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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 4  |  Issue : 1  |  Page : 13-16

Assessment of cardiac dyssynchrony in Nigerian patients with dilated cardiomyopathy


1 Department of Medicine, Federal Medical Centre, Umuahia, Nigeria
2 Department of Medicine, Cardiology Unit, University of Teaching Hospital, Enugu, Nigeria
3 Department of Medicine, Federal Medical Centre, Umuahia; Department of Medicine, Cardiology Unit, University of Calabar Teaching Hospital, Calabar, Nigeria

Date of Web Publication2-Jun-2016

Correspondence Address:
Kelechukwu Uwanuruochi
Department of Medicine, Federal Medical Centre, Umuahia, PMB 7001
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2321-4848.183375

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  Abstract 

Background: Interventricular, intraventricular, and atrioventricular dyssynchrony (AVD) have been reported in patients with dilated cardiomyopathy (DCM). However, the causes of DCM vary with the regional distribution in various etiologies, with expected differences in the pattern and frequency of cardiac dyssynchrony. Objective: The aim of this study was to evaluate cardiac dyssynchrony in patients with DCM by conventional echocardiographic assessment. Materials and Methods: Fifteen patients with DCM were studied. All patients underwent conventional Doppler echocardiographic evaluation including septal-to-posterior wall motion delay (SPWMD), interventricular motion delay (IVMD), and diastolic filling period. Results: Cardiac dyssynchrony was present in 13 of the 15 patients (86.7%). The overall frequencies of intra-left ventricular dyssynchrony (intra-LVD), interventricular dyssynchrony (inter-VD), and AVD are 38.5%, 30.8%, and 53.9%, respectively. Conclusion: The prevalence of dyssynchrony in our patients with DCM was significant. This raises the need for the development of local expertise in interventional cardiology including cardiac resynchronization therapy (CRT).

Keywords: Cardiac dyssynchrony, dilated cardiomyopathy (DCM), Nigerian patients


How to cite this article:
Offiah E, Uwanuruochi K, Chukwuemeka AB, Jones OB, Odigwe CO. Assessment of cardiac dyssynchrony in Nigerian patients with dilated cardiomyopathy. Arch Med Health Sci 2016;4:13-6

How to cite this URL:
Offiah E, Uwanuruochi K, Chukwuemeka AB, Jones OB, Odigwe CO. Assessment of cardiac dyssynchrony in Nigerian patients with dilated cardiomyopathy. Arch Med Health Sci [serial online] 2016 [cited 2022 Jan 26];4:13-6. Available from: https://www.amhsjournal.org/text.asp?2016/4/1/13/183375


  Introduction Top


The pattern of cardiovascular diseases in the developing countries have generated a lot of interest in recent years because there is an upsurge of cardiovascular diseases in the developing countries.[1],[2] DCM is characterized by structural abnormalities of ventricular myocardium, affecting both ventricular activation and mechanical contraction.[3],[4] In case of DCM, the electrical activation of ventricular segments may be delayed consequent to pathological involvement of the ventricular conduction system or due to inhomogeneous spread of excitation wave fronts across scarred tissue. In patients with left bundle branch block and no structural heart disease, a decreased left ventricular ejection fraction is observed in association with marked interventricular asynchrony.

While a number of reports have documented cardiac synchrony in dilated cardiomyopathy (DCM) from patients in the developed nations,[5],[6],[7],[8] a few such studies have been carried out in the West African subregion.[9] No study to the best of our knowledge has assessed for the presence of cardiac synchrony in Nigerians with DCM. We sought to establish the pattern of interventricular, intraventricular, and atrioventricular synchrony in a cohort of patients with DCM.


  Materials and Methods Top


This is a descriptive and prospective study on consecutive echocardiographic records obtained between September 2 2014 and June 4 2015 from Federal Medical Centre, Umuahia, Nigeria. The study was carried out at the Echocardiography Laboratory of Cardiology Unit, Department of Medicine, Federal Medical Centre, Umuahia, Nigeria. Federal Medical Centre, Umuahia, is a tertiary health-care institution located in the capital city of Abia State, Nigeria. It was founded on 24 March 1956. The institution is equipped with 327 beds. The hospital receives about 84,262 patients annually from the entire south-eastern part of the country, being accessible to Imo, Rivers, Akwa-Ibom, Enugu, Anambra, and Ebonyi states. The underlying objective was to document the presence of any intra-left ventricular dyssynchrony (intra-LVD), inter-ventricular dyssynchrony (inter-VD), or atrioventricular dyssynchrony (AVD) in consecutive patients with DCM.

