Acute Myocardial Infarction (AMI) is one of the leading causes of death in the world, and immune cells such as neutrophils and macrophages are implicated in its pathophysiology. Despite decades of research, there is much debate on the roles of these immune cells, however, new concepts are emerging. This review summaries the recent advances in our understanding of the involvement of neutrophils and macrophages in post-AMI cardiac healing. Recently, neutrophils and monocytes were found to begin their phenotypical transformation in the bone marrow following an AMI, before migration to the infarct region. Novel cytokines and feedback loops have been identified in coordinating the process of immune cell recruitment to the heart post-AMI including subsets of pro- and anti-inflammatory neutrophils and new pathways of WNT signalling that alter macrophage phenotypes to a pro-inflammatory phenotype. There is also an interplay between these cells during regulation of immune cell migration as neutrophils are involved in polarising macrophages toward a reparative archetype that promotes clearance of apoptotic cells and cellular debris. Resident macrophages in the pericardial cavity also showed a cardioprotective role which may have important implications in cardiac surgeries that involve removal of the pericardium.
Background: The diagnosis of myocarditis is challenging, and typically relies on clinical presentation, non-invasive imaging, and serum biomarkers. We examine if implementation of hsTnT has affected recognition of myocarditis and patient outcomes. Methods: Retrospective analysis of >18-year-old patients diagnosed with myocarditis in Meir Medical Center since January 2000 to the end of April 2020. Patients were divided based on their diagnosis date - up to January 2014, for which there was a regular troponin test (REG group) and starting February 2014 for which there was a hsTnT test (HS group). We examined the difference in the rate of myocarditis diagnosis, mortality, and hospitalizations due to heart failure. Results: We identified 262 patients who were diagnosed with myocarditis. There were no significant differences between the groups. After the implementation of hsTnT there was a two-fold increase in the diagnosis rate (0.0366 vs. 0.0625 cases per day; P<0.0001). The REG group presented with more ST changes (51% vs. 29%; p=0.006) and less cases of normal heart function (69% vs. 79%; P=0.048). There was a higher mortality rate in HS group (6 deaths vs. 2; p=0.011). Conclusions: hsTnT test leads to increase in myocarditis diagnosis and allows for diagnosing more mild case.
Objective: The genetic lineage tracing method was used to examine the Epithelial-Mesenchymal Transition (EMT) process and the contribution of epicardial cells to mesenchymal cells at various stages of fetal heart development. Methods: In Wt1-CreER; R26-tdTomato transgenic mice, tamoxifen was utilized to promote the tagging of epicardial cells with tdTomato fluorescence at E10. At E11.5, E12.5, and E16.5, embryonic hearts were harvested and photographed using confocal fluorescence microscopy and stereomicroscopy. Results: According to the findings, the tdTomato+ cells at E11.5 were still in the epicardium and had not yet moved into the myocardium. Epicardial cells began to separate from the epicardium and give rise to epicardial-derived cells at embryonic day 12.5 (E12.5). On the valve primordium, fibroblasts generated from epicardium have been found. By E16.5, many epicardial cells had moved into the myocardium and formed fibroblasts, mesenchymal cells, vascular smooth muscle cells, as well as migrated into the ventricular septum and valves, contributing to their growth and creation. Conclusions: The contribution of epicardial cells to mesenchymal cells during development is shown by genetic lineage tracing, opening up possibilities and offering references for creating relevant treatment approaches based on epicardial cells.
Between coronary artery anomalies, myocardial bridging means an epicardial coronary artery, mostly left anterior descending artery (LAD), running through an intramyocardial “tunnel” (usually in the middle segment), leading during systolic contraction, flow reduction, through the vessel. When this anomaly is associated with a coronary fistula, which “steals” more from the bloodstream, the symptoms are more pronounced, and the management complex is surgical in particular. Despite the presence from birth remains asymptomatic and it becomes clinically manifest later in the third to fourth decade of life, with a diverse palette of symptoms; angina, arrhythmias, and acute myocardial infarction up to sudden death. Diagnosis and particular management, medical, interventional, and surgical should avoid major cardiac complications and sudden death. We present two adult patients, with coronary artery bridging, one case associated with coronary artery fistula, LAD to pulmonary artery trunk, very symptomatic with surgical management, and the second only myocardial bridging controlled with medication and supervision.
