bluuebunny/crossref_metadata_2025 huggingface dataset:
Progression of definite and non-definite Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC) and risk of major adverse cardiac events
Authors: Aljehani A , Baig S , Sommerfeld L C , Fabritz L , Steeds R P
Published: November 2023

Background

In patients with Arrhythmogenic right ventricular cardiomyopathy (ARVC, also called"Arrhythmogenic Cardiomyopathy"), it is a challenge to predict those at greatest risk of major adverse cardiac events (MACE). Our hypothesis is that risk of arrhythmia may be preceded by change in ventricular structure and function.

Purpose

To assess the association between change in ventricular structure and function over time and risk of (MACE) in ARVC.

Methods

101 definite and non-definite ARVC patients (defined as per Revised Task Force criteria (TFC)) were included with at least two sequential echocardiography and ECGs between 2010 and 2022. Structural progression was defined as development of new 2010 TFC on echocardiography during follow-up. MACE were defined as ventricular fibrillation (VF), sustained ventricular tachycardia (Sus VT), appropriate implantable cardio-defibrillator (ICD) therapy (shock/anti-tachycardia pacing (ATP)), heart failure, cardiac transplantation and death.

Results

Of the 101 patients, 51 had a definite diagnosis of ARVC, and 50 had a non-definite ‘early’ diagnosis, of whom a total of 66 (68%) carried a pathogenic variant associated with ARVC. Most were male 58 (57%), and the median age at presentation was 39 years (IQR: 27 - 53). Palpitations 41 (41%) and syncope 25 (25%) were the most common symptoms at baseline. 21 (23%) of the entire population were engaged in competitive exercise. At baseline, 22/101 (22%) patients presented with MACE, in which 20 (91%) definite patients met either minor or major imaging criteria at inclusion. During 4 years follow up (IQR: 2 – 6), 22 patients experienced MACE, in which 11 with history of MACE and 11 without, of those (15 (68%)) had structural progression. Additionally, 9 patients had structural progression of which 5 patients had history of MACE and no second event during follow up and 4 patients had no MACE at baseline or during follow up. Results showed that the odds of structural progression were significantly higher in patients with MACE than without (Table 1).

Conclusion

Structural progression was strongly associated with MACE events. This finding raises the possibility that tracking change over time identifies those patients at greatest risk of arrhythmia, with significant changes in right ventricular measurements.
Quantification of extracellular volume with cardiac computed tomography in patients with left ventricle dysfunction
Authors: Baggiano A , Fusini L , Mushtaq S , Annoni A , Formenti A , Mancini E , Fazzari F , Volpe A , Tassetti L , Maragna R , Junod D , Gaudenzi M , Conte E , Guaricci A I , Pontone G
Published: November 2023

Background

Myocardial fibrosis (MF) is a common endpoint in the majority of pathological mechanisms affecting cardiac muscle, ultimately resulting in cardiac failure. Cardiovascular magnetic resonance (CMR) with gadolinium-based contrast agent and T1 mapping technique is able to deliver a non-invasive quantification of the extracellular volume (ECV) expansion. Recently, ECV estimation with cardiac computed tomography (ECV-CCT) has been validated in the setting of cardiac amyloidosis, showing good agreement with ECV-CMR. However, no evidence is available with last generation single source single energy CT scanner in the clinical context of newly diagnosed left ventricular dysfunction. Therefore, the aim of this study is to test the diagnostic accuracy of ECV-CCT for the detection of MF in patients with recent diagnosis of reduced left ventricle ejection fraction (LVEF), having ECV-CMR as reference technique.

Methods

A consecutive cohort of 41 patients with newly diagnosed left ventricle dysfunction (LVEF < 50%) was enrolled. Time interval of maximum 30 days was present between CCT and CMR. Myocardial segment evaluability with each technique, agreement between ECV-CMR and ECV-CCT, regression analysis and Bland-Altman analysis were performed.

Results

Age of enrolled patients was 62 ± 11 years, and mean LVEF at CMR was 35.2 ± 10.7%. Mean total amount of administrated iodinated contrast was 112.6 ± 22.2 ml, while overall radiation exposure for ECV estimation was2.1 ± 1.1 mSv. Out of 656 myocardial segments available, 656 (100%) segments were evaluable at CCT while 640 (97.6%) were evaluable at CMR. ECV-CCT demonstrated slightly lower values compared to ECV-CMR both at global and region-based comparison (all segments, 33.1 ± 8.5% vs 35.5 ± 10.7%, p < 0.001). At regression analysis, strong correlations were described both at global and region-based analysis (all segments, r = 0.877, 95% CI: 0.840 to 0.914). On Bland-Altman analysis, bias between ECV-CMR and ECV-CCT for global analysis was 2.4 (95% CI: -7.8 to 12.7).

Conclusions

ECV estimation with last-generation single source single energy CT scanner is feasible and accurate. Integration of ECV measurement in comprehensive CCT evaluation of patients with newly diagnosed left ventricular dysfunction can be performed with a small increase in overall radiation exposure.
Qp/Qs in ostium secundum atrial septal defect mitigates right ventricular dysfunction in patients with secondary pulmonary hypertension
Authors: Guerra E C , Espinola-Zavaleta N , Cabello-Ganem A , Luna-Alcala S , Aparicio-Ortiz A D , Proano-Bernal L , Antonio-Villa N E
Published: November 2023

Background

Ostium-secundum atrial septal defect (OS-ASD) can potentially lead to pulmonary hypertension (PH) and associated right ventricle (RV) - pulmonary artery (PA) uncoupling. This, in turn, may eventually result in RV systolic dysfunction. Notwithstanding, whether the characteristics of the OS-ASD could mitigate this relationship is unclear.

