Michael Roughton

University College London Hospitals NHS Foundation Trust, Londinium, England, United Kingdom

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Publications (127)833.12 Total impact

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    ABSTRACT: Transcatheter aortic valve implantation (TAVI) is an effective treatment option for patients with severe degenerative aortic valve stenosis who are high risk for conventional surgery. Computed tomography (CT) performed prior to TAVI can detect pathologies that could influence outcomes following the procedure, however the incidence, cost, and clinical impact of incidental findings has not previously been investigated. 279 patients underwent CT; 188 subsequently had TAVI and 91 were declined. Incidental findings were classified as clinically significant (requiring treatment), indeterminate (requiring further assessment), or clinically insignificant. The primary outcome measure was all-cause mortality up to 3 years. Costs incurred by additional investigations resultant to incidental findings were estimated using the UK Department of Health Payment Tariff. Incidental findings were common in both the TAVI and medical therapy cohorts (54.8 vs. 70.3 %; P = 0.014). Subsequently, 45 extra investigations were recommended for the TAVI cohort, at an overall average cost of £32.69 per TAVI patient. In a univariate model, survival was significantly associated with the presence of a clinically significant or indeterminate finding (HR 1.61; P = 0.021). However, on multivariate analysis outcomes after TAVI were not influenced by any category of incidental finding. Incidental findings are common on CT scans performed prior to TAVI. However, the total cost involved in investigating these findings is low, and incidental findings do not independently identify patients with poorer outcomes after TAVI. The discovery of an incidental finding on CT should not necessarily influence or delay the decision to perform TAVI.
    The international journal of cardiovascular imaging 06/2015; DOI:10.1007/s10554-015-0685-z · 2.32 Impact Factor
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    ABSTRACT: We hypothesized that fibrosis detected by late gadolinium enhancement (LGE) cardiovascular magnetic resonance predicts outcomes in patients with transposition of the great arteries post atrial redirection surgery. These patients have a systemic right ventricle (RV) and are at risk of arrhythmia, premature RV failure, and sudden death. Fifty-five patients (aged 27±7 years) underwent LGE cardiovascular magnetic resonance and were followed for a median 7.8 (interquartile range, 3.8-9.6) years in a prospective single-center cohort study. RV LGE was present in 31 (56%) patients. The prespecified composite clinical end point comprised new-onset sustained tachyarrhythmia (atrial/ventricular) or decompensated heart failure admission/transplantation/death. Univariate predictors of the composite end point (n=22 patients; 19 atrial/2 ventricular tachyarrhythmia, 1 death) included RV LGE presence and extent, RV volumes/mass/ejection fraction, right atrial area, peak Vo2, and age at repair. In bivariate analysis, RV LGE presence was independently associated with the composite end point (hazard ratio, 4.95 [95% confidence interval, 1.60-15.28]; P=0.005), and only percent predicted peak Vo2 remained significantly associated with cardiac events after controlling for RV LGE (hazard ratio, 0.80 [95% confidence interval, 0.68-0.95]; P=0.009/5%). In 8 of 9 patients with >1 event, atrial tachyarrhythmia, itself a known risk factor for mortality, occurred first. There was agreement between location and extent of RV LGE at in vivo cardiovascular magnetic resonance and histologically documented focal RV fibrosis in an explanted heart. There was RV LGE progression in a different case restudied for clinical indications. Systemic RV LGE is strongly associated with adverse clinical outcome especially arrhythmia in transposition of the great arteries, thus LGE cardiovascular magnetic resonance should be incorporated in risk stratification of these patients. © 2015 American Heart Association, Inc.
    Circulation Cardiovascular Imaging 05/2015; 8(5). DOI:10.1161/CIRCIMAGING.114.002628 · 6.75 Impact Factor
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    ABSTRACT: Heart failure (HF) is predominantly a disease of the elderly. Reliable risk stratification would help in the management of this population, but no model has been well evaluated in elderly HF patients in both acute and chronic settings and not being restricted by ejection fraction. To evaluate the utility of the SENIORS risk model, developed from a clinical trial of elderly patients with chronic HF, in an independent cohort (National Spanish Registry: RICA) of elderly acute HF patients.