Objectives: To clarify the 2 years outcome of Bioabsorbable Polymer Everolimus-Eluting Stent (BP-EES) using several criteria/definitions. Previous reports have showed worse outcomes in Real-World (RW) setting than case-Controlled Clinical trials (CC). Methods and Materials: We studied consecutive patients who received BP-EES implantation from October 2017 through January 2018. We adopted the parameters used in previous BP-EES associated CC (SYNERGY, EVOLVE), compared the CC inclusion criteria (on-label) with others (offlabel) at 2 years follow-up. Results: There were 678 BP-EESs inserted in 437 patients (283 male, mean age 72.3±11.2 years). Data from 4 patients lacked, and therefore the follow-up rate was 99.1%. There were 381 patients (87.2%) satisfying the CC criteria. Male gender, ejection fraction <40%, smoker, multiple stenting, total stent length, target vessel failure and all death was higher in the off-label group (P<0.05). Regarding revascularization- related parameters (all target lesion/non-target lesion revascularization), there was no difference between the 2 groups (TLR 6.1% vs 3.6%, non-TL TVR 5.6% vs 10.9%; CC vs off-label, p=ns, respectively). On the other hand, comparison of TLR using the CC definition (ischemia-oriented TLR) and real-world definition (any TLR) showed approximately 2-3 times higher frequency in the real-world basis (1.6% vs 5.8% per patient basis and 2.1%vs 5.8% per stent basis). Conclusions: Different definitions for repeat angioplasty among the reports may be a key cause of the discrepancy in revascularization frequency in dug-eluting stent studies, and it is the different inclusion criteria among studies that are associated with patient vulnerability.
Cardiovascular complications in pregnancy increase risk for subsequent heart disease, suggesting adverse events during pregnancy may permanently alter maternal heart health. The heart undergoes physiologic hypertrophy with pregnancy, which is distinct from pathological remodeling associated with obesity. We previously demonstrated that C57BL/6 mice fed a high-fat diet, a model of diet-induced obesity, had attenuated cardiac hypertrophy with pregnancy compared to low-fat controls, associated concentric remodeling. Dual effects of pregnancy and obesity on cardiac metabolism during hypertrophy have not been studied. We investigated whether expression of genes regulating fatty acid metabolism in the heart were altered in pregnant mice fed a high-fat diet. The Nanostring Metabolic Pathways Panel and nCounter analysis system was used to quantify individual mRNA transcripts of genes regulating fatty acid metabolism from the left ventricles of pregnant and non-pregnant female C57BL/6 mice fed a high-fat or control low-fat diet. Pregnancy increased expression of genes regulating fatty acid transport (Cd36, Slc27a1, Cpt1b) and β-oxidation (Acaa2, Acadl, Acox1, Ehhadh, Mlycd), but the effect was observed in low-fat mice only. Increases in gene expression with high-fat feeding were pronounced in non-pregnant mice, but effects not additive with pregnancy. Further, three genes with functions related to energy metabolism (Glul, Mat2a, Ogdhl,) were increased in low fat–fed pregnant mice only. Obesity during pregnancy may “max out” cardiac fatty acid utilization through upregulation of transporters and oxidation of long-chain fatty acids, and also downregulate metabolic pathways essential to cardiac adaptation. These 48 results suggest pre-existing obesity could disrupt cardiac physiologic remodeling during pregnancy.
Interrupted Aortic Arch (IAA) is a rare congenital abnormality characterized by a complete discontinuity of the aortic lumen, usually located after the origin of the left subclavian artery. IAA is mainly diagnosed during childhood and has an extremely high mortality rate if left untreated. Therefore, only a few cases have been diagnosed in adulthood. We report the case of a patient with Non-ST Segment Elevation Myocardial Infarction (NSTEMI) and unknown IAA abnormality, who underwent urgent percutaneous coronary angioplasty (PCI). It was not possible to reach ascending aorta from the right radial artery because of the presence of tangled arteries connecting the pre-vertebral subclavian segment to the descending aorta. PCI was completed successfully through the left radial artery. A post-procedural Angio-CT scan confirmed the Aortic Arch interruption. The presented case highlights the crucial role of a multi-imaging modality approach for those patients with such congenital abnormalities before undergoing PCI.
