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

Anesthetic Considerations for Robotic Liver Transplantation

Liver transplantation has traditionally been performed through a large, bilateral subcostal incision. Recently, liver transplant programs across the world, including our own, have reported successful liver transplants via total robotic approaches on recipients with low Model for End-stage Liver Disease scores and preexisting abdominal wall laxity. This review discusses the unique anesthetic considerations of robotic liver transplantation based on our group's initial experience with this novel surgical approach. Robotic liver transplantation presents a unique set of considerations and challenges for the anesthesiologist, and a thorough understanding of liver disease, liver transplant surgery, venovenous bypass, and the various implications of robotic surgery is essential to ensure optimal patient outcomes. Specific management topics discussed here include appropriate patient selection, preoperative assessment, and intraoperative management. We also discuss certain theoretical and actual challenges that our group has experienced.

Nomogram for Predicting 1-, 3-, and 5-Year Survival in Hemodynamically Significant Aortic Regurgitation: The ARISE Score

BACKGROUND

A user-friendly tool that integrates key clinical variables to estimate prognosis in aortic regurgitation is lacking. We aimed to develop and validate a nomogram-based score to predict survival and identify high-risk patients for timely aortic valve surgery referral.

METHODS AND RESULTS

From 2008 to 2022, 1229 patients (derivation data set: 764 Taiwanese; validation data set: 465 Japanese; age: 64±17 years) with isolated chronic moderately severe to severe aortic regurgitation from 3 centers were included. All echocardiograms were reviewed de novo. At a median follow-up of 5.0 (interquartile range, 2.2-8.2) years, 204 all-cause deaths occurred and 247 underwent aortic valve surgery within 3 months. In multivariable analysis, age (P<0.001), Charlson Comorbidity Index (P<0.001), New York Heart Association functional class IV (P<0.001), left ventricular ejection fraction (P<0.001), left ventricular end-systolic dimension index (P=0.03), and aortic valve surgery in 3 months (P=0.03) were associated with all-cause death. These variables, along with sex and maximal aorta diameter index, were incorporated into the combined left ventricular ejection fraction and left ventricular end-systolic dimension index nomogram to estimate 1-, 3-, and 5-year survival and to calculate the Aortic Regurgitation/Insufficiency Survival Estimation (ARISE) score. Calibration plots demonstrated good performance, with the area under the receiver operating characteristic curve reaching 0.79 in the validation data set. The left ventricular end-systolic dimension index-based nomogram showed similar performance. By using the tertiles of the ARISE score to risk stratify individuals, Kaplan-Meier curves demonstrated significant survival differences among 3 risk groups in both the derivation and validation cohorts (P<0.001).

CONCLUSIONS

The ARISE score (https://arise-score.vercel.app/), which includes guideline-recommended parameters, effectively predicts survival in patients with aortic regurgitation. It may facilitate shared decision-making between the heart team and patients.

Validation of a Novel Risk Prediction Score for Sudden Cardiac Death in the Framingham Heart Study

BACKGROUND

We have previously reported a novel clinical risk score (risk prediction score for shockable sudden cardiac arrest [VFRisk]) for the prediction of shockable sudden cardiac arrest, discovered and validated in 2 US west coast communities. We hypothesized that VFRisk predicts sudden cardiac death (SCD) risk in the geographically distinct FHS (Framingham Heart Study).

METHODS

We performed a nested case-referents study in the FHS to test VFRisk. Cases were participants who experienced SCD among the original and offspring FHS cohorts. Referents were randomly selected from FHS participants frequency-matched (ratio of 1:3) to cases on age, sex, cohort, and exam. VFRisk was the sum of 12 risk factors, each multiplied by its respective points.

RESULTS

Among 312 cases and 935 referents, mean ages were 69.5 and 69.7 years with 70.8% male in both groups. SCD cases had significantly higher prevalence of diabetes, heart failure, stroke, atrial fibrillation, and myocardial infarction compared with the referents group. The VFRisk score was validated with good discrimination (C-statistic, 0.71 [95% CI, 0.66-0.77]) for SCD. Cases had higher VFRisk scores than referents (3.8±2.8 versus 1.8±1.7; P<0.001). A 1-unit increase in VFRisk score was associated with a 48% increase in odds of SCD (odds ratio, 1.48 [95% CI, 1.34-1.64]). The highest VFRisk quartile had 7.8-fold higher odds of SCD than the lowest quartile.

CONCLUSIONS

The VFRisk score successfully predicted SCD in the FHS. The differences in discrimination between the 2 studies could partially be explained by the inability to distinguish shockable versus nonshockable events in the FHS.

Routine preoperative transthoracic echocardiography for predicting incomplete endothelialization of the watchman left atrial appendage occluder: A single-center five-year study

BACKGROUND & OBJECTIVES

Incomplete endothelialization of the left atrial appendage(LAA) occluder potentially affects the long-term efficacy of stroke prevention in atrial fibrillation(AF) patients. This study aims to explore the value of routine preoperative transthoracic echocardiography(TTE) in predicting the endothelialization of Watchman LAA occluder.

METHODS

This single-center retrospective study included 437 AF patients who underwent the LAA closure with Watchman 2.5 occluder from January 2017 to December 2022. Cardiac CTA was performed 3-6 months after the procedure. Based on contrast infiltration into the LAA cavity, two groups were defined as follows: completely and incompletely endothelialized. The baseline and pre-procedural TTE parameters were analyzed.

RESULTS

The average age was 70.2 years old, with 208 females(47.6 %). The incompletely endothelialized group had an older age (71.4 ± 7.5 vs 69.8 ± 7.6,p = 0.053), a larger left atrial(LA) diameter (44.0 ± 5.9 vs 42.7 ± 6.1 mm,p = 0.045) and a lower left ventricular ejection fraction(LVEF%)(62.5 ± 7.5 vs 63.0 ± 5.4 %,p = 0.016) than the completely endothelialized group. Univariate analysis revealed that incomplete endothelialization was associated with persistent AF(OR:1.68;95 % CI:1.08-2.10;p = 0.021), a higher LA diameter(OR:1.04;95 % CI:1.00-1.07;p = 0.046), a higher left ventricular diastolic diameter(LVDD)(OR:1.05;95 % CI:1.00-1.10;p = 0.032),and the presence of mild mitral stenosis (mean pressure gradient <5 mmHg and mitral valve area > 1.5 cm2,OR:11.29;95 % CI:1.25-102.10;p = 0.031), while it was negatively correlated with mild left ventricular diastolic dysfunction (OR:0.49;95 % CI:0.26-0.94;p = 0.033). Multivariate analysis demonstrated that mild mitral stenosis(OR: 13.79;95 % CI:1.37-139.13;p = 0.026) was an independent predictor for incomplete endothelialization.

CONCLUSION

Preoperative TTE may predict the outcomes of endothelialization after left atrial appendage occlusion. Mild or severe mitral stenosis is an independent predictive factor for poor endothelial coverage.

Obstructive sleep apnea is associated with cardiac structural and functional alterations in patients with advanced diabetic kidney disease

AIMS

Obstructive sleep apnea (OSA) is common in type 2 diabetes mellitus (T2DM), but its association with cardiac structure and function in advanced diabetic kidney disease (DKD) remains unclear.

METHODS

T2DM patients with estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2 and albuminuria were assessed for OSA using the apnea-hypopnea index (AHI). Cardiac structure and function were assessed by transthoracic echocardiography following standard guidelines. 39 patients without OSA (AHI < 5) were compared to 34 patients with moderate-severe OSA (AHI ≥ 15).

RESULTS

Mean age was 71.4 ± 9.4 years (73 % male), and eGFR was 32.1 ± 12.3 mL/min/1.73 m2. DKD patients with moderate-severe OSA had a higher left atrial volume index (LAVI: 36.6 ± 13.9 vs. 28.1 ± 10.5 mL/m2, p < 0.01) left ventricular mass index (LVMI: 48.8 ± 11.7 vs. 41.8 ± 9.7 g/m2.7, p < 0.01) and right ventricular diameter (RVD: 34.1 ± 5.8 vs. 28.4 ± 4.4 mm, p < 0.001) than DKD patients without OSA. Left ventricular ejection fraction (LVEF) did not differ, but global longitudinal strain (GLS) was reduced (-15.1 ± 3.0 vs. -16.6 ± 2.8 %, p < 0.05). In multivariable linear regression analyses, moderate-severe OSA remained significantly associated with LAVI, LVMI, RVD, and GLS but not with LVEF.

CONCLUSIONS

Moderate-severe OSA is associated with cardiac hypertrophy and chamber dilatation, potentially contributing to cardiovascular risk in advanced DKD.

Airway Obstruction in Patients With Left-Ventricular Hypertrophy

Background: The relationship between left-ventricular hypertrophy (LVH), left-ventricular mass index (LVMI), body mass index (BMI), and their corresponding pulmonary function test parameters remains unknown. Methods: In this prospective observational study, we assessed the pulmonary function of subjects with LVH. The severity of airway obstruction was graded into five levels using the FEV1% predicted value and the prevalence of obstruction with left-ventricular mass was also correlated. Results: Our study included 289 subjects [142 (49.1%) LVH and 147 (50.8%) non-LVH]. The mean age of subjects with LVH was 56 ± 17.8 years. Sixty-two subjects with normal BMI had LVH. One-hundred forty-two subjects with LVH underwent spirometry; 9 (6.3%), 16 (11.3%), 18 (12.7%), 49 (34.5%), and 48 (33.8%) had mild, moderate, moderately severe, severe, and very severe obstruction before the administration of bronchodilator, respectively. After bronchodilator administration, the numbers (n%) were 13 (9.15%), 17 (11.9%), 27 (19%), 52 (36.6%), and 30 (21.1%), respectively. There was a strong inverse relationship (r = -0.87, r = -0.86) for pre bronchodilator and post bronchodilator, respectively; R2 = 0.76 and R2 = 0.74 for pre and post bronchodilator respectively, P < .001 for both) between LVMI and FEV1%. Conclusions: LVH was associated with high prevalence of obstructive pulmonary disease. The severity of obstruction was correlated with left-ventricular mass. The early screening of such underlying obstruction may help to reduce the risk of further complications.

Etiology of tricuspid regurgitation and mortality: a multicenter cohort study

BACKGROUND

Significant tricuspid regurgitation (TR) encompasses a wide range of etiologies, complicating a comprehensive understanding of disease progression and prognostic factors. This study aimed to assess mortality associated with significant TR, focusing on the role of valvular disease etiology and other predictive factors.

METHODS

This is a retrospective, multicenter, cohort observational study, including all consecutive patients with moderate-to-severe or greater TR. The patients were classified into five etiological groups: organic TR, TR secondary to left valvulopathy, TR secondary to left or right ventricular dysfunction, TR secondary to pulmonary hypertension, and atrial TR. The long-term mortality was assessed (median follow-up: 39.8 months).

RESULTS

757 patients were included. The overall mortality incidence rate was 162.5 deaths per 1000 patient-years. Compared to atrial TR, all other etiologies presented a higher mortality risk: organic TR adjusted hazard ratio (aHR) = 2.344 (95% confidence interval [CI]: 1.138-4.829), left valvulopathy-related TR aHR = 1.901 (95% CI: 1.011-3.574), ventricular dysfunction-related TR aHR = 3.683 (95% CI: 1.627-8.338), and pulmonary hypertension-related TR aHR = 2.446 (95% CI: 1.215-4.927). In addition to known factors, male sex was associated with a higher mortality risk (aHR = 1.608, 1.175-2.201), while beta-blocker use was linked to a lower risk (aHR = 0.674, 0.502-0.904).

