Low-grade inflammation and hypoadiponectinaemia have an additive detrimental effect on aortic stiffness in essential hypertensive patients

AIMS

In this study, we investigated the combined effect of increased high-sensitivity C-reactive protein (hs-C-reactive protein) and hypoadiponectinaemia on aortic stiffness in essential hypertensive subjects.

METHODS AND RESULTS

A total of 267 untreated patients with stage I-II essential hypertension underwent ambulatory BP and carotid-femoral pulse wave velocity (c-f PWV) evaluation. The distributions of hs-C-reactive protein and adiponectin were split by the median (1.3 mg/L and 7.8 microg/mL, respectively) and accordingly subjects were stratified into those with high and low values. Patients with high (n = 134) compared with those with low hs-C-reactive protein (n = 133) values exhibited greater c-f PWV levels (by 0.8 m/s, P < 0.0001), whereas patients with low (n = 133) compared with those with high (n = 134) adiponectin levels had higher c-f PWV (by 0.9 m/s, P < 0.0001). Stepwise regression analysis revealed that age, 24 h systolic BP, hs-C-reactive protein and adiponectin were independent predictors of arterial stiffness. In patients with low hs-C-reactive protein, hypoadiponectinaemia (n = 46) compared with high adiponectin (n = 87) was accompanied by increased c-f PWV (by 0.8 m/s, P < 0.0001). Similarly in patients with high hs-C-reactive protein, hypoadiponectinaemia (n = 84) compared with high adiponectin (n = 50) was related to heightened c-f PWV (by 0.7 m/s, P = 0.008).

CONCLUSION

In essential hypertension, pronounced low-grade inflammation in conjunction with hypoadiponectinaemia exerts an additive detrimental effect on aortic stiffness, accelerating the vascular ageing process.

Nosocomial vs. community-acquired infective endocarditis in Greece: changing epidemiological profile and mortality risk

Current epidemiological trends of infective endocarditis (IE) in Greece were investigated via a prospective cohort study of all cases of IE that fulfilled the Duke criteria during 2000-2004 in 14 tertiary and six general hospitals in the metropolitan area of Athens. Demographics, clinical data and outcome were compared for nosocomial IE (NIE) and community-acquired IE (CIE). NIE accounted for 42 (21.5%) and CIE for 153 (78.5%) of 195 cases. Intravenous drug use was associated exclusively with CIE, while co-morbidities (cardiovascular disease, diabetes mellitus, chronic renal failure requiring haemodialysis and malignancies) were more frequent in the NIE group (p <0.05). Prosthetic valve endocarditis (PVE) predominated in the NIE group (p 0.006), and >50% of NIE cases had a history of vascular intervention. Coagulase-negative staphylococci and enterococci were more frequent in cases of NIE than in cases of CIE (26.2% vs. 5.2%, p <0.01, and 30.9% vs. 16.3%, p 0.05, respectively). Enterococci accounted for 19.5% of total IE cases and were the leading cause of NIE. Staphylococcus aureus IE was hospital-acquired in only 11.9% of cases. In-hospital mortality was higher for NIE than for CIE (39.5% vs. 18.6%, p 0.02). Cardiac failure (New York Heart Association grade III-IV; OR 13.3, 95% CI 4.9-36.1, p <0.001) and prosthetic valve endocarditis (OR 3.7, 95% CI 1.3-10.6, p 0.01) were the most important predictors of mortality.

The interplay between haemodynamic load, brain natriuretic peptide and left atrial size in the early stages of essential hypertension

OBJECTIVE

Left atrial (LA) enlargement is an index of adverse cardiovascular events. We sought to investigate any possible correlation between haemodynamic load, neurohumoral factors and LA size in the early stages of essential hypertension.

METHODS

We studied 94 consecutive middle-aged subjects, with newly diagnosed stage I-II essential hypertension without left ventricular (LV) hypertrophy and 34 age and sex-matched normotensive individuals. Ambulatory blood pressure (BP) monitoring, plasma levels of brain natriuretic peptide (BNP), metabolic profile and left atrial volume index (LAVI), an echocardiographic measurement of LA volume indexed for the body surface area, constituted the work-up of all subjects.

