Recommendations for chamber quantification: a report from the American Society of Echocardiography's Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology

Valvular Heart Disease Care in Pakistan: Impact of the Multidisciplinary Valve Heart Team

Background

Patients with complex valvular heart disease (VHD) should be evaluated by a multidisciplinary heart team (HT). In low- and middle-income countries, referral practices are more variable, permitting any physician to refer patients directly to a cardiac surgeon without prior formal evaluation by a cardiologist with expertise in VHD.

Objectives

The goal of the study was to examine the demographics of VHD patients seen in a large heart valve center in a low- and middle-income country and to assess the impact of the multidisciplinary HT in patients referred for valve surgery.

Methods

Over a 20-month period, all patients with VHD seen in the National Institute of Cardiovascular Diseases (Karachi, Pakistan) outpatient cardiovascular surgery clinic were referred to the heart valve center and assessed by a multidisciplinary HT. The multidisciplinary HT developed individualized plans for each patient.

Results

A total of 2,003 patients (52.8% female, mean age: 43.9 ± 14.4 years) were enrolled. Rheumatic heart disease was identified as the predominant cause of mitral valve disease, whereas bicuspid valve was the most common cause of significant aortic stenosis. All patients had been referred for valve surgery. Based on the HT's evaluation, 1,521 patients (76%) were deemed suitable for surgery, 335 patients (17%) were recommended for medical therapy, and 147 patients (7%) were considered candidates for transcatheter treatments. Notably, the HT reclassified the management strategies for 24% of the patients, all of whom had initially been referred for surgical intervention.

Conclusions

The integration of collaborative decision-making through a multidisciplinary HT led to individualized and tailored treatment strategies, with a significant proportion of patients receiving alternative interventions or medical management instead of surgery.

First report of the clinical characteristics and outcomes of cardiac amyloidosis in Saudi Arabia

AIMS

Cardiac amyloidosis (CA) is a potentially fatal multisystemic disease that remains significantly underdiagnosed, particularly in the Middle East. This study aims to evaluate the prevalence and clinical characteristics of CA in a high-risk population at a tertiary centre in Saudi Arabia.

METHODS

This cross-sectional, retrospective, single-centre study was conducted at a tertiary hospital in Riyadh, Saudi Arabia. We reviewed the medical records of heart failure patients seen between August 2018 and July 2022 who exhibited red flags for CA and subsequently underwent CA screening. Red flags that prompted the workup included at least two of the following factors: the presence of unilateral or bilateral carpal tunnel syndrome, a family history of transthyretin amyloid (ATTR) amyloidosis and specific electrocardiographic features (relative/absolute low QRS voltage, pseudoinfarct pattern and atrioventricular/interventricular conduction abnormalities). Echocardiographic red flags included mainly increased wall thickness (≥12 mm), significant diastolic dysfunction, reduced left ventricular (LV) longitudinal function, right ventricular (RV) dysfunction and elevated right atrial (RA)/pulmonary artery (PA) pressure. Cardiac magnetic resonance (CMR) red flags included aspects similar to those in an echocardiogram as well as a subendocardial or transmural late gadolinium enhancement (LGE) pattern. These patients were assessed for CA through technetium-99m pyrophosphate ([99mTc]Tc-PYP) bone scintigraphy, serum and urine protein electrophoresis with immunofixation and a serum-free light chain assay.

RESULTS

A total of 177 patients were screened, of which 21.0 (11.9%) patients were diagnosed with transthyretin amyloid CA (ATTR-CA) and 13 (7.3%) patients were diagnosed with light chain CA (AL-CA). Compared with patients with negative/equivocal [99mTc]Tc-PYP scans (grades 0-1), patients with positive [99mTc]Tc-PYP scans (grades 2-3) were older (78.0 vs. 68.0 years, P < 0.001), had higher levels of troponin (P = 0.003) and N-terminal pro-brain natriuretic peptide (NT-proBNP) (P < 0.001), had a higher LV mass index (P < 0.001), displayed a more depressed global longitudinal strain (GLS) (P < 0.001) with a greater prevalence of a relative apical sparing pattern (P < 0.001) and demonstrated a higher incidence of first-degree atrioventricular block (P = 0.008) and low voltage patterns on electrocardiography (P < 0.001). Patients with ATTR-CA and AL-CA were more likely to have a subendocardial or transmural LGE pattern on CMR (P < 0.001) and had a significantly lower overall survival (P < 0.001) when compared with other heart failure aetiologies.

CONCLUSIONS

This is the first study to describe the clinical characteristics and outcomes of CA in the Middle East and Saudi Arabia. The prevalence of CA among screened heart failure patients here aligns with major international studies, suggesting significant underdiagnosis in the region. Therefore, larger multicentric studies and regional screening programmes are urgently needed to accurately characterize the epidemiology and outcomes of CA in the Middle East.

Genotype is associated with left ventricular reverse remodelling and early events in recent-onset dilated cardiomyopathy

AIMS

Recent-onset dilated cardiomyopathy (RODCM) is characterized by heterogeneous aetiology and diverse clinical outcomes, with scarce data on genotype-phenotype correlates. Our aim was to correlate individual RODCM genotypes with left ventricular reverse remodelling (LVRR) and clinical outcomes.

METHODS AND RESULTS

In this prospective study, a total of 386 Czech RODCM patients with symptom duration ≤6 months underwent genetic counselling and whole-exome sequencing (WES). The presence of pathogenic (class 5) or likely pathogenic (class 4) variants in a set of 72 cardiomyopathy-related genes was correlated with the occurrence of all-cause death, heart transplantation, or implantation of a ventricular assist device (primary outcome) and/or ventricular arrhythmia event (secondary outcome). LVRR was defined as an improvement of left ventricular ejection fraction to >50% or ≥10% absolute increase, with a left ventricular end-diastolic diameter ≤33 mm/m2 or ≥10% relative decrease. Median follow-up was 41 months. RODCM was familial in 98 (25%) individuals. Class 4-5 variants of interest (VOIs) were identified in 125 (32%) cases, with 69 (18%) having a single titin-truncating variant (TTNtv) and 56 (14%) having non-titin (non-TTN) VOIs. The presence of class 4-5 non-TTN VOIs, but not of TTNtv, heralded a lower probability of 12-month LVRR and proved to be an independent baseline predictor both of the primary and the secondary outcome. The negative result of genetic testing was a strong protective baseline variable against occurrence of life-threatening ventricular arrhythmias. Detection of class 4-5 VOIs in genes coding nuclear envelope proteins was another independent predictor of both study outcomes at baseline and also of life-threatening ventricular arrhythmias after 12 months. Class 4-5 VOIs of genes coding cytoskeleton were associated with an increased risk of life-threatening ventricular arrhythmias after baseline assessment. A positive family history of dilated cardiomyopathy alone only related to a lower probability of LVRR at 12 months and at the final follow-up.

CONCLUSIONS

RODCM patients harbouring class 4-5 non-TTN VOIs are at higher risk of progressive heart failure and life-threatening ventricular arrhythmias. Genotyping may improve their early risk stratification at baseline assessment.

Influencing and prognostic factors of end-stage hypertrophic cardiomyopathy

AIMS

End-stage hypertrophic cardiomyopathy (ES-HCM) is a disease with severe complications and a poor prognosis. This study aimed to explore the influencing and prognostic factors of ES-HCM.

METHODS AND RESULTS

A total of 1282 patients with HCM who were hospitalized for the first time at Fujian Medical University Union Hospital between 1 January 2013 and 30 September 2021 were recorded. The patients with HCM and left ventricular ejection fraction (LVEF) < 50% were defined as having ES-HCM, and a control group (LVEF ≥ 50%) was generated from the collected medical records of HCM. The patients were matched in a ratio of 4:1 based on age and sex. Logistic regression analysis was used to determine the influencing factors of ES-HCM. Kaplan-Meier survival analysis was performed to analyse the clinical outcomes of ES-HCM patients. A total of 250 inpatients with HCM were enrolled in the study; 50 patients had ES-HCM, and 200 had HCM with LVEF ≥ 50%. The mean age of the patients at enrolment was 62.5 ± 10.3 years, and 215 patients (215/250, 86.0%) were male. The median follow-up time of the patients was 2.8 (1.4-5.4) years. The incidence of all-cause death and cardiovascular death in patients with ES-HCM was higher than those in patients with HCM and LVEF ≥ 50% (22/50 [44.0%] vs. 13/200 [6.5%]; 12/50 [24.0%] vs. 4/200 [2.0%], all P < 0.001). Multivariate logistic regression analysis showed that the influencing factors associated with ES-HCM included age at first symptom onset (odds ratio [OR] = 0.95, 95% CI [0.90, 1.00], P = 0.042), New York Heart Association (NYHA) class (OR = 7.73, 95% CI [2.93, 20.41], P < 0.001), heart rate (OR = 1.07, 95% CI [1.02, 1.12], P = 0.003), QRS duration (OR = 1.03, 95% CI [1.00, 1.05], P = 0.020), left ventricular end-diastolic diameter (LVEDD) (OR = 1.15, 95% CI [1.04, 1.28], P = 0.006), left atrial anteroposterior diameter (LAD) (OR = 1.13, 95% CI [1.03, 1.24], P = 0.012), and maximum left ventricular wall thickness (MLVWT) (OR = 0.80, 95% CI [0.68, 0.93], P = 0.005). Among the 50 patients with ES-HCM, NYHA class (P < 0.001) and heart rate (P = 0.017) were each associated with a higher likelihood and earlier occurrence of heart transplantation or all-cause mortality in univariate analyses.

CONCLUSIONS

The influencing factors for ES-HCM included the age at first symptom onset, NYHA class, heart rate, QRS duration, LVEDD, LAD, and MLVWT. Both NYHA class and heart rate were related to the prognosis of ES-HCM.

The MuCAYAplus Study-Influence of Physical Activity and Metabolic Parameters on the Structure and Function of the Cardiovascular System in Young Athletes

Exercise has a significant impact on the cardiovascular (CV) health of children and adolescents, with resultant alterations in CV structure and function being evident, even at an early age. Engagement in regular, moderate physical activity (PA) is associated with long-term CV health benefits and a reduced risk of CV disease and mortality later in life. However, competitive sports often involve PA training intensities that are beyond recommended levels for young athletes, potentially leading to adverse CV outcomes. This situation emphasizes the importance of early monitoring of CV status, to prevent detrimental adaptations to intense physical exercise. The Munich Cardiovascular Adaptations in Young Athletes Study (MuCAYAplus; NCT06259617) aims to investigate the as-yet-unclear adaptations to intense exercise that occur in young athletes. The study focuses on various factors, including CV health, PA, cardiopulmonary performance, body composition, eating habits, and biochemical markers. In this longitudinal, prospective study, a sample of 250 young competitive athletes (aged 10-17 years) will undergo yearly examinations at the Institute of Preventive Pediatrics at the Technical University of Munich (TUM), over the span of 3 years. The testing protocol includes the following: anthropometric measurements; basic medical examinations; electrocardiography, with blood-pressure and pulse-wave analysis; echocardiography; sonography of the carotid artery; blood sampling for laboratory analysis; cardiopulmonary exercise testing on a bicycle ergometer; and participant completion of questionnaires regarding PA (the Motorik-Modul Longitudinal Study PA Questionnaire [MoMo-PAQ]) and nutrition. Areas that are not yet fully understood are how exercise influences cardiac and vascular remodeling during long-term exercise, and how different biochemical and metabolic parameters, body composition, and nutrition impact such adaptations. The MuCAYAplus study seeks to address these gaps in knowledge and provide comprehensive evidence on the longitudinal effects of exercise on the CV system of young athletes.