CONCLUSIONS

In a large cohort of patients with significant TR, and after adjusting for clinical and echocardiographic variables, all etiological groups exhibited a higher mortality risk compared to atrial TR. Additionally, male patients with TR had a higher mortality risk, while beta-blocker therapy emerged as a protective factor.

Evaluation of Mortality and Hospitalization Due to Decompensated Heart Failure and Appropriate Shocks in Reduced Ejection Fraction in Patients with an Implantable Cardioverter-Defibrillator According to a Novel Tissue Doppler Echocardiographic Method

Background/Objectives: Heart failure is a very common disease, and its incidence is increasing. Echocardiography is a non-invasive tool frequently used in the diagnosis and risk stratification of heart failure. In our study, we aimed to evaluate the risk of all-cause mortality, hospitalization due to decompensated heart failure, and appropriate shocks in reduced ejection fraction patients (HFrEF) with an implantable cardioverter-defibrillator (ICD) according to a novel tissue Doppler echocardiographic parameter that reflects pulmonary capillary wedge pressure. Methods: A total of 320 HFrEF patients with ICD were included in the study between 1 February 2021 and 30 June 2023, from the cardiology outpatient clinic and cardiology ward. Using tissue Doppler, the peak systolic velocity (ST) at the free wall side of the tricuspid annulus and the peak systolic velocity (SM) at the lateral side of the mitral annulus were measured, and the ratio of ST to SM (ST/SM) was calculated. The inferior vena cava diameter (IVCDi) was measured during inspiration. These two values were multiplied to form the formula IVCDi × (ST/SM). Based on the IVCDi × (ST/SM) value, patients were divided into two groups: those with high values (>17, n = 144) and those with low values (≤17, n = 176). The primary endpoint of our study was all-cause mortality, and the secondary endpoint was major adverse cardiovascular events (MACE), including appropriate shocks, hospital admission due to acute heart failure decompensation, and mortality. Results: Long-term mortality was higher in the high IVCDi × (ST/SM) group compared to the low-value group (44% vs. 15%, p < 0.001). The MACE frequency was also higher in patients with high IVCDi × (ST/SM) values (71% vs. 30%, p < 0.001). In multivariable analysis, IVCDi × (ST/SM) was an independent predictor of both mortality (HR: 1.027, 95%CI: 1.009-1.046, p = 0.003), and MACE (HR: 1.018, 95%CI: 1.004-1.032, p = 0.013). Conclusions: We demonstrated that the IVCDi × ST/SM value, a novel tissue Doppler echocardiographic parameter, is an independent predictor of both long-term mortality and major adverse cardiac events (MACE) in HFrEF patients with ICD. This parameter may be valuable in identifying high-risk patients and optimizing their treatment management.

High-Resolution Maps of Left Atrial Displacements and Strains Estimated With 3D Cine MRI Using Online Learning Neural Networks

The functional analysis of the left atrium (LA) is important for evaluating cardiac health and understanding diseases like atrial fibrillation. Cine MRI is ideally placed for the detailed 3D characterization of LA motion and deformation but is lacking appropriate acquisition and analysis tools. Here, we propose tools for the Analysis of Left Atrial Displacements and DeformatIons using online learning neural Networks (Aladdin) and present a technical feasibility study on how Aladdin can characterize 3D LA function globally and regionally. Aladdin includes an online segmentation and image registration network, and a strain calculation pipeline tailored to the LA. We create maps of LA Displacement Vector Field (DVF) magnitude and LA principal strain values from images of 10 healthy volunteers and 8 patients with cardiovascular disease (CVD), of which 2 had large left ventricular ejection fraction (LVEF) impairment. We additionally create an atlas of these biomarkers using the data from the healthy volunteers. Results showed that Aladdin can accurately track the LA wall across the cardiac cycle and characterize its motion and deformation. Global LA function markers assessed with Aladdin agree well with estimates from 2D Cine MRI. A more marked active contraction phase was observed in the healthy cohort, while the CVD $\text {LVEF}_{\downarrow } $ group showed overall reduced LA function. Aladdin is uniquely able to identify LA regions with abnormal deformation metrics that may indicate focal pathology. We expect Aladdin to have important clinical applications as it can non-invasively characterize atrial pathophysiology. All source code and data are available at: https://github.com/cgalaz01/aladdin_cmr_la.

The impact of left ventricular ejection fraction on cardiovascular and renal outcome in hypertensive patients with nondialysis chronic kidney disease

OBJECTIVES

Identification of nondialysis chronic kidney disease (CKD) patients at a higher risk of end-stage kidney disease (ESKD) or adverse cardiovascular events is the first essential step to optimize management. We evaluated the role of left ventricular ejection fraction (LVEF) in predicting cardiac and renal outcome in CKD.

METHODS

We prospectively studied 580 consecutive patients with nondialysis CKD followed in two Italian renal clinics in order to evaluate the association between LVEF as either continuous variable or categories (>60, 50-60 and <50%) and adjusted risks (hazard ratio, 95% confidence interval) of either cardiovascular (composite of fatal and nonfatal cardiovascular events) or renal events (composite of ESKD and all-cause death before ESKD).

RESULTS

The mean age of participants was 65.0 ± 13.5 years, 62% men, eGFR 41.3 ± 21.1 ml/min/1.73 m 2 , LVEF 60.6 ± 8.1% and left ventricular mass index (LVMI) 59.3 ± 17.6 g/m 2.7 . LVEF more than 60%, 50-60% and <50% was recorded in 274, 234 and 72 patients, respectively. Patients with LVEF less than 50% were predominantly men with more frequent history of cardiovascular disease and lower eGFR; in addition, they had higher 24 h, daytime and nighttime blood pressure. During the follow-up (median 5.0 years, IQR 4.9-7.1), cardiovascular and renal endpoints were registered in 113 and 228 patients, respectively. LVEF as a continuous variable was inversely associated with the adjusted risk of either cardiovascular (0.97, 0.95-0.99) or renal endpoint (0.98, 0.97-0.995). In comparison with patients with LVEF more than 60%, the risk of cardiovascular events was increased in patients with LVEF 50-60% (1.64, 1.06-2.53) and less than 50% (2.17, 1.27-3.72). The same occurred for renal endpoint (1.68, 1.24-2.27 and 1.73, 1.15-2.59 for LVEF 50-60% and <50%, respectively).

CONCLUSION

In CKD patients, lower LVEF is associated with worse cardiorenal prognosis, independently from LVMI.

Curative Parathyroidectomy in Primary Hyperparathyroidism Improves Both Systolic and Diastolic Cardiac Dysfunction: A Six-Month Follow-Up Study at a Tertiary Care Hospital

BACKGROUND

Primary hyperparathyroidism (PHPT) is associated with hypertension, left ventricular hypertrophy, and myocardial and valvular calcifications, leading to increased mortality rates. While the association between PHPT and diastolic dysfunction has been well-documented, data on systolic dysfunction and its reversal after curative parathyroidectomy (PTX) remains limited.

PURPOSE

To evaluate the effect of PTX on cardiovascular parameters, especially systolic dysfunction, in PHPT patients using conventional and speckle-tracking echocardiography (STE).

METHODS

This prospective study was conducted at a tertiary care hospital from August 2016 to September 2019; 59 patients underwent successful PTX based on standard criteria, with 58 completing the study. Preoperative and 6-month postoperative biochemical and cardiovascular evaluations, including echocardiography, were performed. Global longitudinal strain (GLS) was assessed using speckle-tracking echocardiography (STE).

RESULTS

The mean age of subjects was 45.2 ± 10.4 years with a male-to-female ratio of 1.5:1. Normalization of serum calcium and phosphorus with significant reductions in serum intact PTH, alkaline phosphate, total cholesterol, HDL, and uric acid levels (p ≤ 0.0001) were seen after curative PTX. Echocardiographic evaluations significantly improved diastolic parameters, including E velocity (cm/s) and E/A(atrial) ratio. Systolic dysfunction also showed significant improvement on conventional echocardiography and STE, as evidenced by reduced left ventricular (LV) mass, ejection fraction (EF), and postoperative GLS. Although a relative drop in EF was noted postprocedure, STE findings suggested a significant improvement in systolic dysfunction, signifying GLS as a more appropriate means of assessing systolic dysfunction. Serum PTH demonstrated a strong positive correlation (r = 0.638, p < 0.001) with changes in GLS, while serum calcium showed a weak correlation (r = 0.291, p = 0.027) with changes in GLS following surgery.

CONCLUSION

This study demonstrates significant improvements in diastolic and systolic functions, as evidenced by conventional echocardiography and STE, and suggests that PTX benefits cardiovascular health in PHPT patients.

A probabilistic reduced-order modeling framework for patient-specific cardio-mechanical analysis

Cardio-mechanical models can be used to support clinical decision-making. Unfortunately, the substantial computational effort involved in many cardiac models hinders their application in the clinic, despite the fact that they may provide valuable information. In this work, we present a probabilistic reduced-order modeling (ROM) framework to dramatically reduce the computational effort of such models while providing a credibility interval. In the online stage, a fast-to-evaluate generalized one-fiber model is considered. This generalized one-fiber model incorporates correction factors to emulate patient-specific attributes, such as local geometry variations. In the offline stage, Bayesian inference is used to calibrate these correction factors on training data generated using a full-order isogeometric cardiac model (FOM). A Gaussian process is used in the online stage to predict the correction factors for geometries that are not in the training data. The proposed framework is demonstrated using two examples. The first example considers idealized left-ventricle geometries, for which the behavior of the ROM framework can be studied in detail. In the second example, the ROM framework is applied to scan-based geometries, based on which the application of the ROM framework in the clinical setting is discussed. The results for the two examples convey that the ROM framework can provide accurate online predictions, provided that adequate FOM training data is available. The uncertainty bands provided by the ROM framework give insight into the trustworthiness of its results. Large uncertainty bands can be considered as an indicator for the further population of the training data set.

Thoracic Aorta Measurements Using Intraoperative Transesophageal Echocardiography: Validation via Cardiac Magnetic Resonance

OBJECTIVES

To examine the association and magnitude of agreement between intraoperative transesophageal echocardiography (TEE) and cardiac magnetic resonance imaging (CMR) on aortic diameter measurements, to guide perioperative decision making for ascending aortic aneurysms.

DESIGN

This prospective study included patients with an ascending aortic aneurysm undergoing surgical ascending aortic repair using a prosthetic graft between February 2018 and December 2019. Intraoperative TEE in 2-dimensional (2D) and 3-dimensional (3D) views were obtained and assessed relative to preoperative cine-CMR and contrast-enhanced 3D magnetic resonance angiography.

SETTING

Weill Cornell Medicine, a single large academic medical center.

PARTICIPANTS

Thirty patients undergoing ascending aortic repair using a prosthetic graft (polyethylene terephthalate [Dacron]) without severe aortic valve disease (stenosis or regurgitation).

INTERVENTIONS

CMR, TEE, and ascending aortic repair using prosthetic grafts.

MEASUREMENTS AND MAIN RESULTS

TEE-derived measurements correlated significantly with CMR at all aortic segments: root (r = 0.94-0.97; p < 0.001 for all), ascending (r = 0.95-0.98; p < 0.001 for all), arch (r = 0.88; p < 0.001), and descending (r = 0.91; p < 0.001). Bland-Altman analyses showed small mean differences between 2D and 3D TEE versus CMR (range, 0.05-0.22 cm and 0.04-0.18 cm, respectively), with narrow limits of agreement at all segments, although TEE underestimated CMR-derived measurements.

