BACKGROUND: Data regarding catheter ablation of post-surgical atrial tachycardia occurring after mitral valve surgery are scarce. Through a search of the literature, this study aimed to assess the feasibility of catheter ablation and the characteristics of atrial arrhythmias ablated in these patients. METHODS: Studies assessing the main procedure parameters and the electrophysiologic findings of the investigated atrial tachycardia were selected. The electrophysiologic mechanism (focal vs. reentrant arrhythmias), site of arrhythmia origin (left atrium vs. right atrium) and their anatomic correlation with specific surgical access and/or prior Cox-Maze IV procedure were all addressed. RESULTS: Eleven studies including 206 patients undergoing catheter ablation of 297 post-surgical arrhythmia morphologies occurring after mitral valve surgery were considered. Major complications were observed in 2 patients only (0.9%). Restoration of sinus rhythm was achieved in 96% of patients. Macro-reentrant arrhythmia was mostly observed (90.4%) with a non-negligible proportion of focal arrhythmia (9.6%). Left-sided arrhythmia was common (54.4%,) but cavotricuspid isthmus-dependent arrhythmia was frequently reported (33%). Although specific atriotomies showed trends towards peculiar locations of the investigated arrhythmia, Cox-Maze IV procedure was the only independent predictor for left-sided arrhythmia (OR=17.3; 95% CI 7.2-41.2; p<0.0001). CONCLUSIONS: Catheter ablation of post-surgical arrhythmia occurring after mitral valve surgery is feasible, and, in this setting, the vast majority of the arrhythmia morphologies are based on macroreentry and in about one third of cases show cavotricuspid isthmus-dependent arrhythmia. Prior Cox-Maze-IV associated with mitral valve surgery is an independent predictor of left-sided arrhythmia possibly due to non-transmural surgical lesions.
BACKGROUND Long term efficacy and safety of either surgical or percutaneous treatment left main coronary artery disease treatment is lacking. METHODS We conducted a systematic review and meta-analysis of the most updated randomized clinical trials that compared the efficacy of coronary artery bypass surgery (CABG) or percutaneous coronary intervention (PCI) for the Left Main Coronary Artery (LMCA) disease. RESULTS We identified 6 studies, providing data on 5812 patients. The mean follow-up was 6.7 years. PCI was associated with an increased risk of major vascular events (MACE) (IRR 1.24, 95% confidence interval (CI) [1.03-1.67], p<0.01), and coronary revascularization (IRR 1.69, 95% CI [1.42-2.03], p<0.01) compared to CABG. Furthermore, all-cause death, MI and stroke events were not statistically different between the two therapeutic revascularization methodologies (IRR 1.06, 95% CI [0.90-1.24], p=0.47, IRR 1.35, 95% CI [0.84-2.16], p=0.03 and IRR 0.66, 95% CI [0.43-1.01], p=0.05, respectively). CONCLUSIONS LMCA PCI has an overall same survival compared to CABG in the long term follow up. Nevertheless, MACE and revascularization events were more frequent in PCI compared to CABG.
BACKGROUND: Takotsubo syndrome (TS) is an acute, reversible form of heart failure, often mimicking an acute coronary syndrome (ACS). Data regarding racial differences in TS are inconsistent. The aim is to assess clinical features associated with unfavorable in-hospital outcomes between African American (AA) and Caucasian (CAU) patients.METHODS: A retrospective electronic health record query identified 44 AA patients and 110 CAU patients with a diagnosis of TS. Our primary outcome was a composite of death, stroke, and cardiogenic shock during hospitalization. Variables associated with an increased risk of the primary composite outcomes were included in a logistic regression model.RESULTS: Compared to CAU patients, AA patients were a more comorbid population, and presented a higher prevalence of history of illicit drug use (27.3% vs 13.6% p=0.044). There were no significant differences regarding in-hospital complication rates between AA and CAU patients. In the logistic regression model, infection was associated with greater risk of developing the primary outcome in AA patients (OR=7.26 95% CI [1.22-43.17], p=0.029), whereas angina was a protective factor (OR=0.11 95% CI [0.02-0.65], p=0.015). In CAU patients, severely depressed ejection fraction and worse peak creatinine during hospitalization increased risk of developing the primary outcome (OR=5.88 95% CI [2.01-17.17], p<0.001 and OR=1.64 95% CI [1.15-2.58], p=0.031, respectively). Meanwhile, emotional stressors were protective (OR=0.16 95% CI [0.03-0.88], p=0.004).CONCLUSIONS: Despite experiencing the same rate of in-hospital complications, the clinical profiles of AA patients are distinct from CAU patients admitted for TS, and clinical variables correlated with worse in-hospital outcomes also differ by race.