[Prevalence of Fabry disease in patients with left ventricular hypertrophy and renal involvement (PrEFaCe)]

INTRODUCTION AND AIMS

Fabry disease (FD) causes glycosphingolipid accumulation in the vascular endothelium, with predominantly cardiac and renal involvement. Its prevalence in patients with concomitant involvement of these two organs is unknown. The objective of the study was to determine the prevalence of FD in patients with left ventricular hypertrophy and any degree of chronic kidney disease.

PATIENTS AND METHODS

Patients with ventricular thickness ≥13mm and kidney disease from 29 Spanish hospitals were included. Sociodemographic variables and target organ involvement of FD were collected. Laboratory determinations of EF were carried out, with an enzymatic activity test±genetic test in men and direct genetic test in women.

RESULTS

Eight hundred ninety-eight patients with left ventricular hypertrophy and chronic kidney disease were included. The presence of heart failure and cardiorenal syndrome was common (46.1% and 40.1%). Three patients (2 men and 1 woman) were diagnosed with FD, based on the presence of a pathogenic variant in the GLA gene and classic signs of FD, resulting in a prevalence of 0.33% (CI 95% 0.06-1%). Six patients (0.66%) presented genetic variants of unknown significance, without showing classic signs of FD, while in 13 patients (3.2%) performing the blood test was impossible.

CONCLUSIONS

FD is an important cause of left ventricular hypertrophy and chronic kidney disease. Genetic diagnosis is crucial for avoiding biases and ensuring accurate identification of FD, especially in women. The results support the inclusion of this disease in the differential diagnosis of patients with ventricular hypertrophy ≥13mm and chronic kidney disease.

Sex-Specific Left Ventricular and Aorta Size Cut-Off Values for Hemodynamically Significant Chronic Aortic Regurgitation - Implications for Treatment in Asian Populations

BACKGROUND

There are no sex-specific guidelines for chronic aortic regurgitation (AR). This retrospective study examined sex-specific differences and propose treatment criteria from an Asian AR cohort.

METHODS AND RESULTS

Consecutive 1,305 patients with moderate-severe AR or greater at 3 tertiary centers in Taiwan and Japan (2008-2022) were identified. Study endpoints were aortic valve surgery (AVS), all-cause death (ACD), and cardiovascular death (CVD). The median follow up was 3.9 years (interquartile range 1.3-7.1 years). Compared with men (n=968), women (n=337) were older, had more advanced symptoms, more comorbidities, larger indexed aorta size (iAortamax) and indexed left ventricular (LV) end-systolic dimension (LVESDi; P<0.001 for all). Symptomatic status was poorly correlated with the degree of LV remodeling in women (P≥0.18). Women received fewer AVS (P≤0.001) and men had better overall 10-year survival (P<0.01). Ten-year post-AVS survival (P=0.9) and the progression of LV remodeling were similar between sexes (P≥0.16). Multivariable determinants of ACD and CVD were age, advanced symptoms, iAortamax, LV ejection fraction (LVEF), LVESDi, LV end-systolic volume index (LVESVi), and Taiwanese ethnicity (all P<0.05), but not female sex (P≥0.05). AVS was associated with better survival (P<0.01). Adjusted LVEF, LVESDi, LVESVi, and iAortamaxcut-off values for ACD were 53%, 24.8 mm/m2, 44 mL/m2, and 25.5 mm/m2, respectively, in women and 52%, 23.4 mm/m2, 52 mL/m2, and 23.2 mm/m2, respectively, in men.

CONCLUSIONS

Early detection and intervention using sex-specific cut-off values may improve survival in women with AR.

Male Wistar Rats Chronically Fed with a High-Fat Diet Develop Inflammatory and Ionic Transport Angiotensin-(3-4)-Sensitive Myocardial Lesions but Preserve Echocardiographic Parameters

The central aim of this study was to investigate whether male Wistar rats chronically fed a high-fat diet (HFD) over 106 days present high levels of interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-α), and Na+ and Ca2+ transport alterations in the left ventricle, together with dyslipidemia and decreased glucose tolerance, and to investigate the influence of Ang-(3-4). The rats became moderately overweight with an expansion of visceral adiposity. Na+-transporting ATPases, sarco-endoplasmic reticulum Ca2+-ATPase (SERCA2a), and the abundance of Angiotensin II receptors were studied together with lipid and glycemic profiles from plasma and left-ventricle echocardiographic parameters fractional shortening (FS) and ejection fraction (EF). IL-6 and TNF-α increased (62% and 53%, respectively), but returned to normal levels with Angiotensin-(3-4) administration after 106 days. Significant lipidogram alterations accompanied a decrease in glucose tolerance. Angiotensin II receptors abundance did not change. (Na+ + K+)ATPase and ouabain-resistant Na+-ATPase were downregulated and upregulated, respectively, but returned to normal values upon Angiotensin-(3-4) administration. SERCA2a lost its ability to respond to excess ATP. Echocardiography showed no changes in FS or EF. We conclude that being overweight causes an increase in Ang-(3-4)-sensitive IL-6 and TNF-α levels, and ion transport alterations in the left ventricle that could evolve into future heart dysfunction.

Diastolic dysfunction and risks of heart failure and death in long-term adult cancer survivors

BACKGROUND

Cancer survivors face elevated risks of heart failure (HF) and death, with cardiac dysfunction being a significant concern. Current evaluations often emphasize systolic function while insufficiently addressing diastolic function. This study aims to investigate the prevalence of diastolic dysfunction and assess its prognostic implications in long-term cancer survivors.

METHODS

We analyzed participants from the Atherosclerosis Risk in Communities (ARIC) Study with complete echocardiographic assessments and documented cancer histories. Diastolic function was classified by guideline criteria: normal (≤ 1 abnormal parameter), indeterminate (2 abnormal parameters), and dysfunction (≥ 3 abnormal parameters). The primary outcomes were incident HF and all-cause death. Diastolic dysfunction prevalence was compared between cancer survivors and non-cancer participants after propensity score matching. Cox regression, Kaplan-Meier, and restricted cubic spline (RCS) analyses were used to assess associated risks.

RESULTS

A total of 5322 participants were included, with 18.4% (N = 979) being cancer survivors. The mean age of cancer survivors at echocardiography was 76.3 (5.10) years, with a median of 12.17 years since diagnosis. There were no significant differences in diastolic dysfunction prevalence (12.26% vs 10.73%, P = 0.29) after matching. Cox regression revealed a graded association between diastolic dysfunction and risks of HF and death. Fully adjusted hazard ratios were 2.59 (95% CI: 1.59-4.20, P < 0.001) for indeterminate diastolic function and 4.41 (95% CI: 2.40-8.12, P < 0.001) for diastolic dysfunction in HF; and 1.68 (95% CI: 1.26-2.25, P < 0.001) for indeterminate and 2.21 (95% CI: 1.51-3.22, P < 0.001) for diastolic dysfunction in all-cause death. These results were consistent across subgroup and sensitivity analyses and supported by Kaplan-Meier curves. RCS analyses demonstrated dose-response relationships between individual diastolic parameters and outcomes.

CONCLUSIONS

Diastolic dysfunction is prevalent among long-term cancer survivors and is stepwise associated with adverse outcomes. These findings underscore the essential need for ongoing monitoring of diastolic function in this population.

The prognostic value of cartilage intermediate layer protein 1 (CILP1) in patients with diabetic cardiomyopathy

OBJECTIVE

To measure the plasma levels of human cartilage intermediate layer protein 1 (CILP1) in patients with diabetic cardiomyopathy (DCM), and to investigate its association with the occurrence of major adverse cardiovascular events (MACE) in DCM.

METHODS

A total of 336 diabetic patients were enrolled and assigned into two groups based on the presence or absence of DCM (DCM group and N-DCM group). The baseline clinical data including glutamic-pyruvic transaminase (ALT), glutamic oxaloacetic acid transferase (AST), albumin, serum creatinine, glycosylated hemoglobin (HbA1c), C-reactive protein (CRP), and N-terminal pro brain natriuretic peptide (NT-proBNP) were recorded. Subsequently, plasma levels of CILP1 at admission were detected by the enzyme linked immunosorbent assay (ELISA) method. Echocardiographic parameters were also acquired for all patients. The association of CILP1 with LVEF, LVDD and CRP was determined. In addition, the occurrence of MACE was examined during the 12-month follow-up in the DCM group.

RESULTS

The concentration of CILP1 in the DCM group was higher than in the N-DCM group [1329.97 (1157.14, 1494.36) ng/L vs. 789.00 (665.75, 937.06) ng/L, P < 0.05], higher in the MACE group than in the non-MACE group [1777.23 (1532.83, 2341.26)ng/L vs. 885.00 (722.40, 1224.91) ng/L, P < 0.05). Correlation analysis revealed that CILP1 expression was associated with LVEF, CRP and LVDD (r = -0.58, 0.29 and 0.44, respectively, P < 0.05). Analysis of a nomogram demonstrated that CILP1, sex, age, BMI, LVEF and LVDD could predict the occurrence of MACE in DCM patients at 12 months (P < 0.05). The plasma levels of CILP1 were independently associated with a stronger discriminating power for DCM. Furthermore, inclusion of CILP1 as a covariate in the model caused a significant improvement in risk estimation compared with traditional risk factors for DCM [BASIC: AUC: 0.556, 95%CI: 0.501-0.610; BASIC + CILP1: AUC: 0.913, 95%CI: 0.877-0.941, P < 0.05] and MACE [BASIC: AUC: 0.710, 95%CI: 0.616-0.792; BASIC + CILP1: AUC: 0.871, 95%CI: 0.794-0.928, P < 0.05].

CONCLUSIONS

The serum concentration of CILP1 was increased in DCM patients. Elevated fasting plasma CILP1 levels was a robust diagnostic marker of DCM and was independently associated with an increased risk of MACE.

High Burden Ventricular Ectopy > 10% in Children with Structurally Normal Hearts: Investigating the Association of Ventricular Ectopy Frequency, Holter and ECG Findings, and Ventricular Dysfunction

Frequent ventricular ectopy (VE) ≥ 10% in children with structurally normal hearts and the development of ventricular dysfunction is not well described. We aim to describe frequent VE ≥ 10% in children with structurally normal hearts and characterize the development of dysfunction. Patients with VE burden ≥ 10% on 24-h Holter performed between 2010 and 2019 were included in this retrospective review. Patients with structural heart disease and cardiomyopathy preceding the onset of VE were excluded. Medical records, electrocardiogram, Holter, and transthoracic echocardiogram data were analyzed. Patients were classified based on maximum VE burden on Holter ("frequent" 10-29% versus "very frequent" ≥ 30%), presence of runs of VE, VE morphology on ECG, coupling interval, and development of dysfunction. Two hundred thirty-four patients met inclusion criteria, 187 with frequent VE and 47 with very frequent VE. Seventeen (7%) patients developed ventricular dysfunction, the majority of whom had mild dysfunction. Very frequent VE > 30% and non-sustained ventricular tachycardia (NSVT) on Holter were associated with dysfunction. There was no association between coupling interval or prematurity index and dysfunction. Ventricular dysfunction is uncommon in children with structurally normal hearts and frequent VE burden > 10%, though VE burden > 30% and presence of NSVT were associated with dysfunction. Previously described characteristics to delineate higher risk VE based on coupling interval were not associated with dysfunction.

Sex-related differences concerning the profile and evolution of cardiovascular complications in patients with post-acute COVID-19 syndrome

BACKGROUND

During the COVID-19 pandemic sex-related differences concerning the spectrum of cardiovascular complications have been observed in the acute infection, and during recovery. This study aims to emphasize sex-related disparities regarding left ventricular systolic function (LVSF), right ventricular function (RVF), diastolic dysfunction (DD), and pericardial pathologies during the post-COVID-19 syndrome.

METHODS

274 patients with post-acute COVID-19 syndrome, 127 men and 147 women, aged under 55, were evaluated within 90 days after the acute illness and followed at 3 and 6 months.