Purpose

To evaluate a potential interaction of the OS-ASD shunt (Qp/Qs ratio) on the relationship with RV–PA coupling and RV systolic function in patients with secondary PH.

Methods

We designed a cross-sectional study of 63 adult patients with OS-ASD in which we performed a conventional transthoracic echocardiogram using Vivid 9X-clear equipment (GE Vingmed Ultrasound, Horten, Norway). We evaluated the OS-ASD shunt and other echocardiographic parameters, including the tricuspid annular plane systolic excursion (TAPSE), the systolic pulmonary artery pressure (sPAP) ratio and the right ventricular free wall longitudinal strain (RVFWLS). Polynomic adjusted correlations were performed to model the relationship between the TAPSE/sPAP ratio and the RVFWLS, then we evaluated an interaction effect of the OS-ASD shunt (Qp/Qs ratio), respectively adjusted for age, sex, body mass index, body surface area and right atrial area.

Results

In our study, 49 (78%) subjects were male, with a mean age of 41.8 (±15) years; 7.94% (n=5) had mild PH, 42.9% (n=27) had moderate PH and 49.2% (n=31) had severe PH. Mean echocardiographic parameters were: TAPSE 24.5 (±5.1) mm , sPAP of 55.9 (±20.7) mmHg, TAPSE/sPAP 0.49 (±0.2) mm/mmHg, RVFWLS -25.6 (±6.6) % and Qp/Qs 2.9 (±0.9). We observed a quadratic relationship between the TAPSE/sPAP ratio and the RVFWLS (r=0.691, p < 0.001; Figure 1). OS-ASD shunt had a positive interaction effect (β=10.9, 95% CI: 2.09-19.6, p=0.018) on the relationship between TAPSE/sPAP and RVFWLS after adjusting for covariates (Figure 2).

Conclusions

In conclusion, in patients with OS-ASD, the RV systolic function decreases as the RV-PA uncoupling increases, as reflected in the quadratic regression between the TAPSE/sPAP and the RVFWLS. Moreover, the increase in OS-ASD shunt decreases RVFWLS values in relationship to the TAPSE/sPAP ratio as observed in the interaction model. These results could suggest that the OS-ASD characteristics could potentially mitigate RV dysfunction in patients with secondary PH.Figure 1.Quadratic regressionFigure 2.Interaction model
Presence of patent foramen ovale increases risk of filamentous thrombi on interatrial septum in atrial fibrillation/flutter patients
Authors: Chen H , Luan L , Kang Y , Tian F , Liu Y , Shu X
Published: November 2023

Introduction

The presence of interatrial septum (IAS) strands in atrial fibrillation or flutter (Afi/Afl) patients is frequently overlooked despite being a common occurrence.

Purpose

The study aims to understand the prevalence and possible pathological nature of these strands.

Methods

The study included 454 consecutive Afi/Afl patients who underwent transesophageal echocardiography from June 2019 to January 2020. Patients were divided into two groups based on the presence of strands on the IAS (strand and non-strand group). The echocardiograms and clinical characteristics of the patients were reviewed. The difference between the two groups was compared using independent t or chi-square test. Univariate and multivariate logistic regression analyses were performed to identify factors associated with the IAS strands. The study also examined surgical samples of the IAS strands of a patient pathologically.

Results

The study found that 127 (28%) of the enrolled patients had strands on the right atrial side of the IAS. The strand group had a significantly higher incidence of patent foramen ovale (PFO) (p<0.0001) than the non-strand group. Patients in the strand group were also more likely to be over 60 years of age(p=0.085), obese(p=0.073), and have abnormal renal function(p=0.086). Multivariate analysis revealed that PFO was independently associated with the presence of IAS strands (OR=64.51, 95% CI: 31.35-132.76, p<0.0001). The pathological examination of the IAS strands in a patient revealed filamentous thrombi.

Conclusions

The study highlights the high prevalence of IAS strands in Afi/Afl patients. The presence of PFO significantly increases the risk of IAS filamentous thrombi. This study is the first report on the pathological nature of IAS filaments in Afi/Afl patients, offering important insights into the causes of Afi/Afl-induced cardiogenic embolism other than left atrial appendage thrombi.
Differences in clinical characteristics and outcomes between patients with left ventricular thrombus following non-anterior and anterior ST-elevation myocardial infarction
Authors: Goh F , Teo Y N , Teo Y H , Leow A S T , Chan M Y Y , Yeo L L L , Kong W K F , Poh K K , Ho J S Y , Yeo T C , Tan B Y Q , Sia C H
Published: November 2023

Background

Left ventricular thrombus (LVT) is a serious complication following ST-elevation myocardial infarction (STEMI), and occurs more frequently in anterior compared to non-anterior myocardial infarction (MI).1 There is limited data on the clinical characteristics and outcomes in patients with LVT following non-anterior MI.

Purpose

We aimed to describe the clinical characteristics and outcomes of patients with LVT following non-anterior MI, and compare them against patients with LVT associated with anterior MI.