    International Journal of Cardiology 01/2015; 116. DOI:10.1016/j.ijcard.2014.12.173 · 6.18 Impact Factor
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    ABSTRACT: Objectives Multicentre registries facilitate studies of rarer conditions, but may introduce unidentified confounders. Fetal aortic valvuloplasty may prevent progression of aortic stenosis to hypoplastic left heart syndrome and allow biventricular rather than univentricular postnatal treatment. We investigate whether a blinded, simulated multidisciplinary team (MDT) approach aids interpretation of multicentre data to uncover institutional bias in postnatal decision-making following fetal cardiac intervention (FCI).Methods The MDT, blinded to FCI, institutional location and postnatal treatment assigned a surgical pathway to 109 neonates diagnosed prenatally with aortic stenosis in 13 European countries, where 32 had undergone FCI. MDT decisions were the numerical consensus of silent voting with case review where a decision was split. Funnel plots showing concordance between MDT and local team's surgical choice (first pathway) and with outcome (final pathway) were created.Results105 had biventricular or univentricular decision with 4 undecided. Blinded MDT consensus for first pathway matched surgical centre decisions in 93/105 (89%) with no difference in agreement in those undergoing FCI (n = 32) and no (74) or unsuccessful (3) valvuloplasty (no-FCI) (Kappa 0.73, 95% CI 0.38-1.00 vs 0.74, 95% CI 0.51-0.96). However funnel plots comparing MDT individual decisions with local teams’ display more discordance (meaning biventricular – univentricular conversion) for final surgical pathway following FCI than no-FCI (36/74 vs 34/130), p = 0.002 and identified one outlying centre. The important difference was a deficiency of their integrated surgical programme.Conclusions This method may improve interpretation of outcomes in multicentre studies by identifying and investigating outliers identified in funnel plots.
    Ultrasound in Obstetrics and Gynecology 11/2014; 44(5). DOI:10.1002/uog.13447 · 3.14 Impact Factor
  • Ultrasound in Obstetrics and Gynecology 09/2014; 44(S1):143-143. DOI:10.1002/uog.13964 · 3.14 Impact Factor
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    ABSTRACT: AimsThere is limited information about the effects of beta-blockers in heart failure (HF) stratified by blood pressure, especially in the elderly and those with preserved EF. We evaluate the effects of nebivolol on outcomes in elderly patients with HF stratified by baseline systolic blood pressure (SBP) and EF.Methods and resultsThe SENIORS trial evaluated the effects of nebivolol and enrolled 2128 patients ≥70 years of age with HF. Patients were divided into three baseline pre-treatment SBP categories (<110, 110–130, and >130 mmHg). In addition, we evaluated the influence of SBP (≤130 and >130 mmHg) on patients with LVEF <40% vs. ≥40%. Low baseline SBP was associated with worse clinical outcomes irrespective of treatment group, both in patients with reduced EF and in those with preserved EF. Nebivolol had similar benefits irrespective of baseline SBP: the hazard ratio (HR) for primary outcome of all-cause mortality or cardiovascular hospitalization in the three SBP categories for nebivolol vs. placebo was 0.85 [95% confidence interval (CI) 0.50–1.45], 0.79 (95% CI 0.61–1.01), and 0.88 (95% CI 0.72–1.07), respectively (P for interaction = 0.61). Similar results were obtained for the secondary endpoint of all-cause mortality. There was no significant interaction for the effects of nebivolol by baseline SBP stratified by LVEF.Conclusions Elderly HF patients with lower SBP have a worse outcome than those with higher SBP, but nebivolol appears to be safe and well tolerated, with similar benefits on the composite outcome of death or cardiovascular hospital admission irrespective of baseline SBP and LVEF.