Background: Surgical ablation (SA) is widely performed to eliminate atrial fibrillation (AF) and maintain atrial contraction. A larger left atrial diameter (LAD) has long been associated with the late recurrence of AF post-ablation. Objectives: We conducted a meta-analysis to assess the relationship between LAD and AF recurrence after SA and investigated the effect of LAD cut-off values on the probability of AF recurrence via subgroup analysis. Methods: The literature search was performed in the MEDLINE and Cochrane Central Register of Controlled Trials databases, from inception to July 2021. A random-effects model was used to estimate the odds ratios (ORs) and 95% confidence intervals (CIs). From 401 initial articles, 16 studies, comprising a total of 4,291 patients, were included in this review. Results: A meta-analysis of 10 studies (2,599 patients) demonstrated that the predicted probability of AF recurrence was 7% greater with each 1 mm increase in LAD (OR: 1.07; 95% CI: 1.04–1.09; P<0.01). Meanwhile, subgroup analysis revealed that the larger the cut-off value, the higher the risk of AF recurrence. The synthesis effect value (OR: 2.45; 95% CI: 1.77–3.39) was close to the OR when the LAD cut-off value was 55 mm (OR: 2.56; 95% CI: 1.22–5.38). Conclusions: In conclusion, a larger LAD is a significant risk factor for predicting AF recurrence after SA. More rigorously designed studies with larger sample sizes are needed to identify the best cut-off value of LAD when performing SA.
Background: There are increasing evidences in the role of the involvement of the fibroblast growth factor 23 (FGF 23) - clotho axis in the pathogenesis of endothelial disfunction and cardiovascular disease. This study intended to explore the role of FGF 23 - clotho axis in the development of allograft vasculopathy. Methods: A total of 38 biatrial heart transplant patients who were operated were included in the study (20 males, 11 females; mean age: 44 ± 7 years). CFR was measured in all patients and the patients were divided into two groups according to respective CFR values. CFR > 2 patients constituted CAV (-) group, CFR < 2 patients were enrolled into CAV (+) group. FGF 23 and clotho levels were analyzed and compared in both groups. Results: FGF 23 levels were significantly higher in CAV (+) group (264.0±114.4 vs. 183.5±56.0 p=0.04). There was a good but inverse correlation between CFR and FGF 23 levels in CAV (+) group (r= - 0.71 p=0.03). Clotho levels were significantly lower in patients who have CAV (2.76±1.6 vs. 4.77±0.87 p=0.01). There was a moderate correlation between CFR and clotho levels in CAV (+) group (r=0.62 p=0.04). There was an inverse correlation between clotho and FGF 23 levels in both CAV (+) and CAV (-) groups. Conclusion: In transplanted patients, there was a good but negative correlation between CFR and FGF 23 levels. Conversely, there was a good correlation between CFR and clotho levels. These results gave rise to the thought clotho-FGF 23 axis has a role in the development of CAV.
Background: Acute Renal Failure (ARF) is a common complication after open heart surgery with Cardiopulmonary Bypass (CPB) because of the capillary leak syndrome. Peritoneal Dialysis (PD) has been widely used to treat ARF after CPB. In this study, the clearance of inflammatory cytokines of PD in infants with ARF following open heart surgery was investigated. Methods: Twenty-nine infants with ARF following open heart surgery who underwent PD were divided into survival and nonsurvival groups. Clinical records were reviewed to document clinical features, operative procedures, and perioperative courses. The serum inflammatory cytokine levels, including those of Tumor Necrosis Factor (TNF)-a, interleukin (IL)-6, IL-8, and IL-10, were measured perioperatively. Results: There was no difference in the preoperative characters between the 2 groups. Longer CPB time, duration of mechanical ventilation, duration from surgery to the beginning of PD, and higher central venous pressure appeared in the nonsurvival group. The serum concentrations of IL-6 and IL-8 were significantly higher in the nonsurvival group than in the survival group before PD and on PD 1 day, PD 4 days, and PD 7 days, respectively. The serum concentrations of IL-10 were higher in the nonsurvival group than in the survival group on PD day 4 and PD day 7, respectively. There were no significant differences of TNF-a between the 2 groups during the perioperative period and PD. Conclusion: PD could eliminate inflammatory cytokines effectively in patients with mild ARF after open heart surgery.