Methods

We retrospectively studied 217 consecutive patients with post-STEMI LVT from our tertiary centre’s echocardiography database between March 2011 and January 2021. Trans-thoracic echocardiography was performed at day 2 or 3 post-MI. We compared baseline co-morbidities and echocardiographic parameters between patients with LVT following non-anterior versus anterior MI. The Kaplan Meier method with log-rank test was used to compare rates of thrombus resolution, stroke and all-cause mortality between the 2 groups. Multivariable Cox regression models were constructed to correct for potential confounders.

Results

Mean age of the study population was 56.0 (IQR 48.0, 63.0) years old and 16/217 (7.4%) were female. LVT following non-anterior MI made up 24/217 patients (11.1%), and included lateral (n=3), inferior (n=15), inferoposterior (n=4) and inferolateral (n=2) MI. Patients with LVT associated with non-anterior MI were older and more frequently had a history of ischaemic heart disease (Figure 1). These patients also had a lower median left ventricular ejection fraction (LVEF) of 29% compared to their counterparts with anterior MI (mean LVEF 38%). Rate of anticoagulation was lower in patients with LVT associated with non-anterior MI (75.0% versus 92.2%). There were no differences in rates of thrombus resolution between the 2 groups (Figure 2). Patients with LVT following non-anterior MI had a higher incidence of stroke, however this observation was not present after correction for baseline embolic risk (CHA2DS2-VASc score) and rate of anticoagulation. Mortality rates were similar in patients with LVT following non-anterior MI versus anterior MI, after correction for baseline co-morbidities as well as in-hospital mortality – as this was more likely due to acute MI complications rather than longer term consequences of LVT.

Conclusions

Patients with LVT following non-anterior MI are older with a greater prevalence of prior ischaemic heart disease. These patients had a greater rate of stroke and mortality, although baseline co-morbidities and less frequent use of anticoagulation may have contributed to these findings. This needs to be clarified in future prospective studies.Figure 1:Baseline characteristicsFigure 2:Outcomes
Hemodynamic evaluation of right-sided congestion with doppler ultrasonography in pulmonary hypertension: portal vs intra-renal venous flow patterns
Authors: Gomez-Rodriguez C A , Tadeo-Espinoza H N , Solis-Huerta F , Leal-Villarreal M A , Guerrero-Cabrera J P , Vasquez-Ortiz Z Y , Gamba-Ayala G , Verbrugge F H , Argaiz E
Published: November 2023

Introduction

Renal congestion is a key pathophysiological mechanism mediating adverse outcomes in patients with heart failure. Novel approaches to evaluate renal congestion like renal Doppler ultrasonography show promise as a noninvasive hemodynamic monitoring tool. Portal Doppler ultrasound is a less challenging exam and could potentially provide similar information than intra-renal Doppler.

Methods and Results

We enrolled 95 patients with suspected or diagnosed pulmonary hypertension (PH) presenting to the emergency department or to a scheduled ambulatory clinic. Patients underwent renal and portal Doppler ultrasonography. Renal congestion was graded using the validated renal venous stasis index (RVSI) or renal venous patterns. The portal vein pulsatility fraction (PVPF) was used to quantify portal congestion. We found high degree of correlation (R = 0.93) between portal and renal congestion, with excellent agreement (κ = 0.92 [0.86-0.98]). Both RVSI and PVPF showed excellent interclass correlation and agreement amongst operators (ICC 0.93). 90-day mortality or need for renal replacement therapy was significantly more frequent in patients with high PVPF (p=0.001) HR: 5.3 (1.9-17.0).

Conclusions

Altered portal venous flow accurately predicts the presence of renal congestion and is technically easier to obtain. Portal vein Doppler may identify patients with pulmonary hypertension at risk for renal deterioration secondary to venous congestion.Portal-renal patterns and their outcomes
Negative pressure booth with HEPA filter reduces the risk of airborne infection associated with transoesophageal echocardiography
Authors: Machino T , Watabe K , Imura Y , Kawamatsu N , Sato K , Yamamoto M , Ishizu T , Kawakami Y
Published: November 2023

Background

The pandemic of coronavirus infection 2019 has persisted, despite reductions in disease severity and deaths. Transoesophageal echocardiography (TOE) is one of the aerosol-generating procedures and increases the risk of airborne infection. However, the effective strategy to reduce the risk has not been fully established.

Purpose

To evaluate the effectiveness of negative-pressure booth with high-efficiency particulate air (HEPA) filter in control of aerosol generated by TOE.

Methods and Results

In the TOE examination room, we installed negative-pressure booth. This booth has an air supply port on the ceiling and exhaust port on the head side of examination table, and the airflow is controlled by a push-pull method (Figure 1). The air changes per hour (ACH) for the entire room with was only 8, but 38 inside the booth, meeting the CDC recommended standard for airborne infection isolation room (ACH≥12). Visualization of the airflow by laser light scattering showed that the airflow in the booth bent the trajectory of particulates produced by the patient's cough and sent them to the exhaust port (Figure 2A). The size-specific quantifications for >0.3μm-, >0.5μm-, >1.0μm-diameter particles by a particle counter revealed that the peak particle concentrations within the booth were reduced by approximately 70% after 7 min of ventilation (Figure 2B) in unattended situation. In clinical setting, we monitored particle counts during TOE in 70 cases. Echocardiologists were at greater risk of aerosol exposure than assistants. Multiple regression analysis revealed that patients’ discomfort level during TOE and less experienced echocardiologists were independently correlated with increased particle counts (β=0.376, p=0.003 and β=0.355, p=0.005, respectively). However, aerosols generated in the early time of TEE were almost eliminated by the end of the examination by negative pressure booth.