    European Journal of Heart Failure 09/2014; 16(9). DOI:10.1002/ejhf.136 · 6.58 Impact Factor
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    ABSTRACT: Background The assessment of myocardial iron using T2* cardiovascular magnetic resonance (CMR) has been validated and calibrated, and is in clinical use. However, there is very limited data assessing the relaxation parameters T1 and T2 for measurement of human myocardial iron. Methods Twelve hearts were examined from transfusion-dependent patients: 11 with end-stage heart failure, either following death (n = 7) or cardiac transplantation (n = 4), and 1 heart from a patient who died from a stroke with no cardiac iron loading. Ex-vivo R1 and R2 measurements (R1 = 1/T1 and R2 = 1/T2) at 1.5 Tesla were compared with myocardial iron concentration measured using inductively coupled plasma atomic emission spectroscopy. Results From a single myocardial slice in formalin which was repeatedly examined, a modest decrease in T2 was observed with time, from mean (±SD) 23.7 ± 0.93 ms at baseline (13 days after death and formalin fixation) to 18.5 ± 1.41 ms at day 566 (p < 0.001). Raw T2 values were therefore adjusted to correct for this fall over time. Myocardial R2 was correlated with iron concentration [Fe] (R2 0.566, p < 0.001), but the correlation was stronger between LnR2 and Ln[Fe] (R2 0.790, p < 0.001). The relation was [Fe] = 5081•(T2)-2.22 between T2 (ms) and myocardial iron (mg/g dry weight). Analysis of T1 proved challenging with a dichotomous distribution of T1, with very short T1 (mean 72.3 ± 25.8 ms) that was independent of iron concentration in all hearts stored in formalin for greater than 12 months. In the remaining hearts stored for <10 weeks prior to scanning, LnR1 and iron concentration were correlated but with marked scatter (R2 0.517, p < 0.001). A linear relationship was present between T1 and T2 in the hearts stored for a short period (R2 0.657, p < 0.001). Conclusion Myocardial T2 correlates well with myocardial iron concentration, which raises the possibility that T2 may provide additive information to T2* for patients with myocardial siderosis. However, ex-vivo T1 measurements are less reliable due to the severe chemical effects of formalin on T1 shortening, and therefore T1 calibration may only be practical from in-vivo human studies.
    Journal of Cardiovascular Magnetic Resonance 08/2014; 16(1-1):62. DOI:10.1186/s12968-014-0062-4 · 5.11 Impact Factor
  • Journal of Cardiovascular Magnetic Resonance 08/2014; · 5.11 Impact Factor
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    ABSTRACT: Background Microvascular dysfunction in HCM has been associated with adverse clinical outcomes. Advances in quantitative cardiovascular magnetic resonance (CMR) perfusion imaging now allow myocardial blood flow to be quantified at the pixel level. We applied these techniques to investigate the spectrum of microvascular dysfunction in hypertrophic cardiomyopathy (HCM) and to explore its relationship with fibrosis and wall thickness. Methods CMR perfusion imaging was undertaken during adenosine-induced hyperemia and again at rest in 35 patients together with late gadolinium enhancement (LGE) imaging. Myocardial blood flow (MBF) was quantified on a pixel-by-pixel basis from CMR perfusion images using a Fermi-constrained deconvolution algorithm. Regions-of-interest (ROI) in hypoperfused and hyperemic myocardium were identified from the MBF pixel maps. The myocardium was also divided into 16 AHA segments. Results Resting MBF was significantly higher in the endocardium than in the epicardium (mean ± SD: 1.25 ± 0.35 ml/g/min versus 1.20 ± 0.35 ml/g/min, P < 0.001), a pattern that reversed with stress (2.00 ± 0.76 ml/g/min versus 2.36 ± 0.83 ml/g/min, P < 0.001). ROI analysis revealed 11 (31%) patients with stress MBF lower than resting values (1.05 ± 0.39 ml/g/min versus 1.22 ± 0.36 ml/g/min, P = 0.021). There was a significant negative association between hyperemic MBF and wall thickness (β = −0.047 ml/g/min per mm, 95% CI: −0.057 to −0.038, P < 0.001) and a significantly lower probability of fibrosis in a segment with increasing hyperemic MBF (odds ratio per ml/g/min: 0.086, 95% CI: 0.078 to 0.095, P = 0.003). Conclusions Pixel-wise quantitative CMR perfusion imaging identifies a subgroup of patients with HCM that have localised severe microvascular dysfunction which may give rise to myocardial ischemia.