RESULTS

Based on detailed transthoracic echocardiography (TTE), we identified significantly more frequently (p˂0.001) altered LVSF in men, while in women impaired RVF, and DD were significantly more common (p˂0.001). Pericardial impairment did not seem to be influenced by gender. The TTE parameters characterizing these patterns were correlated with the severity of the initial infection and the time elapsed since and alleviated in time. The multivariate regression analysis confirmed these sex-related associations and their impact on patients' functional status.

CONCLUSIONS

Male patients had a higher tendency to develop altered LVSF, while female subjects had more frequently impaired RVF and DD. These abnormalities alleviated in time and exerted a significant influence on patients' functional status.

Utility of Cardiac Magnetic Resonance in Assessing Arrhythmic Risk in Patients With Nonischemic Cardiomyopathy Undergoing Biventricular Pacing

BACKGROUND

Nonischemic cardiomyopathy (NICM) is responsible for approximately one-third of heart failure and is associated with significant morbidity and mortality. Recent data suggested the lack of mortality reduction from adding a defibrillator to cardiac resynchronization therapy (CRT) in all patients with NICM. Myocardial fibrosis detected by cardiac magnetic resonance late gadolinium enhancement (CMR-LGE) can help risk stratify patients who would benefit from adding a defibrillator to CRT in this patient population.

OBJECTIVES

We aim to assess the relationship between the presence of myocardial fibrosis detected by CMR-LGE and the rate of major arrhythmic events (MAE) that included sustained ventricular tachycardia (VT), appropriate cardiac resynchronization therapy-defibrillator (CRT-D) intervention, ventricular fibrillation (VF), and sudden cardiac death (SCD) in patients with NICM undergoing CRT and to compare all-cause mortality and heart failure improvement between patients receiving cardiac resynchronization therapy-pacing (CRT-P) versus those receiving CRT-D based on the presence of myocardial fibrosis.

METHODS

All consecutive patients with NICM satisfying a guideline-directed indication for CRT implantation were included in the study after excluding patients who refused to consent, patients with acute decompensated heart failure, and those contraindicated for a cardiac magnetic resonance (CMR). Patients were divided into two groups based on the presence of fibrosis in cardiac MRI: the LGE/CRT-D group and the No LGE/CRT-P group. They were then followed for 1 year.

RESULTS

Sixty patients were enrolled. Sixteen patients (26.6%) developed MAE during the study duration, among those patients, seven had myocardial fibrosis (receiving CRT-D as per protocol), while nine had no myocardial fibrosis (receiving CRT-P as per protocol), (41.2% vs. 20.9%, p = 0.045). The presence of CMR-LGE, regardless of the extent and distribution, predicted MAE with an odds ratio of 2.6 (CI = 1.78-8.9, p = 0.04). The presence of ≥7.5% of myocardial fibrosis by CMR was associated with 54% sensitivity and 100% specificity for MAE in the study population. All-cause mortality was significantly higher in the No LGE/CRT-P group versus the LGE/CRT-D group (15 [34.9%] vs. 2 [11.8%], p = 0.076).

CONCLUSION

In patients with NICM candidates for biventricular pacing, the presence of LGE on CMR, irrespective of the extent or segmental pattern, is independently associated with an MAE and is associated with worse heart failure outcomes. However, the absence of LGE did not rule out MAE, and implanting CRT-P based on lack of fibrosis may result in higher all-cause mortality.

Cardiovascular Adaptation in Normal Pregnancy With 2D and 3D Echocardiography, Speckle Tracking, and Radial Artery Tonometry

Background

Comprehensive cardiovascular assessment in normal pregnancy using advanced techniques has limited data.

Objectives

The aim of the study was to evaluate cardiovascular changes in normal pregnancy using two-dimensional/three-dimensional (3D) echo and applanation tonometry in healthy pregnant women.

Methods

Two-dimensional/Doppler, speckle tracking strain, 3D echocardiography, and vascular compliance by applanation tonometry were performed during the first, second, and third trimesters and postpartum.

Results

There were 45 healthy women (96% Hispanic) included. The heart rate increased in all trimesters vs postpartum (70.538 ± 9.208 beats/min, 74.878 ± 8.094 beats/min, 74.107 ± 9.231 beats/min vs 61.613 ± 9.790 beats/min, P < 0.001). A 3D left ventricular (LV) end systolic volume (34.583 ± 6.946 mL, 39.405 ± 7.345 mL, 45.994 ± 15.180 mL, 36.077 ± 7.116 mL), LV end diastolic volume (83.672 ± 14.022 mL, 91.512 ± 14.602 mL, 97.581 ± 19.864 mL, 85.163 ± 13.960 mL), right ventricular (RV) end systolic volume (30.690 ± 6.194 mL, 35.390 ± 7.345 mL, 40.929 ± 15.178 mL, 30.740 ± 6.911 mL), RV end diastolic volume (77.074 ± 14.875 mL, 86.871 ± 16.783 mL, 92.926 ± 18.083 mL, 78.267 ± 15.07 mL), and cardiac output increased (P < 0.01 for all) in the 2nd and 3rd trimester. LV longitudinal strain rate (SR) (-1.242 ± 0.350, -1.194 ± 0.181, -1.231 ± 0.263 vs -1.068 ± 0.218, P < 0.05) increased in all trimesters, RV longitudinal SR (-1.612 ± 0.314, -1.540 ± 0.284, -1.281 ± 0.748 vs -1.361 ± 0.306) in the 1st and 2nd trimester, P < 0.01), left atrial SR (1.735 ± 0.461, 1.687 ± 0.540, 1.588 ± 0.0.526 vs 1.414 ± 0.325), and right atrial SR (2.389 ± 0.582, 2.264 ± 0.741, 2.241 ± 0.793 vs 1.861 ± 0.600) in all trimesters, (P < 0.05). Left atrial volume increased in 2nd and 3rd trimesters, left atrial contraction velocity in 3rd trimester (P < 0.05), and pulmonary vein systolic filling velocity throughout pregnancy (P < 0.001). E/e' ratio did not change and LV ejection duration increased. Systolic augmentation of central aortic pressure decreased throughout.

Conclusions

Increased contractility of all four cardiac chambers, LV ejection-duration, and reduced LV afterload provide efficient cardiovascular adaptation despite increased chamber volumes and heart rate during normal pregnancy.

Superiority of 3D planimetry over pressure half-time method for the assessment of mitral valve area after percutaneous edge-to-edge mitral repair

INTRODUCTION AND OBJECTIVES

There is limited evidence to identify the most accurate method for measuring the mitral valve area (MVA) after percutaneous edge-to-edge mitral repair. Our objective was to evaluate the optimal method in this context and its correlation with the mean transmitral gradient.

METHODS

A registry of patients undergoing percutaneous mitral repair was conducted, analyzing different methods of measuring MVA and their correlation with the mean gradient.

RESULTS

We analyzed data from 167 patients. The mean age was 76±10.3 years, 54% were men, and 46% were women. Etiology was degenerative in 45%, functional in 39%, and mixed in 16%. Postclip MVA measurements were 1.89±0.60 cm2 using pressure half-time (PHT), 2.87±0.83 cm2 using 3D planimetry, and the mean gradient was 3±1.19mmHg. MVA using 3D planimetry showed a stronger correlation with the mean gradient (r=0.46, P<.001) than MVA obtained by PHT (r=0.19, P=.048). Interobserver agreement was also higher with 3D planimetry than with PHT (intraclass correlation coefficient of 0.90 vs 0.81 and variation coefficient of 9.6 vs 19.7%, respectively).

CONCLUSIONS

Our study demonstrates that the PHT method significantly underestimates MVA after clip implantation compared with direct measurement using transesophageal 3D planimetry. The latter method also correlates better with postimplantation gradients and has less interobserver variability. These results suggest that 3D planimetry is a more appropriate method for assessing postclip mitral stenosis.

Cardiovascular Risk Factors and Disparities in Management of Embolic Stroke: A Western Sydney Perspective

BACKGROUND

Ischaemic stroke remains one of the leading causes of death and disability worldwide. The population of Western Sydney has a unique demographic with lower socioeconomic status and a culturally and linguistically diverse population. This study aims to investigate the demographics and cardiovascular risk factors of patients in Western Sydney, focusing on the prevalence and profile of cardioembolic (CE) strokes and embolic strokes of undetermined source (ESUS).

METHOD

Prospective data were collected in 463 patients with ischaemic stroke presenting to a tertiary centre in Western Sydney, who underwent predischarge transthoracic echocardiography. Patients with haemorrhagic strokes or unclear stroke diagnosis were excluded. Analysis of stroke subtype (CE, ESUS, or non-embolic) and clinical characteristics was performed based on age, gender, and prior atrial fibrillation (AF) prevalence.

RESULTS

Of the 463 patients, 147 (32%) had CE strokes, and 147 (32%) had ESUS. Cardioembolic (CE) strokes were associated with older age (≥65 years) and a history of congestive cardiac failure. Older patients had higher rates of hypertension, ischaemic heart disease, AF, and congestive heart failure. History of AF was present in 67 patients (14.5%); however, only 51% received anticoagulation before admission despite a low bleeding risk. The transthoracic echocardiography characteristics of ESUS/non-embolic strokes differed from those of CE strokes; 20% of patients with ESUS had an enlarged left atrium, suggesting a subset of patients with ESUS with a left atrial myopathy.

CONCLUSIONS

Patients with ischaemic stroke in Western Sydney have a high prevalence of cardiovascular risk factors which were often undertreated. Half of the patients with prior AF did not receive anticoagulation despite low bleeding risk, indicating a gap in optimal stroke prevention. There were distinct echocardiographic characteristics among stroke subtypes. Further analysis of left atrium parameters may provide greater insights into the pathogenesis and prevention of embolic strokes.

Right ventricular dysfunction and impaired right ventricular-pulmonary arterial coupling in paradoxical low-flow, low-gradient aortic stenosis

AIMS

Paradoxical low-flow, low-gradient aortic stenosis (pLFLG AS) may represent a diagnostic challenge, and its pathophysiology is complex. While left ventricular (LV) systolic function is preserved, right ventricular dysfunction (RVD) and consecutive LV underfilling may contribute to low-flow and reduced stroke volume index, and to adverse outcomes following transcatheter aortic valve implantation (TAVI). The aim of this study was to evaluate the potential role of RVD in pLFLG AS, and to assess the impact of pre-procedural RVD on clinical outcomes after TAVI in patients with pLFLG AS.

METHODS AND RESULTS

Out of 2739 native AS patients, who received TAVI at the University of Cologne Heart Center between March 2013 and June 2021, 114 patients displayed pLFLG AS and were included in this study. Right ventricular (RV) function was assessed by transthoracic echocardiography, and a fractional area change (FAC) ≤35% and/or a tricuspid annular plane systolic excursion (TAPSE) <18 mm determined RVD. In addition, the TAPSE/systolic pulmonary artery pressure ratio (TAPSE/sPAP) was monitored as a measure of RV-pulmonary arterial (PA) coupling. An impaired FAC and TAPSE was present in 21.9% and 45.6% of patients, respectively, identifying RVD in 50.0%. RVD (p = 0.016), reduced FAC (p = 0.049), reduced TAPSE (p = 0.035) and impaired RV-PA coupling (TAPSE/sPAP ratio <0.31 mm/mmHg; p = 0.009) were associated with significantly higher all-cause mortality compared to patients with normal RV function. After adjustment for sex, age, body mass index, EuroSCORE II, previous myocardial infarction and mitral regurgitation, independent predictors for all-cause mortality were FAC, sPAP, TAPSE/sPAP ratio, right atrial area, RV diameter and tricuspid regurgitation.

CONCLUSIONS

Adverse RV remodelling, RVD and impaired RV-PA coupling provide an explanation for low-flow and reduced stroke volume index in a subset of patients with pLFLG AS, and are associated with excess mortality after TAVI.