Conclusion

The negative pressure booth effectively and quickly reduces small particles equating aerosols. It might be effective to reduce the risk of airborne infection and shorten the patients turnover time of TOE room even in the pandemic of infectious diseases.Figure 1Figure 2
Left atrial appendage morphology and function predict thromboembolic risk in patients with embolic stroke of undetermined sources
Authors: Skrebelyte-Strom L , Jorg Saberniak J S , Janne Mykland Hilde J M H , Harald Kjekshus H K , Ole Morten Ronning O M R , Kjetil Steine K S
Published: November 2023

Introduction

Embolic stroke of undetermined sources (ESUS) is supposed to be associated with intracardiac thrombus formation, in particular in the left atrial appendage (LAA). We aimed to investigate the impact of LAA morphology and function on thromboembolic risk condition (TRC) and LAA thrombus in ESUS patients.

Methods

185 ESUS patients (mean age 68 ±13 years, 33% female) without history of AF were included. All patients underwent clinical evaluation by CHA2DS2-VASc and complete transthoracic and transesophageal echocardiography shortly after index ESUS (4 days, IQR 3-6). LAA function and LAA morphology were evaluated by conventional 2D and 3D echocardiography and speckle tracking strain. TRC was defined as combination of thrombus, sludge and spontaneous echo contrast (SEC) in LAA.

Results

In 185 study patients, following LAA types were found: chicken wing (LAA CW) 79 (43%), windsock 64 (34%), cactus 35 (19%), cauliflower 7 (4%) and multilobate LAA, defined as LAA with ≥ 1 lobe, in 115 (62%) of patients. TRC was found in 123 (67%) and thrombus formation in 29 (16%). LAA CW and multilobate LAA were independent predictors of TRC (OR 2.3 (CI 1.2 - 4.5), p= 0. 01 and OR 2.2 (CI 1.2 - 4.2), p= 0.02, respectively) and furthermore, LAA CW and LAA-Sr were independent predictors of LAA thrombus (OR 2.5 (CI 1.1 - 5.8), p=0.04 and OR 0.9 (CI 0.8 – 1.0), p<0.01, respectively), all adjusted for CHA2DS2-VASc-score.

Conclusion

LAA type CW, multilobate LAA and novel LAA strain predicted independently TRC and LAA thrombus, respectively. These results indicate that LAA morphology and function are important in assessment of thromboembolic risk in ESUS patients.Table 1.
Ultrasound imaging of renal fibrosis using gold nanoparticles
Authors: Wu J , Chen M I A O N A , Deng Z , Liang F , Cai Q , Li S
Published: November 2023

Introduction

Microbubble ultrasound contrast agents have limitations due to their short circulation half-life and poor acoustic attenuation. In our previous study, pH-responsive gold nanoparticles (2∼3 nm) were optimized for ultrasound fluorescence molecular imaging of mouse kidneys. Renal fibrosis is associated with increased expression of the integrin αvβ3 receptor in neovascular endothelial cells. To address this, gold nanoparticles (cRGD-GSH-AuNPs) were synthesized by introducing RGD peptide, which specifically binds to integrin.

Purpose

The purpose of this study was to evaluate the potential of cRGD-GSH-AuNPs as a contrast agent for targeted ultrasound imaging of renal fibrosis.

Methods

Cyclic arginine-glycine-aspartic (cRGD) targeting integrin αvβ3 receptors was linked with glutathione (GSH)-modified gold nanoparticles (AuNPs) to create cRGD-GSH-AuNPs. After characterizing their physical properties and verifying their biocompatibility, GSH-AuNPs and cRGD-GSH-AuNPs were injected into mice with the renal fibrosis model. The renal imaging effect was evaluated by ultrasound and fluorescence imaging, and the targeting of the particles was confirmed by pathological tissue staining.

Results

The average size of cRGD-GSH-AuNPs determined by electron microscopy was 1.7 ± 0.2 nm, and the particles maintained biological stability after modification. The average ultrasound intensity of cRGD-GSH-AuNPs in the renal fibrosis group (22 ± 2 dB) was significantly higher than that of GSH-AuNPs in the fibrosis group (3.5 ± 3 dB), cRGD-GSH-AuNPs in the control group (1.5 ± 1 dB), and GSH-AuNPs in the control group (2 ± 1.5 dB) (all, P < 0.05). Intravenous injection of cRGD-GSH-AuNPs significantly enhanced the ultrasound signal intensity in fibrotic kidneys (see Figure 1).

Conclusions

Gold nanoparticles targeting integrin αVβ3 receptors achieve specific non-invasive imaging of renal fibrosis, and are a promising ultrasound contrast agent for the evaluation of renal fibrosis.Figure 1
Multi-dimensional evaluation in patients with aortic stenosis who are candidates for cardiac surgery
Authors: Bonanni F , Berteotti M , Grasso Granchietti A , Tozzetti V , Cenni N , Marchi E , Bandini M , Servoli C , Grandi G , Del Pace S , Targetti M , Di Mario C , Stefano P L , Caciolli S
Published: November 2023

Introduction

In patients with severe aortic stenosis (AS), the presence of left ventricular systolic dysfunction is one of the main predictors of adverse events after valve replacement surgery (SAVR). However, more and more patients are being referred for surgery early on and have preserved systolic function at the time of surgery. Within this category, global longitudinal strain (GLS) has been proposed as a marker of ventricular remodeling after cardiac surgery.