RESULTS

Hypertensive compared with normotensive subjects had significantly increased office and ambulatory systolic and diastolic BP (P < 0.0001 for all cases) as well as body mass index and waist-to-hip ratio (P < 0.05 for both cases). BNP levels were greater in hypertensive compared with normotensive subjects but were not statistically significant (20.4 versus 17.1 pg/ml, P = NS). Hypertensive compared with normotensive subjects also had significantly increased LV mass index (105 versus 84 g/m, P < 0.0001), LA diameter (39 versus 36 mm, P < 0.0001), and LAVI (22 versus 19 ml/m, P < 0.05). In the hypertensive population, LAVI exhibited significant positive relationships with office systolic BP, ambulatory pulse pressure, LV mass index and BNP. In multiple linear regression analysis only LV mass index and BNP were significantly associated with LAVI (beta = 0.298, P = 0.030 and beta = 0.322, P = 0.009, respectively).

CONCLUSIONS

Increased LAVI, closely associated with LV mass index and BNP, was still found in the early stages of essential hypertension. However, the clinical significance of these findings remains to be elucidated in future studies.

Structural and functional characterization of a novel biosurfactant from Bacillus sp. IITD106

Plant saponins are attractive biosurfactants and have been used to enhance phytoremediation. There are only limited reports on saponins produced by bacteria. Here, we report structural and functional characterization of a novel saponin produced by Bacillus sp. IITD106. Biosurfactant production was determined by emulsion index, drop collapse, oil displacement and hemolytic assays. The biosurfactant was stable over a range of temperature (30 °C to 70 °C), salinity (0-150 g liter^-1) and pH (4-10). The surface tension of the medium reduced from 58.89 mN/m to 27.29 mN/m using the isolated biosurfactant. Chromatographic analysis revealed the biosurfactant to be a glycolipid. LCMS, FT-IR and NMR analysis identified the biosurfactant to be a saponin containing two sugar groups and a 5 ringed triterpene sapogenin unit. Genome sequencing of the strain revealed the presence of genes responsible for biosynthesis of saponin. Statistical optimization of culture medium resulted in 9.3-fold increase in biosurfactant production. Kinetics study of biosurfactant production performed in a stirred tank batch bioreactor resulted in 6.04 g liter^-1 and 6.9 g liter^-1 biomass and biosurfactant concentration, respectively. The biosurfactant was found to solubilize polycyclic aromatic hydrocarbons. The potential of cell free biosurfactant containing broth to enhance oil recovery was tested in a sand pack column and recovery of 63% of residual oil was observed. To our knowledge this is the first report of saponin production by any of the strains of Bacillus.

Programmed ventricular stimulation predicts arrhythmic events and survival in hypertrophic cardiomyopathy

BACKGROUND

Sudden cardiac death (SCD) risk stratification in hypertrophic cardiomyopathy (HCM) in the context of primary prevention remains suboptimal. The purpose of this study was to examine the additional contribution of programmed ventricular stimulation (PVS) on established risk assessment.

METHODS

Two-hundred-and-three consecutive patients with diagnosed HCM and ≥1 noninvasive risk factors were prospectively enrolled over 19years. Patients were risk stratified, submitted to PVS and received an implantable cardioverter-defibrillator (ICD) according to then-current American Heart Association (AHA) guidelines and inducibility. Participants were prospectively followed-up for primary endpoint occurrence (appropriate ICD therapy or SCD). Contemporary (2015) AHA and European Society of Cardiology (ESC) guidelines were retrospectively assessed.

RESULTS

During a median follow-up period of 60months the primary endpoint occurred in 20 patients, 19 of whom were inducible and received an ICD. Overall, 79 patients (38.9%) were inducible and 92 patients (45.3%) received an ICD (PVS sensitivity=95%, specificity=67.2%, positive predictive value=24%, negative predictive value=99.2%). AHA and ESC guidelines application misclassified 3 and 9 primary endpoint-meeting patients, respectively. Inducibility was the most important determinant of event-free survival in multivariate Cox regression (hazard ratio=33.3). A combined approach of ESC score≥6% or AHA indication for ICD with PVS inducibility yielded absolute sensitivity and negative predictive value, the former at a more cost-effective and specific way.

