Left atrial expansion index measured with cardiovascular magnetic resonance estimates pulmonary capillary wedge pressure in dilated cardiomyopathy
Pulmonary capillary wedge pressure (PCWP) assessment is fundamental for managing dilated cardiomyopathy (DCM) patients. Although cardiovascular magnetic resonance (CMR) has become the gold-standard imaging technique for evaluating cardiac chamber volume and function, PCWP is not routinely assessed w...
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| Veröffentlicht in: | Journal of cardiovascular magnetic resonance 2023-11, Vol.25 (1), p.71-71, Article 71 |
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| creator | Genovese, Davide De Michieli, Laura Prete, Giacomo De Lazzari, Manuel Previtero, Marco Mele, Donato Cernetti, Carlo Tarantini, Giuseppe Iliceto, Sabino Perazzolo Marra, Martina |
| description | Pulmonary capillary wedge pressure (PCWP) assessment is fundamental for managing dilated cardiomyopathy (DCM) patients. Although cardiovascular magnetic resonance (CMR) has become the gold-standard imaging technique for evaluating cardiac chamber volume and function, PCWP is not routinely assessed with CMR. Therefore, this study aimed to validate the left atrial expansion index (LAEI), a LA reservoir function parameter able to estimate filling pressure with echocardiography, as a novel CMR-measured parameter for non-invasive PCWP estimation in DCM patients.
We performed a retrospective, single-center, cross-sectional study. We included electively admitted DCM patients referred to our tertiary center for further diagnostic evaluation that underwent a clinically indicated right heart catheterization (RHC) and CMR within 24 h. PCWP invasively measured during RHC was used as the reference. LAEI was calculated from CMR-measured LA maximal and minimal volumes as LAEI = ( (LAVmax-LAVmin)/LAVmin) × 100.
We enrolled 126 patients (47 ± 14 years; 68% male; PCWP = 17 ± 9.3 mmHg) randomly divided into derivation (n = 92) and validation (n = 34) cohorts with comparable characteristics. In the derivation cohort, the log-transformed (ln) LAEI showed a strong linear correlation with PCWP (r = 0.81, p < 0.001) and remained a strong independent PCWP determinant over clinical and conventional CMR parameters. Moreover, lnLAEI accurately identified PCWP ≥ 15 mmHg (AUC = 0.939, p < 0.001), and the optimal cut-off identified (lnLAEI ≤ 3.85) in the derivation cohort discriminated PCWP ≥ 15 mmHg with 82.4% sensitivity, 88.2% specificity, and 85.3% accuracy in the validation cohort. Finally, the equation PCWP = 52.33- (9.17xlnLAEI) obtained from the derivation cohort predicted PCWP (-0.1 ± 5.7 mmHg) in the validation cohort.
In this cohort of DCM patients, CMR-measured LAEI resulted in a novel and useful parameter for non-invasive PCWP evaluation. |
| doi_str_mv | 10.1186/s12968-023-00977-2 |
| format | Article |
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We performed a retrospective, single-center, cross-sectional study. We included electively admitted DCM patients referred to our tertiary center for further diagnostic evaluation that underwent a clinically indicated right heart catheterization (RHC) and CMR within 24 h. PCWP invasively measured during RHC was used as the reference. LAEI was calculated from CMR-measured LA maximal and minimal volumes as LAEI = ( (LAVmax-LAVmin)/LAVmin) × 100.
We enrolled 126 patients (47 ± 14 years; 68% male; PCWP = 17 ± 9.3 mmHg) randomly divided into derivation (n = 92) and validation (n = 34) cohorts with comparable characteristics. In the derivation cohort, the log-transformed (ln) LAEI showed a strong linear correlation with PCWP (r = 0.81, p < 0.001) and remained a strong independent PCWP determinant over clinical and conventional CMR parameters. Moreover, lnLAEI accurately identified PCWP ≥ 15 mmHg (AUC = 0.939, p < 0.001), and the optimal cut-off identified (lnLAEI ≤ 3.85) in the derivation cohort discriminated PCWP ≥ 15 mmHg with 82.4% sensitivity, 88.2% specificity, and 85.3% accuracy in the validation cohort. Finally, the equation PCWP = 52.33- (9.17xlnLAEI) obtained from the derivation cohort predicted PCWP (-0.1 ± 5.7 mmHg) in the validation cohort.