Objectives

Our study aims to identify the variation of GLS in patients undergoing SAVR and any differences compared to classes of diastolic dysfunction.

Materials and methods

From June 2020 to October 2022, we analyzed 100 patients with AS with an indication for cardiac surgery treatment admitted to the cardiac surgery department of our AOU. All patients underwent an echocardiogram immediately before surgery and in the early postoperative period (mean 7 days); 52 of them were enrolled for follow-up and repeated an echocardiogram at least 3 months after surgery. In all cases, the GLS of the left ventricle was calculated and patients were divided into four classes by the degree of diastolic dysfunction (0-III) according to the most recent international guidelines; moreover, patients were divided into 2 groups: group A for grades 0-1 of diastolic dysfunction and Group B for grades 2-3. The data were analyzed with SPSS 28 software. Analysis of variance was performed with a t-test and ANOVA test.

Results

In the final analysis, 100 patients with AS were included, with a mean age of 70.8±8.27, of whom 43 were women (43%) and 57 were men (57%). In 20 patients (20%) ischaemic heart disease with an indication for coronary revascularization was also present. The mean preoperative ejection fraction was 58.98±9.5%. The mean GLS values before surgery were 15.13±4.56% with a reduction immediately post-cardiac surgery of 12.26±3.67%, p<0.0001. GLS values were comparable within the various classes of diastolic dysfunction at preoperative examination (p=0.579) and immediately postoperative (p=0.286).

At follow-up, analysis was repeated for 52 patients: an improvement in mean GLS was found: 16.09±3.64%, p<0.0001. The mean GLS in the two groups at follow-up was statistically different: 17.38±3.35% in group A vs 13.44±3.63% in group B, p<0.0001.

Conclusions

In our case series, patients with severe aortic stenosis undergoing SAVR show a significant early reduction in GLS regardless of the degree of diastolic dysfunction, while after at least 3 months of follow-up, they show a great recovery, significantly better in patients with Grades 0 or 1 diastolic dysfunction.GLS at the 3 times
Sodium-glucose cotransporter inhibitors reduce cardiovascular outcomes regardless eGFR range in patients with heart failure. Systematic review and meta-regression meta-analysis
Authors: Cunha I , Nunes J T , Bocchi E
Published: November 2023

Background and aims

Due to the potential for attenuation of the beneficial effects of SGLT2i treatment in patients with both HF and CKD who have lower glomerular filtration rates, and the risk of acute kidney injury following SGLT2i initiation, we performed a meta-analysis and meta-regression to assess the impact of SGLT2i on composite cardiovascular outcomes in this patient population.

Methods

We conducted a systematic literature review to find RCTs that evaluated SGLT2i treatment efficacy in HF and CKD patients. We used a random-effects model (Mantel-Haenszel) for the meta-analysis. Results show odds ratios (ORs) with 95% confidence intervals and P values for the primary outcome risk and in subgroups based on baseline eGFR. All probability values were two-tailed and statistical significance was set at P < 0.05. We also investigated type of SGLT2i and year of publication as predictor variables.

Results

When compared to a placebo, SGLT2 inhibitors reduced the risk of primary cardiovascular outcomes by 27% (HR 0.73, [95% CI 0.63–0.85], I2 = 32%) in patients with eGFR < 60 mL/min/1.73 m2 and by 20% (HR 0.80, [95% CI 0.74–0.88], I2 = 0%) in patients with eGFR > 60 mL/min/1.73 m2. Patients with HFpEF had 28% risk reduction (HR 0.72, [95% CI 0.56–0.93], I2 = 37.23%), and HFrEF had 21% (HR 0.79, [95% CI 0.70–0.89], I2 = 0%). The meta-regression analysis showed that the type of SGLT2i was not a significant predictor of treatment effect (Q = 2.29, p = 0.51). None of the other predictor variables were significant also.

Conclusion

This meta-regression analysis suggests that SGLT2i is an effective treatment for reduce cardiovascular outcomes in patients with concurrent HF and CKD, independent of the type of SGLT2i or eGFR range. Regardless of diferences in participants characteristics, patients with HFpEF had higher risk reduction when compared with patients with HFrEF (28% vs 21%), our hypothesis for this find is that competitive risk favors patients with lower eGFR even in higher ejection fraction extract, further studies are needed to confirm these findings. Limitations of this study include potential publication bias and the exclusion of non-English studies.Forrest plot for composite outcomeBubble plot for composite outcome
Comparison of ventilatory parameters with nasal versus oral breathing during submaximal exercise in patients with cardiac disease and healthy people
Authors: Calamai P , Kalberer A , Huber S , Kaesermann D , Wilhelm M , Eser P
Published: November 2023

Introduction

Inefficient ventilation, namely a high ventilation/carbon dioxide production ratio (VE/VCO2) is a well established predictor for disease progression and mortality in patients with heart failure (HF). Two previous studies in healthy people have found improved ventilatory efficiency with nasal compared to oral breathing during submaximal exercise. No study has compared nasal with oral breathing in patients with HF or coronary heart disease.

Method

Four study groups were recruited: Patients with HF, patients with acute or chronic coronary syndrome (ACS/CCS), old healthy controls (age>45 years) and young healthy controls (age>20 years and <35 years). Acute measurements of 5 min (after 3 min warm-up) with nasal and 5 min with oral breathing in randomized order were performed at 50% peak power. Ventilation parameters were averaged over the last minute of each condition and analysed by linear mixed models adjusted for body mass index.