BACKGROUND:Anemia is a common health problem worldwide and is associated with a poor prognosis for cardiovascular diseases. It can alter myocardial depolarization and repolarization by affecting the generation and propagation of electrical impulses. The frontal QRS-T angle is a novel marker of the absolute difference between myocardial depolarization and repolarization. This study investigated the effects of anemia on the frontal QRS-T angle.METHODS:The study included 66 anemic subjects with no cardiac disorders, and 50 age- and gender-matched controls. Twelve-lead electrocardiography (ECG) was obtained for all subjects, and the frontal QRS-T angle was calculated based on the automatic report of the ECG machine.RESULTS:Subjects with anemia had a significantly higher frontal QRS-T angle than subjects without anemia (28.9±14.1 vs. 22.5±11.8, P=0.011). In correlation analysis, the frontal QRS-T angle was positively correlated with the Body Mass Index (BMI; r=0.287, P=0.002), left ventricular mass (LVM; r=0.264, P=0.004), and heart rate (r=0.275, P=0.003) and negatively correlated with the hemoglobin level (r=-0.349, P<0.001). Multivariate regression analysis showed that the hemoglobin level (β=-0.254, tβ=-2.805, P=0.006), BMI (β=0.240, t=2.770, P=0.007), and LVM (β=0.201, t=2.303, P=0.023) were independently associated with the frontal QRS-T angle.CONCLUSIONS:The hemoglobin level was found to be an independent predictor of the frontal QRS-T angle.
Aim to study the development of ischemic stroke (IS) or transient ischemic attack (TIA) in patients with extrasystoles (ES), depending on the moment of ES ventricular systole occurrence in cardiocycle. Material and methods. The study group included 440 patients with ES 700 per day; the control group consisted of 88 patients with ES 700 per day. The following instrumental and laboratory methods were used: echocardiography, Doppler ultrasound of brachiocephalic arteries, 24-hours ECG monitoring, digital sphygmography of common carotid arteries; CT or MRI of the brain; lipid spectrum. The study group was divided into two subgroups according to the moment of ES ventricular systole occurrence in cardiocycle, regardless of ectopia: subgroup 1 120 patients with ES before the transmitral blood flow peak; subgroup 2 320 patients with ES after the transmitral blood flow peak. We analyzed the development of stroke or TIA during 1 year. Results. For most parameters, subgroups 1, 2 and the control group were identical. The important differences were registered in the hemodynamic and kinetic parameters of common carotid arteries. The earlier the ES ventricular systole occurred in cardiocycle, the higher increase of the parameters was observed. During one year of follow-up, stroke and TIA occurred more frequently in subgroup 1. Conclusion. ES is an additional risk factor for stroke. The most dangerous is ES with ventricular systole occurrence before transmitral blood flow peak. The wave of the 1st post-extrasystolic contraction causes additional trauma of arterial wall and can become a key factor for instability of atherosclerotic plaques with their defragmentation, embolism and stroke.