CONCLUSIONS

Inducibility at PVS predicts SCD or appropriate device therapy in HCM. Non-inducibility is associated with prolonged event-free survival, while the procedure was proven safe. Reintegration of PVS into established risk stratification models in HCM may improve patient assessment.

Nondipping status does not attenuate the conjugated estrogen-induced improvement in aortic stiffness in postmenopausal women with untreated hypertension

BACKGROUND

Whether the blunted nocturnal blood pressure (BP) fall alters the potential beneficial effects of estrogen replacement therapy (ERT) on arterial elastic properties in hypertensive postmenopausal women has not been clarified. The aim of this study was to determine the potential beneficial effects of ERT on arterial elastic properties and to investigate whether a blunted nocturnal BP fall could unfavorably modify the estrogen-induced alterations of large-artery stiffness in postmenopausal women with untreated essential hypertension.

METHODS

A total of 66 postmenopausal women with untreated essential hypertension underwent carotid-femoral pulse wave velocity (PWV) measurements at baseline and after 12 weeks of ERT with 0.625 mg conjugated estrogen. By 24-h ambulatory BP monitoring, women were classified according to dipping status (nondippers, n = 21; dippers, n = 45).

RESULTS

The two groups were similar regarding age, body mass index, time since menopause, and lipidemic profile. Initially, nondippers compared to dippers, although they had significantly greater office systolic BP (SBP), 24-h SBP, daytime SBP and night-time SBP (by 5, 2, 3, and 19 mm Hg, respectively, P < .05 for all cases), did not differ regarding left ventricular (LV) mass index and aortic PWV (116 v 114 g/m2 and 8.40 v 7.95 cm/sec, respectively, P = NS for both cases). Use of ERT, without affecting the office SBP and DBP, reduced significantly the aortic PWV in both nondippers and dippers (by 1.28 and 1.50 cm/sec, respectively, P < .05 for both cases). However, these PWV reductions were not different between the two groups (P = NS). A multivariate analysis identified patient age and 24-h SBP as significant determinants of estrogen-induced aortic PWV reduction (P < .05).

CONCLUSIONS

A blunted nocturnal BP fall does not attenuate the estrogen-induced favorable modifications of large artery elastic properties in hypertensive postmenopausal women. Whether these findings suggest that hypertensive women with ERT-induced attenuation of PWV represent a specific clinical subgroup of patients with possible ERT-associated cardiovascular benefit remains to be determined by properly randomized trials.

Experimental sepsis using Pseudomonas aeruginosa: the significance of multi-drug resistance

In order to clarify whether susceptible and multidrug-resistant Pseudomonas aeruginosa differ in the mechanism of induction of sepsis, three different isolates were used; one susceptible (isolate A) and two (isolates B and C) multidrug-resistant. Isolate B had moderately elevated MICs of antipseudomonal antimicrobials and isolate C highly elevated MICs. Each isolate was infused by a catheter inserted into the right jugular vein of six rabbits. Survival was recorded; blood was sampled at regular time intervals for estimation of bacterial blood counts, malondialdehyde (MDA) and tumour necrosis factor-alpha (TNFalpha). Quantitative cultures of various organs were performed after death or sacrifice. Mean survival after challenge by isolates A, B and C was 0.73, 2.58 and 11.00 days, respectively (P of comparisons A versus B, 0.0048; A versus C, 0.0012; B versus C, 0.0005). The number of viable organisms in the blood after challenge using isolates A and B was greater than the viable counts of C. Serum MDA was lower after challenge with B and C compared with A. Serum TNFalpha levels were higher after challenge by isolate A compared with isolate C. The bacterial loads of the liver, lower right lung lobe, spleen and mesenteric lymph nodes were greater after challenge by isolate A than the other isolates. It is concluded that infection by multidrug-resistant P. aeruginosa is accompanied by increased survival compared with infection by susceptible isolates; that finding might be explained by the different mechanisms leading to sepsis. Further studies must be done to clarify the significance of these observations for therapeutics.