    Journal of Cardiovascular Magnetic Resonance 08/2014; 16(1):49. DOI:10.1186/s12968-014-0049-1 · 5.11 Impact Factor
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    ABSTRACT: Background Heart failure activates neurohormones, and elevated levels of brain natriuretic peptide (BNP) are associated with adverse outcomes. The SENIORS trial showed that nebivolol, a highly selective beta-1 antagonist with vasodilating properties, reduced the composite outcome of all cause mortality or cardiovascular hospital admissions in older patients with heart failure. We explored the effects of nebivolol on a range of neurohormones, cytokines and markers of nitric oxide activity in heart failure. Methods In a subset of patients in SENIORS we measured N-terminal pro-brain natriuretic peptide (NT-BNP), pro atrial natriuretic peptide (Pro-ANP), endothelin-1 (ET-1), peripheral norepinephrine (PNE), soluble Fas (sFas), soluble Fas-ligand (sFas-L), tumour necrosis factor-alpha (TNF-α), serum uric acid (SUA), symmetrical dimethyl arginine (SDMA), arginine, citrulline and asymmetrical dimethyl arginine (ADMA) at baseline (before study drug), at 6 months and 12 months in a prespecified substudy. Results One hundred and six patients were enrolled and 75 had a baseline and at least one follow-up sample. There were no significant differences in neurohormone cytokines or nitric oxide markers measured between the two groups at six or twelve months. NT-ProBNP showed a numerical increase in the nebivolol group compared to placebo (P = 0.08) and sFas showed a numerical increase in patients on placebo (P = 0.08). Mean baseline LVEF was 35% in both groups and at 12 months was 43% on nebivolol group and 34% on placebo group (P = 0.01). Conclusion There were trends but no clear changes associated with nebivolol in neurohormones, cytokines or markers of nitric oxide activity in this study of elderly patients with heart failure. Further studies are needed to understand the mechanistic effects of beta blockers on biomarkers in heart failure.
    International Journal of Cardiology 08/2014; 175(2):253–260. DOI:10.1016/j.ijcard.2014.05.018 · 6.18 Impact Factor
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    ABSTRACT: Abstract Purpose: Dysfunctional breathing (DB) is associated with an abnormal breathing pattern, unexplained breathlessness and significant patient morbidity. Treatment involves breathing retraining through respiratory physiotherapy. Recently, manual therapy (MT) has also been used, but no evidence exists to validate its use. This study sought to investigate whether MT produces additional benefit when compared with breathing retraining alone in patients with DB. Methods: Sixty subjects with primary DB were randomised into either breathing retraining (standard treatment; n = 30) or breathing retraining plus MT (intervention; n = 30) group. Both the groups received standardised respiratory physiotherapy, which included: DB education, breathing retraining, home regimen, and audio disc. Intervention group subjects additionally received MT following further assessment. Data from 57 subjects were analysed. Results: At baseline, standard treatment group subjects were statistically younger (41.7 + 13.5 versus 50.8 + 13.0 years; p = 0.001) with higher Nijmegen scores (38.6 + 9.5 versus 31.5 + 6.9; p = 0.001). However, no significant difference was found between the groups for primary outcome Nijmegen score (95% CI (-1.1, 6.6) p = 0.162), or any secondary outcomes (Hospital Anxiety & Depression Score, spirometry or exercise tolerance). Conclusion: Breathing retraining is currently the mainstay of treatment for patients with DB. The results of this study suggest MT provides no additional benefit in this patient group. Implications for Rehabilitation Dysfunctional breathing (DB) is associated with significant patient morbidity but often goes unrecognised, leading to prolonged investigation and significant use of health care resources. Breathing retraining remains the primary management of this condition. However, physiotherapists are also using manual therapy (MT) as an adjunctive treatment for patients with DB. However, the results of this study suggest that MT provides no further benefit and cannot be recommended in the clinical management of this condition.
    Disability and Rehabilitation 07/2014; 37(9):1-8. DOI:10.3109/09638288.2014.941020 · 1.84 Impact Factor
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    ABSTRACT: Objective: Myocardial fibrosis identified by late gadolinium enhancement (LGE) cardiovascular magnetic resonance (CMR) in patients with hypertrophic cardiomyopathy (HCM) is associated with adverse cardiovascular events, but its value as an independent risk factor for sudden cardiac death (SCD) is unknown. We investigated the role of LGE-CMR in the risk stratification of HCM. Methods: We conducted a prospective cohort study in a tertiary referral centre. Consecutive patients with HCM (n=711, median age 56.3 years, IQR 46.7-66.6; 70.0% male) underwent LGE-CMR and were followed for a median 3.5 years. The primary end point was SCD or aborted SCD. Results: Overall, 471 patients (66.2%) had myocardial fibrosis (median 5.9% of left ventricular mass, IQR: 2.2-13.3). Twenty-two (3.1%) reached the primary end point. The extent but not the presence of fibrosis was a significant univariable predictor of the primary end point (HR per 5% LGE: 1.24, 95% CI 1.06 to 1.45; p=0.007 and HR for LGE: 2.69, 95% CI 0.91 to 7.97; p=0.073, respectively). However, on multivariable analysis, only LV-EF remained statistically significant (HR: 0.92, 95% CI 0.89 to 0.95; p<0.001). For the secondary outcome of cardiovascular mortality/aborted SCD, the presence and the amount of fibrosis were significant predictors on univariable but not multivariable analysis after adjusting for LV-EF and non-sustained ventricular tachycardia. Conclusions: The amount of myocardial fibrosis was a strong univariable predictor of SCD risk. However, this effect was not maintained after adjusting for LV-EF. Further work is required to elucidate the interrelationship between fibrosis and traditional predictors of outcome in HCM.