Clinical evaluation

Baseline clinical and demographic characteristics of the subjects are studied in this article. These are as follows: Date of birth, age, gender, weight, height, pulse rate, blood pressure, and indication for echocardiography.

Echocardiography

Two-dimensional guided M-mode echocardiography with the use of commercially available echo-machine Vivid-1 (General Electric Inc., Conneticut, USA) and a 2.5-5.0 MHz linear array transducer was performed on each subject in the partial decubitus position. Echocardiographic examination was performed in the parasternal long axis, short axis, apical four chamber, and five chamber views. Measurements and echocardiographic diagnoses were based on the standard criteria. DCM was diagnosed based on the dilatation [left ventricular end diastolic diameter (LVEDD) >5.6 cm and left ventricular end systolic diameter (LVESD) >4.1 cm] and impaired contraction of the left ventricle (left ventricular ejection fraction <0%).[10] Hypertensive heart disease was diagnosed on the basis of systemic hypertension or a history, coupled with symmetric hypertrophy of the left ventricle and/or dilatation of the left ventricle.[11] The presence of left atrial dilatation or diastolic dysfunction was also considered. Cardiac dyssynchrony was defined as intraventricular when the septal-to-posterior wall motion delay (SPWMD) exceeded 130 ms, interventricular when the interventricular motion delay (IVMD) exceeded 40 ms, and atrioventricular when the diastolic filling time was less than 40% of the R-R interval.[12],[13]

Statistics

Data management and analysis were performed using Statistical Package for the Social Sciences (SPSS) software version 15.0. (SPSS, Inc. Chicago, Illinois). Continuous variables were expressed as mean ± standard deviation, while categorical variables are expressed as proportions. Probability levels of less than 0.05 were considered significant.


  Results Top


Fifteen cases diagnosed with DCM were consecutively recruited. [Table 1] depicts the basic characteristics of study population while [Table 2] shows the indications for echocardiography. None of these patients had cardiac pacemakers. The frequencies of associated cardiovascular abnormalities in the patients studied are as follows: Hypertensive heart disease 4 (26.7%), atrial fibrillation 2 (13.3%), intracardiac thrombus 1 (12.5%), pericardial effusion 1 (6.7%), and peripartum cardiomyopathy 1 (6.7%). Mitral regurgitation was present in 14 patients, being severe in 9 (60%), moderate in 3 (20%) and mild in 2 (13.3%) patients. Tricuspid regurgitation was present in 12 patients (80.0%), out of whom 4 (26.7%) presented with severe, 6 (40.0%) with moderate, and 1 (6.7%) with mild tricuspid regurgitation. The severity of both mitral and tricuspid regurgitation were not documented in 1 patient. Standard aortic, left atrial, left ventricular systolic, and diastolic measurements are presented in [Table 3], while the mean of measurements of cardiac synchrony are presented in [Table 4]. Cardiac dyssynchrony was present in 13 (86.7%) patients and absent in 2 (13.3%) patients. The pattern of dyssynchrony was presented in [Table 5]. The overall frequencies of intra-LVD [Figure 1], inter-VD, and AVD are 38.5%, 30.8%, and 53.9%, respectively. The Pearson's correlation of both gender and age with intra-LVD, inter-VD, and AVD were all nonsignificant (P = 0.706, 0.545, 0.622, respectively, for gender, and 0.513, 0.126, 0.770, respectively, for age).
Table 1: The clinical and demographic characteristics of the subjects

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Table 2: Patients echocardiographic diagnoses

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Table 3: Mean echocardiographic measurements

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Table 4: Mean of cardiac synchrony measurements

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Table 5: Pattern of cardiac dyssynchrony

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Figure 1: Increased septal-to-posterior wall motion delay

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  Discussion Top


Most cases of DCM in the tropics are attributed to myocardial damage that could be provoked by multiple insults, including hemodynamic, infective, immunologic, toxic, nutritional, and genetic factors.[14] Cardiac dyssynchrony is expected to be less prevalent in patients with DCM in the tropics, most cases being reportedly idiopathic in origin, unlike DCM in the developed nations, which usually complicate advanced ischemic heart diseases (IHD), especially because wall motion abnormalities are regional in distribution in case of IHD. The prevalence of dyssynchrony however was still high in our study. Intraventricular, interventricular, and AVD were found in 38.5%, 30.8%, and 53.9%, respectively. In comparison, Anzouan-Kacou et al. [9] from Ivory Coast found 47.5% and 40% as the frequencies for inter-VD and AVD. The proportion of intra-LVD (70%) in their study was however much higher than that (38.5%) in our study. This may be related to the primary cause of DCM; LVD may be more prevalent in cases following advanced hypertensive heart disease, where the pathology predominates in the left ventricle. Similar proportions were reported by Aranda et al