CONCLUSIONS

This study demonstrates the feasibility of intraoperative TEE to accurately measure aortic diameters in patients with ascending aortic aneurysms. The excellent correlations with CMR and small mean differences with narrow limits of agreement support intraoperative TEE to guide surgical decision making for possible aortic replacement.

Cardiovascular imaging techniques for electrophysiologists

Rapid technological advancements in noninvasive and invasive imaging including echocardiography, computed tomography, magnetic resonance imaging and positron emission tomography have allowed for improved anatomical visualization and precise measurement of cardiac structure and function. These imaging modalities allow for evaluation of how cardiac substrate changes, such as myocardial wall thickness, fibrosis, scarring and chamber enlargement and/or dilation, have an important role in arrhythmia initiation and perpetuation. Here, we review the various imaging techniques and modalities used by clinical and basic electrophysiologists to study cardiac arrhythmia mechanisms, periprocedural planning, risk stratification and precise delivery of ablation therapy. We also review the use of artificial intelligence and machine learning to improve identification of areas for triggered activity and isthmuses in reentrant arrhythmias, which may be favorable ablation targets.

Therapeutic Potential of Local and Systemic Adipose-Derived Mesenchymal Stem Cell Injections in a Rat Model of Experimental Periodontitis: Implications for Cardiac Function

Periodontitis is a common inflammatory disease that not only damages periodontal tissues but also induces systemic effects, including cardiac dysfunction. Mesenchymal stem cells (MSCs) offer regenerative potential due to their ability to differentiate, modulate immune responses, and secrete anti-inflammatory factors. However, the relative efficacy of local versus systemic MSC administration remains unclear. This study evaluated the therapeutic effects of adipose-derived MSCs (AD-MSCs) in a rat model of experimental periodontitis, comparing local and systemic administration. AD-MSCs were characterized based on morphology, surface marker expression, and differentiation potential. Ligature-induced periodontitis was established over 60 days, after which AD-MSCs (1 × 106 cells) were administered either supraperiosteally (local group) or intravenously (systemic group). Periodontal regeneration was assessed through clinical, radiographic, and histopathological analyses, while cardiac function was evaluated using echocardiography and histopathological examinations. Results demonstrated that local AD-MSC administration provided superior therapeutic benefits compared to systemic delivery. Locally administered cells significantly enhanced bone regeneration, reduced inflammation, and improved periodontal tissue architecture. In contrast, systemic administration offered moderate benefits but was less effective in restoring periodontal integrity. Similarly, in the heart, local treatment resulted in greater improvements in systolic function, as indicated by enhanced ejection fraction and fractional shortening, along with reduced myocardial fibrosis. Although systemic administration also provided cardioprotective effects, diastolic dysfunction persisted in both treatment groups. In conclusion, local AD-MSC administration proved more effective in regenerating periodontal tissues and mitigating cardiac dysfunction, highlighting its potential as an optimized therapeutic strategy for periodontitis and its systemic complications.

Prediction of sudden death in obstructive hypertrophic cardiomyopathy after septal myectomy: Targeting the candidate

OBJECTIVE

To evaluate the applicability of current guidelines for patients with postoperative hypertrophic cardiomyopathy and identify key risk factors for sudden cardiac death (SCD).

METHODS

We retrospectively analyzed 1915 adult patients who underwent septal myectomy from 2010 to 2019. Competing risk models assessed the effectiveness of the updated 2024 American Heart Association (AHA)/American College of Cardiology and 2023 European Society of Cardiology (ESC) guidelines in guiding implantable cardioverter defibrillator (ICD) recommendations for preventing SCD after surgery.

RESULTS

Over a follow-up period of 4.6 ± 2.7 years, 19 SCD events and 1 ICD discharge were observed. No significant differences were found in AHA (Class 2a: 55% vs 39.3%; Class 2b: 5% vs 5.4%; Class 3: 40% vs 55.3%, P = .354) or ESC (Class 2a: 45% vs 45.3%; Class 2b: 20% vs 22.8%; Class 3: 35% vs 31.9%, P = .937) ICD recommendations, prevalence of major SCD risk factors, or 5-year SCD risk between event and nonevent groups. Survival analysis showed that ESC and AHA stratification did not significantly predict SCD (both P > .05). Left ventricular wall thickness (LVWT) (P = .028) and late gadolinium enhancement (LGE) (P = .015) were significant predictors. Cardiac index showed a potential association with SCD (nonlinear trend, P = .012; overall, P = .027). Patients with LVWT ≥30 mm and LGE ≥15% had a greater risk of SCD (subdistribution hazard ratio, 5.60; 95% confidence interval, 1.90-16.5, P = .002).

CONCLUSIONS

Current guidelines are inadequate for assessing postoperative SCD risk in patients with hypertrophic cardiomyopathy. LGE and LVWT are reliable indicators, highlighting the need for novel approaches to guide ICD implantation.

Impact of diabetes and glycemic status on ventricular-arterial coupling in the general population

BACKGROUND/AIMS

Ventricular-arterial coupling (VAC) plays a crucial role in cardiovascular physiology, affecting cardiac function and arterial properties for optimal organ perfusion. Considering that diabetes mellitus (DM) is a known risk factor for incident heart disease and vascular damage, this study aims to investigate whether changes in VAC due to DM occur earlier, even before the onset of clinically evident cardiovascular disease in the general population.

METHODS

This retrospective study included 2,884 participants (mean age 57 years, 48% male) of the Swedish CArdioPulmonary BioImage Study (SCAPIS), where data on echocardiography and Pulse wave velocity (PWV) were available. Of these, 162 individuals (6%) had prevalent type 2 diabetes (DM), and 334 (12%) had prediabetes. VAC was quantified as the ratio of PWV to Global longitudinal strain (GLS). Linear regression models were used to assess associations between glycemic status (DM, prediabetes), HbA1c, fasting plasma glucose (fP-glucose), and VAC, adjusting for relevant covariates.

RESULTS

I the fully adjusted model, prevalent DM and the combination of DM and prediabetes were significantly associated with increased values of PWV/GLS (Beta = 0.28, p < 0.001 and Beta = 0.14, p < 0.001 respectively), while no significant association was found between prediabetes and PWV/GLS. Increasing values of HbA1c and fP-glucose were significantly associated with higher values of PWV/GLS (Beta = 0.01,p < 0.001 and Beta = 0.07,p < 0.001, respectively) signaling worse VAC. In participants without prevalent DM, higher HbA1c levels were linked to increased PWV/GLS in the age- and sex-adjusted model; however, this association was attenuated after further adjustment for additional confounders. Conversely, fP-glucose remained significantly associated with elevated PWV/GLS across all adjusted models.

CONCLUSIONS

This study demonstrates a significant association between DM and impaired VAC, as reflected by elevated PWV/GLS, while no such link was observed in prediabetes. The transition from prediabetes to DM appears critical for VAC deterioration. Additionally, higher HbA1c and fP-glucose levels, even in non-diabetic individuals, were associated with worsened VAC, highlighting the impact of glycemic control on vascular function.

Effects of community-acquired pneumonia on biventricular cardiac functions in children

BACKGROUND

This study aimed to evaluate the effects of community-acquired pneumonia (CAP) on cardiac function in children and compare the effectiveness of tissue Doppler imaging (TDI) and two-dimensional speckle tracking echocardiography (2D-STE) with conventional echocardiography in the early detection of biventricular cardiac dysfunction in children with CAP.

METHODS

The study included 50 hospitalized children diagnosed with CAP and 50 matched healthy controls. All patients underwent cardiac evaluation including conventional echocardiography, TDI, and 2D-STE.

RESULTS

Fifty children with CAP with a mean age of 5.02 ± 2.46 years participated in the study. Thirty-two were male (64.0%). LV systolic function (S) and RV diastolic function (E'/A') were significantly lower in the diseased group compared to the control group (p < 0.001). The myocardial performance index (MPI) of both ventricles was significantly higher in the diseased group compared to the control group (p < 0.001). In patients with CAP, the mean value of two-dimensional longitudinal strain (2D LS) was significantly lower than that of the control group (p < 0.001). No statistically significant differences in echocardiographic parameters were observed when comparing complicated and non-complicated CAP subgroups.

CONCLUSION

TDI and 2D-STE demonstrated the ability to detect early biventricular dysfunction in pediatric patients diagnosed with CAP.

The correlation between insulin-like growth factor 1 and left ventricular mass index in obese children

OBJECTIVE

Low levels of Insulin-like Growth Factor 1 (IGF-1) are known risk factors for cardiovascular diseases. Left Ventricular Mass Index (LVMI) serves as an early predictor of adverse cardiovascular events. Obese children have relatively low concentrations of IGF-1 in their blood. To date, there is no research on whether there is a correlation between IGF-1 levels and LVMI in obese children. This study aims to investigate the potential correlation between IGF-1 and LVMI in obese children at a single center.

METHODS

A total of 104 obese children were selected as the case group, while 61 healthy children undergoing physical examinations served as the normal control group. Anthropometric measurements, assessments of IGF-1, and cardiovascular metabolic factors were conducted. Echocardiographic examinations were also performed to calculate the LVMI.

RESULTS

Compared to the control group, the obese group had significantly higher LVMI and significantly lower standard deviation scores for Insulin-like Growth Factor 1 (IGF-1 SDS). After controlling for confounding factors including total cholesterol (TC), triglycerides (TG), and uric acid (UA), there was a significant linear negative correlation between IGF-1 SDS and LVMI, and a significant linear positive correlation between homeostasis model of assessment for insulin resistance (HOMA-IR) and LVMI. Each unit increase in IGF-1 SDS resulted in a 16.1% decrease in LVMI (β = -0.161; p = 0.046), and each unit increase in HOMA-IR resulted in a 24.1% increase in LVMI (β = 0.241; p = 0.007).

CONCLUSION

IGF-1 and LVMI exhibit an independent negative correlation. Monitoring IGF-1 levels might provide valuable insights into the cardiovascular health of obese children, facilitating early identification and management of cardiovascular risk factors.

CLINICAL TRIAL NUMBER

Not applicable.

Predictive model development for left atrial remodeling in hypertrophic cardiomyopathy

Left atrial structural remodeling is closely linked with the prognosis of patients with hypertrophic cardiomyopathy (HCM). This study aimed to evaluate the clinical characteristics and risk factors associated with left atrial remodeling in HCM and to develop an early prediction model. HCM patients who underwent echocardiography during hospitalized enrolled. Patients with a left atrial diastolic anteroposterior diameter ≥ 40 mm were classified as the remodeling group, while others were assigned to the control group. Logistic regression analysis was employed to identify independent predictors, and a nomogram was constructed for prediction. A total of 1554 patients were enrolled, including 442 patients in the remodeling group. Significant differences in clinical and echocardiographic characteristics were observed between the two groups. Multivariate logistic regression analysis identified the following as independent predictors of left atrial remodeling: prothrombin time (P < 0.001; OR 0.863; 95% CI 0.813-0.915), main pulmonary artery diameter (P < 0.001; OR 0.881; 95% CI 0.852-0.911), left ventricular ejection fraction (P < 0.001; OR 1.057; 95% CI 1.043-1.071), and interventricular septal thickness (P < 0.001; OR 0.937; 95% CI 0.916-0.959). A nomogram prediction model based on these factors demonstrated good discriminatory power, with a receiver operating characteristic curve area of 0.7328 (95% CI 0.7052-0.7603). The model's calibration showed high accuracy and consistency with actual outcomes, particularly in intermediate probability ranges. Prothrombin time, main pulmonary artery diameter, left ventricular ejection fraction, and interventricular septal thickness were identified as risk factors for left atrial remodeling in HCM patients. The developed nomogram provides a valuable tool for early risk assessment, aiding in the early detection of left atrial remodeling and facilitating optimized treatment strategies to improve patient prognosis.