Comparative elution of moxifloxacin from Norian skeletal repair system and acrylic bone cement: an in vitro study

The objective of this study was to evaluate the efficacy of Norian skeletal repair system (SRS), a novel biodegradable and injectable form of calcium phosphate cement with a composition similar to that of cancellous bone, as a carrier for moxifloxacin, which is the most potent quinolone agent against staphylococci and Enterobacteriaceae. Norian SRS was mixed with moxifloxacin at a ratio of ca. 100:3 at room temperature and solidified in the bottom of a cylindrical vial. The same procedure was followed for acrylic bone cement. A total of five vials were prepared per system. Mueller-Hinton broth was placed over the free surface of both systems and the vials were transferred to a 37 degrees C incubator. The broth was replaced daily until visual degradation of both systems. Moxifloxacin was measured in aliquots of broth after passage through a high-performance liquid chromatography system. Optical degradation of both systems occurred after 450 days. Until Day 17, concentrations eluted from both systems were similar. After Day 18 until degradation, concentrations eluted by Norian SRS were statistically higher than those eluted by acrylic bone cement and ranged between 100 mg/L and 800 mg/L. The mean area under the concentration-time curve (AUC) over 450 days of sampling was 241 935.0 mg/L day for Norian SRS and 18 300.0 mg/L day for the acrylic bone cement system (P=0.043). Norian SRS is a novel biodegradable system providing excellent strength and mineralisation to bone. It was shown that this system allows in vitro elution of moxifloxacin at significant concentrations, making it a promising candidate for the therapy of chronic osteomyelitis.

Permanent pacemaker implantation in unexplained syncope patients with borderline sinus bradycardia and electrophysiology study-proven sinus node disease

BACKGROUND

Significant sinus bradycardia (SB) in the context of sinus node dysfunction (SND) has been associated with neurological symptoms. The objective was to evaluate the effect of permanent pacing on the incidence of syncope in patients with rather mild degrees of SB, unexplained syncope, and "positive" invasive electrophysiologic testing.

METHODS

This was an observational study based on a prospective registry of 122 consecutive mild SB patients (61.90 ± 18.28 years, 61.5% male, 57.88 ± 7.73 bpm) presenting with recurrent unexplained pre and syncope attacks admitted to our hospital for invasive electrophysiology study (EPS). Τhe implantation of a permanent antibradycardia pacemaker (ABP) was offered to all patients according to the results of the EPS. Eighty patients received the ABP, while 42 denied.

RESULTS

The mean of reported syncope episodes was 2.23 ± 1.29 (or presyncope 2.36 ± 1.20) in the last 12 months before they were referred for a combined EP guided diagnostic and therapeutic approach. Over a mean follow-up of approximately 4 years (50.39 ± 32.40 months), the primary outcome event (syncope) occurred in 18 of 122 patients (14.8%), 6 of 80 (7.5%) in the ABP group as compared to 12 of 42 (28.6%) in the no pacemaker group (P = .002).

CONCLUSIONS

Among patients with mild degree of SB and a history of unexplained syncope, a set of positivity criteria for the presence of EPS defined SND after differentiating reflex syncope, identifies a subset of patients who will benefit from permanent pacing.

Sustained ventricular tachycardia as a first manifestation of hypertrophic cardiomyopathy with mid-ventricular obstruction and apical aneurysm in an elderly female patient

Sustained ventricular tachycardia complicating left ventricular apical aneurysms has been reported previously solely in middle-aged patients with hypertrophic cardiomyopathy and mid-cavity obstruction. We report a case of an elderly female patient who presented with incessant ventricular tachycardia as the first clinical manifestation of hypertrophic cardiomyopathy with mid-ventricular obstruction and apical aneurysm.