    Heart (British Cardiac Society) 06/2014; 100(23). DOI:10.1136/heartjnl-2013-305471 · 6.02 Impact Factor
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    ABSTRACT: Background There is a need to standardise non-invasive measurements of liver iron concentrations (LIC) so clear inferences can be drawn about body iron levels that are associated with hepatic and extra-hepatic complications of iron overload. Since the first demonstration of an inverse relationship between biopsy LIC and liver magnetic resonance (MR) using a proof-of-concept T2* sequence, MR technology has advanced dramatically with a shorter minimum echo-time, closer inter-echo spacing and constant repetition time. These important advances allow more accurate calculation of liver T2* especially in patients with high LIC. Methods Here, we used an optimised liver T2* sequence calibrated against 50 liver biopsy samples on 25 patients with transfusional haemosiderosis using ordinary least squares linear regression, and assessed the method reproducibility in 96 scans over an LIC range up to 42 mg/g dry weight (dw) using Bland-Altman plots. Using mixed model linear regression we compared the new T2*-LIC with R2-LIC (Ferriscan) on 92 scans in 54 patients with transfusional haemosiderosis and examined method agreement using Bland-Altman approach. Results Strong linear correlation between ln(T2*) and ln(LIC) led to the calibration equation LIC = 31.94(T2*)-1.014. This yielded LIC values approximately 2.2 times higher than the proof-of-concept T2* method. Comparing this new T2*-LIC with the R2-LIC (Ferriscan) technique in 92 scans, we observed a close relationship between the two methods for values up to 10 mg/g dw, however the method agreement was poor. Conclusions New calibration of T2* against liver biopsy estimates LIC in a reproducible way, correcting the proof-of-concept calibration by 2.2 times. Due to poor agreement, both methods should be used separately to diagnose or rule out liver iron overload in patients with increased ferritin.
    Journal of Cardiovascular Magnetic Resonance 06/2014; 16(1):40. DOI:10.1186/1532-429X-16-40 · 5.11 Impact Factor
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    ABSTRACT: Compare cardiac function at ten years in three groups of monochorionic twin pairs (MCDA): uncomplicated MCDA (n = 6), Twin-Twin Transfusion Syndrome (TTTS) managed by amnioreduction (TTTS-amnio, n = 9) or laser photocoagulation (TTTS-laser, n = 10).and dichorionic (DCDA, n = 6) controls. Echocardiograms optimising apical 4-chamber and short axis left ventricular views were stored for off-line speckle-tracking analysis, blinded to twin type. Myocardial long axis shortening (S') and lengthening (E' and A') velocities were measured using pulsed Doppler at the cardiac base. M-mode measurements of fractional shortening (short axis) and maximal displacement of the atrioventricular annulus (4-chamber) were recorded. Syngo Vector Velocity Imaging software tracked left ventricular myocardial motion off-line to produce free wall Strain, Strain Rate and Rotation. Inter-twin pair and group differences were investigated using ANOVA. Cardiac measurements lay within normal ranges for 10 year olds. No significant within twin-pair and inter-group differences were found in current size, heart rates, Strain or Strain Rate. Compared to DCDA controls, TTTS showed lower cardiac rotation (TTTS-laser, p < 0.001 and TTTS-amnio, p = 0.054) with significant inter-twin pair reduction in ex-Recipient, TTTS-amnio (p = 0.006) and larger MCDA twins (p = 0.027) compared to their co-twins. A similar pattern was seen in left ventricular early relaxation velocities (MVE') in all monochorionic groups only achieving significance in TTTS-amnio (p = 0.037). Intra-pair differences in rotation and MVE' were significantly different following treatment at Quintero stages 3 or 4. Within twin-pair patterns of left ventricular rotation and diastolic function differ at 10 years in ex-Recipients of TTTS-amnio compared with TTTS-laser and controls.