Results

We present data of 8 patients with HF, 8 with ACS/CCS, 10 old and 15 young healthy controls. Minute ventilation, breathing frequency and end-tidal oxygen partial pressure (PETO2) were significantly lower and tidal volume and end-tidal carbon dioxide partial pressure (PETCO2) significantly higher during nasal compared to oral breathing in all groups (Figure 1). Differences between breathing modes were between 5-20% and similar in all groups except for breathing frequency that declined more from oral to nasal breathing, namely by 27%, in patients with HF compared to the other groups. The largest discrepancies between patients and healthy controls were found for VE/VCO2 ratio, PETCO2 and PETO2.

Conclusion

Nasal breathing during submaximal exercise significantly improved the abnormal breathing pattern of patients with HF and ACS/CCS. Nasal breathing during exercise may be promising in patients with inefficient ventilation as it increases PETCO2 and is likely to increase arterial partial CO2 pressure, a known vasodilator, herewith facilitating perfusion of the working musculature.Figure 1
Enhancing Quality of Life in Cardiovascular Patients: The Role of Comprehensive Interventions and Cardiac Rehabilitation
Authors: Almeida Carvalho S , Costa C , Fernandes A , Adrega T , Albuquerque N , Neves A , Mesquita Bastos J
Published: November 2023

Introduction

Cardiac rehabilitation is an established strategy to improve cardiovascular outcomes in patients with Acute Coronary Syndrome (ACS) and Heart Failure (HF). However, not all patients can participate in such programs. Intermediate interventions focused on lifestyle modification may be a potential strategy to improve outcomes. Depression and anxiety are common in patients with CVD and are linked to increased mortality. The Hospital Anxiety and Depression Scale (HADS) is a 14-item tool used to measure anxiety and depression symptoms and has been shown to be useful in assessing the psychological well-being of patients undergoing cardiac rehabilitation.

Objective

The objective of this retrospective study was to evaluate the impact of different levels of intervention on the quality of life of patients after cardiovascular events - ACS and CHF - in terms of depressive and anxious outcomes.

Materials and Methods

The study analyzed 56 patients who were previously hospitalized in the Cardiology department within one year: 47 for ACS and 9 for decompensated HF. After discharge, 19 patients attended a cardiac rehabilitation program (group 1), 19 had regular cardiovascular risk appointments and educational sessions conducted by psychiatrists, nutritionists, physiatrists, and cardiologists, but without participating in a physical rehabilitation program (group 2), and 18 patients were selected as controls without any of previous strategies (group 3). The group 1 intervention include also the measures implemented in group 2. All participants signed informed consent and completed the HADS questionnaire.

Results

The average age of the participants was 54.9 ± 9.9 years, with 29% females, and an average of 2.7 ± 0.6 cardiovascular risk factors. There were no significant differences in the distribution of ACS or decompensated heart failure between the groups. Group 1 predominantly presented a normal pattern of HADS scores (56% vs 40% vs 4%), respectively for group 1, 2 and 3. Conversely, in group 3 compared with group 1 and 2, there was a predominance of the abnormal score, respectively (50% vs 17% vs 33.3%); p <0.01.

Conclusion

The results suggest that patients who underwent regular appointments/education and cardiac functional rehabilitation exhibited lower levels of anxiety and depressive symptoms.

In conclusion, the study indicates that a comprehensive intervention continuum, including cardiac rehabilitation and regular appointments/education, can significantly improve patients' quality of life and reduce their cardiovascular risk. Patients who undergo cardiac rehabilitation may experience the greatest benefits. The findings support the potential value of intermediate interventions focused on lifestyle modification as a strategy to improve outcomes for patients who cannot participate in a rehabilitation program.
Prognostic role of data transmitted by implanted cardiac electric devices in patients with advanced heart failure referred for heart transplantation
Authors: Aloisio A , Marchi F , Ziacchi M , Masetti M , Massaro G , Frisoni J , Corrado M C , Borgese L , Sabatino M , Biffi M , Diemberger I , Potena L
Published: November 2023

Background

Patients (pts) with advanced heart failure (HF) are poorly tolerant to GDMT, frequently hospitalized and are often carriers of implantable cardioverter-defibrillators (ICD) or of cardiac resynchronization therapy (CRT-D). These devices allow HF centers to remotely monitor the occurrence of arrhythmic events and of ICD interventions, such as anti-tachycardia pacing (ATP) bursts or DC-shocks. While HF hospitalizations are an established prognostic marker, the role of remote monitoring in a context of pts referred for heart transplantation (HT) is poorly explored.

Purpose

In this retrospective monocentric study we aim to evaluate the prognostic value of remotely-transmitted information from ICD/CRT in pts with advanced HF followed in a tertiary Center dedicated to HF and HT.

Methods

We included all adult pts with a remotely transmitting device followed by both Electrophysiology and Heart Failure Teams in our Center between September 2016 and January 2023. We collected data about heart disease, medical therapy, echocardiography, device-delivered therapies, and hospital admissions for any cause. The outcome was the combined incidence of death from any cause or urgent heart transplantation.