Ultrasound Assessment of Pleural Effusions After Orthotopic Pig-to-Baboon Cardiac Xenotransplantation

BACKGROUND

Pleural effusions develop frequently after cardiac surgery in humans. Lung ultrasound is an essential non-invasive tool in the diagnosis and treatment of these effusions. Pleural effusions also develop regularly after preclinical cardiac xenotransplantation experiments. Unlike in the human setting, modern ultrasound devices lack pre-installed tools for calculating the volume of pleural effusions in baboons. The aim of this study was to analyze ultrasound examinations of pleural effusions after orthotopic pig-to-baboon cardiac xenotransplantation experiments in order to develop a formula for calculating the effusion volume based on ultrasound measurements.

METHODS

Hearts from seven genetically modified (GGTA1-KO, hCD46/hTBM transgenic) juvenile pigs were orthotopically transplanted into male baboons. Postoperatively, the baboons were tested regularly for the development of pleural effusions using ultrasound. When thoracocentesis was required, the drained effusion volume (EV) was compared to ultrasound-derived calculations using various formulas. These calculations were based on measuring the distance between lung and diaphragm at the effusions' maximum height (Hmax). Subsequently, the most promising formula was used to describe the interobserver variability between trained and untrained staff members to predict effusion volumes based on ultrasound measurements.

RESULTS

Ultrasound measurement correlated very strongly with the absolute EV (r = 0.9156, p < 0.0001), with EV indexed to total body weight (r = 0.9344, p < 0.0001) and with EV indexed to body surface area (BSA) (r = 0.9394, p < 0.0001). The ratio between Hmax and EV increased with total body weight and BSA and also depended on the baboon species. The sonographic measurements taken by an experienced and an inexperienced observer showed only low interobserver variability. A Bland-Altman plot of both observers' measurements showed an overall bias of -2.39%.

CONCLUSION

Ultrasound imaging provides a simple and non-invasive tool for measuring pleural effusion quantity in baboons. This facilitates simple and efficient monitoring even in the hands of untrained personnel and may guide the decision-making to perform thoracocentesis.

Circulating osteoprotegerin as a cardiac biomarker for left ventricular diastolic dysfunction in patients with pre-dialysis chronic kidney disease: the KNOW-CKD study

BACKGROUND

Heart failure with preserved ejection fraction (HFpEF) is a major cause of mortality in patients with chronic kidney disease (CKD), and diagnosis is challenging. Moreover, no specific biomarker for HFpEF has been validated in patients with CKD. The present study aimed to investigate the association between serum osteoprotegerin (OPG) levels and the risk of left ventricular diastolic dysfunction (LVDD), a surrogate of HFpEF, in patients with pre-dialysis CKD.

METHODS

A total of 2039 patients with CKD at stage 1 to pre-dialysis 5 were categorized into quartiles (Q1 to Q4) by serum OPG levels, and were cross-sectionally analyzed. The study outcome was LVDD, which was operationally defined as the ratio of early transmitral blood flow velocity to early diastolic velocity of the mitral annulus (E/e') > 14.

RESULTS

In the analysis of baseline characteristics, higher serum OPG levels were clearly related to the risk factors of HFpEF. A scatter plot analysis revealed a moderate correlation between serum OPG levels and E/e' (R = 0.351, P < 0.001). Logistic regression analysis demonstrated that the risk of LVDD in Q3 (adjusted odds ratio 2.576, 95% confidence interval 1.279 to 5.188) and Q4 (adjusted odds ratio 3.536, 95% confidence interval 1.657 to 7.544) was significantly higher than that in Q1.

CONCLUSIONS

Elevated serum OPG levels are associated with the risk of LVDD in patients with pre-dialysis CKD. The measurement of serum OPG levels may help the diagnosis of LVDD, which is an important echocardiographic feature of HFpEF.

Age-dependent association between aneurysmal and isolated redundant inter-atrial septum with patent foramen ovale

BACKGROUND

Interatrial septum (IAS) could be redundant by abnormal movement with or without aneurysmal bulging. We aimed to determine the prevalence of isolated redundant and aneurysmal IAS motion and their probable relationship with age and presence of patent foramen ovale (PFO) in a large-scale referral center.

METHOD

A total of 15,288 patients who underwent transthoracic echocardiography (TTE) at Tehran Heart Center were included From March 2019 to March 2021. Contrast echocardiography was conducted on patients with suspected PFO. Data were retrospectively analyzed from our previously established database. The prevalence of aneurysmal and redundant IAS and their relationship with age and PFO presence was evaluated.

RESULTS

Aneurysmal and isolated redundant IAS were present in 4% and 12.4% of the participants, respectively. The aneurysmal group was older, more frequently female and had higher frequency of PFO. The frequency of PFO among patients with aneurysmal IAS was about 14.4% and 5.3% in isolated redundant IAS patients. In both groups, the prevalence of abnormal IAS motion increased across age groups from the youngest to the oldest, while the prevalence of PFO decreased.

CONCLUSION

In conclusion, the frequency of PFO among patients with aneurysmal IAS was about 2.5 times more than that among patients with isolated redundant IAS and 24 times more than the normal population. The increasing trend observed across the aging group proposes a potential role for age in the pathophysiology of abnormal IAS. Furthermore, the decreasing prevalence of PFO among patients underlies its clinical significance as an important risk factor.

Computed Tomography Confirms Increased Left Atrial Volume in Patients with Bayés Syndrome Referred for Catheter Ablation of Atrial Fibrillation

Background: Bayés syndrome is a recently identified condition that is defined by the presence of an interatrial block on a surface electrocardiogram, in addition to atrial arrhythmias such as atrial fibrillation, tachycardia, or left atrial flutter. This syndrome is linked to an increased risk of stroke, morbidity, and mortality. An interatrial block is a conduction delay between the right atrium and left atrium and can be recognized by a P wave duration >120 ms. It is known that P wave duration can estimate the size of the left atrium measured via echocardiography, which is a marker for stratifying cardiovascular risk. Our study aims to verify whether the duration of the P wave can estimate the volume of the left atrium measured by computed tomography in patients with an interatrial block. Methods: We included 105 patients with a sinus rhythm and a partial or advanced interatrial block (IAB) who underwent contrast-enhanced cardiac computed tomography (CT). The mean age was 62.2 ± 10.1 years, and 38% of the patients were women. Results: The mean P wave duration was 122.6 ± 11.4 ms in the partial IAB group and 150 ± 8.4 ms in the advanced IAB group (p < 0.01). The mean left atrial volume was 115 ± 39 mL in the partial IAB group and 142 ± 34 mL in the advanced IAB group (p = 0.001). P wave duration was longer in patients with an advanced as opposed to partial interatrial block. Left atrial volume and LAVI were higher in patients with an advanced as opposed to partial interatrial block. Conclusions: All the patients (100%) with an advanced IAB had a dilated left atrium. P wave duration can accurately estimate LA volume in patients with an IAB using the formula: LA volume = 0.6 × P wave + 46 mL.

Diagnostic and Prognostic Value of Soluble Triggering Receptor Expressed on Myeloid Cells-1 (sTREM-1) for Septic Cardiomyopathy

Purpose

The early diagnosis of septic cardiomyopathy remains a challenge. The present work aims to evaluate the diagnostic and prognostic value of plasma soluble triggering receptor expressed on myeloid cells-1 (sTREM-1) levels in septic cardiomyopathy when compared with traditional myocardial biomarkers.

Methods

In the 143 sepsis enrolled patients, 67 and 76 patients were classified as non-septic cardiomyopathy and septic cardiomyopathy, respectively. Their blood samples were harvested up to 14th day after hospital admission for measurements of sTREM-1 and other biomarkers, such as N-terminal pronatriuretic peptide (NT-proBNP), highly sensitive troponin (TNT-HS), myoglobin (MYO), creatine kinase isoenzyme (CK-MB), etc. All the data were collected at 8:00 a.m. The area under the receiver operating characteristic curve was obtained to assess the diagnostic accuracy of those biomarkers. The Log rank test was utilized to evaluate the prognostic value of sTREM-1 on septic cardiomyopathy.

Results

Circulating sTREM-1 showed a high specificity (88.1%) and moderate sensitivity (64.5%) to distinguish patients with septic cardiomyopathy in the 143 septic patients. The diagnostic efficiency of sTREM-1 was higher than inflammatory biomarkers and traditional myocardial markers. Logistic regression revealed that plasma sTREM-1 was an independent predictor of septic cardiomyopathy. Furthermore, in the whole septic cardiomyopathy cohorts, the sTREM-1 levels in the non-survivors were significantly higher than those of survivors during ICU stay. In addition, the left ventricular systolic dysfunction had a high odds ratio (3.968) to predict 90-day mortality in septic patients with cardiomyopathy.

Conclusion

High plasma sTREM-1 level may be a diagnostic marker in predicting ICU poor outcome of patients with septic cardiomyopathy.

Electrocardiographic abnormalities attributable to infiltrative cardiomyopathies: review and prevalence in patients with congestive heart failure

BACKGROUND

The electrocardiogram (ECG) is routinely used in patients with suspected infiltrative cardiomyopathies; heart diseases characterized by the abnormal deposition of pathological substances in the myocardium. This study presents a review of ECG features attributable to various infiltrative cardiomyopathies and analyzes the prevalence and overlap of electrocardiographic abnormalities in patients with adjudicated CHF.

RESULTS

The study included 573 consecutive CHF patients without severe aortic stenosis, further stratified by LV hypertrophy (LVH) and preserved or decreased LV ejection fraction. Comprehensive ECG analysis revealed at least one ECG abnormality typically associated with infiltrative cardiomyopathies in 95% of patients, and more than one ECG abnormality in 70%. An average number of ECG abnormalities was 2.2 ± 1.2 per patient. There was substantial overlap in ECG abnormalities in individual patients, particularly those attributable to Fabry's disease and hemochromatosis (51.5%) or cardiac amyloidosis (46.1%), and hemochromatosis and cardiac amyloidosis (44.2%). Prevalence of various ECG abnormalities was similar across various patient demographics and co-morbidities, including LVH status and/or history of CAD which did not increase the number of ECG abnormalities (2.155 ± 1.238 vs. 2.228 ± 1.192 in patients without CAD history, p = 0.969). Patients with reduced LV ejection fraction had a higher prevalence of widened QRS and premature ventricular complexes.

CONCLUSION

ECG abnormalities attributable to infiltrative cardiomyopathies are common in heart failure patients, with a significant overlap in findings classically attributed to various infiltrative cardiomyopathies. The presence of LVH and decreased LV ejection fraction do not significantly affect the prevalence of ECG abnormalities.

Mitral-specific cardiac damage score (m-CDS) predicts risk of death in functional mitral regurgitation: a study from the National Echo Database of Australia

AIMS

We set out to explore associations between a 'mitral-specific' cardiac damage score (m-CDS) and survival outcomes in mitral regurgitation (MR) and compare the performance of the m-CDS and an 'aortic-specific' CDS (a-CDS) in patients with MR within the large National Echo Database of Australia.

METHODS

Among 620 831 unique adults investigated with echocardiography, there were 17 658 individuals (3.1%) with moderate or greater functional MR (aged 76±13 years, 51% female) who met inclusion criteria. A randomly selected cohort of 5000 of these patients was used to test seven different CDS models for prediction of subsequent all-cause mortality during an average 3.8-year follow-up. The best-performing CDS model in the derivation cohort was then applied to a validation cohort of the remaining 12 658 individuals (aged 76±13 years, 51% female).

RESULTS

The best-performing m-CDS model stratified the full cohort into Stage 0: control (1046 patients, 8%); Stage 1: left atrial damage (3416 patients, 27%); Stage 2: left ventricular damage (3352 patients, 26%); Stage 3: right ventricular damage (1551 patients, 12%) and Stage 4: pulmonary hypertension (3293 patients, 26%). Increasing m-CDS stage was consistently and incrementally associated with both all-cause and cardiovascular mortality at 1 year, 5 years and all-time and remained so after adjustment for increasing age and severity of MR, with a ~35% increase in mortality for each increase in CDS stage (p<0.001).