Impact of left ventricular rehabilitation on surgical outcomes in patients with borderline left heart hypoplasia

Objective

The clinical significance of left ventricular rehabilitation for borderline left ventricular hypoplasia is controversial. This study aimed to review the surgical results of patients with borderline left ventricular hypoplasia and to evaluate the impact of left ventricular rehabilitation on outcomes.

Methods

Patients diagnosed with borderline left ventricular hypoplasia and surgically treated from 2018 to 2022 were included. Overall surgical outcomes were evaluated. The changes in left ventricular volumes were calculated using angiography, and age-adjusted z-score N-terminal pro-B-type natriuretic peptide levels were analyzed in patients who underwent left ventricular rehabilitation.

Results

Thirty-three patients were included. Sixteen patients underwent primary biventricular repair, 3 patients underwent primary single ventricle palliation, and the remaining 14 patients underwent left ventricular rehabilitation; 9 received bilateral pulmonary artery banding and ductal stenting, 4 received central pulmonary artery banding, and 1 received ductal stenting. Of 14 patients who received left ventricular rehabilitation, 1 died, 1 underwent single ventricle palliation, 1 was waiting for further procedure, and 11 underwent biventricular repair. After biventricular repair, 2 patients died, and 1 patient developed hemodynamic failure. As a result, only 8 patients were alive and in good condition. In patients who underwent left ventricular rehabilitation, left ventricular end-diastolic volume index, end-systolic volume index, and left ventricular stroke volume index increased over time after left ventricular rehabilitation (P = .001, P = .007, and P = .009, respectively). The age-adjusted z-score N-terminal pro-B-type natriuretic peptide levels were stable until biventricular repair, but significantly higher in patients who presented with hemodynamic failure after biventricular repair compared with patients who did not exhibit hemodynamic failure.

Conclusions

In patients with borderline left heart hypoplasia, the left ventricular rehabilitation procedure promoted an increase in left ventricular volume and contributed to establishing a biventricular circulation. The short-term results of this strategy are satisfactory, but further studies are essential to determine the long-term outcomes.

Use of Advanced Echocardiographic Modalities to Discriminate Preclinical Hypertrophic Cardiomyopathy Mutation Carriers From Non-Carriers

BACKGROUND

It remains challenging to determine which hypertrophic cardiomyopathy (HCM) family members will subsequently develop HCM. Standard 2-dimensional and conventional Doppler echocardiography have been unable to reliably distinguish HCM genotype-positive and phenotype-negative (G+P-) from genotype-negative and phenotype-negative (G-P-) family members. We aimed to determine if advanced echocardiographic modalities can discriminate HCM G+P- from G-P- individuals.

METHODS

Comprehensive echocardiography including speckle tracking evaluation of myocardial deformation and color M-mode were performed in 199 participants aged ≥16 years who had undergone genetic testing from families with a known HCM pathogenic variant: 58 G+P-, 39 G-P-, and 102 overt patients with HCM (genotype-positive and phenotype-positive). The primary analysis compared these measures in all G+P- and G-P- individuals. A secondary analysis was undertaken in younger subjects (age ≤40 years).

RESULTS

Comparing G+P- and G-P- individuals, there were no significant differences in left ventricular ejection fraction, cavity size, wall thickness and outflow tract gradient, and tissue Doppler-derived myocardial velocities; however, septal/posterior wall thickness ratio was higher (1.06±0.09 versus 1.02±0.04, P=0.007). G+P- individuals had significantly lower color M-mode flow propagation velocity (color M-mode velocity propagation, 42.6 cm/s [interquartile range, 34.5-48.5 cm/s] versus 51.0 cm/s [interquartile range, 45.2-61.0 cm/s]; P<0.001) and higher global longitudinal strain (P=0.021), circumferential strain (P=0.003), and peak apical rotation (P=0.005). Multivariable logistic regression identified 2 independent predictors (color M-mode velocity propagation and peak apical rotation). A derived regression equation allowed reasonable discrimination of G+P- individuals with a sensitivity of 82.6% and specificity of 72.2% (P<0.0001) at the optimal cutoff. Similar findings were demonstrated when the analysis was restricted to younger subjects, although in addition to color M-mode velocity propagation and apical rotation, left ventricular ejection fraction was also independently predictive.

CONCLUSIONS

In HCM family members, color M-mode velocity propagation and apical rotation provide good sensitivity and specificity for identifying mutation carriers and may represent early disease markers before the onset of hypertrophy. Longitudinal studies involving larger cohorts are required to validate these findings.

Usefulness of tissue tracking to differentiate tachycardia-induced cardiomyopathy from dilated cardiomyopathy in patients admitted for heart failure

INTRODUCTION

Differentiation of tachycardia-induced cardiomyopathy (TIC) from dilated cardiomyopathy (DCM) in patients admitted for heart failure (HF) with left ventricular dysfunction and supraventricular tachyarrhythmia (SVT) remains challenging. The role of tissue tracking (TT) in this setting remains unknown.

METHODS

Forty-three consecutive patients admitted for HF due to SVT with left ventricular ejection fraction (LVEF) < 50% undergoing CMR were retrospectively included. Those eventually evolving to LVEF > 50% at follow-up were classified as TIC and those maintaining a LVEF < 50% were classified as DCM. Clinical, echocardiography, and CMR findings, including TT, were analyzed to predict LVEF recovery.

RESULTS

Twenty-five (58%) patients were classified as TIC. Late gadolinium enhancement (LGE) was more frequent in DCM group (61% vs 16%, p = 0.004). Left ventricle (LV) peak systolic radial velocity and peak diastolic radial strain rate were lower in DCM group (7.24 ± 4.44 mm/s vs 10.8 ± 4.5 mm/s; p = 0.015 and -0.12 ± 0.33 1/s vs -0.48 ± 0.51 1/s; p = 0.016, respectively). Right ventricle (RV) peak circumferential displacement was lower in patients with TIC (0.2 ± 1.3 vs 1.3 ± 0.9°; p = 0.009). In the multivariate analysis, diabetes (p = 0.046), presence of LGE (p = 0.028), LV peak systolic radial velocity < 7.5 mm/s (p = 0.034), and RV peak circumferential displacement > 0.5° (p = 0.028) were independent predictors of lack of LVEF recovery.

CONCLUSION

In the setting of acute HF with LV dysfunction related to SVT, diabetes, LGE, LV peak systolic velocity, and RV peak circumferential displacement are independent predictors of lack of LVEF recovery and, therefore, represent clinically useful parameters to differentiate TIC from DCM.

Portal vein pulsatility is associated with the cumulative fluid balance: A post hoc longitudinal analysis of a prospective, general intensive care unit cohort

BACKGROUND

Previous studies have explored tools for evaluating the effects of positive fluid balance, with recent emphasis, and controversies, on venous ultrasound parameters and composite scores. The portal vein pulsatility index and the renal venous pattern have emerged as the most promising indicators of volume-induced venous congestion. But in the general intensive care unit (ICU), numerous factors influence cardiovascular homeostasis, affecting venous function.

OBJECTIVES

This study aimed to evaluate the factors associated with portal vein pulsatility index in general ICU patients. Secondary objectives were to examine the correlations between pulsatility index and additional markers of congestion.

DESIGN

This exploratory study was a post hoc analysis of a prospective, multicentric, observational database.

SETTING

The data collection was performed in four ICUs in university-affiliated or tertiary hospitals.

PATIENTS

This study included adult patients within 24 h of general ICU admission with an expected ICU length of stay of more than 2 days.

INTERVENTION

Patients underwent clinical, biological, and echocardiographic assessments at several times: ICU admission, day 1, day 2, day 5 and the last day of ICU.

MAIN OUTCOME MEASURE

The study primary endpoint was the portal vein pulsatility index during the course of the patients' stay on the ICU.

RESULTS

One hundred forty-five patients and 514 haemodynamic evaluations were analysed. The mean age of the patients was 64 ± 15 years, 41% were women, with a median [IQR] admission simplified acute physiology score II of 46 [37 to 59]. The univariable followed by multivariable mixed-effects linear regression analyses demonstrated an association between portal vein pulsatility index, heart rate [estimate -0.002 (95% CI, -0.003 to -0.001), P  < 0.001] and the cumulative fluid balance [estimate 0.0007 (95% CI, 0.00007 to 0.001), P  = 0.024]. Portal vein pulsatility index showed no agreement with CVP of at least 12 mmHg (kappa correlation -0.008, P  = 0.811), negative passive leg raising (kappa correlation -0.036, P  = 0.430), mean inferior vena caval (IVC) diameter greater than 2 cm (kappa correlation -0.090, P  = 0.025), maximal IVC diameter greater than 2 cm (kappa correlation -0.010, P  = 0.835), hepatic vein systolic/diastolic ratio less than 1 (kappa correlation 0.043, P  = 0.276), or renal vein pulsatile pattern (kappa correlation -0.243, P  < 0.001).

CONCLUSION

The study findings emphasise the unique sensitivity of portal vein pulsatility index in assessing fluid balance in general ICU patients. The lack of correlation between portal vein pulsatility index and other parameters of venous congestion underscores its potential to provide distinctive insights into venous congestion.

Age- and sex-based normal reference ranges of the cardiac time intervals: the Copenhagen City Heart Study

BACKGROUND

Color tissue Doppler imaging (TDI) M-mode can be used to measure the cardiac time intervals including the isovolumic contraction time (IVCT), the left ventricular ejection time (LVET), the isovolumic relaxation time (IVRT), and the combination of all the cardiac time intervals in the myocardial performance index (MPI) defined as [(IVCT + IVRT)/LVET]. The aim of this study was to establish normal age- and sex-based reference ranges for the cardiac time intervals.

METHODS AND RESULTS

A total of 1969 participants free of cardiovascular diseases and risk factors from the general population with limited age range underwent an echocardiographic examination including TDI. The median age was 46 years (25th-75th percentile: 33-58 years), and 61.5% were females. In the entire study population, the IVCT was observed to be 40 ± 10 ms [95% prediction interval (PI) 20-59 ms], the LVET 292 ± 23 ms (95% PI 248-336 ms), the IVRT 96 ± 19 ms (95% PI 59-134 ms) and MPI 0.47 ± 0.09 (95% PI 0.29-0.65). All the cardiac time intervals differed significantly between females and males. With increasing age, the IVCT increased in females, but not in males. The LVET did not change with age in both sexes, while the IVRT increased in both sexes with increasing age. Furthermore, we developed regression equations relating the heart rate to the cardiac time intervals and age- and sex-based normal reference ranges corrected for heart rate.

CONCLUSION

In this study, we established normal age- and sex-based reference ranges for the cardiac time intervals. These normal reference ranges differed significantly with sex.