Heart failure study of multipoint pacing effects on ventriculoarterial coupling: Rationale and design of the HUMVEE trial

Cardiac resynchronization therapy (CRT) is an established therapy for symptomatic heart failure (HF). Unfortunately, many recipients remain nonresponders. Studies have revealed the potential role of multipoint pacing (MPP) in improving response and outcomes. The aim of this study is to compare the effects of MPP against those of standard biventricular pacing (BVP) on (i) ventriculoarterial coupling (VAC) and energy efficiency of the failing heart, (ii) diastolic function, (iii) quality of life, and (iv) NT-proBNP levels and glomerular filtration rate (GFR) during a follow-up of 13 months. HUMVEE is a single-center, prospective, observational, crossover cohort study. Seventy-six patients with BVP indication will be implanted with a system able to deliver both pacing modes. BVP will be activated at implantation and optimized 1 month after. At 6 months postoptimization MPP will be activated and optimized. Optimization will be performed based on stroke volume maximization, as assessed by ultrasound. Laboratory measurements (GFR and NT-proBNP) and echocardiographic studies (VAC calculation, strain rate, diastolic function) will be performed at implantation, 6 months post-BVP optimization and at the end of 13 months of follow-up (6 months post-MPP optimization). Potential reduction in arrhythmogenesis by MPP will also be assessed. MPP is a pacing modality with the potential to improve HF patients' outcomes. The HUMVEE trial will attempt to associate any potential added beneficial effects of MPP over standard BVP with alterations in VAC and energy efficiency of the heart, thus uncovering a novel mechanistic link between MPP and improved outcomes in HF.

Asphaltene biotransformation for heavy oil upgradation

Globally, the reserves of heavy crude oil are seven times more abundant than that of light crude, and yet, they are underutilized because of their high viscosity and density, which is largely due to the presence of large amounts of asphaltenes. Biotransformation of heavy oil asphaltenes into smaller metabolites can be used for reducing their viscosity. Several microorganisms capable of asphaltene biodegradation have been reported but only few have been characterized for its biotransformation. In the present study, a 9-membered microbial consortium was isolated from an oil contaminated soil. About 72% and 75% asphaltene biotransformation was achieved by growing cells at shake flask level and in a 1.5 l bioreactor, respectively. A representative structure of asphaltene was constructed based on LC–MS, ¹H-NMR, ¹³C-NMR, FT-IR, ICPMS and elemental analysis (CHNS) of n-heptane purified asphaltene from Maya crude oil. Biotransformation of asphaltene, as analyzed by performing ¹H-NMR, FT-IR and elemental analysis, resulted in 80% decrease in S and N when compared to the control along with incorporation of oxygen in the structure of asphaltene. About 91% decrease in the viscosity of the Maya crude oil was observed after two weeks when oil: aqueous phase ratio was 1:9. The results suggest that the isolated microbial consortium can be used for biological upgradation of heavy crude oil. To our knowledge, this is the first report where a microbial consortium resulted in such high asphaltene biotransformation.

Dexamethasone as adjuvant therapy to moxifloxacin attenuates valve destruction in experimental aortic valve endocarditis due to Staphylococcus aureus

Although the beneficial effects of dexamethasone have frequently been investigated in various serious-infection settings, insufficient data on valve histology and cardiac function for infective endocarditis are available. The efficacy of moxifloxacin for the treatment of experimental aortic valve endocarditis due to methicillin-susceptible Staphylococcus aureus and the long-term effects of dexamethasone were evaluated in the current study. Sixty-eight rabbits were randomly assigned to four groups: A, B, C, and D. Group A consisted of 18 animals and functioned as a control group. Groups B and C consisted of 11 and 23 subjects, respectively, which received moxifloxacin for 5 days in a human-like pharmacokinetic simulation. Group D consisted of 16 animals that were administered moxifloxacin plus dexamethasone (0.25 mg/kg of body weight twice a day intravenously). The group B animals were sacrificed a day after the completion of treatment, and group C and D animals were sacrificed after 12 days in order to monitor any possible relapse and allow microbiological, histopathological, and echocardiographic evaluation of the long-term effects of glucocorticoids. No differences in survival, sterilization rates, or inflammatory infiltration and calcification of valve tissue were observed among the treated groups. However, the degrees of valve damage and collagenization were significantly worse, the fibroblast content was higher, and fractional shortening of the left ventricle fluctuated significantly in group C compared to group D (all groups, P < 0.05). We concluded that dexamethasone treatment for experimental S. aureus endocarditis attenuates valve destruction and preserves overall cardiac function without impeding the efficacy of moxifloxacin.