article: The role of chronic obstructive pulmonary disease in acute coronary syndrome patients: a critical risk factor for lipid plaque burden? - Minerva Cardiology and Angiology 2021 December;69(6):735-7 - Minerva Medica - Journals
BACKGROUND: Although transradial approach has been increasingly preferred for percutaneous coronary interven-tions, radial artery spasm (RAS) is still one of the major disadvantages. Flow-mediated dilation (FMD) is a well-known method for assessing endothelial function through dilation. The aim of this study was to investigate the efficacy of pre -puncture flow mediated dilation in preventing RAS during transradial approach. METHODS: The present study prospectively included 222 consecutive patients who underwent transradial coronary intervention. Patients were 1:1 randomized into two groups who underwent prepuncture FMD and who did not (FMD [+] and FMD [-], respectively). RESULTS: In FMD [+] group the incidence of RAS was lower (5.4% vs. 16.2%, P=0.009). Multivariate logistic regres-sion analysis demonstrated that female sex, more than two catheter usage and transradial approach without prepuncture FMD independently predicted RAS (odds ratio [OR]=4.66, 95% confidence interval [CI]: 1.8-12.06, P=0.001, OR=5.73, 95% CI: 2.01-16.39, P=0.001, and OR=5.01, 95% CI: 1.74-14.48, P=0.003; respectively). However, access site crossover number was very low in both groups and not different between groups. CONCLUSIONS: Prepuncture FMD can significantly reduce RAS during transradial coronary interventions. Thus, pre -puncture FMD can be used as a simple adjunctive method to prevent RAS.
Diabetes mellitus is emerging as a major risk factor for heart failure. Diabetic cardiomyopathy is defined as a myocardial dysfunction that is not caused by underlying hypertension or coronary artery disease. Studies about clinical features, natural history and outcomes of the disease are few and often conflicting, because a universally accepted operative definition of diabetic cardiomyopathy is still lacking. Hyperglycemia and related metabolic and endocrine disorders are the triggering factors of myocardial damage in diabetic cardiomyopathy through multiple mechanisms. Among these mechanisms, inflammation has a relevant role, similar to other chronic myocardial disease, such as hypertensive or ischemic heart disease. A balance between inflammatory damage and healing processes is fundamental for homeostasis of myocardial tissue, whereas diabetes mellitus produces an imbalance, promoting inflammation and delaying healing. Therefore, diabetes-related chronic inflammatory state can produce a progressive qualitative deterioration of myocardial tissue, which reflects on progressive left ventricular functional impairment, which can be either diastolic, with prevalent myocardial hypertrophy, or systolic, with prevalent myocardial fibrosis. The aim of this narrative review is to summarize the existing evidence about the role of inflammation in diabetic cardiomyopathy onset and development. Ultimately, potential pharmacological strategies targeting inflammatory response will be reviewed and discussed.
BACKGROUND: Takotsubo Cardiomyopathy (TTC) is classified into 4 types dependent on anatomical area affected identified on gross visual assessment. We have sought to understand if it is feasible and advantageous to use left ventricular global longitudinal strain (LVGLS), LV segmental longitudinal strain and right ventricle free wall strain (RVFWS) to classify TTC.METHODS: We conducted a retrospective observational study on twenty-five patients who meet the Modified Mayo Clinic Criteria for TTC [1]. Two independent reviewers performed strain analysis, they were both blinded to patient's diagnosed classification and outcomes.RESULTS: Based on classification by traditional assessment the 92% (n=23) were diagnosed with typical TTC, indicating apical involvement. The entire LV was affected, 67% (n=16) had abnormal strain (STE>-18) in all three LV regions (base, mid ventricle and apex). 71% of patients (n=17) had abnormal LVGLS (>-18). Abnormal strain across all three LV regions was associated with higher prevalence (70%, n=8 Vs 30%, n=4 respectively) of composite cardiovascular events and longer length of hospital stay. There was a statistically significant difference in average length of hospital stay in those patients who had abnormal strain in all three region compared to those that did not have abnormal strain across all three regions (8 days compared to 3.44 days, p value 0.02).CONCLUSIONS: A new classification of TCC based on strain analysis should be developed. The traditional model is arbitrary; it fails to recognize that in most patients the entire LV is affect, it does not have prognostic significance and the most prevalent typical variant indicates apical involvement. Our study suggests that the entire LV is affected, and strain analysis has prognostic significance.