In this cohort of DCM patients, CMR-measured LAEI resulted in a novel and useful parameter for non-invasive PCWP evaluation.</description><identifier>ISSN: 1097-6647</identifier><identifier>EISSN: 1532-429X</identifier><identifier>DOI: 10.1186/s12968-023-00977-2</identifier><identifier>PMID: 38031092</identifier><language>eng</language><publisher>England: Elsevier Inc</publisher><subject>Accuracy ; Atrial Fibrillation ; Capillary pressure ; Cardiac catheterization ; Cardiomyopathy ; Cardiomyopathy, Dilated - diagnostic imaging ; Catheters ; Clinical medicine ; Cross-Sectional Studies ; Derivation ; Dilated cardiomyopathy ; Echocardiography ; Evaluation ; Female ; Filling pressures ; Heart ; Humans ; Identification ; Imaging techniques ; Intubation ; Left atrial compliance ; Left atrial pressure ; Left atrial reservoir function ; Left atrial volume ; Magnetic resonance ; Magnetic Resonance Spectroscopy ; Male ; Multivariate analysis ; Parameter identification ; Predictive Value of Tests ; Pulmonary Wedge Pressure ; Retrospective Studies ; Statistical analysis</subject><ispartof>Journal of cardiovascular magnetic resonance, 2023-11, Vol.25 (1), p.71-71, Article 71</ispartof><rights>2023 © 2023 THE AUTHORS. Published by Elsevier Inc on behalf of the Society for Cardiovascular Magnetic Resonance</rights><rights>2023. The Author(s).</rights><rights>2023. This work is licensed under http://creativecommons.org/licenses/by/4.0/ (the “License”). Notwithstanding the ProQuest Terms and Conditions, you may use this content in accordance with the terms of the License.</rights><rights>The Author(s) 2023</rights><lds50>peer_reviewed</lds50><oa>free_for_read</oa><woscitedreferencessubscribed>false</woscitedreferencessubscribed><cites>FETCH-LOGICAL-c435t-d14b0bf02cd38254e7c837dfd834e075982e2335f9ae1206137651c86513ce4a3</cites><orcidid>0000-0002-8814-0969</orcidid></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><linktopdf>$$Uhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC10688459/pdf/$$EPDF$$P50$$Gpubmedcentral$$Hfree_for_read</linktopdf><linktohtml>$$Uhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC10688459/$$EHTML$$P50$$Gpubmedcentral$$Hfree_for_read</linktohtml><link.rule.ids>230,314,727,780,784,864,885,27924,27925,53791,53793</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/38031092$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Genovese, Davide</creatorcontrib><creatorcontrib>De Michieli, Laura</creatorcontrib><creatorcontrib>Prete, Giacomo</creatorcontrib><creatorcontrib>De Lazzari, Manuel</creatorcontrib><creatorcontrib>Previtero, Marco</creatorcontrib><creatorcontrib>Mele, Donato</creatorcontrib><creatorcontrib>Cernetti, Carlo</creatorcontrib><creatorcontrib>Tarantini, Giuseppe</creatorcontrib><creatorcontrib>Iliceto, Sabino</creatorcontrib><creatorcontrib>Perazzolo Marra, Martina</creatorcontrib><title>Left atrial expansion index measured with cardiovascular magnetic resonance estimates pulmonary capillary wedge pressure in dilated cardiomyopathy</title><title>Journal of cardiovascular magnetic resonance</title><addtitle>J Cardiovasc Magn Reson</addtitle><description>Pulmonary capillary wedge pressure (PCWP) assessment is fundamental for managing dilated cardiomyopathy (DCM) patients. Although cardiovascular magnetic resonance (CMR) has become the gold-standard imaging technique for evaluating cardiac chamber volume and function, PCWP is not routinely assessed with CMR. Therefore, this study aimed to validate the left atrial expansion index (LAEI), a LA reservoir function parameter able to estimate filling pressure with echocardiography, as a novel CMR-measured parameter for non-invasive PCWP estimation in DCM patients.