Arrhythmic risk stratification in ischemic, non-ischemic and hypertrophic cardiomyopathy: A two-step multifactorial, electrophysiology study inclusive approach

Annual arrhythmic sudden cardiac death ranges from 0.6% to 4% in ischemic cardiomyopathy (ICM), 1% to 2% in non-ischemic cardiomyopathy (NICM), and 1% in hypertrophic cardiomyopathy (HCM). Towards a more effective arrhythmic risk stratification (ARS) we hereby present a two-step ARS with the usage of seven non-invasive risk factors: Late potentials presence (≥ 2/3 positive criteria), premature ventricular contractions (≥ 30/h), non-sustained ventricular tachycardia (≥ 1episode/24 h), abnormal heart rate turbulence (onset ≥ 0% and slope ≤ 2.5 ms) and reduced deceleration capacity (≤ 4.5 ms), abnormal T wave alternans (≥ 65μV), decreased heart rate variability (SDNN < 70ms), and prolonged QTc interval (> 440 ms in males and > 450 ms in females) which reflect the arrhythmogenic mechanisms for the selection of the intermediate arrhythmic risk patients in the first step. In the second step, these intermediate-risk patients undergo a programmed ventricular stimulation (PVS) for the detection of inducible, truly high-risk ICM and NICM patients, who will benefit from an implantable cardioverter defibrillator. For HCM patients, we also suggest the incorporation of the PVS either for the low HCM Risk-score patients or for the patients with one traditional risk factor in order to improve the inadequate sensitivity of the former and the low specificity of the latter.

Successful treatment with moxifloxacin of experimental aortic valve endocarditis due to methicillin-resistant Staphylococcus aureus (MRSA)

Moxifloxacin (MXF) is an 8-methoxyquinolone with high activity against Gram-positive bacteria. In an experimental model of aortic valve endocarditis (EAVE), the efficacy of MXF was evaluated against a strain of methicillin-resistant Staphylococcus aureus (MRSA). Rabbits with catheter-induced aortic valve vegetations were randomly assigned to a control group or to groups receiving MXF 20 mg/kg intravenous (i.v.) twice a day (bid) or vancomycin (VAN) 30 mg/kg i.v. bid for a total of eight doses (4 days). Rabbits were sacrificed 15 h after the last dose of antibiotics. In another group, treatment with MXF was extended to 5 days and rabbits were sacrificed 5 days after the last dose (10th dose) of MXF in order to detect possible relapses of endocarditis after the end of treatment (test-of-cure (TOC) study). Both MXF and VAN significantly reduced the bacterial load in vegetations (P < 0.001 vs. controls). All animals in the MXF-TOC group had sterile vegetations. MXF given at a dose of 20 mg/kg i.v. bid for 4 days was equally effective as VAN in the treatment of EAVE due to MRSA. When treatment with MXF was extended to 5 days, the cure rate reached 100% and no relapses of endocarditis were observed.

Comparison of left ventricular and biventricular pacing: Rationale and clinical implications