Results

123 pts were enrolled ( 57±10 yrs, 75% males, LVEF 34%±10%). 68 had an ICD, 55 CRT-D. 50 pts (41%) received at least one device-delivered therapy (34 pts had at least one ATP; 29 pts had at least one DC-shock, of whom 26 were appropriate). During a mean follow-up of 29 months, we recorded 121 hospitalizations (53% for arrhythmias, 47% for acute HF) in 44 pts. The endpoint occurred in 14 pts : 12 (9.8%) died, 2 (1.6%) underwent to urgent HT; overall, 12 pts (9.8%) were transplanted. Pts with arrhythmic events had more frequently a spontaneous QRS >120ms (60% vs. 40%, p=0.04) and a trend towards more hospitalizations for heart failure (64% vs. 35%, p=0.059). The predictor of the combined endpoint of death or urgent transplant was hospitalization for HF (RR: 4.2, p<0.01); ATP and/or DC-shocks (RR 7.3) and intolerance to vasodilators (ACE-I, ARB, ARNI), (RR (1.5) showed a borderline statistical significance (p=0.06 for both). However, in the subgroup of patients without any HF hospitalization, device-delivered therapies from ICDs and CRT-D carried an higher risk of death and urgent HT (p=0.03), see Figure .

Conclusion

In a population of patients with advanced HF, while confirming the known prognostic role of HF hospitalization, we found that remote monitoring of ICD shocks/ATP in patients not hospitalized for HF identifies a subgroup of patients at high risk of death or urgent HT. These results underscore the importance of considering these patients for advanced HF therapies and of an integrated approach between electrophysiologists and HF specialists.
Acute deterioration in dyssynchrony and systolic function from Lot-CRT to LBBB pacing
Authors: Tan J , Zhang Q , Kang Y , Luo Y R , Yu S , Feng K
Published: November 2023

Background

Better electrical synchronization and left ventricular (LV) systolic function was recently reported in left bundle branch–optimized cardiac resynchronization therapy ( Lot-CRT ) when compared with conventional CRT. The implantation of left bundle branch pacing (LBBP) is less expensive, easier to operate and has shorter exposure time to X-ray than Lot-CRT.

Purpose

To observe whether there are negative changes in dyssynchrony and LV systolic function when switched from Lot-CRT to LBBP. determine whether LBBP pacing alone can replace CRT therapy.

Methods

30 patients (21 males, 64.4±9.5 years, 43% with persistent atrial fibrillation) who fulfilled the criteria of CRT implantation received Lot-CRT. The right atrial electrode of the patients with atrial fibrillation or the right ventricular electrode of those with sinus rhythm was implanted into the left bundle branch area. After six months, 20 patients whose LV ejection fraction (LVEF) increased by more than 5% and New York Heart Association functional class increased by at least 1 grade were selected for further investigation. Right and left ventricular pacemaker electrodes were programmed to shut off, leaving only the left bundle branch area pacing for one month. The LV size, systolic function, interventricular mechanical delay (IVMD), and LV mechanical dyssynchrony (LVMD) were compared by using two-dimensional speckle tracking echocardiography.

Results

It was found that QRS duration slightly widened, the LA size increased, the LV size slightly increased and LVEF decreased, p<0.05. There was no statistical significance in the IVMD (p=0.064). The LV mechanical dyssynchrony increased significantly, p<0.001.

Conclusions

Deteriotation of LV dyssynchrony and systolic function was recorded when Lot-CRT to LBBP for a short period in recovering patients with systolic dysfunction. It indicates that LBBP may not yet maintain the benefits of Lot-CRT in this group of patients.The comparison between Lot-CRT and LBBP
Comparative study of the effects of left ventricular and biventricular pacing on indices of cardiac function and clinical status of heart failure patients: preliminary results of READAPT study
Authors: Chrysohoou C , Dilaveris P , Xydis P , Kordalis A , Laina A , Kalantzis C , Vouliotis A , Pozios I , Kariori M , Sideris S , Tsioufis C
Published: November 2023

Nonresponse to cardiac resynchronization therapy (CRT) has been related with right ventricular dysfunction. Preferential left ventricular pacing (pLVP) can overcome iatrogenic right ventricular dysfunction by achieving left ventricle resynchronization and by allowing for intrinsic activation of the right side, with ramifications extending beyond cardiac output and atrial fibrillation occurrence. Moreover, the AdaptivCRT® algorithm also automatically adjusts interventricular (V-V) delay every minute, optimizing it by means of comparing relative activation delay between right and left ventricles (electrically – driven optimization).

In the present study we evaluated the effects of a pLVP algorithm on 50 heart failure patients (all Caucasians, 49% male; 66 +/- 8 years old; 46% ischemic cardiomyopathy; 41% diabetics; NYHA II-III) following randomization to standard biventricular pacing and pLVP, on echocardiographic and cardiopulmonary exercise test indices of functional status, as well as a self-reported quality of life questionnaire. Device programming was based on echocardiography-evaluated maximization of stroke volume and subsequent interventricular and atrioventricular delay adjustments delegated to the device. The follow-up consisted of 6 and 12-months visits; after the 1rst month of optimizing maximum CRT response.

Results

Significant comparative effects of LVP over optimized CRT were noted regarding RV systolic velocity in TDI even from 6-months from baseline (6% increase, p=0.01); while end-systolic diameter of left ventricle was increased by 4% in 6-months in CRT group (p=0.01), while no significant difference was observed in LVP group. At 12 months endsystolic volume was significantly decreased (16%, p=0.01) and left ventricular systolic longitudinal strain was improved in 12 months in LVP group compared to CRT group (p- for interaction =0.001). Additionally, in cardiorespiratory exercise test LVP group showed improved inotropic reserve compared to CRT group according to maximum SBP achieved (20% increase, p<0.01 for interaction); while all other cardiorespiratory indices shoed borderline significant changes at 12 -months. Minnesota score was significantly reduced in LV-P group by 70% at 6-months; whereas no significant change was observed in CRT group (p for interaction <0.01).