CONCLUSION

A m-CDS was robustly and incrementally associated with short-, medium- and long-term risk of all-cause and cardiovascular mortality in patients with functional MR in this large registry study.

Weight status change during four years and left ventricular hypertrophy in Chinese children

Objective

It is well-established that overweight/obesity is a major risk factor for left ventricular hypertrophy (LVH) in childhood. However, it is still unclear if reversing from overweight/obesity to normal weight is associated with decreased LVH in children. This study aimed to examine the association between weight status change during four years and LVH among Chinese children based on a prospective cohort study.

Methods

Data were obtained from the Huantai Childhood Cardiovascular Health Cohort Study in China. A total of 1,178 children without LVH at baseline (mean age: 8.3 years) were included in this study. According to weight status [normal weight or overweight (including obesity)] at baseline (2017) and follow-up (2021), children were divided, based on sex- and age-adjusted body mass index (BMI), into four groups: persistent normal weight (normal weight at both baseline and follow-up), incident overweight (normal weight at baseline but overweight at follow-up), reversal to normal weight (overweight at baseline but normal weight at follow-up), persistent overweight (overweight at both baseline and follow-up).

Results

After adjustment for potential confounding factors, children with incident overweight (n = 114, 30.63 ± 4.74 g/m2.7) and those with persistent overweight (n = 363, 31.56 ± 6.24 g/m2.7) had higher left ventricular mass index (LVMI) at the end of the follow-up period than those with persistent normal weight (n = 632, 28.46 ± 7.64 g/m2.7), while those who reversed from overweight to normal weight had a non-significantly lower LVMI (n = 69, 28.51 ± 4.28 g/m2.7). Compared to children with persistent normal weight, those with persistent overweight [odds ratio (OR) = 5.14, 95% confidence interval (CI) = 3.33-7.95] and those with incident overweight (OR = 3.34, 95% CI = 1.77-6.30) had an increased risk of LVH. The risk of LVH tended to decrease, although not significantly, in those who reversed from overweight to normal weight (OR = 0.76, 95% CI = 0.22-2.55).

Conclusion

Our findings demonstrate a positive association between overweight and left ventricular mass in children and suggest that LVH in childhood could be attenuated by weight loss.

Role of standard echocardiography in Anderson-Fabry disease

Cardiac involvement strongly impacts prognosis in patients with Anderson-Fabry disease (AFD). All cardiac structures, such as the left ventricle and the left atrium, the aorta, the right sections, and the heart valves can be affected by morphological and functional abnormalities. Standard echocardiography has a crucial role in the characterization of AFD cardiomyopathy. Being a diffuse, non-invasive, easily reproducible, and inexpensive investigation, echocardiography represents the most appropriate tool for screening AFD cardiomyopathy. Furthermore, echocardiographic evaluation is the essential imaging method to support the physician also in the follow-up and risk stratification of AFD patients. Therefore, echocardiography is useful in all stages of the disease, both to reveal the first signs of cardiac involvement and to guarantee timely treatment in the preclinical stage and to estimate the extent of cardiac involvement, define possible complications, and evaluate the response to treatment in patients with established cardiomyopathy. The latest advanced echocardiographic techniques, such as speckle-tracking analysis, are offering new insights into the early detection of AFD cardiac involvement, thus suggesting a promising role for echocardiography in selecting appropriate candidates for treatment. In this review, we will examine the role of standard echocardiography in AFD, focusing on its use in screening for cardiac involvement, detailed characterization of AFD cardiomyopathy, and risk stratification of AFD patients.

Right ventricular remodeling induced by prolonged excessive endurance exercise is mediated by upregulating Wnt/β-catenin signaling in rats

BACKGROUND

The aim of this study was to develop an animal model to investigate whether prolonged intensive endurance exercise induces RV remodeling, taking into account the involvement of Wnt/β-catenin signaling.

METHODS

Four-week-old male Wistar rats (100 to 125 g) were assigned to four groups (n = 8/group): 1) sixteen weeks of intensive (36 m/min) exercise (INT), 2) twelve weeks of the intensive exercise followed by four weeks of moderate intensity (18 m/min) exercise (INT + MOD), 3) twelve weeks of the intensive exercise followed by four weeks of detraining (INT + DT), and 4) sedentary rats (SED). The exercise protocols were performed five days a week for one h/day. Echocardiography, real-time PCR, western blotting, and histological staining were performed at the end of week sixteen.

RESULTS

INT rats developed concentric hypertrophy without diastolic dysfunction compared to SED (p = 0.006) and INT + DT (p = 0.035). Wnt1, β-catenin and CyclinD1 proteins in the training groups were significantly higher than SED rats (p < 0.001). Interestingly, INT rats had higher protein levels than INT + DT and INT + MOD (p < 0.001), with higher gene expression compared to SED rats (p < 0.05). There was also a significant increase in collagen deposition in INT rats compared to SED (p = 0.046) and INT + DT (p = 0.034). Furthermore, INT + MOD and INT + DT rats did not show any adverse structural, functional, or histological changes.

CONCLUSIONS

Long-term intensive endurance training seems to be associated with increased collagen deposition and wall thickness in the RV through Wnt/β-catenin signaling (which is concentration dependent), without changes in diastolic function.

CLINICAL PERSPECTIVE

Over the past decades, there has been an ongoing debate about whether the structural and functional adaptations of the cardiovascular system in trained endurance athletes are benign physiological responses to training or potentially pathological changes related to disease. While the adaptations of the left heart are well-documented, the remodeling of the right heart remains a subject of discussion. To gain insights into the ability of sustained high-intensity exercise to cause adverse right ventricular (RV) remodeling, we conducted an experimental study in which male rats were trained to run vigorously for 1 h daily over a 16-week period and compared them to a parallel group of sedentary control rats. Our findings revealed that intense long-term exercise induced morphological changes along with fibrosis affecting the RV. These fibrotic changes were a result of the 16-week vigorous exercise training regimen. If these results are confirmed in humans, they suggest that prolonged high-intensity endurance exercise training may lead to adverse cardiac remodeling. Our findings have important potential implications for the assessment of cardiac remodeling in individuals engaged in high-level exercise training.

Doxorubicin Incorporation into Gold Nanoparticles: An In Vivo Study of Its Effects on Cardiac Tissue in Rats

Gold nanoparticles (Au-NPs) have been explored as potential vectors for enhancing the antitumor efficacy of doxorubicin (DOX) while minimizing its cardiotoxic effects. However, the impacts of DOX Au-NPs on cardiac function and oxidative stress remain inadequately understood. This study aimed to explore the effects of DOX Au-NPs in comparison to free DOX, focusing on oxidative stress markers, inflammation, ultrastructural changes, and cardiac function. Male rats were divided into the following four groups: control, citrate Au-NPs, DOX, and DOX Au-NPs. Cardiac function was assessed using echocardiography, and oxidative stress was evaluated through Nrf2, malondialdehyde (MDA) and superoxide dismutase (SOD) levels, and the GSH/GSSG ratio. The ultrastructure of cardiac tissue was assessed by transmission electron microscopy (TEM). Rats treated with DOX Au-NPs exhibited significant cardiac dysfunction, as indicated by a reduction in fractional shortening and ejection fraction. Oxidative stress markers, including elevated MDA levels and a reduced GSH/GSSG ratio, were significantly worse in the DOX Au-NP group. SOD levels decreased, indicating compromised antioxidant defenses. Citrate Au-NPs also caused some alterations in cardiac function and ultrastructure but without other molecular alterations. DOX Au-NPs failed to mitigate cardiotoxicity, instead exacerbating oxidative stress and cardiac dysfunction. DOX Au-NPs possess cardiotoxic effects, necessitating further investigation into alternative nanoparticle formulations or therapeutic combinations to ensure both efficacy and safety in cancer treatment.

Novel Method for Risk Stratification of Major Adverse Clinical Events Using Pre- and Post-Ablation Left Atrial Volume Index in Patients With Persistent Atrial Fibrillation

Background

The relationship between changes in the left atrial volume index (LAVI) post-catheter ablation (CA) and long-term prognostic events in patients with persistent atrial fibrillation (AF) remains unclear. We evaluated the incidence of major adverse clinical events (MACE), including all-cause death, unplanned heart failure hospitalization, and unplanned cardiovascular hospitalization using pre- and post-CA LAVI.

Methods and Results

We collected data retrospectively from 150 patients with persistent AF who underwent their first CA. LAVI was calculated during preprocedural echocardiography under AF rhythm (pre-CA LAVI) and 3 months post-CA under sinus rhythm (post-CA LAVI). The cumulative incidence of MACE was compared among 3 subgroups based on the cutoff values of pre-CA (45.5 mL/m2) and post-CA (46.5 mL/m2; both determined using the c-statistic) LAVI. The subgroup of a pre-CA LAVI >45.5 mL/m2 with a post-CA LAVI >46.5 mL/m2 (n=45) had a significantly higher MACE incidence compared with other subgroups (P=0.002). Multivariate analysis identified this subgroup as independently at higher risk for MACE. The subgroup of a pre-CA LAVI >45.5 mL/m2 with a post-CA LAVI ≤46.5 mL/m2 (n=49) had an incidence comparable with those with pre-CA LAVI ≤45.5 mL/m2 (n=56) and exhibited a significantly greater reduction in LAVI than other subgroups did (P<0.001).

Conclusions

Combining pre-CA and post-CA LAVIs is valuable in stratifying long-term MACE development risk following CA.

Role of aldosterone in various target organ damage in patients with hypertensive emergency: a cross-sectional study

BACKGROUND

Hypertensive emergency is a critical disease that causes multiple organ injuries. Although the renin-angiotensin-aldosterone system (RAS) is enormously activated in this disorder, whether the RAS contributes to the development of the organ damage has not been fully elucidated. This cross-sectional study was conducted to characterize the association between RAS and the organ damage in patients with hypertensive emergencies.

METHODS

We enrolled 63 patients who visited our medical center with acute severe hypertension and multiple organ damage between 2012 and 2020. Hypertensive target organ damage was evaluated on admission, including severe kidney impairment (eGFR less than 30 mL/min/1.73 m2, SKI), severe retinopathy, concentric left ventricular hypertrophy (c-LVH), thrombotic microangiopathy (TMA), heart failure with reduced ejection fraction (HFrEF) and cerebrovascular disease. Then, whether each organ injury was associated with blood pressure or a plasma aldosterone concentration was analyzed.

RESULTS

Among 63 patients, 31, 37, 43 and 8 cases manifested SKI, severe retinopathy, c-LVH and ischemic stroke, respectively. All populations with the organ injuries except cerebral infarction had higher plasma aldosterone concentrations than the remaining subset but exhibited a variable difference in systolic or diastolic blood pressure. Twenty-two patients had a triad of SKI, severe retinopathy and c-LVH, among whom 5 patients manifested TMA. Furthermore, the number of the damaged organs was correlated with plasma aldosterone levels (Spearman's coefficient = 0.50), with a strong association observed between plasma aldosterone (≥ 250 pg/mL) and 3 or more complications (odds ratio = 9.16 [95%CI: 2.76-30.35]).

CONCLUSION

In patients with hypertensive emergencies, a higher aldosterone level not only contributed to the development of the organ damage but also was associated with the number of damaged organs in each patient.