Cardiac resynchronization therapy constitutes a cornerstone in advanced heart failure treatment, when there is evidence of dyssynchrony, especially by electrocardiography. However, it is plagued both by persistently high (~30%) rates of nonresponse and by deterioration of right ventricular function, owing to iatrogenic dyssynchrony in the context of persistent apical pacing to ensure delivery of biventricular pacing. Left ventricular pacing has long been considered an alternative to standard biventricular pacing and can be achieved as easily as inserting a single pacing electrode in the coronary sinus. Although monoventricular left ventricular pacing has been proven to yield comparable results with the standard biventricular modality, it is the advent of preferential left ventricular pacing, combining both the powerful resynchronization potential of multipolar coronary sinus and right-sided electrodes acting in concert and the ability to preserve intrinsic, physiological right ventricular activation. In this review, we aim to present the underlying principles and modes for delivering left ventricular pacing, as well as to highlight advantages of preferential over monoventricular configuration. Finally, current clinical evidence, following implementation of automated algorithms, regarding performance of left ventricular as compared with biventricular pacing will be discussed. It is expected that the field of preferential left ventricular pacing will grow significantly over the following years, and its combination with other advanced pacing modalities may promote clinical status and prognosis of patients with advanced dyssynchronous heart failure.

Multipoint left ventricular pacing effects on hemodynamic parameters and functional status: HUMVEE single-arm clinical trial (NCT03189368)

OBJECTIVES

The aim of this study was to assess the capacity of optimized multipoint pacing (MPP) over optimized cardiac resynchronization therapy (CRT), in terms of clinical, functional, and echocardiographic parameters among patients with dyssynchronous heart failure (HF).

METHODS

Eighty patients (Caucasian, 77.5% male, 68.4 ± 10.1 years, and 53.8% ischemic cardiomyopathy) sequentially received optimized CRT and optimized MPP over 6- and 12-month periods in a single-arm clinical trial. Clinical, laboratory, and echocardiographic assessment was conducted at baseline and after the completion of each step.

RESULTS

Significant additive effects of optimized MPP over optimized CRT were noted with regard to 6-min walking distance (baseline/optCRT/optMPP: 293 ± 120 m vs 367 ± 94 m vs 405 ± 129 m and p < 0.001), NYHA class (2.36 vs 2.19 vs 1.45 and p < 0.001), VTIlvot (14.25 ± 3.2 cm vs 16.2 ± 4 cm vs 17.5 ± 3.4 cm and p < 0.001), stroke volume (48 ± 13.5 ml vs 55 ± 15 ml vs 59 ± 15 ml and p < 0.001), left ventricular ejection fraction (LVEF) (29% ± 7.1% vs 33% ± 7.3% vs 37% ± 7.7% and p < 0.001), maximal left atrial volume (77.2 ± 34.2 ml vs 74.2 ± 39.5 ml vs 67.7 ± 32 ml and p = 0.02), pulmonary artery systolic pressure (35.9 mmHg vs 33.5 mmHg vs 31 mmHg and p < 0.001), and right ventricular strain (-8.3% ± 6.9% vs -8.8% ± 6.6% vs -11.8% ± 6.1% and p = 0.022). With regard to VAC, stroke work (SW), and CP as percentages of maximal, there was a significant difference detected as compared to baseline for both CRT and MPP. Additive effects persisted only if suitable MPP dipoles were present. Exploratory analysis revealed that ischemic cardiomyopathy continued to exhibit significant differences that favor MPP, whereas nonischemic cardiomyopathy had similar findings with regard to total left atrial strain and quality of life.

CONCLUSIONS

Optimized MPP showed significant improvements in hemodynamic parameters and ventricular function in patients with HF over optimized CRT. The beneficial effect was more prominent in men and in those with rather reduced LVEF, consistent with findings that suggest a beneficial trend in VAC and CP with more homogeneous depolarization offered by optimized MPP.

Moderate to Severe Osteoarthritis: What is the Economic Burden for Patients and the Health Care System? Insights from the "PONOS" Study

OBJECTIVE

To assess the economic burden of moderate to severe osteoarthritis (OA) management for patients and the health care system in Greece.

DESIGN

A noninterventional, cross-sectional, prospective, epidemiological analysis of data from the medical records of patients with moderate to severe OA, recruited in a single visit from 9 sites in Greece. Outcomes included health care resource use (direct/indirect costs) associated with this patient population.