Cardioprotection and neurobehavioral impact of swimming training in ovariectomized rats

Cardiovascular (CV) disease is the major cause of mortality. Estrogens (E) exert multiple CV and neuroprotective effects. During menopause, CV and cognitive pathologies increase dramatically. At present, it is known that E exert many of their beneficial effects through the G protein-coupled estrogen receptor (GPER). Exercise reduces the risk of developing CV diseases. Sodium/proton exchanger (NHE-1) is overexpressed in ovariectomized (OVX) rats, probably due to the increase in reactive oxidative species (ROS). Insulin-like growth factor 1 (IGF-1), the main humoral mediator of exercise, inhibits the NHE-1. We aim to explore the subcellular mechanisms involved in the heart and brain impact of physiological exercise in OVX rats. We speculate that physical training, via IGF-1, prevents the increase in ROS, improving heart and brain physiological functions during menopause. Exercise diminished cardiac ROS production and increased catalase (CAT) activity in OVX rats. In concordance, IGF-1 treatment reduces brain ROS, surely contributing to the improvement in brain behavior. Moreover, the aerobic routine was able to prevent, and IGF-1 therapy to revert, NHE-1 hyperactivity in OVX rats. Finally, our results confirm the proposed signaling pathway as IGF-1/PI3K-AKT/NO. Surprisingly, GPER inhibitor (G36) was able to abolish the IGF-1 effect, suggesting that directly or indirectly GPER is part of the IGF-1 pathway. We propose that IGF-1 is the main responsible for the protective effect of aerobic training both in the heart and brain in OVX rats. Moreover, we showed that not only it is possible to prevent but also to revert the menopause-induced NHE-1 hyperactivity by exercise/IGF-1 cascade.

Hypertensive Heart Disease in the Nigerian Population: Prevalence, Phenotypes, and Cardiovascular Comorbidities

Objective There is a lack of studies on the phenotyping of hypertensive heart disease (HHD) that examine both left ventricular (LV) structure and function in patients with essential hypertension (HTN) in sub-Saharan Africa. In this study, we investigated the prevalence of HHD, its phenotypic characteristics, and associated cardiovascular (CV) comorbidities by analyzing both LV structure and function. This can significantly enhance the understanding of HHD in the Nigerian population. Methods This cross-sectional study involved 1,799 patients diagnosed with essential HTN, who were recruited from the Federal Medical Centre Abuja Hypertension Registry between 2016 and 2021. HHD was defined as the presence of abnormal LV geometry and/or LV diastolic dysfunction (LVDD), as assessed by echocardiography in accordance with the guidelines set by the American Society of Echocardiography and the European Association of CV Imaging. Abnormal LV geometry was characterized by either concentric remodeling, which is defined as a normal left ventricular mass index (LVMI) with a relative wall thickness (RWT) > 0.42, or left ventricular hypertrophy (LVH), which is indicated by an increased LVMI (> 95 g/m² in women and > 115 g/m² in men) with an RWT > 0.42. Patients with secondary HTN and those with HTN during pregnancy were excluded from the study. Results The mean age of the study participants was 55.3±13.0 years and the majority were female patients (55.9%). The prevalence of HHD, concentric LV remodeling, LVH, and LVDD was 90.8%, 38.2%, 47.4%, and 61.6%, respectively. After multivariate analysis, heart failure (adjusted odds ratio (OR): 9.71, confidence interval (CI) 6.20-15.23, p<0.001), stroke (OR: 1.59, CI 1.01-2.52, p=0.045), LVDD (OR: 2.01, CI 1.61-2.50, p<0.001), and female sex (OR: 1.47, CI 1.20-1.80, p<0.001) were independently and positively associated with LVH. Similarly, LVH (OR: 3.51, CI 2.53-4.87, p<0.001), diabetes mellitus (OR: 1.83, CI 1.37-2.44, p<0.001), concentric LV remodeling (OR: 2.18, CI 1.58-3.01, p<0.001), stroke (OR: 1.87, CI 1.06-3.32, p=0.032), and age ≥60 years (OR: 3.92, CI 3.09-4.96, p<0.001) were independently and positively associated with LVDD. Conclusion Our study showed a high prevalence of HHD with LVH and LVDD as common phenotypes in our hypertensive cohort. These findings suggest that the widespread use of echocardiography should be promoted to aid the early diagnosis of HHD.

Spectral Doppler of aortic and carotid blood flow in horses with aortic valve regurgitation

OBJECTIVES

This study aimed to compare two-dimensional, M-mode, color, pulsed-wave Doppler (PWD) and continuous-wave Doppler (CWD) echocardiography, and PWD ultrasonography of the caudal common carotid artery (CCA) in horses with aortic regurgitation (AR).

ANIMALS

Warmblood horses without (n = 20) and with mild, moderate, and severe AR (n = 60) were included in the study.

MATERIALS AND METHODS

A retrospective descriptive study focused on cardiac dimensions, aortic and CCA Doppler flow. Non-invasive blood pressure and presence of ventricular arrhythmia were recorded. Groups were compared using analysis of variance, chi-square, Spearman's rho, and Kruskal-Wallis tests.

RESULTS

Maximal aortic antegrade flow velocity was higher in horses with moderate and severe AR than in normal horses and higher in those with severe AR than in those with mild AR (P<0.001). Mean (standard deviation) antegrade CCA flow velocities were 0.9 m/s (0.3 m/s) in normal horses and 1.0 m/s (0.2 m/s), 1.2 m/s (0.3 m/s), and 1.5 m/s (0.4 m/s) in horses with mild, moderate, and severe AR, respectively. Retrograde mid-to-end diastolic PWD ultrasonography of the common carotid artery (PWD-CCA) flow occurred in horses with moderate (6/20) and severe (13/20) AR. The presence of pathologic retrograde PWD-CCA flow was associated with presence of increased left ventricular dimensions and pulse pressures >60 mmHg. The CWD regurgitant jet pressure half-time failed to differentiate between AR severity grades.

STUDY LIMITATIONS

The limitations of this study included retrospective design with missing values, AR classification system not validated by longitudinal follow-up, and CCA retrograde velocities <10 cm/s not measured.

CONCLUSIONS

Pulsed-wave Doppler ultrasonography of the common carotid artery identifies moderate and severe AR in horses with hemodynamic overload. Presence of retrograde PWD-CCA flow was associated with moderate and severe AR and with left ventricular dilation. Quantification of CWD pressure half-time appeared unreliable for AR severity assessment.

Real-world characteristics and treatment of cardiac transthyretin amyloidosis: A multicentre, observational study

AIMS

Data on the clinical profiles of patients with transthyretin amyloidosis cardiomyopathy (ATTR-CM) in the post-approval era of tafamidis 61 mg are lacking. Study aims were characterization of contemporary ATTR-CM patients, analysis of potential eligibility for the 'Transthyretin Amyloidosis Cardiomyopathy Clinical Trial' (ATTR-ACT) and identification of factors associated with the decision on tafamidis 61 mg treatment.

METHODS AND RESULTS

This retrospective study analysed ATTR-CM patients seen at eight University Hospitals in the first year after approval of tafamidis 61 mg for ATTR-CM in Germany (April 2020 to March 2021). The cohort comprised 366 patients (median age 79 [74; 82] years, 84% male), with 47% and 45% of the cohort being in National Amyloidosis Centre ATTR stage ≥ II and NYHA class ≥ III, respectively. Sixty-four per cent of patients met key eligibility criteria of the pivotal ATTR-ACT. In recently diagnosed patients (58% with diagnosis ≤6 months), the rate of variant ATTR was significantly lower than in patients diagnosed more than 6 months ago (9.3% vs. 19.7%). Of the 293 patients without prior ATTR specific treatment, tafamidis 61 mg was newly initiated in 77%. Patients with tafamidis 61 mg treatment were significantly younger, were more often eligible for ATTR-ACT, had lower NYHA class and higher serum albumin levels. These variables explained 16% of the variance of treatment decision. Unadjusted survival was higher in patients with than those without treatment (1-year survival 98.6% vs. 87.3%, P < 0.001).

CONCLUSIONS

Wild-type ATTR was the primary aetiology amongst contemporary ATTR-CM patients and almost two-thirds of patients were in an advanced disease stage. Clinical profiles of 64% of patients in routine care matched those of the ATTR-ACT. Further effort is needed to detect patients at an earlier disease stage and to validate criteria justifying treatment initiation.

Efficacy of febuxostat on hyperuricemia and estimated glomerular filtration rate in patients with non-dialysis stage 3/4 chronic kidney disease and assessment of cardiac function: a 12-month interventional study

Objectives

Febuxostat, an oral medication for treating hyperuricemia (HUA), is a non-purine xanthine oxidase inhibitor that regulates serum uric acid (SUA) metabolism in patients with chronic kidney disease (CKD). However, the drug's effectiveness in improving renal function in patients with non-dialysis stage 3/4 CKD remains unclear. Our aim is to investigate the efficacy of febuxostat on kidney function. In addition, the cardiac function will be assessed.

Method

We conducted a single-center, interventional, randomized, controlled, open-label study. A total of 316 patients with non-dialysis stage 3/4 CKD, with SUA ≥6mg/dL in women and ≥7mg/dL in men, were assigned to either the febuxostat group (n=156) or the control group (n=160). The primary endpoint was the evaluation of changes in kidney biomarkers from baseline to 12 months of treatment, and any changes in cardiac biomarkers and echocardiographs were the secondary endpoint.

Results

The primary endpoint was a comparison between the two groups from baseline to 12 months of treatment. SUA was significantly decreased in patients treated with febuxostat 40 mg (6.85 ± 0.41mg/dL at baseline and 5.27 ± 0.70mg/dL at 12 months of treatment, P<0.001) and this was associated with increased eGFR (34.48 ± 8.42ml/min at baseline and 38.46 ± 8.87ml/min at 12 months of treatment, P<0.001). There were significant decreases in high-sensitivity troponin T (19.50 ± 7.24ng/L at baseline and 16.98 ± 7.32ng/L at 12 months of treatment, P<0.001) and N-terminal-pro brain natriuretic peptide (941.35 ± 374.30pg/ml at baseline and 762.22 ± 303.32 pg/ml at 12 months of treatment, P<0.001) in the febuxostat group. These changes were also associated with increased left ventricular ejection fraction in the febuxostat group (50.47 ± 3.95% at baseline and 51.12 ± 3.96% at the end of the study, P<0.001).

Conclusion

In the interventional group, febuxostat was well-tolerated and demonstrated a reduction in SUA associated with an increase in eGFR. This slowed down the progression of renal disease in patients with non-dialysis stage 3/4 CKD and improved cardiac function.

Atrial Translocation of Porphyromonas gingivalis Exacerbates Atrial Fibrosis and Atrial Fibrillation

BACKGROUND

Recent studies have indicated an association between periodontitis and atrial fibrillation (AF), although the underlying mechanisms remain unclear. Porphyromonas gingivalis is a causative agent of periodontal disease and is highly pathogenic. This study focused on P gingivalis and aimed to investigate the relationship among periodontitis, atrial translocation of P gingivalis, and atrial fibrosis and AF.

METHODS

An experiment was conducted using P gingivalis-infected C57BL/6J mice, in which P gingivalis was inoculated into the pulp of the molars. Immunohistochemistry was used to visualize the localization of P gingivalis, and loop-mediated isothermal amplification was employed to detect P gingivalis DNA in the left atrium. AF inducibility was examined by intracardiac stimulation. Moreover, left atrial appendage specimens were obtained from 68 patients with AF. A periodontal examination was conducted before the surgery, and the periodontal epithelial surface area and periodontal inflamed surface area, which are quantitative indices used to determine the clinical severity of periodontitis, were measured. The bacterial number of P gingivalis in human atrial tissue was analyzed via quantitative polymerase chain reaction. Atrial fibrosis was assessed using Azan-Mallory staining.

