:Adult; D000368:Aged; D001145:Arrhythmias, Cardiac / Q000235:genetics / Q000473:pathology; D002312:Cardiomyopathy, Hypertrophic / Q000235:genetics / Q000473:pathology*; D005260:Female; D006333:Heart Failure / Q000235:genetics / Q000473:pathology*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011486:Protein C / Q000235:genetics; D018487:Ventricular Dysfunction, Left / Q000235:genetics / Q000473:pathology; D055815:Young Adult
D011486:Protein C