RESULTS

A total of 164 patients were included in the analysis: mean age was 70.5 years, and the majority of participants were females (78.7%). The presence of comorbidities was reported by 87.2% of patients, with hypertension being the most frequently reported (53.7%). Paracetamol was the most commonly used analgesic treatment (96%), followed by systemic nonsteroidal anti-inflammatory drugs (NSAIDs) (75%) and opioids (50%). The mean overall annual direct costs per patient was estimated at 1,675.3€, with approximately half incurred by the National Health Insurance Fund, whereas the mean overall annual indirect cost (absenteeism of patients and informal caregivers) was estimated at 3,501.4€. Joint replacement (JR) procedures and paid care were the major drivers of annual direct costs in this patient population (4,326.3€ and 9,360.0€, respectively).

CONCLUSIONS

This real-world analysis of direct and indirect costs confirmed the substantial economic burden imposed by moderate to severe OA to the health care system and the patients. Our findings emphasize the need for interventions to enhance disease management, to improve patients' health outcomes and reduce the global burden of OA on society.

Estrogen-induced improvement in coronary flow responses during atrial pacing in relation to endothelin-1 levels in postmenopausal women without coronary disease

BACKGROUND

The cardioprotective role of hormonal replacement therapy remains in doubt, but interest is increasing in the vascular effects of estrogens especially in coronary circulation.

METHODS

Coronary blood flow (CBF) was measured in 24 postmenopausal women (age 55+/-3 years), whose coronary arteries appeared angiographically normal, during incremental atrial pacing (AP) before and 20 minutes after intracoronary administration of either 75 ng/mL 17-beta estradiol (treated group, n=18) or 0.9% saline (controls, n=6).

RESULTS

Before estrogen, no differences in the coronary vasomotor responses at AP between the two groups (p=NS) could be detected. After estrogen, in the treated group, at the peak of the second AP, the coronary artery diameter decreased by 0.17 mm (p<0.005) while the CBF increased by 61 mL/min (p<0.05). These changes differed significantly from those observed at the peak of first AP (p<0.001 for both cases). In contrast, in the control group no such changes were observed. The endothelin-1 (ET-1) levels in the coronary sinus were significantly reduced after estrogen infusion, which was negatively correlated with the degree of coronary artery constriction (r= -0.40, p=0.03) and positively correlated with the increase in CBF (r=0.54, p=0.01).

CONCLUSIONS

In postmenopausal women without coronary artery disease, the intracoronary estrogen infusion mediates a greater increase in CBF and is positively correlated with the reduction of the coronary sinus ET-1 levels at the peak of AP.

Catheter ablation in grown-up congenital heart disease patients: A single-center experience

Background

Supraventricular and ventricular tachyarrhythmias represent a common complication in grown-up patients with congenital heart defects (CHD) associated with worsening of functional capacity and increased morbidity. The aim of this study was to present the experience of our department on catheter ablation (CA) addressing safety and efficacy concerns.

Methods

Consecutive patients with CHD treated with CA between 2002 and 2021 in our hospital were included in this study. The established ablation techniques modified according to the patient's special anatomic characteristics were applied. NYHA functional status along with the underlying cardiac rhythm were recorded during the follow-up.

Results

In total, 35 patients (44.9 ​± ​2.7 years, 22 males) underwent CA for the management of either supraventricular or ventricular (n ​= ​2) arrhythmia during the study period. The most common anatomical diagnoses were atrial septal defect (13), Tetralogy of Fallot (5) and transposition of great arteries (3). Atrial fibrillation or atrial flutter was the most frequent baseline diagnosis, observed in 15 (42.8%) patients, followed by intra-atrial reentrant tachycardia in 9 (25.7%) patients and atrioventricular nodal reentry tachycardia (AVNRT) in 5 (14.2%). No significant complication occurred during CA. Patients were followed for a median period of 9 years after the index procedure. At this time, arrhythmia recurrence was observed in 13 patients (37,1%) of whom 6 underwent a redo procedure. Furthermore, 4 patients underwent a permanent pacemaker implantation, while 6 were offered an ICD treatment.

Conclusion

CA is a safe method offering significant benefits regarding the management of tachyarrhythmias and preserving functional capacity in adult patients with CHD.