RESULTS

The translocation path of P gingivalis from the dental granuloma to the left atrium via the circulatory system was demonstrated by immunohistochemistry and loop-mediated isothermal amplification in P gingivalis-infected mice, which showed a higher degree of atrial fibrosis (21.9% versus 16.3%; P=0.0003) and a higher AF inducibility (30.0% versus 5.0%; P=0.04) than the control mice. Upregulation of GAL3 (galectin 3) and transforming growth factor-beta 1 in the left atrium was observed in P gingivalis-infected mice. Moreover, immunohistochemistry revealed that P gingivalis was also present in human atrial tissue. The number of P gingivalis in the human atrial tissue was positively correlated with periodontal epithelial surface area (ρ=0.35; P=0.004), periodontal inflamed surface area (ρ=0.52, P<0.0001), and the degree of atrial fibrosis (ρ=0.38; P=0.002).

CONCLUSIONS

P gingivalis translocation to the left atrium correlates with the clinical severity of periodontitis, which may exacerbate atrial fibrosis and AF. Atrial translocation of P gingivalis is a potential pathway explaining the causal relationship between periodontitis and AF.

Long term outcome after surgical tetralogy of Fallot repair at young age: Longitudinal follow-up up to 50 years after surgery

BACKGROUND

Little is known about the very long-term outcome in Tetralogy of Fallot (ToF) patients.

OBJECTIVES

To prospectively evaluate clinical outcome and quality-of-life after surgical repair of ToF.

METHODS

Single-centre, longitudinal cohort-study evaluating every decade 144 ToF patients who underwent surgical repair <15 years of age between 1968 and 1980.

RESULTS

Evaluated were 66 patients (92 %) of the 72 eligible survivors (58 % male, median age at study 48.5 years) with a median follow-up of 45 (range 39-52) years. Cumulative survival at 50 years was 71 % and 84 % when excluding 30-days mortality, while event-free survival was 9 %. Reintervention (40 %) and symptomatic arrhythmias (21 %) were the most common complications, although ventricular tachycardia (VT) was rare (7 %). Cardiac magnetic resonance imaging showed a right ventricular ejection fraction <45 % in 45 % of the cohort and 42 % had a diminished left ventricular function. The aortic root diameter increased over time to >40 mm in 45 % of patients. VO2max was reduced in 53 % of patients but stable over time. Self-perceived quality-of-life was stable and comparable to the general Dutch population. Early post-operative arrhythmias, pre-operative low oxygen saturation of the left atrium, VT and declining exercise capacity over time were predictive for mortality, transannular patch for both arrhythmia and pulmonary valve replacement. Surgery post-1975 was protective for pulmonary valve replacement.

CONCLUSION

Only 9 % of ToF patients is alive without a major event at 50 years after surgical repair. Reintervention and symptomatic arrhythmias are especially common, although symptomatic VT is rare. Exercise capacity and self-perceived quality-of-life remained stable.

Follow-up of incidentally detected mild to moderate ascending aortic dilation and risk factors for rapid progression in a Swedish middle-aged population

BACKGROUND

Thoracic aortic aneurysm is a life-threatening disease due to the risk for acute aortic syndromes, and subjects with dilated ascending aortas are recommended surveillance imaging to assess the need for preventive surgery. Our objectives were to investigate the progression of dilated ascending aortas and risk factors for rapid progression in a prospectively enrolled general population-based cohort of subjects aged 50-65 years.

METHODS

From the 5058 subjects prospectively enrolled in the general population-based Swedish CArdioPulmonary bioImage Study (SCAPIS) in Linköping, we followed all 74 subjects (22% female, mean age 59±4 years) with ascending aortic dilation (≥40 mm) identified by CT angiography, thoracic CT or transthoracic echocardiography. Office and home blood pressure (BP), pulse wave velocity, coronary artery calcification and carotid plaques were assessed at baseline. Transthoracic echocardiography was used to follow ascending aortic diameters over time.

RESULTS

Three subjects underwent acute or elective aortic repair before the first follow-up examination. Among the remaining subjects, the mean progression rate of ascending aortic diameter was 0.4 mm/year (range 0-1.8 mm/year) during a mean follow-up of 6.1±1.3 years. In 10 (14%) subjects, all men, no progression was seen. In multivariable analysis, higher 7-day home systolic BP was the only factor associated with faster progression rate.

CONCLUSIONS

Progression of mild to moderate ascending aortic dilation was in general slow. Our findings emphasise the benefit of home BP measurements over office BP and underline the importance of BP control in subjects with a dilated ascending aorta.

Developing a Novel Index for Individual-Level Social Determinants and Cardiovascular Diseases in the Coronary Artery Risk Development in Young Adults (CARDIA) Study

BACKGROUND

Social determinants of health (SDH) have been found to contribute to cardiovascular risk and the development of cardiovascular disease (CVD). However, few studies have examined early-life exposure to SDH and the combined effect of multiple SDH measures on CVD. There is an urgent need to develop an SDH index for use in practice and clinical settings.

METHODS

A total of 3189 participants from the CARDIA Study who had chest CT scans at the year-25 (Y25) visit were included in this study. Personal and parental SDH measures, including education, occupation, income, financial strain, and childhood family environment, were obtained through interviews. The participants' coronary artery calcification (CAC) was measured using chest CT scans, and left-ventricular mass (LVM) was measured using M-mode echocardiography. The values of the individual social determinants of health (iSDH) index were determined based on individual-level measures and CAC using a supervised learning method-the Boosted Regression Tree (BRT) model. This index's association with the LVM index (LVMI) was evaluated as an external validation using linear regression models adjusting for race, sex, BMI, smoking status, alcohol intake, and physical activity.

RESULTS

Each one-standard-deviation (SD) increase in the iSDH index was associated with an increase in LVMI ranging from 0.376 (95% CI -0.016, 0.767) at year 0 to 0.468 (95% CI 0.115, 0.821) at year 20. The association between the iSDH index and the LVMI was more pronounced as the participants aged. Also, the iSDH indices were more strongly associated with LVMI among Black participants (β = 0.969, 95% CI = 0.081, 1.858) than White participants (β = 0.202, 95% CI = -0.228, 0.633) at year 5.

CONCLUSIONS

Higher iSDH indices in early adulthood were associated with increased LVMI values in midlife. The association between the iSDH index and CVD was stronger among Black adults than with White adults.

Characteristics, management and outcomes of central versus peripheral pulmonary embolism: a retrospective cohort study

BACKGROUND

The location of thrombus in acute pulmonary embolism (PE) is a debatable prognostic factor. We compared the characteristics and outcomes of hospitalized patients with central versus peripheral PE.

METHODS

This retrospective study evaluated patients with acute PE diagnosed by CT pulmonary angiography who were hospitalized between 01/01/2016 and 31/12/2022. We compared patients with central (pulmonary trunk/main pulmonary artery) and peripheral (lobar/segmental/subsegmental) PE.

RESULTS

We studied 438 patients (median age: 63 years; PE diagnosis in the Emergency Department: 64.8%; PE peripheral in 305 patients [69.6%] and central in 133 [30.4%]). Patients with central PE had higher levels of troponin I and brain natriuretic peptide and more frequent right ventricular strain by CT pulmonary angiography/ echocardiography (72.1% versus 33.3%, p < 0.0001). PE mortality risk could be classified in 355 patients; 24.4% of the 238 patients with peripheral PE were intermediate-high/ high-risk compared with 63.3% of the 117 patients with central PE. Patients with central PE had more systemic thrombolysis (13/133 [9.8%] versus 6/305 [2.0%], p < 0.0001) and more advanced endovascular therapy (15/133 [11.3%] versus 2/305 [0.7%], p < 0.0001). All-cause hospital mortality rate was similar in patients with central and peripheral PE (5.3% and 6.6%, respectively; p = 0.61). On multivariable logistic regression analysis, central versus peripheral PE was not associated with hospital mortality (odds ratio 0.392, 95% confidence interval 0.128, 1.199).

CONCLUSIONS

The majority of patients with central PE and a minority of those with peripheral PE were classified as intermediate-high/ high-risk, however, the central thrombus location was not associated with an increased risk of mortality.

Nutritional Status Is Associated with Mortality but Not Appropriate Discharge of Implantable Cardioverter Defibrillators in Patients with Heart Failure

Objective: To investigate the predictive value of nutritional status in heart failure (HF) patients with an implantable cardioverter defibrillator (ICD), and to identify factors associated with ICD discharge and mortality. Methods: This retrospective study was conducted by analyzing data from 2017 to 2021. HF patients who underwent ICD implantation for primary prevention were included. Follow-up visits were continued until December 2022. Patients were examined based on ICD shock occurrence (ICD-A: appropriate shock), ICD non-discharge (ICD-X), and mortality. Nutritional status was assessed by the Prognostic Nutritional Index (PNI) and the Controlling Nutritional Status (CONUT) scores. Results: A total of 221 patients were included in the study, 86 of whom were in the ICD-A group (135 in the ICD-X group). Age and sex distribution were similar in these groups. The all-cause mortality rate was 20.36%. A PNI with a cut-off value of <47.25 and a CONUT score with a cut-off value of >2.5 were able to significantly predict all-cause mortality. The PNI had a greater area under the curve compared to the CONUT. Non-ischemic cardiomyopathy and high left-ventricle end-systolic diameter (ESD) were independently associated with appropriate ICD shock. Low systolic blood pressure, high ESD, low sodium, low total cholesterol, low (<47.25) PNI, and ICD shock were independently associated with all-cause mortality. Conclusions: Malnutrition appears to be associated with mortality in patients with primary-prevention ICDs, and the PNI appears to be a more useful indicator than the CONUT for determining the risk of mortality in these patients.

Understanding Sex Differences in Hypertrophic Cardiomyopathy Surgery: Insights From a Decade-Long Cohort Study From China

BACKGROUND

Sex differences in patients with hypertrophic cardiomyopathy have been elaborated by many studies. However, large studies of the association of patient sex with outcomes after surgical myectomy are scarce. This study evaluated sex disparities in a large Chinese cohort undergoing hypertrophic cardiomyopathy surgery.

METHODS

The cohort encompassed 1613 patients, including 627 (38.9%) women who underwent septal myectomy between 2009 and 2018.

RESULTS

At the time of surgery, women were 6 years older and had 1 year longer disease onset-to-surgery delay than men. They were more frequently in New York Heart Association class III/IV and had more severe left ventricular outflow tract obstruction. Compared with men, women had a notably higher left ventricular wall thickness index and a lower extent of late gadolinium enhancement. Women also had more mutations in MYH7 and fewer in MYBPC3. Postoperatively, women had a higher operative mortality rate (1.3% versus 0.1%, P=0.006). The follow-up results showed no significant difference between the sexes in all-cause death (hazard ratio [HR], 0.67 [95% CI, 0.38-1.18]; P=0.166). A U-shaped association was observed between age and death in the overall population. However, women exhibited this association more obviously at age ≥55 years and men at <35 years. Moreover, women also had a higher risk of cardiovascular rehospitalization after surgery (HR, 1.40 [95% CI, 1.03-1.89]; P=0.030).

CONCLUSIONS

In patients with obstructive hypertrophic cardiomyopathy, women had a similar fatal outcome but a worse nonfatal outcome than men after surgery. Measures improving quality of life may further enhance the event-free survival of female patients. Close monitoring and follow-up are warranted, especially in younger men and older women.

Outpatient diuretic intensification: a simple prognostic marker in cardiac transthyretin amyloidosis

BACKGROUND

Currently, simple clinical parameters indicating disease progression are lacking in patients with transthyretin amyloid cardiomyopathy (ATTR-CM). This study aimed to evaluate the prognostic value of outpatient diuretic intensification (ODI) in ATTR-CM patients.

METHODS

This retrospective study examined ATTR-CM patients at a tertiary care center between August 1, 2020, and June 30, 2023. ODI was defined as any loop diuretic increase within 6 months after baseline visit, and its impact on all-cause mortality and hospitalization for heart failure (HF) was analyzed.