We performed a retrospective, single-center, cross-sectional study. We included electively admitted DCM patients referred to our tertiary center for further diagnostic evaluation that underwent a clinically indicated right heart catheterization (RHC) and CMR within 24 h. PCWP invasively measured during RHC was used as the reference. LAEI was calculated from CMR-measured LA maximal and minimal volumes as LAEI = ( (LAVmax-LAVmin)/LAVmin) × 100.
We enrolled 126 patients (47 ± 14 years; 68% male; PCWP = 17 ± 9.3 mmHg) randomly divided into derivation (n = 92) and validation (n = 34) cohorts with comparable characteristics. In the derivation cohort, the log-transformed (ln) LAEI showed a strong linear correlation with PCWP (r = 0.81, p < 0.001) and remained a strong independent PCWP determinant over clinical and conventional CMR parameters. Moreover, lnLAEI accurately identified PCWP ≥ 15 mmHg (AUC = 0.939, p < 0.001), and the optimal cut-off identified (lnLAEI ≤ 3.85) in the derivation cohort discriminated PCWP ≥ 15 mmHg with 82.4% sensitivity, 88.2% specificity, and 85.3% accuracy in the validation cohort. Finally, the equation PCWP = 52.33- (9.17xlnLAEI) obtained from the derivation cohort predicted PCWP (-0.1 ± 5.7 mmHg) in the validation cohort.
In this cohort of DCM patients, CMR-measured LAEI resulted in a novel and useful parameter for non-invasive PCWP evaluation.</description><subject>Accuracy</subject><subject>Atrial Fibrillation</subject><subject>Capillary pressure</subject><subject>Cardiac catheterization</subject><subject>Cardiomyopathy</subject><subject>Cardiomyopathy, Dilated - diagnostic imaging</subject><subject>Catheters</subject><subject>Clinical medicine</subject><subject>Cross-Sectional Studies</subject><subject>Derivation</subject><subject>Dilated cardiomyopathy</subject><subject>Echocardiography</subject><subject>Evaluation</subject><subject>Female</subject><subject>Filling pressures</subject><subject>Heart</subject><subject>Humans</subject><subject>Identification</subject><subject>Imaging techniques</subject><subject>Intubation</subject><subject>Left atrial compliance</subject><subject>Left atrial pressure</subject><subject>Left atrial reservoir function</subject><subject>Left atrial volume</subject><subject>Magnetic resonance</subject><subject>Magnetic Resonance Spectroscopy</subject><subject>Male</subject><subject>Multivariate analysis</subject><subject>Parameter identification</subject><subject>Predictive Value of Tests</subject><subject>Pulmonary Wedge Pressure</subject><subject>Retrospective Studies</subject><subject>Statistical analysis</subject><issn>1097-6647</issn><issn>1532-429X</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2023</creationdate><recordtype>article</recordtype><sourceid>EIF</sourceid><sourceid>ABUWG</sourceid><sourceid>AFKRA</sourceid><sourceid>AZQEC</sourceid><sourceid>BENPR</sourceid><sourceid>CCPQU</sourceid><sourceid>DWQXO</sourceid><sourceid>GNUQQ</sourceid><recordid>eNp9kc2KFDEUhQtRnHH0BVxIwI2b0vxVJQFBZBh_oMGNgruQTm51Z6hKyiTVM_0aPvGk7XZQF26ScO93T3JymuY5wa8Jkf2bTKjqZYspazFWQrT0QXNOOkZbTtX3h_Vcq23fc3HWPMn5GmOiBBaPmzMmMatNet78XMFQkCnJmxHB7WxC9jEgHxzcoglMXhI4dOPLFlmTnI87k-0ymoQmswlQvEUJcgwmWECQi59MgYzmZZxqMe3r1OzH8XC6AbcBNFf8IFqvQM6PlXYn5WkfZ1O2-6fNo8GMGZ6d9ovm24err5ef2tWXj58v369ay1lXWkf4Gq8HTK1jknYchJVMuMFJxgGLTkkKlLFuUAYIxT1hou-IlXVhFrhhF827o-68rCdwFkJJZtRzqh7SXkfj9d-d4Ld6E3ea4F5K3qmq8OqkkOKPpbrXk88Wqt0AccmaStUJrHrGK_ryH_Q6LilUf5oqTA9JclopeqRsijknGO5fQ7A-ZK6Pmeuauf6VuT4MvfjTx_3I75Ar8PYIQP3NnYeks_VQA3M-gS3aRf8__TtOmr-P</recordid><startdate>20231130</startdate><enddate>20231130</enddate><creator>Genovese, Davide</creator><creator>De Michieli, Laura</creator><creator>Prete, Giacomo</creator><creator>De Lazzari, Manuel</creator><creator>Previtero, Marco</creator><creator>Mele, Donato</creator><creator>Cernetti, Carlo</creator><creator>Tarantini, Giuseppe</creator><creator>Iliceto, Sabino</creator><creator>Perazzolo Marra, Martina</creator><general>Elsevier Inc</general><general>BioMed Central</general><scope>6I.