BACKGROUND The optimal management of patients with ST-elevation acute coronary syndromes and multivessel coronary artery disease is challenging. There is a growing body of evidence supporting invasive functional evaluation of multivessel disease with FFR or iFR has been added to the literature. In this regard, the WAVE study recently demonstrated the diagnostic accuracy of iFR functional assessment of non-culprit lesions in multivessel patients with STEMI. However, no studies have still verified the long-term clinical impact of an iFR-guided revascularization in this setting of patients. METHODS Patients undergoing primary PCI for STEMI and presenting multivessel disease will be enrolled. After the treatment of the culprit lesion, an iFR-guided functional assessment of non-culprit lesions will be done: if iFR ≤ 0.89 PCI will be performed during the index procedure or staged. Conversely, iFR> 0.89 will be direct the patient towards a conservative approach. RESULTS The study start date was May 1, 2018. The enrollement phase was completed on March 30, 2020. The primary endpoint is the occurrence of Target Lesion Failure (TLF), a composite of cardiovascular death, non-fatal myocardial infarction, and ischemia-driven revascularization of the vessel previously assessed with iFR. Secondary end points include MACE (Cardiovascular death, non-fatal MI, any revascularization). CONCLUSIONS The aim of the present study is to evaluate the long-term clinical impact of an iFR-guided revascularization of the non-culprit lesions in STEMI patients with multivessel coronary artery disease.
In the present paper we review data of the efficacy of CRT based on baseline QRS duration and morphology in patients with heart failure due to left ventricle systolic dysfunction. We specifically review data that analyzed men and women separately. The main findings suggest benefit of CRT in patients with baseline LBBB, but not in patients without LBBB. Benefit is directly related to QRS duration at baseline with increasing rates and magnitude of echocardiographic response (in terms of improvement in ejection fraction and decrease in LV size) and clinical response with increasing baseline QRS. The effect was most pronounced when QRSd was above 150 ms. Among women treated with CRT, similar to men, the benefit is also confined mainly to patients with baseline LBBB. In contrast to men benefit is evident starting with QRSd >130 ms. These findings may suggest that different QRS duration criteria should be used for men and women considered for CRT.
Despite significant advances in our understanding of cardiovascular disease (CVD) we are still far from having developed breakthrough strategies to combat coronary atherosclerosis and heart failure, which account for most of CV deaths worldwide. Available cardiovascular therapies have failed to show to be equally effective in all patients, suggesting that interindividual diversity is an important factor when it comes to conceive and deliver effective personalized treatments. Genome mapping has proved useful in identifying patients who could benefit more from specific drugs depending on genetic variances; however, our genetic make-up determines only a limited part of an individual's risk profile. Recent studies have demonstrated that epigenetic changes - defined as dynamic changes of DNA and histones which do not affect DNA sequence - are key players in the pathophysiology of cardiovascular disease and may participate to delineate cardiovascular risk trajectories over the lifetime. Epigenetic modifications include changes in DNA methylation, histone modifications and non-coding RNAs and these epigenetic signals have shown to cooperate in modulating chromatin accessibility to transcription factors and gene expression. Environmental factors such as air pollution, smoking, psychosocial context and unhealthy diet regimens have shown to significantly modify the epigenome thus leading to altered transcriptional programs and CVD phenotypes. Therefore, the integration of genetic and epigenetic information might be invaluable to build individual maps of cardiovascular risk and hence, could be employed for the design of customized diagnostic and therapeutic strategies. In the present review, we discuss the growing importance of epigenetic information and its putative implications in cardiovascular precision medicine.