Sex-Specific Insights into Etiology, Diagnosis, Treatment, and Prognosis in Significant Tricuspid Regurgitation: A Narrative Review

In recent decades, a burgeoning interest in tricuspid regurgitation (TR) has been prompted by a heightened awareness of its prevalence and the advent of dedicated percutaneous treatment approaches. Despite considerable understanding of its intricate anatomy and response to varying pressure and loading conditions, the impact of biological sex remains a subject of investigation. While TR typically afflicts more women, significant differences in TR etiology and post-treatment outcomes have not been conclusively established. This narrative review seeks to consolidate the latest evidence concerning sex-related nuances in anatomy, pathophysiology, diagnosis, treatment, and prognosis of significant tricuspid regurgitation. Through synthesizing this information, we aim to provide a comprehensive understanding of how sex may influence the management and prognosis of this condition.

Effect of Ciprofol on Left Ventricular Myocardial Strain and Myocardial Work in Children Undergoing Cardiac Surgery: A Single-center Double-blind Randomized Noninferiority Study

OBJECTIVE

The current work was designed to compare the effects of ciprofol and propofol on left ventricular systolic function and myocardial work by noninvasive speckle-tracking echocardiography in children undergoing surgical repair of atrial septal or ventricular septal defects.

DESIGN

A single-center double-blind randomized noninferiority study was conducted.

SETTING

The research occurred at a tertiary care center affiliated with Shanghai Jiao Tong University, China.

PARTICIPANTS

One hundred and twelve children aged 1 month to 16 years undergoing atrial septal or ventricular septal defect surgery with cardiopulmonary bypass were included.

INTERVENTIONS

One hundred and twelve children were allocated randomly to receive ciprofol (n = 67) or propofol (n = 45) in a 1.5:1 ratio. Ciprofol or propofol were intravenously infused at loading doses of 0.4 mg/kg or 2.0 mg/kg, respectively, over 30 seconds, depending on the physical condition of each patient. When the bispectral index was maintained between 45 and 55 after induction, transthoracic echocardiography, including apical two-chamber, three-chamber, and four-chamber views, were collected bedside.

MEASUREMENTS AND MAIN RESULTS

Of the 112 patients enrolled, 104 completed the study. Global longitudinal strain in the ciprofol and propofol groups after anesthesia was -17.3% (95% confidence interval [CI] -18.0% to -16.6%) and -17.8% (95% CI -18.7 to -17.0%) in the full analysis set and -17.5% (95% CI -18.2% to -16.9%) and -17.8% (95% CI -18.7% to -17.0%) in the per-protocol set, respectively. The noninferiority margin was set at 2% and confirmed with a lower limit of two-sided 95% CI for the intergroup difference of 1.58% in the full analysis set and 1.34% in the per-protocol set. There were no significant differences between the groups in left ventricular systolic and diastolic function and myocardial work indices. Postoperative vasoactive-inotropic score, NT-proBNP, duration of mechanical ventilation, and the length of stay in the cardiac intensive care unit and hospital were also comparable between the two groups (all p > 0.05).

CONCLUSIONS

Ciprofol did not show different effects on myocardial function and postoperative outcomes from propofol. Further, on the sensitive cardiac systole marker global longitudinal strain, ciprofol demonstrated noninferiority to propofol. Ciprofol might be an alternative solution for cardiac anesthesia in children with congestive heart disease with mild lesion.

Takotsubo syndrome induced by severe hyponatraemia in mineralocorticoid-responsive hyponatraemia of the elderly: a case report

Background

There are limited reports on mineralocorticoid-responsive hyponatraemia of the elderly (MRHE), a condition that can cause severe hyponatraemia.

Case summary

An 85-year-old woman presented with transient loss of consciousness and nausea likely due to untreated severe hyponatraemia (114 mEq/L). Thirty-nine hours after initial admission, she developed sudden cardiac dysfunction and entered a circulatory collapse state. The patient was diagnosed with Takotsubo syndrome. Her hyponatraemia was an essential feature of syndrome of inappropriate antidiuretic hormone secretion. However, she was clinically hypovolaemic. Therefore, the hyponatraemia was diagnosed as MRHE. The serum sodium level was corrected with 3% hypertonic saline administered at a rate of 10 mL per hour, with careful monitoring to avoid overly rapid correction and prevent osmotic demyelination. After 14 days, her serum sodium level, electrocardiogram findings, and cardiac contractions on echocardiography improved.

Discussion

To our knowledge, this is the first documented case of Takotsubo syndrome induced by severe hyponatraemia resulting from MRHE. The present report shows that acute cardiomyopathy can develop when severe hyponatraemia is not treated within several hours and at least a day. Since patients with MRHE are hypovolaemia statement, avoidance of diuretic drugs and water restriction for the treatment of hyponatraemia should be carefully considered, especially if they have acute cardiac dysfunction. This report highlights the need for prompt management of severe hyponatraemia in elderly patients and calls for further research on MRHE treatment protocols and its link to cardiomyopathy.

Heart failure biomarkers and prediction of early left ventricle remodeling after acute coronary syndromes

INTRODUCTION

Several biomarkers are characteristically elevated in patients with acute heart failure (AHF). Our hypothesis was they could predict early changes in left ventricular (LV) characteristics in acute coronary syndrome (ACS) patients. The objective of this study was two-fold: a) compare circulating concentrations of NT-pro BNP, CA-125, ST2, galectin-3 and pro-adrenomedullin among 4 groups of individuals (healthy controls; patients with ACS without AHF; patients with ACS and AHF and patients admitted for AHF); and b) evaluate whether these biomarkers predict adverse LV remodeling and ejection fraction changes in ACS.

METHODS

6 biomarkers (NT-pro BNP, CA-125, ST2, galectin-3, pro-adrenomedullin and C-reactive) were measured within the first 48 h of admission. Echocardiograms were performed during admission and at 3 months. Variables associated with LV end-diastolic volume (EDV) and ejection fraction (LVEF) change were assessed by multivariate linear regression.

RESULTS

We analyzed 51 patients with ACS, 16 with AHF and, 20 healthy controls. NT-pro BNP and ST2 concentrations were elevated at similar values in patients admitted for AHF and ACS complicated with HF but CA-125 concentrations were higher in AHF patients. NT-pro BNP concentrations were positively correlated with CA-125 (rho = 0.58; p < 0.001), ST2 (rho = 0.58; p < 0.001) and galectin-3 (rho = 0.37; p < 0.001) Median change (median days was 83 days after) in EDV and LVEF was 5 %. CA-125 concentrations were positively associated to LV EDV change (β-coefficient 1.56) and negatively with LVEF trend (β-coefficient = -0.86). No other biomarker predicted changes in EDV or LVEF.

CONCLUSIONS

CA-125 correlates with early LV remodeling and LVEF deterioration in ACS patients.

Long-term cognitive and brain morphologic changes in chronic heart failure: Results of the Cognition.Matters-HF study

AIMS

Cognitive impairment (CI) is a common, yet frequently unrecognized co-morbidity in chronic heart failure (HF). We quantified trajectories of cognitive performance, brain volume, and related clinical outcome over a time course of 6 years.

METHODS AND RESULTS

The Cognition.Matters-HF cohort study recruited patients with stable HF of any aetiology and severity. Beyond cardiological assessment, the workup included cognitive testing and brain magnetic resonance imaging (MRI). Of 148 recruited patients, 70% exhibited CI at baseline. During the median follow-up time of 69 months (quartiles: 68, 70), indicators of HF severity remained essentially unaltered. CI was also stable, with the exception of intensity of attention, where age-adjusted t-scores decreased from 42 (38, 46) to 38 (34, 44; P < 0.001). Complete sets of four serial brain MRI scans were available in 47 patients (32% of total sample). Total brain volume shrank by 0.4% per year, from 1103 (1060, 1143) cm3 to 1078 (1027, 1117) cm3, which was within limits observed in non-diseased ageing individuals. During follow-up, 29 study participants (20%) died, and 26 (18%) were at least once hospitalized due to worsening HF. The presence of CI was not associated with overall (P = 0.290) or hospitalization-free (P = 0.450) survival.

CONCLUSIONS

In patients with stable HF patients receiving guideline-directed pharmacologic treatment and regular medical care, the presence of CI did not affect overall and hospitalization-free 6-year survival. The loss of brain parenchyma observed in patients with stable HF did not exceed that of normal ageing.

Impact of Chronic Consumption of Herbal Rooibos on Cardiovascular Function in Adults with Cardiovascular Risk

The prevalence of cardiovascular disease (CVD) has increased in South Africa, emphasizing the importance of prevention strategies. This study used echocardiography to investigate the impact of Rooibos on cardiovascular function in those at risk of CVD. This research aims to contribute to understanding its effects on reducing cardiovascular risk factors. The study design involved a 12-week randomized, parallel, double-blinded, placebo-controlled dietary intervention trial using capsules containing standardized water-soluble extracts of green and traditional fermented Rooibos alongside a placebo control. Echocardiography was incorporated as a diagnostic imaging tool to assess cardiac function in the participant cohort. Aorta (AO) dimensions showed no significant change in any intervention group. Left atrium (LA) reduced in size from 3.832 ± 0.071 cm to 3.675 ± 0.067 cm (P = 0.01). There was no significant change in LA/AO ratio in any intervention group. Interventricular septum diameter in the placebo group decreased from 1.334 ± 0.030 cm to 1.250 ± 0.025 cm (P = 0.002), with no significance in fermented Rooibos, while green Rooibos resulted in a decrease from 1.282 ± 0.036 cm to 1.186 ± 0.029 cm (P = 0.002). Left ventricle posterior wall (LVPW) showed no significant changes in any of the intervention group. The left ventricle mass in the placebo and green Rooibos groups demonstrated no significance changes, while fermented Rooibos caused a decrease from 204.102 ± 7.102 g to 191.394 ± 6.707 g (P = 0.015). The phytochemical bioactive components, such as the polyphenolic antioxidants present in green and fermented Rooibos, improved cardiovascular function. This study confirms the effectiveness of echocardiography as imaging tool for assessing cardiac function in this particular population. Regular Rooibos consumption may offer promising therapeutic benefits for preventing and managing CVD risk.

Reappraisal of the Concept and Implications of Pulmonary Hypertension in Degenerative Mitral Regurgitation

BACKGROUND

European and U.S. clinical guidelines diverge regarding pulmonary hypertension (PHTN) in degenerative mitral regurgitation (DMR). Gaps in knowledge underpinning these divergences affect risk assessment and management recommendations attached to systolic pulmonary pressure (SPAP) in DMR.

OBJECTIVES

This study sought to define PHTN links to DMR severity, prognostic thresholds, and independent outcome impact in a large quantitative DMR registry.

METHODS

This study gathered a large multicentric registry of consecutive patients with isolated moderate-to-severe DMR, with DMR and SPAP quantified prospectively at diagnosis.

RESULTS

In 3,712 patients (age 67 ± 15 years, 36% women) with ≥ moderate-to-severe DMR, effective regurgitant orifice (ERO) was 0.42 ± 0.19 cm2, regurgitant volume 66 ± 327 mL/beat and SPAP 41 ± 16 mm Hg. Spline-curve analysis showed excess mortality under medical management emerging around SPAP 35 mm Hg and doubling around SPAP 50 mm Hg. Accordingly, severe pulmonary hypertension (sPHTN) (SPAP ≥50 mm Hg) was detected in 916 patients, moderate pulmonary hypertension (mPHTN) (SPAP 35-49 mm Hg) in 1,128, and no-PHTN (SPAP <35 mm Hg) in 1,668. Whereas SPAP was strongly associated with DMR-ERO, nevertheless excess mortality with sPHTN (adjusted HR: 1.65; 95% CI: 1.24-2.20) and mPHTN (adjusted HR: 1.44; 95% CI: 1.11-1.85; both P ≤ 0.005) was observed independently of ERO and all baseline characteristics and in all patient subsets. Nested models demonstrated incremental prognostic value of mPHTN and sPHTN (all P < 0.0001). Despite higher operative risk with mPHTN and sPHTN, DMR surgical correction was followed by higher survival in all PHTN ranges with strong survival benefit of early surgery (<3 months). Postoperatively, excess mortality was abolished (P ≥ 0.30) in mPHTN, but only abated in sPHTN.