    Ultrasound in Obstetrics and Gynecology 06/2014; 43(6). DOI:10.1002/uog.13279 · 3.14 Impact Factor
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    ABSTRACT: Localized rotors have been implicated in the mechanism of persistent atrial fibrillation (AF). Although regions of highest dominant frequency (DF) on spectral analysis of the left atrium (LA) have been said to identify rotors, other mechanisms such as wavefront collisions will sporadically also generate an inconsistent distribution of high DF. We hypothesized that if drivers of AF were present their distinctive spectral characteristics would result more from their temporal stability than their high frequency. Ten patients with persistent AF underwent LA noncontact mapping. Following subtraction of far-field ventricular components, noncontact electrograms at 256 sites underwent fast Fourier transform. Mean absolute difference in DF between five sequential 7-second segments of AF was defined as the DF variability (DFV) at each site. Mean ratio of the DF and its harmonics to the total power of the spectrum was defined as the organizational index (OI). Mean DFV was significantly lower in organized areas (OI >1 SD above mean) than at all sites (0.34±0.04 vs 0.46±0.04 Hz; P<0.001). When organized areas were ablated during wide area circumferential ablation, AF organised in remote regions (LA appendage ΔOI ablated vs unablated: +0.21 (0.06-0.41) vs -0.04 (-0.14-0.05); P = 0.005). At sites of organized activation, the activation frequency was also significantly more stable over time. This observation is consistent with the existence of focal sources, and inconsistent with a purely random activation pattern. Ablation of such regions is technically feasible, and was associated with organization of AF in remote atrial regions. This article is protected by copyright. All rights reserved.
    Journal of Cardiovascular Electrophysiology 01/2014; 25(4). DOI:10.1111/jce.12352 · 2.88 Impact Factor
  • 09/2013; 4(4):296-301. DOI:10.1136/flgastro-2013-100333
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    ABSTRACT: Cardiovascular Magnetic Resonance (CMR) is the gold-standard technique for assessment of ventricular function. Although left ventricular (LV) volumes and ejection fraction are strong predictors of outcome in dilated cardiomyopathy (DCM), there are limited data regarding the prognostic significance of right ventricular (RV) systolic dysfunction (RVSD). We investigated whether CMR assessment of RV function has prognostic value in DCM. We prospectively studied 250 consecutive DCM patients using CMR. RVSD, defined by RV ejection fraction ≤45%, was present in 86 (34%) patients. During a median follow-up period of 6.8 years, there were 52 deaths and 7 patients underwent cardiac transplantation . The primary end point of all-cause mortality or cardiac transplantation was reached by 42 of 86 patients with RVSD and 17 of 164 patients without RVSD (49% vs. 10%; hazard ratio [HR], 5.90; 95% confidence interval [CI], 3.35 to 10.37; P<0.001). On multivariable analysis, RVSD remained a significant independent predictor of the primary end point (HR, 3.90; 95% CI, 2.16 to 7.04; P<0.001), as well as secondary outcomes of cardiovascular mortality or cardiac transplantation (HR, 3.35; 95% CI, 1.76 to 6.39; P<0.001), and heart failure (HF) death, HF hospitalization or cardiac transplantation (HR, 2.70; 95% CI, 1.32 to 5.51; P=0.006). Assessment of RVSD improved risk stratification for all-cause mortality or cardiac transplantation (net reclassification improvement, 0.31; 95% CI 0.10 to 0.53; P=0.001). RVSD is a powerful, independent predictor of transplant-free survival and adverse HF outcomes in DCM. CMR assessment of RV function is important in the evaluation and risk stratification of DCM patients.