Conclusions

In the preliminary findings of READAPT study, it seems that LV pacing optimized by a standardized echocardiographic protocol in patients with preserved AV conduction, LBBB, can achieve a higher percentage of synchronized LV pacing associated with improved patient quality of life; right ventricular function and endsystolic volume at 6 and 12-months of follow-up, over echo-optimized CRT pacing.
Does scar burden predict sudden cardiac death in patients with cardiac resynchronization therapy? - A Systematic Review and Meta-Analysis
Authors: Masszi R , Turan C , Zsigmond E , Ehrenberger R , Hegyi P , Fehervari P , Kosztin A , Merkely B
Published: November 2023

Background

Based on latest guidelines, scar burden assessment may have a crucial role in appropriate device choice in cardiac resynchronization therapy (CRT), but no randomized controlled trials have been made yet.1 Scar burden is associated with a higher prevalence of ventricular arrhythmias (VA) and sudden cardiac death (SCD).2 Late gadolinium enhancement cardiovascular magnetic resonance (LGE-CMR) can accurately evaluate the extent of myocardial scar.3.

Purpose

Our aim is to investigate the association between scar burden and SCD risk in cardiac resynchronization therapy patients.

Methods

We performed a systematic literature search on MEDLINE using the PubMed, Embase, Scopus, and CENTRAL databases. Heart failure patients with reduced ejection fraction and CRT therapy were collected. The primary endpoint was sudden cardiac death events. Meta-analyses were performed using the META and DMETAR packages in R, using a random-effects model. The risk of bias was assessed using Quips tool and the quality of evidence was evaluated using the GRADE assessment.

Results

18 eligible articles have been included in our study, with a total of 2917 patients, of whom 830, 1324, and 391 have been implanted with an ICD, CRT-D, CRT-P respectively. Altogether 59,05 % of the total population were LGE-CMR positive. The average proportion of appropriate ICD shock was 15,65 % per the total population during the median follow-up time of 39,45 months. Based on the univariant analysis of 14 articles, the cumulative hazard ratio of developing sudden cardiac death events, in the scar burden positive population compared to scar burden negative was 1,95 with CI: 1,29- 2,96 p<0,001. The multivariant analysis shows the HR of 1,88 with CI: 1,20- 2,93 p<0,001. There were 4 articles using the competing risk model which is considered to be the highest evidence level. Based on that analysis we found only a trend with a HR of 1,55 CI: 0,75-2,92. Calculating from the event numbers based on 8 eligible articles, the high scar burden group had 5.55 higher odds of getting SCD events. (OR: 5.55. CI 2,52-12,22 p<0,001).

Conclusion

In our meta-analysis, LGE-CMR was associated with a trend toward appropriate device therapy and can identify a subgroup of patients with an increased risk of life-threatening VA. Based on our results performing an MRI before device implantation might be important to select high-risk patients for SCD.Forest plot O.R.Forest plot uni. H.R.
CineECG repolarization gradients predict acute hemodynamical response in CRT patients
Authors: Sedova K , Azarov J , Van Dam P , Kautzner J
Published: November 2023

Background

Cardiac resynchronization therapy (CRT) is widely used for patients with conduction disorders and heart failure. The proportion of the CRT-non-responders can exceed 30%, which warrants search for new approaches to optimize the CRT device implantation and follow-up. CineECG is a novel cardiac anatomy-based ECG modality proposed for better visualization of the myocardial depolarization and repolarization processes. This method yielded promising results in patients with sinus rhythm but has not been tested in ventricular pacing.

Purpose

The aim of the present study was to evaluate CineECG-derived mean temporo-spatial isochrone (TSI) trajectory in different pacing protocols and test its association with acute hemodynamical responses in CRT patients.

Methods

CineECG uses a generic heart/torso model to construct the average electrical pathway within the cardiac anatomy from the 12 lead ECG. CineECG and invasive hemodynamical parameters were tested in 15 patients undergoing multisite CRT system implantation. ECG recording and hemodynamical measurements were performed simultaneously, while the patients were undergoing 4-6 biventricular pacing protocols with the same interventricular pacing delay (30 ms) and different left ventricular (LV) lead localizations (apical, basal, multisite). LV dP/dt max was tested for association with the parameters of standard ECG (QRS duration, QT duration, Tpeak-Tend duration) and CineECG pathway parameters. The latter pathway directions were computed for QRS and ST-T intervals for anteroposterior (X), left-to-right (Y), and apicobasal (Z) directions.

Results

Biventricular protocols did not differ between each other in LV dP/dt. In univariate linear regression analysis, LV dP/dt max was associated with QRS and ST-T pathway directions (Figure 1 - table). The left-to-right (Y) and apicobasal (Z) ST-T pathway directions remained independent predictors of LV dP/dt max in multivariate linear regression analysis with the adjustment for a pacing protocol [regression coefficient 571.6 (319.3 – 823.8), p<0.001; regression coefficient -406.9 (-636.7 – -177.2), p=0.001, respectively]. Optimal repolarization sequences associated with better acute hemodynamic responses assessed by LV dP/dt max were from right to left and from base to apex (Figure 2).

Conclusion

CineECG repolarization pathway gradients in the left-to-right and apicobasal directions outperform temporal ECG parameters and predict the acute hemodynamical response in biventricular pacing protocols in CRT patients.