CONCLUSIONS

This large international registry, with prospectively quantified DMR and SPAP, demonstrates a Doppler-defined PHTN impact on mortality, independent of DMR severity. Crucially, it defines objectively the new and frequent mPHTN range, independently linked to excess mortality under medical management, which is abolished by DMR correction. Thus, at DMR diagnosis, Doppler-SPAP measurement defining these new PHTN ranges, is crucial to guiding DMR management.

A heart failure program in low-income patients in Argentina (COMM-HF)

Objective

In low- and middle-income countries, heart failure (HF) is the leading cause of death and disability.

Materials and methods

A feasibility study was conducted to assess the fidelity, reach, and adoption of an educational program led by non-medical staff to improve outpatient care for patients hospitalized with HF in the local public health system.

Results

Thirty patients were included, with a mean age of 55.3 years (63.3% male). A total of 97.3% of planned home visits and 90% of scheduled phone calls were completed. Counselling modules were delivered during 90.4% of home visits, with no significant challenges reported during implementation. At the end of follow-up, there was a trend towards improved lifestyle habits, a reduction in mean heart rate (78.0 to 68.3 beats per minute; p = 0.016), a decrease in the proportion of patients in NYHA functional class III (20% to 7.4%; p = 0.041), and a slight reduction in mean body mass index (29.5 vs. 28.9; p = 0.042).

Conclusions

A home-based educational program, designed to optimize outpatient management of heart failure and led by non-medical healthcare personnel, was well-received and demonstrated feasibility for implementation in low-income patients relying solely on the Argentine public health system.

NT-proBNP levels in patients with primary hyperaldosteronism and autonomous cortisol cosecretion

CONTEXT

Patients with primary aldosteronism (PA) have higher cardiac comorbidities including more pronounced left ventricular hypertrophy than patients with essential hypertension.

OBJECTIVE

Autonomous cortisol cosecretion (ACS) is a common subtype in PA associated with a worse metabolic profile.

HYPOTHESIS

Autonomous cortisol cosecretion may affect myocardial parameters and result in a worse cardiac outcome compared to patients with PA and without ACS.

METHODS

Three hundred and sixty-seven patients with PA undergoing 1 mg dexamethasone suppression test (DST) and echocardiography at baseline from 2 centers of the German Conn's Registry were included. Follow-up for up to 3.8 years was available in 192 patients.

RESULTS

Patients with PA and ACS had higher NT-proBNP levels at baseline compared to patients with PA without ACS (114 vs 75.6 pg/mL, P = .02), but showed no difference in echocardiography values. NT-proBNP levels showed a significant positive correlation (r = 0.141, P = .011) with cortisol levels after DST at baseline. In response to therapy of PA, NT-proBNP levels decreased, but remained significantly higher in patients with ACS compared to patients without ACS. At follow-up, left ventricle end-diastolic dimension (LVEDD) decreased significantly only in patients without ACS. Left atrial diameter (LAD) decreased significantly in patients without ACS and in female patients with ACS but not in male patients. Left ventricular mass index (LVMI) significantly improved in female patients without ACS but remained unchanged in female patients with ACS as well as in male patients at follow-up.

CONCLUSIONS

In patients with PA, concomitant ACS is associated with a worse cardiac profile and only partial recovery even years after initiation of targeted PA therapy.

Impact of epicardial fat on coronary vascular function, cardiac morphology, and cardiac function in women with suspected INOCA

AIMS

Epicardial fat is a metabolically active adipose tissue depot situated between the myocardium and visceral pericardium that covers ∼80% of the heart surface. While epicardial fat has been associated with the development of atherosclerotic coronary artery disease, less is known about the relationship between epicardial fat and coronary vascular function. Moreover, the relations between excess epicardial fat and cardiac morphology and function remain incompletely understood.

METHODS AND RESULTS

To address these knowledge gaps, we retrospectively analysed data from 294 individuals from our database of women with suspected ischaemia with no obstructive coronary disease (INOCA) who underwent both invasive coronary function testing and cardiac magnetic resonance imaging. Epicardial fat area, biventricular morphology, and function, as well as left atrial function, were assessed from cine images, per established protocols. The major novel findings were two-fold: first, epicardial fat area was not associated with coronary vascular dysfunction. Secondly, epicardial fat was associated with increased left ventricular concentricity (β = 0.15, P = 0.01), increased septal thickness (β = 0.17, P = 0.002), and reduced left atrial conduit fraction (β = -0.15, P = 0.02), even after accounting for age, BMI, and history of hypertension.

CONCLUSION

Taken together, these data do not support a measurable relationship between epicardial fat and coronary vascular dysfunction but do suggest that epicardial fat may be related to concentric remodelling and diastolic dysfunction in women with suspected INOCA. Prospective studies are needed to elucidate the long-term impact of epicardial fat in this patient population.

Blood Urea Nitrogen to Left Ventricular Ejection Ratio as a Predictor of Short-Term Outcome in Acute Myocardial Infarction Complicated by Cardiogenic Shock

INTRODUCTION

Cardiogenic shock (CS) is the most critical complication after acute myocardial infarction (AMI) with mortality above 50%. Both blood urea nitrogen and left ventricular ejection fraction were important prognostic indicators. We aimed to evaluate the prognostic value of admission blood urea nitrogen to left ventricular ejection fraction ratio (BUNLVEFr) in patients with AMI complicated by CS (AMI-CS).

METHODS

268 consecutive patients with AMI-CS were divided into two groups according to the admission BUNLVEFr cut-off value determined by Youden index. The primary endpoint was 30-day all-cause mortality and the secondary endpoint was the composite events of major adverse cardiovascular events (MACEs). Cox proportional hazard models were performed to analyze the association of BUNLVEFr with the outcome.

RESULTS

The optimal cut-off value of BUNLVEFr is 16.63. The 30-day all-cause mortality and MACEs in patients with BUNLVEFr≥16.63 was significantly higher than in patients with BUNLVEFr<16.63 (30-day all-cause mortality: 66.2% vs. 17.1%, p < 0.001; 30-day MACEs: 80.0% vs. 48.0%, p < 0.001). After multivariable adjustment, BUNLVEFr≥16.63 remained an independent predictor for higher risk of 30-day all-cause mortality (HR = 3.553, 95% CI: 2.125-5.941, p < 0.001) and MACEs (HR = 2.026, 95% CI: 1.456-2.820, p < 0.001). Subgroup analyses found that the effect of BUNLVEFr was consistent in different subgroups (all p-interaction>0.05).

CONCLUSION

The admission BUNLVEFr provided important prognostic information for AMI-CS patients.

Family History of Hypertension and Echocardiographic Left Ventricular Hypertrophy in Hypertensive Nigerians

Introduction

Studies on the relationship between a family history of hypertension and left ventricular hypertrophy are sparse. We evaluated this relationship in patients with essential hypertension.

Methods

A total of 1668 patients with essential hypertension were consecutively enrolled in the prospective Federal Medical Centre Abuja Hypertension Registry. First-degree family history was defined by the presence of a known history of hypertension in any or both parents, siblings, and children. Echocardiographic left ventricular hypertrophy was diagnosed using the criteria of the American Society of Echocardiography and the European Association of Cardiovascular Imaging.

Results

The prevalence of a family history of hypertension, echocardiographic, and electrocardiographic left ventricular hypertrophy were 61.7%, 46.8%, and 30.8%, respectively. After multivariable adjustment, paternal history of hypertension [OR: 1.56, CI: 1.20-2.05, p=0.001] was associated with an increased risk of echocardiographic left ventricular hypertrophy, while maternal history of hypertension [OR: 0.72, CI 0.58-0.91, p=0.006] was associated with a reduced risk. Age ≥50 years (p=0.026), duration of hypertension ≥1 year (p=0.047), and heart failure (p < 0.001) were associated with an increased risk of left ventricular hypertrophy, while male sex (p < 0.001) was associated with a reduced risk.

Conclusion

Our study showed that a paternal history of hypertension is associated with an increased left ventricular hypertrophy risk among patients with essential hypertension, while maternal history is protective.

Clinical Features of Tachycardia-induced Cardiomyopathy in Patients with Atrial Fibrillation

Objective Atrial fibrillation (AF) is the most common cause of tachycardia-induced cardiomyopathy (TIC). However, which patients with AF are prone to developing TIC remains unclear. In this study, we investigated the clinical features of AF patients with TIC. Methods This single-center study included 722 patients with AF (average age, 63.1±10.2 years old; 191 women) who underwent radiofrequency catheter ablation. We defined TIC as an initial left ventricular ejection fraction (LVEF) of <40% and a >20% recovery of the LVEF after successful AF ablation and compared the clinical characteristics between the TIC and control groups. Results The proportions of type 2 diabetes (30.5% vs. 14.7%), renal dysfunction (34.2% vs. 23.8%), hypertension (67.1% vs. 54.8%), and persistent AF (62.2% vs. 32.2%) were significantly higher in the TIC group (n=82) than in the control group (n=640). The atrioventricular nodal effective refractory period (AVNERP) (303±72 ms vs. 332±86 ms; p=0.017) was significantly shorter in the TIC group than in the control group. A multivariable analysis found that persistent AF [odds ratio (OR), 3.19; 95% confidence interval (CI), 1.94-5.24], renal dysfunction (OR, 1.87; 95% CI, 1.06-3.32), and type 2 diabetes (OR, 2.30; 95% CI, 1.31-4.05) were significantly associated with TIC. Conclusion Comorbid renal dysfunction and type 2 diabetes were clinical features of AF patients with TIC. Persistent AF, and short AVNERP may be involved in the development of TIC.

Correlation of aortic root dimensions and mortality in acute heart failure: A nationwide prospective cohort study

Background

An association between increased aortic root dimensions (ARD) and elevated risk of cardiovascular mortality has been reported in the general population. However, evidence regarding the association between ARD and mortality in patients with acute heart failure (AHF) is limited.

Methods

In a nationwide prospective cohort of the China Patient-Centered Evaluative Assessment of Cardiac Events Prospective Heart Failure Study, ARD was measured during diastole using echocardiography and indexed to body mass index (BMI). Cox proportional hazard models were used to validate the association between BMI-indexed ARD and mortality. Additionally, the relationship between BMI-indexed ARD and mortality was presented using restricted cubic spline in all populations, and both sexes.

Results

A total of 2125 participants with ARD were included in the final analysis, among of 38.4 % were women, with a median age of 67 years. Over a median follow-up period of 54.4 (interquartile range: 30.1 to 59.7) months, 895 deaths occurred, with 750 attributed to cardiovascular causes and 145 to non-cardiovascular causes. Compared to the highest tertile group of BMI-indexed ARD, the lowest tertile group had a lower risk of cardiovascular mortality (hazard ratio [HR], 0.71; 95 % confidence interval [CI], 0.58 to 0.87; P < 0.001) and all-cause mortality (HR, 0.68; 95 % CI, 0.56 to 0.81; P < 0.001). Similarly, the middle tertile group also had a lower risk of cardiovascular mortality (HR, 0.78; 95 % CI, 0.65 to 0.93; P = 0.007) and all-cause mortality (HR, 0.75; 95 % CI, 0.63 to 0.89; P < 0.001). Considering the competing risks, the lowest BMI-indexed ARD groups showed a significant mortality risk of cardiovascular mortality in all populations, and both sexes. Moreover, the relationship between BMI-indexed ARD and mortality was linear in males, while a "J" shaped relationship was observed in females.

Conclusion

Lower BMI-indexed ARD was associated with a decreased risk of all-cause and cardiovascular mortality than those with higher BMI-indexed ARD in AHF. Additionally, a discrepancy was observed between the sexes in the relationship between BMI-indexed ARD and mortality. These findings contribute to the prompt identification of potential mortality risks in patients with AHF.