    Circulation 08/2013; 128(15). DOI:10.1161/CIRCULATIONAHA.113.002518 · 14.95 Impact Factor
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    ABSTRACT: ABSTRACT Accumulation of myocardial iron is the cause of heart failure and early death in most transfused thalassemia major patients. T2* cardiovascular magnetic resonance provides calibrated, reproducible measurements of myocardial iron. However, there is little data regarding myocardial iron loading and its relation to outcome across the world. A survey is reported of 3,095 patients in 27 worldwide centres using T2* cardiovascular magnetic resonance. Data on baseline T2* and numbers of patients with symptoms of heart failure at first scan (defined as symptoms and signs of heart failure with objective evidence of left ventricular dysfunction) were requested together with more detailed information about patients who subsequently developed heart failure or died. At first scan, 20.6% had severe myocardial iron (T2*≤10ms), 22.8% had moderate myocardial iron (T2* 10-20ms) and 56.6% of patients had no iron loading (T2*>20ms). There was significant geographic variation in myocardial iron loading (24.8-52.6%, p<0.001). At first scan, 85 (2.9%) of 2,915 patients were reported to have heart failure (81.2% had T2* <10ms; 98.8% had T2* <20ms). During follow-up, 108 (3.8%) of 2,830 patients developed new heart failure. Of these, T2* at first scan had been <10ms in 96.3% and <20ms in 100%. There were 35 (1.1%) cardiac deaths. Of these patients, myocardial T2* at first scan had been <10ms in 85.7% and <20ms in 97.1%. Therefore, in this worldwide cohort of thalassemia major patients, >43% had moderate/severe myocardial iron loading with significant geographic differences, and myocardial T2* values <10ms were strongly associated with heart failure and death.
    Haematologica 06/2013; 98(9):1368-1374. DOI:10.3324/haematol.2013.083634 · 5.87 Impact Factor
  • Gut 06/2013; 62(Suppl 1):A158-A158. DOI:10.1136/gutjnl-2013-304907.357 · 13.32 Impact Factor
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    ABSTRACT: BACKGROUND: Early recognition and accurate risk stratification are important in the management of arrhythmogenic right ventricular cardiomyopathy (ARVC). Identification of predictors of outcome by cardiovascular magnetic resonance (CMR) in patients undergoing evaluation for ARVC is limited. We investigated the predictive value of morphological abnormalities detected by CMR for major clinical events in patients with suspected ARVC. METHODS: We performed a longitudinal study on 369 consecutive patients with at least one criterion for ARVC. Abnormal CMR was defined by the presence of one of the following: increased right ventricular (RV) volumes, reduced RV ejection fraction, RV regional wall motion abnormalities, myocardial fatty infiltration, and myocardial fibrosis. The end-point was a composite of cardiac death, sustained ventricular tachycardia, ventricular fibrillation, and appropriate ICD discharge. RESULTS: Twenty patients met the composite end-point over a mean follow-up of 4.3±1.5years. An abnormal CMR was an independent predictor of outcomes (p<0.001). The presence of multiple abnormalities heralded a particular high risk of events (HR 23.0, 95% CI 5.7-93.2, p<0.001 for 2 abnormalities; HR 35.8, 95% CI 9.7-132.6, p<0.001 for 3 or more abnormalities). The positive predictive value of an abnormal CMR study was 21.0% for an adverse event, whilst the negative predictive value of a normal CMR study was 98.8% over the follow-up period. CONCLUSIONS: CMR provides important prognostic information in patients under evaluation for ARVC. A normal study portends a good prognosis. Conversely, the presence of multiple abnormalities identifies a high risk group of patients who may benefit from ICD implantation.
    International journal of cardiology 05/2013; 168(4). DOI:10.1016/j.ijcard.2013.04.208 · 6.18 Impact Factor

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3k Citations
833.12 Total Impact Points


  • 2014
    • University College London Hospitals NHS Foundation Trust
      Londinium, England, United Kingdom
    • UK Department of Health
      Londinium, England, United Kingdom
  • 2012–2014
    • Royal College of Physicians
      Londinium, England, United Kingdom
  • 2006–2014
    • Imperial College London
      Londinium, England, United Kingdom
  • 2008–2013
    • Centre for Statistics in Medicine
      Oxford, England, United Kingdom
    • The Royal Society of Medicine
      Londinium, England, United Kingdom
    • University College London
      Londinium, England, United Kingdom
  • 2007–2013
    • Royal Brompton and Harefield NHS Foundation Trust
      • Department of Paediatrics
      Harefield, England, United Kingdom
  • 2011
    • University of Alcalá
      Cómpluto, Madrid, Spain
  • 2007–2009
    • King's College London
      • Division of Asthma, Allergy and Lung Biology
      Londinium, England, United Kingdom