</scope><scope>AAFTH</scope><scope>CGR</scope><scope>CUY</scope><scope>CVF</scope><scope>ECM</scope><scope>EIF</scope><scope>NPM</scope><scope>AAYXX</scope><scope>CITATION</scope><scope>3V.</scope><scope>7SC</scope><scope>7SP</scope><scope>7U5</scope><scope>7X7</scope><scope>7XB</scope><scope>88E</scope><scope>8FD</scope><scope>8FE</scope><scope>8FG</scope><scope>8FH</scope><scope>8FI</scope><scope>8FJ</scope><scope>8FK</scope><scope>ABUWG</scope><scope>AFKRA</scope><scope>ARAPS</scope><scope>AZQEC</scope><scope>BBNVY</scope><scope>BENPR</scope><scope>BGLVJ</scope><scope>BHPHI</scope><scope>CCPQU</scope><scope>DWQXO</scope><scope>FR3</scope><scope>FYUFA</scope><scope>GHDGH</scope><scope>GNUQQ</scope><scope>HCIFZ</scope><scope>JQ2</scope><scope>K9.</scope><scope>L7M</scope><scope>LK8</scope><scope>L~C</scope><scope>L~D</scope><scope>M0S</scope><scope>M1P</scope><scope>M7P</scope><scope>M7Z</scope><scope>P5Z</scope><scope>P62</scope><scope>P64</scope><scope>PIMPY</scope><scope>PQEST</scope><scope>PQQKQ</scope><scope>PQUKI</scope><scope>7X8</scope><scope>5PM</scope><orcidid>https://orcid.org/0000-0002-8814-0969</orcidid></search><sort><creationdate>20231130</creationdate><title>Left atrial expansion index measured with cardiovascular magnetic resonance estimates pulmonary capillary wedge pressure in dilated cardiomyopathy</title><author>Genovese, Davide ; De Michieli, Laura ; Prete, Giacomo ; De Lazzari, Manuel ; Previtero, Marco ; Mele, Donato ; Cernetti, Carlo ; Tarantini, Giuseppe ; Iliceto, Sabino ; Perazzolo Marra, Martina</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-c435t-d14b0bf02cd38254e7c837dfd834e075982e2335f9ae1206137651c86513ce4a3</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2023</creationdate><topic>Accuracy</topic><topic>Atrial Fibrillation</topic><topic>Capillary pressure</topic><topic>Cardiac catheterization</topic><topic>Cardiomyopathy</topic><topic>Cardiomyopathy, Dilated - diagnostic imaging</topic><topic>Catheters</topic><topic>Clinical medicine</topic><topic>Cross-Sectional Studies</topic><topic>Derivation</topic><topic>Dilated cardiomyopathy</topic><topic>Echocardiography</topic><topic>Evaluation</topic><topic>Female</topic><topic>Filling pressures</topic><topic>Heart</topic><topic>Humans</topic><topic>Identification</topic><topic>Imaging techniques</topic><topic>Intubation</topic><topic>Left atrial compliance</topic><topic>Left atrial pressure</topic><topic>Left atrial reservoir function</topic><topic>Left atrial volume</topic><topic>Magnetic resonance</topic><topic>Magnetic Resonance Spectroscopy</topic><topic>Male</topic><topic>Multivariate analysis</topic><topic>Parameter identification</topic><topic>Predictive Value of Tests</topic><topic>Pulmonary Wedge Pressure</topic><topic>Retrospective Studies</topic><topic>Statistical analysis</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Genovese, Davide</creatorcontrib><creatorcontrib>De Michieli, Laura</creatorcontrib><creatorcontrib>Prete, Giacomo</creatorcontrib><creatorcontrib>De Lazzari, Manuel</creatorcontrib><creatorcontrib>Previtero, Marco</creatorcontrib><creatorcontrib>Mele, Donato</creatorcontrib><creatorcontrib>Cernetti, Carlo</creatorcontrib><creatorcontrib>Tarantini, Giuseppe</creatorcontrib><creatorcontrib>Iliceto, Sabino</creatorcontrib><creatorcontrib>Perazzolo