RESULTS

Altogether, 182 patients were included (median age 80 [76; 84] years; 88% male), and 25% experienced ODI (median increase 10 [10; 40] mg furosemide equivalent). Independent predictors of ODI were higher baseline New York Heart Association (NYHA) class and polyneuropathy. Both any ODI and the magnitude of furosemide equivalent increase were significantly associated with mortality and HF hospitalization during a median follow-up of 17 months. After adjusting for baseline NYHA class and National Amyloidosis Centre stage, significantly increased risk of all-cause mortality (hazard ratio [HR] 2.38, 95% confidence interval [CI] 1.03-5.53; p = 0.043) and HF hospitalization (HR 3.27, 95% CI 1.41-7.60; p = 0.006) persisted in patients with ODI. Its prognostic value was similar in strata of age, ATTR subtype, previous cardiac decompensation, biomarkers, left ventricular ejection fraction, six-minute walk distance, and tafamidis treatment.

CONCLUSION

ODI occurred in one in four ATTR-CM patients within 6 months and was associated with more severe baseline amyloid organ manifestations. ODI and the magnitude of diuretic dose increase provide easily assessable clinical markers of disease progression in patient monitoring.

Ultrasound-Guided Fluid Volume Management in Patients With Septic Shock: A Randomized Controlled Trial

BACKGROUND

Ultrasound-guided fluid management is increasingly used in the intensive care unit, yet it's benefits in septic shock remains unknown.

OBJECTIVE

To evaluate the use of critical care ultrasound for individualized volume management in septic shock patients.

METHODS

A single-center, randomized controlled, prospective study was conducted on patients with septic shock admitted to the intensive care unit in Xi'an Daxing Hospital, Xi'an City, China, from September 2022 to December 2023. Upon intensive care unit admission, the patients were resuscitated according to the latest sepsis and septic shock guidelines and early goal-directed therapy. The study group additionally underwent critical care ultrasound examination to monitor and guide the adjustment of fluid resuscitation in real-time. The two groups' physiological and biochemical indexes and prognoses were compared before (T0) and 6 hours after (T6) fluid resuscitation.

RESULTS

A total of 113 patients with septic shock were selected and randomly allocated into study (n = 57) and control (n = 56) groups. The central venous oxygen saturation, heart rate, mean arterial pressure, blood lactate, and lactate clearance rate of the two groups at T6 were significantly improved compared to T0 (P < .05). At T6, the study group's blood lactate was significantly lower and the lactate clearance was significantly higher than the control group (P < .05). At T6, the incidence of pulmonary edema, incidence of left heart failure, Sequential Organ Failure Assessment (SOFA) score and length of the intensive care unit hospitalization in the study group were significantly lower than the control group (P < .05).

CONCLUSION

The application of critical care ultrasound improved the outcome and helped guide individualized management of patients with septic shock.

Mavacamten-Associated Temporal Changes in Left Atrial Function in Obstructive HCM: Insights From the VALOR-HCM Trial

BACKGROUND

In severely symptomatic patients with obstructive hypertrophic cardiomyopathy (HCM), the VALOR-HCM (A Study to Evaluate Mavacamten in Adults With Symptomatic Obstructive Hypertrophic Cardiomyopathy Who Are Eligible for Septal Reduction Therapy) trial showed that mavacamten reduced the eligibility for septal reduction therapy with sustained improvement in left ventricular outflow tract gradients. Mavacamten also resulted in favorable cardiac remodeling, including improvement in biomarkers (eg, N-terminal pro-B-type natriuretic peptide and troponin T). However, the impact of mavacamten on left atrial (LA) function is unknown.

OBJECTIVES

The aim of this study was to assess serial changes in LA strain measures in patients enrolled in the VALOR-HCM trial.

METHODS

VALOR-HCM included 112 symptomatic patients with obstructive HCM (mean age 60 years; 51% male). Patients assigned to receive mavacamten at baseline (n = 56) continued therapy for 56 weeks and those assigned to placebo transitioned to mavacamten (n = 52) from week 16 to week 56. Echocardiographic LA strain (reservoir, conduit, and contraction) was measured by using a vendor-neutral postprocessing software.

RESULTS

At baseline, the mean LA volume index (LAVI) and LA strain values (conduit, contraction, and reservoir) were 41.3 ± 16.5 mL/m2, -11.8% ± 6.5%, -8.7% ± 5.0%, and 20.5% ± 8.7%, respectively (all worse than reported normal). LAVI significantly improved by -5.6 ± 9.7 mL/m2 from baseline to week 56 (P < 0.001). There was a significant (P < 0.05) improvement in absolute LA strain values from baseline to week 56 (conduit [-1.7% ± 6%], contraction [-1.2% ± 4.5%], and reservoir [2.8% ± 7.7%]). Patients originally receiving placebo had no differences in LA measurements up to week 16. There was no significant improvement in LA strain values (conduit [-0.9% ± 3.8%], contraction [-0.4% ± 3.4%], and reservoir [1.4% ± 6.1%]; all; P = not significant) from baseline to week 56 in patients with history of atrial fibrillation.

CONCLUSIONS

In VALOR-HCM, mavacamten resulted in an improvement in LAVI and LA strain at week 56, suggesting sustained favorable LA remodeling and improved function, except in the atrial fibrillation subgroup. Whether the advantageous LA remodeling associated with long-term treatment with mavacamten results in a favorable impact on the observed high burden of atrial tachyarrhythmias in HCM remains to be proven. (A Study to Evaluate Mavacamten in Adults With Symptomatic Obstructive Hypertrophic Cardiomyopathy Who Are Eligible for Septal Reduction Therapy [VALOR-HCM]; NCT04349072).

Rostafuroxin, the inhibitor of endogenous ouabain, ameliorates chronic undernutrition-induced hypertension, stroke volume, cardiac output, left-ventricular fibrosis and alterations in Na+-transporting ATPases in rats

Our aim has been to investigate the effect of Rostafuroxin, an inhibitor of endogenous cardiotonic steroids (EO/CTS), on cardiac structure and function and cardiac Na+ transport in undernourished hypertensive Wistar rats, and to determine whether chronic undernutrition is a modifiable risk factor for cardiovascular-kidney-metabolic (CKM) syndrome. Echocardiographic studies evaluated stroke volume cardiac output, ejection fraction, mitral valve early diastolic blood flow/late diastolic blood flow (E/A) ratio, and right renal resistive index. The cardiomyocyte area and collagen infiltration of cardiac tissue were investigated, as also the activities of the cardiac ouabain-sensitive (Na++K+)ATPase ((Na++K+)ATPase Sens) and ouabain-resistant Na+-ATPase (Na+-ATPase Res). Undernourished hypertensive rats presented tachycardia, reduced stroke volume, decreased cardiac output, preserved fractional shortening and ejection fraction, unmodified mitral valve E/A ratio, and increased right renal resistive index. Cardiomyocyte size decreased and intense collagen infiltration had occurred. The (Na++K+)ATPase Sens activity decreased, whereas that of Na+-ATPase Res increased. Rostafuroxin selectively modified some of these echocardiographic and molecular parameters: it increased stroke volume and cardiac output and prevented histopathological alterations. The drug decreased and increased the activities of (Na++K+)ATPase Sens and Na+-ATPase Res, respectively, in normonourished rats, and the opposite trend was found in the undernourished group. It is concluded that chronic undernutrition in rats can provoke structural, functional, histological, and molecular cardiovascular alterations that, with the simultaneous changes in renal parameters described in this and in previous studies, configure an undescribed type of CKM syndrome. The data also demonstrate that the blockade of EO/CTS ameliorates stroke volume and cardiac output, thus preventing or delaying the worsening of the syndrome.

Automated Detection of Reduced Ejection Fraction Using an ECG-Enabled Digital Stethoscope: A Large Cohort Validation

BACKGROUND

Asymptomatic left ventricular systolic dysfunction (ALVSD) affects 7 million globally, leading to delayed diagnosis and treatment, high mortality, and substantial downstream health care costs. Current detection methods for ALVSD are inadequate, necessitating the development of improved diagnostic tools. Recently, electrocardiogram-based algorithms have shown promise in detecting ALVSD.

OBJECTIVES

The authors developed and validated a convolutional neural network (CNN) model using single-lead electrocardiogram and phonocardiogram inputs captured by a digital stethoscope to assess its utility in detecting individuals with actionably low ejection fractions (EF) in a large cohort of patients.

METHODS

2,960 adults undergoing echocardiography from 4 U.S. health care networks were enrolled in this multicenter observational study. Patient data were captured using a digital stethoscope, and echocardiograms were performed within 1 week of data collection. The algorithm's performance was compared against echocardiographic EF (EF measurements, categorizing EF as normal and mildly reduced [>40%] or moderate and severely reduced [≤40%]).

RESULTS

The CNN model demonstrated an area under the receiver operating characteristic curve of 0.85, with a sensitivity of 77.5%, specificity of 78.3%, positive predictive value of 20.3%, and negative predictive value of 98.0%. Among those with an abnormal artificial intelligence screen but EF >40% (false positives), 25% had an EF between 41%-49% and 63% had conduction/rhythm abnormalities. Subgroup analyses indicated consistent performance across various demographics and comorbidities.

CONCLUSIONS

The CNN model, utilizing a digital stethoscope, offers a noninvasive and scalable method for early detection of individuals with EF ≤40%. This technology has the potential to facilitate early diagnosis and treatment of heart failure, thereby improving patient outcomes.

Characterization and Mortality Risk of Impaired Left Ventricular Filling in Chronic Obstructive Pulmonary Disease

Rationale: In chronic obstructive pulmonary disease (COPD), impaired left ventricular (LV) filling might be associated with coexisting heart failure with preserved ejection fraction (HFpEF) or due to reduced pulmonary venous return indicated by small LV size. Objectives: We investigated the all-cause mortality associated with small LV or HFpEF and clinical features discriminating between both patterns of impaired LV filling in patients with COPD. Methods: We performed transthoracic echocardiography (TTE) in patients with stable COPD from the COSYCONET (COPD and Systemic Consequences and Comorbidities Network) cohort to define small LV as LV end-diastolic diameter below the normal range and HFpEF features according to recommendations of the European Society of Cardiology. We assessed the ratio of early to late ventricular filling velocity (E/A), ratio of early mitral inflow velocity to annular early diastolic velocity (E/e'), serum N-terminal pro-brain natriuretic peptide, high-sensitivity troponin I, airflow limitation (FEV1), lung hyperinflation (residual volume), and gas transfer capacity (DlCO) and discriminated patients with small LV from those with HFpEF features or no relevant cardiac dysfunction as per TTE (normalTTE). The primary outcome was all-cause mortality after 4.5 years. Measurements and Main Results: In 1,752 patients with COPD, the frequency of small LV, HFpEF features, and normalTTE was 8%, 16%, and 45%, respectively. Patients with small LV or HFpEF features had higher all-cause mortality rates than patients with normalTTE: hazard ratio, 2.75 (95% confidence interval, 1.54-4.89) and 2.16 (95% confidence interval, 1.30-3.61), respectively. Small LV remained an independent predictor of all-cause mortality after adjusting for confounders including exacerbation frequency and measures of residual lung volume, DlCO, or FEV1. Compared with normalTTE, patients with small LV had reduced LV filling, as indicated by lowered E/A. Yet, in contrast to patients with HFpEF features, patients with small LV had normal LV filling pressure (E/e') and lower concentrations of N-terminal pro-brain natriuretic peptide and high-sensitivity troponin I. Conclusions: In COPD, both small LV and HFpEF features are associated with increased all-cause mortality and represent two distinct patterns of impaired LV filling. Clinical trial registered with www.clinicaltrials.gov (NCT01245933).