We report the case of a 29 years old patient brought to emergency after a road traffic accident. His blood pressure was 138/78 mmHg, pulse 119/min, respiratory rate at 24/min and Glasgow coma scale at 6/15. The patient was put on mechanical ventilation then transferred to the intensive care unit. A body CT scan was performed which found multiple hemorraghic contusions and subarachnoid hemorrhage in the head. Lower right limb x-rays showed a mid diaphyseal femur fracture which then was surgically treated. 7 days after surgery, the patient suddenly developed hypotension, sinus tachycardia and acute respiratory distress. What is the most likely diagnosis at this stage?. Considering the patient condition, the most likely diagnosis was massive pulmonary embolism. Thorax CT scan was immediately performed which found coronary air embolism in circumflex artery as shown in figure 1. The high sensibility troponin level was 8900 ng/l. Barotrauma has been estimated to occur in 0.5-38% of critically ill patients [1]. Systemic and eventually coronary gas embolism associated with positive pressure ventilation has been considered a rare, but catastrophic complication of mechanical ventilation associated with a high mortality rate.
We have read with interest Dr. Burri’s Electrocardiographic Analysis for His Bundle Pacing at Implantation and Follow up [1]. A comprehensive guide to understand electrocardiographic (ECG) nuances of His Bundle Pacing (HBP) is presented in this review. The authors, with outstanding didactics, describe a well-organized analysis of challenging HBP electrocardiographic characteristics to confirm conduction tissue (selective or non-selective HBP) at implant and follow-up. Caught our interest, in particular, the paragraph where practical pacing characteristics and benefits of non-selective HBP pacing (NSHBP) are emphasized. In this context we would like to point out the statement that pacing “ventricular myocardium adjacent to the atrioventricular septum, near the His bundle can also result in NSHBP”. Above all, of paramount clinical importance, when Dr. Burri et al. conclude that “No significant differences in cardiac mechanical synchrony or clinical outcome have been found between SHBP and NSHBP”. Our group is in total agreement with these essential features, having abandoned SHBP many years ago by developing a very simple technique to place standard pacing leads in the para-Hisian area (Figure 1). Concordant with the authors, we understand that “With non-selective His bundle pacing (NS-HBP), the lead is usually positioned in the ventricle at a site where the His bundle (HB) is surrounded by or at proximity to myocardial tissue”. That is why we named “para-Hisian pacing”. In our daily practice, at the same time, to verify and prove physiological capture of the conduction system we monitor synchrony online by analyzing the ECG signal variance [8] (Synchromax®) [2].
I have read recently some papers about sophisticated methods for cardiac pacing [1]. Here are some comments and present perspectives. Physiological pacing as a new paradigm has been the subject of papers from a good number of authors for many years. In my particular case I have been witness of discussions within the global electrophysiology community about the best pacing site in terms of physiological pacing and the future of cardiac resynchronization therapy [2]. It is well known that different physiological pacing modalities are being used: selective His bundle pacing S-HBP), non-selective His bundle pacing or NS-HBP (which we prefer to call para-Hisian pacing) and more recently left bundle branch pacing (LBBP).