Marra, Martina</creatorcontrib><collection>ScienceDirect Open Access Titles</collection><collection>Elsevier:ScienceDirect:Open Access</collection><collection>Medline</collection><collection>MEDLINE</collection><collection>MEDLINE (Ovid)</collection><collection>MEDLINE</collection><collection>MEDLINE</collection><collection>PubMed</collection><collection>CrossRef</collection><collection>ProQuest Central (Corporate)</collection><collection>Computer and Information Systems Abstracts</collection><collection>Electronics & Communications Abstracts</collection><collection>Solid State and Superconductivity Abstracts</collection><collection>Health & Medical Collection</collection><collection>ProQuest Central (purchase pre-March 2016)</collection><collection>Medical Database (Alumni Edition)</collection><collection>Technology Research Database</collection><collection>ProQuest SciTech Collection</collection><collection>ProQuest Technology Collection</collection><collection>ProQuest Natural Science Collection</collection><collection>Hospital Premium Collection</collection><collection>Hospital Premium Collection (Alumni Edition)</collection><collection>ProQuest Central (Alumni) (purchase pre-March 2016)</collection><collection>ProQuest Central (Alumni Edition)</collection><collection>ProQuest Central UK/Ireland</collection><collection>Advanced Technologies & Aerospace Collection</collection><collection>ProQuest Central Essentials</collection><collection>Biological Science Collection</collection><collection>ProQuest Central</collection><collection>Technology Collection</collection><collection>Natural Science Collection</collection><collection>ProQuest One Community College</collection><collection>ProQuest Central Korea</collection><collection>Engineering Research Database</collection><collection>Health Research Premium Collection</collection><collection>Health Research Premium Collection (Alumni)</collection><collection>ProQuest Central Student</collection><collection>SciTech Premium Collection</collection><collection>ProQuest Computer Science Collection</collection><collection>ProQuest Health & Medical Complete (Alumni)</collection><collection>Advanced Technologies Database with Aerospace</collection><collection>ProQuest Biological Science Collection</collection><collection>Computer and Information Systems Abstracts Academic</collection><collection>Computer and Information Systems Abstracts Professional</collection><collection>Health & Medical Collection (Alumni Edition)</collection><collection>Medical Database</collection><collection>Biological Science Database</collection><collection>Biochemistry Abstracts 1</collection><collection>Advanced Technologies & Aerospace Database</collection><collection>ProQuest Advanced Technologies & Aerospace Collection</collection><collection>Biotechnology and BioEngineering Abstracts</collection><collection>Publicly Available Content Database</collection><collection>ProQuest One Academic Eastern Edition (DO NOT USE)</collection><collection>ProQuest One Academic</collection><collection>ProQuest One Academic UKI Edition</collection><collection>MEDLINE - Academic</collection><collection>PubMed Central (Full Participant titles)</collection><jtitle>Journal of cardiovascular magnetic resonance</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Genovese, Davide</au><au>De Michieli, Laura</au><au>Prete, Giacomo</au><au>De Lazzari, Manuel</au><au>Previtero, Marco</au><au>Mele, Donato</au><au>Cernetti, Carlo</au><au>Tarantini, Giuseppe</au><au>Iliceto, Sabino</au><au>Perazzolo Marra, Martina</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Left atrial expansion index measured with cardiovascular