Association between obesity and prevalence of significant regurgitant valvular heart disease over time: A cohort study

BACKGROUND

The association between valvular heart disease and obesity is poorly documented. The present study evaluated the prevalence and worsening over time of valvular regurgitation by obesity category.

METHODS

This cohort study included 11385 patients who underwent two echocardiographic examinations at least 1 year apart. Mitral, tricuspid, and aortic regurgitation were graded at the first and last visits. Regurgitation worsening was defined as those going from non/trace to moderate/severe or from moderate to severe. Frequency and worsening of regurgitant valvular heart disease were evaluated across body mass index (BMI) categories and adjusted for age, sex, follow-up time, and significant regurgitation at first exam.

RESULTS

Patients aged 63 ± 15 years old at the last visit (43 % women, 29 % with obesity, median follow-up time of 3 years [interquartile range 2-6]). Valve regurgitation was more common in patients without obesity than in those with obesity across all age groups. The prevalence of mitral, tricuspid and aortic valve regurgitations at the last visit diminished for increased BMI categories: 24 %, 19 %, 16 % and 14 % for patients with normal weight, overweight, obesity and severe obesity, respectively (p < 0.001). The regurgitation worsening observed in any valve followed a similar trend: 14 %, 11 %, 9 % and 8 %, respectively (p < 0.001). These inverse associations with BMI remained significant after adjustments for cofactors.

CONCLUSIONS

Obesity was associated with lower valvular regurgitation prevalence and worsening that persisted in the mitral and tricuspid valves after adjusting for confounders and excluding patients changing weight over time, suggesting the existence of an obesity paradox in valvular heart diseases.

Growth in a two-dimensional model of coarctation of the aorta: A CFD-informed agent based model

In the individualized treatment of a patient with Coarctation of the Aorta (CoA), a non-severe case which initially exhibits no symptoms, and thus requires no treatment, could potentially become severe over time. This progression can be attributed to insufficient growth at the coarctation site relative to the overall growth of the child. Therefore, an agent-based model (ABM) to predict the aortic growth of a CoA patient is introduced. The multi-scale approach combines Computational Fluid Dynamics (CFD) and ABM to study systems that are influenced by both mechanical stimuli and biochemical responses characteristic of growth. Our focus is on ABM development; thus, CFD insights were applied solely to enhance the ABM framework. Comparative medicine was leveraged to develop a species-specific ABM by considering the rat and porcine species commonly used in cardiovascular research together with data from healthy human toddlers. The ABM luminal radius prediction accuracy was observed to be 79% for rat, above 95% for porcine and 91. 6% for the healthy toddler; while that observed for the growth rate was 38.7%, 90% and 64.3% respectively. Given its performance, the ABM was adapted to a 2.5-year-old patient-specific CoA. Subsequently, the model predicted that by age 3, the condition would worsen, marked by persistent CoA enhanced by the predicted least growth compared to growth predicted in the rest of the aorta, hypertension, and increased turbulent flow; thus, increased vessel injury risk. The findings advise for incorporating vascular remodelling into the ABM to enhance its predictive capability for intervention planning.

The Cross-Talk Between the Heart and the Liver: The Involvement of the Mitral Valve as a Novel Actor upon the Ancient Scene of Liver Cirrhosis

BACKGROUND

To date, little is known about correlations between liver dysfunction and circulatory and cardiac abnormalities (e.g.,: mitral valve, MV) in patients with chronic liver disease (CLD). This study aimed to assess a potential parallelism between liver dysfunction and cardiovascular involvement and identify the factors associated with structural and functional MV disorders.

METHODS

Among 995 patients with CLD, 346 were enrolled and compared with 168 controls without liver disease. According to the degree of liver disease, patients were classified as patients with chronic hepatitis (142) or with liver cirrhosis (Child-A: 70; Child-B: 65; Child-C: 69).

RESULTS

Among the chronic hepatitis group, resting heart rate (HR) and left ventricular (LV) mass were higher than in the control group (p = 0.0008), whereas systemic vascular resistance (SVR) was lower (p = 0.01). Among cirrhotic patients, resting HR, left atrium dimensions/volumes, LV walls thickness, LV mass, cardiac output (CO), isovolumetric relaxation time (IVRT), deceleration time (DT) and prevalence of aortic stenosis were higher than in non-cirrhotic patients (p = 0.02), whereas the e/a ratio and SVR were lower (p = 0.0001). Among Child-B/C, CO, IVRT, DT, prevalence of MV regurgitation and MV calcification score were higher than in the remaining patients (p = 0.02), whereas SVR was lower (p < 0.0001). Among cirrhotic patients with MV regurgitation, Child-Pugh score, liver disease duration, resting HR, left chambers dimensions/mass, CO, IVRT, DT and MV calcification score were higher compared to patients without regurgitation (p < 0.000), whereas mean blood pressure, e/a ratio and SVR were lower (p = 0.008). At multivariate analysis, Child-Pugh score, liver disease duration, left chambers volume/mass and MV calcification score were independently associated with MV regurgitation in cirrhotic patients. Child-Pugh score and MV calcification score strongly correlated in cirrhotic patients (r = 0.68, 95% CI 0.60-0.75, p < 0.0001).

CONCLUSIONS

The magnitude of cardiac morpho/functional abnormalities is associated with the severity of liver dysfunction. Structural and functional MV abnormalities could represent a novel sign of cardiac involvement in liver cirrhosis. The severity and duration of liver disease, the enlargement of cardiac chambers and leaflet calcium accumulation could play a key role.

Stress phase bandwidth as a predictor of left ventricular reverse remodeling in patients with new-onset acute decompensated heart failure with reduced ejection fraction

BACKGROUND

Stress phase bandwidth (SPBW), assessed using single-photon emission computed tomography (SPECT), is considered to be a useful indicator of left ventricular dyssynchrony. However, few reports have examined whether it can be used as an indicator for improvement of left ventricular ejection fraction (LVEF) in new-onset heart failure with reduced ejection fraction (HFrEF).

METHODS AND RESULTS

A total of 64 patients (mean age 56 years, 39 male) who were admitted to our hospital with new-onset non-ischemic HFrEF (median LVEF 24.7%) from January 2018 to December 2022 in the SAKURA-HF registry and underwent SPECT were enrolled. The relationship between SPBW in the acute phase and LVEF improvement in the chronic phase was retrospectively investigated in the present study. LVEF improved significantly in the 36 patients (from 27.1 to 62.8%, p < 0.001). Guideline-directed medical therapy in both groups was comparable. SPBW was significantly lower in the group with improved LVEF (median 55.5° vs. 79.0°, p = 0.010). Logistic regression analysis revealed that SPBW was an independent predictor for LVEF improvement. Moreover, an SPBW of 71.0° was suggested as a possible cut-off value.

CONCLUSIONS

SPBW may predict the improvement of LVEF in new-onset non-ischemic HFrEF, suggesting its potential utility in heart failure management.

Evaluation of cardiac electrophysiological balance index in children diagnosed with type 1 diabetes mellitus

OBJECTIVE

The most common cause of morbidity and mortality in type 1 diabetes mellitus is cardiovascular system involvement. Sudden death has been reported in type 1 diabetes mellitus patients. To analyse the use of the cardiac electrophysiological balance index in predicting ventricular arrhythmias in children with type 1 diabetes mellitus disease.

METHODS

One hundred type 1 diabetes mellitus paediatric patients and 100 healthy children, divided into three groups according to their haemoglobin A1C levels, were included in the study. All participants were evaluated with transthoracic echocardiography, 12-lead electrocardiography, and 24-h Holter after a detailed physical examination. Systolic and diastolic function parameters, electrocardiography intervals, and heart rate variability parameters were evaluated.

RESULTS

The mean age in the type 1 diabetes mellitus and control groups was 11.52 (± 3.52) and 11.78 (± 3.45) years, respectively. In total, 57% of the type 1 diabetes mellitus group and 56% of the control group were male. The mean haemoglobin A1C value was 9.14% (± 1.79) and the disease duration was 3.71 years (± 3.13). The type 1 diabetes mellitus group had a higher QTc duration, deceleration time duration, A velocity, and a lower E/A ratio than the control group. In the type 1 diabetes mellitus group, Tpe, Tpe/QT ratio, QTc/QRS ratio, Tpe/QRS ratio, Tpe/(QT × QRS) ratio values were significantly higher than in the control group.

CONCLUSION

Children with type 1 diabetes mellitus are at risk for atrial and ventricular arrhythmias without valvular disease, ischemic heart disease, or diastolic dysfunction despite normal systolic function. No correlation was found between disease duration, metabolic control, autonomic function parameters, and arrhythmia risk; however, it was associated with diastolic function parameters.

Impact of High-Risk Pregnancy on Peripartum Left Ventricular Function

Background

Predictors of the clinical characteristics of pregnant women at risk of peripartum cardiomyopathy (PPCM) remain unclear.

Methods and Results

We enrolled 450 cases of high-risk pregnancy with any risk factor from among ≥35 years of age, hypertensive disorders of pregnancy (HDP), multiple gestation, or other systemic or obstetric complications except for a history of cardiac disease. All the women underwent echocardiography and plasma B-type natriuretic peptide (BNP) measurement during the second/third trimester and the early/late postpartum period. Logistic regression analyses identified clinical factors associated with left ventricular (LV) dysfunction. The incidence of PPCM was 0.89%, which was higher than in previous reports. Early diastolic mitral annular velocity (e') was significantly negatively associated with the occurrence of PPCM, and the BNP level showed a significant positive association with the occurrence of PPCM. The percentages of cases of e' <7 cm/s, and BNP level ≥100 pg/mL were 25.3%, and 20.4%, respectively. Multivariate regression analysis revealed that HDP was independently associated with e'. A negative correlation between e' and BNP level was observed in HDP.

Conclusions

High-risk pregnancy was associated with an increased incidence of PPCM. Measurement of BNP levels and echocardiographic assessment of LV diastolic function during pregnancy may be useful in predicting PPCM.

Impact of Transaortic Valve Flow Velocity on the Development of Systolic Heart Murmurs

Background

Although cardiac auscultation plays an essential role in detecting valvular heart diseases, false-positive rates due to innocent heart murmurs remain a concern because accelerated transaortic valve blood flow can be a major contributor to systolic heart murmurs. In this study we investigated the effect of transaortic valve flow velocity on the development of systolic heart murmurs.

Methods and Results

Cardiac auscultation was performed in 571 patients referred for echocardiography and systolic heart murmur was detected in 103 (18.0%). Maximum transaortic valve flow velocity was higher in patients with murmurs than in those without (2.02 vs. 1.34 m/s, P<0.001; area under the receiver operating characteristic curve, 0.82). A cutoff maximum transaortic flow velocity of 1.7 m/s predicted systolic heart murmurs (sensitivity, 65%; specificity, 88%). The incidence of heart murmur was associated with higher maximum transaortic valve flow velocity (<1.7 m/s, 7.3%; 1.7-2.5 m/s, 50.0%; >2.5 m/s, 73.5%). Multivariate analysis revealed the maximum transaortic valve flow velocity as an independent predictor of systolic heart murmurs (hazard ratio, 9.18; 95% confidence interval, 5.35-15.75; P<0.001).

Conclusions

Accelerated transaortic valve flow velocity is an important determinant of systolic heart murmurs. Systolic heart murmurs can be heard before the transaortic valve flow velocity reaches the clinically significant aortic stenosis criterion, which can constitute a considerable number of innocent heart murmurs.