The Role of Cardiovascular Imaging in the Diagnosis of Athlete's Heart: Navigating the Shades of Grey

Athlete's heart (AH) represents the heart's remarkable ability to adapt structurally and functionally to prolonged and intensive athletic training. Characterized by increased left ventricular (LV) wall thickness, enlarged cardiac chambers, and augmented cardiac mass, AH typically maintains or enhances systolic and diastolic functions. Despite the positive health implications, these adaptations can obscure the difference between benign physiological changes and early manifestations of cardiac pathologies such as dilated cardiomyopathy (DCM), hypertrophic cardiomyopathy (HCM), and arrhythmogenic cardiomyopathy (ACM). This article reviews the imaging characteristics of AH across various modalities, emphasizing echocardiography, cardiac magnetic resonance (CMR), and cardiac computed tomography as primary tools for evaluating cardiac function and distinguishing physiological adaptations from pathological conditions. The findings highlight the need for precise diagnostic criteria and advanced imaging techniques to ensure accurate differentiation, preventing misdiagnosis and its associated risks, such as sudden cardiac death (SCD). Understanding these adaptations and employing the appropriate imaging methods are crucial for athletes' effective management and health optimization.

Serial Changes in Ventricular Strain in Symptomatic Obstructive Hypertrophic Cardiomyopathy Treated With Mavacamten: Insights From the VALOR-HCM Trial

BACKGROUND

In severely symptomatic patients with obstructive hypertrophic cardiomyopathy, VALOR-HCM (A Study to Evaluate Mavacamten in Adults With Symptomatic Obstructive Hypertrophic Cardiomyopathy Who Are Eligible for Septal Reduction Therapy) demonstrated that mavacamten reduces the need for septal reduction therapy with sustained improvement in left ventricular (LV) outflow tract gradients and symptoms. Global longitudinal strain (GLS), a measure of regional myocardial function, is a more sensitive marker of systolic function. In VALOR-HCM, we assessed serial changes in LV and right ventricular (RV) strain.

METHODS

VALOR-HCM included 112 patients with symptomatic obstructive hypertrophic cardiomyopathy (mean, 60 years; 51% male; LV ejection fraction, 68%). Patients assigned to mavacamten at baseline continued the drug for 56 weeks (n=56) and those assigned to placebo (n=52) transitioned to mavacamten from weeks 16 to 56 (40-week exposure). LV-GLS and RV-GLS assessment was performed using a vendor-neutral software. Non-foreshortened apical (4-, 3-, and 2-chamber) views were used to obtain peak LV-GLS. RV focused 4-chamber view was used to calculate RV 4-chamber and free wall strain. A more negative strain value is favorable.

RESULTS

At baseline, the mean LV-GLS, RV 4-chamber, and free wall strain values were -14.7%, -22.2%, and -16.8%, respectively (all worse than reported normal means). In the total study sample, LV-GLS significantly improved from baseline to week 56 (P=0.02). Twelve patients had transient reduction in LV ejection fraction (<50%) requiring temporary drug interruption (including 3 permanent discontinuations). The LV-GLS in this subgroup was worse at baseline versus total study population (-11.4%), with no significant worsening from baseline through week 56 (P=0.64). Both free wall and 4-chamber RV-GLS remained unchanged from baseline to week 56 (P=0.62 and P=0.56, respectively).

CONCLUSIONS

In VALOR-HCM, treatment with mavacamten improved LV-GLS from baseline through week 56 (with no significant worsening of LV-GLS in patients with a reduction in LV ejection fraction ≤50%), suggesting a favorable long-term impact on regional LV systolic function. Additionally, there was no detrimental impact on RV systolic function.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT04349072.

Structural phenotyping in atrial fibrillation with combined cardiac CT and atrial MRI: Identifying and differentiating individual structural remodelling types in AF

INTRODUCTION

Atrial remodelling (AR) is the persistent change in atrial structure and/or function and contributes to the initiation, maintenance and progression of atrial fibrillation (AF) in a reciprocal self-perpetuating relationship. Left atrial (LA) size, geometry, fibrosis, wall thickness (LAWT) and ejection fraction (LAEF) have all been shown to vary with pathological atrial remodelling. The association of these global remodelling markers with each other for differentiating structural phenotypes in AF is not well investigated.

METHOD

Patients referred for first-time AF ablation and controls without AF were prospectively recruited to undergo cardiac computed tomographic angiography (CCTA) and magnetic resonance imaging (MRI) with 3D atrial late-gadolinium enhanced (LGE) sequences. LAWT, atrial myocardial mass, LA volume and sphericity were calculated from CT. Biplane LA EF and LA fibrosis burden were derived from atrial MRI. Results were compared between patients with AF and controls.

RESULTS

Forty two AF patients (64.3% male, age 64.6 ± 10.2 years, CHA2DS2-VASc 2.48 ± 1.5, 69.0% paroxysmal AF, 31% persistent AF, LVEF 57.9 ± 10.5%) and 37 controls (64.9% male, age 56.6 ± 7.2, CHA2DS2-VASc 1.54 ± 1.1, LVEF 60.4 ± 4.9%) were recruited. Patients with AF had a significantly higher LAWT (1.45 ± 0.52 mm vs 1.12 ± 0.42 mm, p = 0.003), tissue mass (15.81 ± 6.53 g vs. 12.18 ± 5.01 g, p = 0.011), fibrosis burden (9.33 ± 8.35% vs 2.41 ± 3.60%, p = 0.013), left atrial size/volume (95.68 ± 26.63 mL vs 81.22 ± 20.64 mL, p = 0.011) and lower LAEF (50.3 ± 15.3% vs 65.2 ± 8.6%, p < 0.001) compared to controls. There was no significant correlation between % fibrosis with LAWT (p = 0.29), mass (p = 0.89), volume (p = 0.49) or sphericity (p = 0.79). LAWT had a statistically significant weak positive correlation with LA volume (r = 0.25, p = .041), but not with sphericity (p = 0.86). LAEF had a statistically significant but weak negative correlation with fibrosis (r = -0.33, p = 0.008) and LAWT (r = -0.24, p = 0.07).

CONCLUSION

AF is associated with significant quantifiable structural changes that are evident in LA size, tissue thickness, total LA tissue mass and fibrosis. These individual remodelling markers do not or only weakly correlate with each other suggesting different remodelling subtypes exist (e.g. fibrotic vs hypertrophic vs dilated). If confirmed, such a detailed understanding of the structural changes observed has the potential to inform clinical management strategies targeting individual mechanisms underlying the disease process.

Patent Foramen Ovale and Other Cardiopathies as Causes of Embolic Stroke With Unknown Source

In patients with stroke caused by cardiac embolism, the responsible heart diseases include atrial fibrillation, acute myocardial infarction, sick sinus syndrome, valvular disease, and significant heart failure. When there is no clear source of the embolism, the condition is referred to as "embolic stroke with unknown source (ESUS)." Recent studies have shown that the most common cause of ESUS is a right-to-left cardiac shunt through a patent foramen ovale (PFO). However, considering that PFOs are found in up to 25% of the general population, their presence does not necessarily indicate causality. In patients with ESUS associated with a PFO, either anticoagulants or antiplatelets are used for the prevention of future strokes or transient ischemic attacks. However, it currently remains unclear which treatment is superior. Nevertheless, recent randomized clinical trials have shown that percutaneous closure of the PFO more effectively reduces the incidence of recurrent strokes compared to medical therapy alone in patients with PFO-related strokes. This benefit is especially significant when the PFO carries high-risk features, such as a large shunt or the presence of an atrial septal aneurysm. Furthermore, the effectiveness of PFO closure has been well documented in young patients (<60 years) with a high-risk PFO development. In other cases, the therapeutic decision should be made through discussion among neurologists, cardiologists, and patients. Notably, in ESUS patients without a PFO, the underlying heart condition itself may be the source of embolism, with left atrial enlargement being the most important factor. Theoretically, anticoagulants such as non-vitamin K antagonist oral anticoagulants (NOACs) would be an effective therapy in these cases. However, recent trials have failed to show that NOACs are superior to antiplatelets in preventing further strokes in these patients. This may be due to the still uncertain definition of emboligenic cardiopathy and the presence of other potential embolic sources, such as mild but emboligenic arterial diseases. Overall, further research is needed to elucidate the source of embolism and to determine an effective management strategy for patients with ESUS.

Cardiac Damage in Early Aortic Stenosis: Is the Valve to Blame?

BACKGROUND

Despite the close association between aortic stenosis (AS) and cardiac damage (CD), it is unclear if CD is limited to patients with moderate and severe AS and which factors affect its progression. Although altered valvular hemodynamic status may drive the development of CD in AS, commonly occurring comorbidities may contribute.

OBJECTIVES

The aim of this study was to determine the prevalence of and factors associated with CD in mild AS.

METHODS

This retrospective study included 9,611 patients with mild AS (peak aortic valve velocity [Vmax] 2-3 m/s and description of abnormal aortic valve) from 2010 through 2021. CD was staged using the Genereux classification.

RESULTS

All but 20% (n = 1,901; stage 0) of patients with mild AS demonstrated CD: 1,613 (17%) stage 1, 4,843 (50%) stage 2, 891 (9%) stage 3, and 363 (4%) stage 4. Patients with higher stages had more comorbidities (hypertension, heart failure, ischemic heart disease, stroke, peripheral arterial disease, chronic kidney disease, chronic pulmonary disease, and diabetes mellitus) but had valvular hemodynamic status similar to those without CD. CD stage did not worsen with higher Vmax range (stage >1 in 64% with Vmax <2.5 m/s vs 61% with Vmax ≥2.5 m/s) but increased with the number of comorbidities, with stage >1 occurring in 50%, 53%, 60%, 66%, 72%, and 73% in the presence of 0, 1, 2, 3, 4, and 5 or more comorbidities, respectively.

CONCLUSIONS

CD was highly prevalent in patients with mild AS. Among patients with mild AS, there was no relationship between the degree of CD and AS severity; instead, CD was highly associated with comorbidities.

Diflunisal versus tafamidis on neuropathy and cardiomyopathy in hereditary transthyretin amyloidosis

OBJECTIVES

Hereditary transthyretin (TTR) amyloidosis (ATTRv) is frequently complicated by polyneuropathy (ATTRv-PN) and cardiomyopathy (ATTRv-CM). The long-term efficacy of diflunisal on both polyneuropathy and cardiomyopathy in ATTRv patients, especially those with non-V30M genotypes, has not been fully investigated and compared with that of tafamidis.

METHODS

We compared the structural and biochemical characteristics of A97S-TTR complexed with tafamidis with those of diflunisal, and prospectively followed up and compared the progression of polyneuropathy and cardiomyopathy between ATTRv-PN patients taking diflunisal and those taking tafamidis.

RESULTS

Both diflunisal and tafamidis effectively bind to the two thyroxine-binding sites at the A97S-TTR dimer-dimer interface and equally and almost sufficiently reduce amyloid fibril formation. Thirty-five ATTRv-PN patients receiving diflunisal and 22 patients receiving tafamidis were enrolled. Compared with no treatment, diflunisal treatment significantly delayed the transition of FAP Stage 1 to 2 and Stage 2 to 3 and decreased the deterioration in parameters of the ulnar nerve conduction study (NCS). The progression of FAP stage or NCS parameters did not differ between patients treated with diflunisal and those treated with tafamidis. Both diflunisal and tafamidis treatments significantly decreased radiotracer uptake on 99mTc-PYP SPECT and stabilized cardiac wall thickness and blood pro-B-type natriuretic peptide levels. No significant adverse events occurred during diflunisal or tafamidis treatment.

INTERPRETATIONS

The binding patterns of both tafamidis and diflunisal to A97S-TTR closely resembled those observed in the wild type. Diflunisal can effectively delay the progression of polyneuropathy and cardiomyopathy with similar efficacy to tafamidis and may become a cost-effective alternative treatment for late-onset ATTRv-PN.