.[15] with a 30-50% incidence of interventricular conduction delays in patients with CHF. Westenberg et al.[8] noted intermediate LVD (septal-to-lateral delay between 50 ms and 80 ms) and extensive LV dyssynchrony (septal-to-lateral delay >80 ms) in 60% of 20 patients using tissue Doppler imaging,. Dyssynchrony did not correlate with age or gender in our study. Bajraktari et al.[16] found LV global dyssynchrony to be exaggerated with age in their study, but Yang et al.[17] did not find such an association. DCM in sub-Saharan Africa is known to be common in the third and fourth decades of life,[14] and not particularly related to advancing age. Ng et al

.[18] also found higher systolic lateral-to-septal wall dyssynchrony in females. Our study subjects were not matched for gender.

That significant dyssynchrony exists in our patients who had DCM raises the need for development of expertise for cardiac resynchronization therapy (CRT), and the field of interventional cardiology in general. CRT has become an accepted recommendation for patients in sinus rhythm with a widened QRS interval (≥150 ms) not due to right bundle branch block who have severe LV systolic dysfunction and persistent the New York Heart Association (NYHA) functional class II-III symptoms despite optimal medical therapy.[19] In addition, CRT is considered reasonable (class II a) for patients with LV ejection fraction (LVEF) (≤35%) with the NYHA functional class III or ambulatory class IV symptoms, who are receiving optimal medical therapy and who have frequent dependence on ventricular pacing, or are in atrial fibrillation.[20] Very few centers locally however offer this procedure.

A significant limitation of our study is that electrocardiographic data were not part of the methodology during data collection; hence, ECG data, such as QRS duration, and abnormalities, such as left bundle branch block, which predispose to septal wall dyssynchrony, were not documented. Another limitation is the small sample size and the etiology of DCM was also not ascertained in all the patients.


  Conclusion Top


There is a high prevalence of cardiac dyssynchrony in Nigerian patients with DCM. This raises the need for the development of local expertise in interventional cardiology including CRT.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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Westenberg JJ, Lamb HJ, van der Geest RJ, Bleeker GB, Holman ER, Schalij MJ, et al. Assessment of left ventricular dyssynchrony in patients with conduction delay and idiopathic dilated cardiomyopathy: Head-to-head comparison between tissue Doppler imaging and velocity-encoded magnetic resonance imaging. J Am Coll Cardiol 2006;47:2042-8.  Back to cited text no. 8
    
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Emkanjoo Z, Esmaeilzadeh M, Mohammad Hadi N, Alizadeh A, Tayyebi M, Sadr-Ameli MA. Frequency of inter- and intraventricular dyssynchrony in patients with heart failure according to QRS width. Europace 2007;9: 1171-6.  Back to cited text no. 13
    
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Sliwa K, Damasceno A, Mayosi BM. Epidemiology and etiology of cardiomyopathy in Africa. Circulation 2005; 112:3577-83.  Back to cited text no. 14
    
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Aranda JM Jr, Schofield RS, Leach D, Conti JB, Hill JA, Curtis AB. Ventricular dyssynchrony in dilated cardiomyopathy: The role of biventricular pacing in the treatment of congestive heart failure. Clin Cardiol 2002;25:357-62.  Back to cited text no. 15
    
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Bajraktari G. Lindqvist P, Henei MY. Left ventricular global dyssynchrony is exaggerated with age. Int Cardiovasc F 2013:47-51.  Back to cited text no. 16
    
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Yang B, Chettiveettil D, Jones F, Aguero M, Lewis JF. Left ventricular dyssynchrony in hypertensive patients without congestive heart failure. Clin Cardiol 2008;31:597-601.  Back to cited text no. 17
    
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Ng A, Tran DT, Newman M, Allman C, Vidaic J, Touzel K, et al. Clinical and echocardiographic determinants of left ventricular synchrony. Circulation 2007;116:II627.  Back to cited text no. 18
    
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Stevenson WG, Hernandez AF, Carson PE, Fang JC, Katz SD, Spertus JA, et al.; Heart Failure Society of America Guideline Committee. Indications for cardiac resynchronization therapy: 2011 update from the Heart Failure Society of America Guideline Committee. J Card Fail 2012;18:94-106.  Back to cited text no. 19
    
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    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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