magnetic resonance estimates pulmonary capillary wedge pressure in dilated cardiomyopathy</atitle><jtitle>Journal of cardiovascular magnetic resonance</jtitle><addtitle>J Cardiovasc Magn Reson</addtitle><date>2023-11-30</date><risdate>2023</risdate><volume>25</volume><issue>1</issue><spage>71</spage><epage>71</epage><pages>71-71</pages><artnum>71</artnum><issn>1097-6647</issn><eissn>1532-429X</eissn><abstract>Pulmonary capillary wedge pressure (PCWP) assessment is fundamental for managing dilated cardiomyopathy (DCM) patients. Although cardiovascular magnetic resonance (CMR) has become the gold-standard imaging technique for evaluating cardiac chamber volume and function, PCWP is not routinely assessed with CMR. Therefore, this study aimed to validate the left atrial expansion index (LAEI), a LA reservoir function parameter able to estimate filling pressure with echocardiography, as a novel CMR-measured parameter for non-invasive PCWP estimation in DCM patients.
We performed a retrospective, single-center, cross-sectional study. We included electively admitted DCM patients referred to our tertiary center for further diagnostic evaluation that underwent a clinically indicated right heart catheterization (RHC) and CMR within 24 h. PCWP invasively measured during RHC was used as the reference. LAEI was calculated from CMR-measured LA maximal and minimal volumes as LAEI = ( (LAVmax-LAVmin)/LAVmin) × 100.
We enrolled 126 patients (47 ± 14 years; 68% male; PCWP = 17 ± 9.3 mmHg) randomly divided into derivation (n = 92) and validation (n = 34) cohorts with comparable characteristics. In the derivation cohort, the log-transformed (ln) LAEI showed a strong linear correlation with PCWP (r = 0.81, p < 0.001) and remained a strong independent PCWP determinant over clinical and conventional CMR parameters. Moreover, lnLAEI accurately identified PCWP ≥ 15 mmHg (AUC = 0.939, p < 0.001), and the optimal cut-off identified (lnLAEI ≤ 3.85) in the derivation cohort discriminated PCWP ≥ 15 mmHg with 82.4% sensitivity, 88.2% specificity, and 85.3% accuracy in the validation cohort. Finally, the equation PCWP = 52.33- (9.17xlnLAEI) obtained from the derivation cohort predicted PCWP (-0.1 ± 5.7 mmHg) in the validation cohort.
In this cohort of DCM patients, CMR-measured LAEI resulted in a novel and useful parameter for non-invasive PCWP evaluation.</abstract><cop>England</cop><pub>Elsevier Inc</pub><pmid>38031092</pmid><doi>10.1186/s12968-023-00977-2</doi><tpages>1</tpages><orcidid>https://orcid.org/0000-0002-8814-0969</orcidid><oa>free_for_read</oa></addata></record> |
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| source | MEDLINE; DOAJ Directory of Open Access Journals; Springer Nature OA Free Journals; EZB-FREE-00999 freely available EZB journals; PubMed Central; Alma/SFX Local Collection |
| subjects | Accuracy Atrial Fibrillation Capillary pressure Cardiac catheterization Cardiomyopathy Cardiomyopathy, Dilated - diagnostic imaging Catheters Clinical medicine Cross-Sectional Studies Derivation Dilated cardiomyopathy Echocardiography Evaluation Female Filling pressures Heart Humans Identification Imaging techniques Intubation Left atrial compliance Left atrial pressure Left atrial reservoir function Left atrial volume Magnetic resonance Magnetic Resonance Spectroscopy Male Multivariate analysis Parameter identification Predictive Value of Tests Pulmonary Wedge Pressure Retrospective Studies Statistical analysis |
| title | Left atrial expansion index measured with cardiovascular magnetic resonance estimates pulmonary capillary wedge pressure in dilated cardiomyopathy |
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