Assessment of Flow-Mediated Dilation (FMD) in patients hospitalized for COVID-19 will assist with regard to early identification of markers at the onset of SARS-CoV-2 infection. Therefore, the early evaluation of simple markers, obtained at the bedside before the most serious manifestations are already installed, can help health professionals to act preventively to save lives, direct care in the initial stage of infection, helping in the prognosis and diagnosis. Given the importance and relevance of this technique in this population at this time and the need to better understand the pathophysiology of COVID-19 as well as its damage to the endothelium, we performed an evaluation of FMD in different severity of COVID-19 in recently hospitalized patients. A total of 100 patients were enrolled in the study and were divided into two groups according to the severity of COVID- 19. The results provide new evidence that patients with COVID-19 classified as severe/critical have greater endothelial dysfunction and that FMD may be a simple marker, helping in the prognosis and diagnosis and, consequently, in the prevention of thrombotic events.
Background: Valvular heart disease presents a unique set of conditions during pregnancy and delivery with the potential of adverse outcomes complicated by prior interventions and anticoagulation. The aim of this study was to describe the profile and outcomes of obstetric valvular heart disease patients who delivered via caesarean section at Charlotte Maxeke Johannesburg Academic Hospital. Methods: A retrospective study was done using patient record files, anaesthetics forms and echocardiogram reports. The study period was a 5-year review from January 2016 to December 2020. Results: Sixty-nine patients were included. The mean age ± SD of the patients in this study was 30.1 ± 5.6. A total of 83% had gravidity of 1-3 and 90% parity of 0-2. Majority of patients (57%) had elective caesarean section. General anaesthesia was the most common mode used and majority of patients had fixed interval analgesia (FIA) mode of analgesia postoperatively. Approximately half of the patients (40.5%) were on anticoagulants. A significantly higher percentage of those who needed anticoagulation (46%) had poorer outcomes when compared to those who did not (7%), (P<0.001). This was a univariable association between adverse maternal outcome and NYHA class and lack of use of anticoagulants [aOR 3.77, 95% CI 1.45 - 9.79, P=0.006 and aOR 0.11, 95% CI 0.018 - 0.67, P=0.017, respectively]. Low ejection fraction was univariably associated with adverse foetal outcome, uOR 0.94, 95% CI 0.90 - 0.99, P=0.032. One (1%) foetus demised. Conclusion: Patients were younger and in relatively good functional status. They carried the pregnancies to term. Patients did experience adverse outcome related to bleeding and arrythmias predominantly, but none demised. One neonate was lost. A structured care plan for these patients, based on a multidisciplinary approach, to afford prehabilitation is necessary.
Functional interrupted aortic arch is a congenital malformation characterized by a complete separation between the ascending aorta and the descending aorta. Untreated patients are in danger of having late complications including cerebral hemorrhage, aneurysm formation, and aortic regurgitation. Traditionally, classical surgical therapies included bypass grafting or orthotopic repair. Herein, we report a simplified percutaneous therapy for functional interrupted aortic arch with a retrograde crossing technique and without an incremental-sized expandable balloon. With the guidance of 3-dimensional printing, percutaneous treatment with a covered stent is a feasible, safe, and effective alternative to surgery with excellent short- and midterm results in selected patients with favorable anatomy.
Background: Noonan’s syndrome is the second most common congenital cardiac syndrome after Down syndrome. Classically it is associated with pulmonary stenosis, Hypertrophic Cardiomyopathy (HCM), and Atrial Septal Defects (ASD). Late presentations, milder phenotypes and atypical presentations can occur in adult life and have cardiovascular implications. Case Summary: A 62-year-old presented to the emergency department with chest pain and atrial fibrillation with fast ventricular rate and RBBB morphology. A transthoracic echocardiogram demonstrated a massive Pulmonary Artery (PA), concerning for pulmonary hypertension and an atrial septal defect (ASD). Right heart catheterization indicated enormous coronary artery ectasia but normal PA pressures and wedge pressures. He was identified as a late presentation of Noonan’s syndrome on subsequent genetic testing. Discussion: Some series indicate a prevalence of 1 in 100 for mild Noonan’s syndrome phenotypes, highlighting the importance of understanding its cardiac presentations. In this case, we present a man with minimal symptoms but gross pathologies of his pulmonary and coronary arteries. Furthermore, pulmonary artery dilatation without pulmonary valve pathology has not been reported in the literature, and only a few reports of coronary artery ectasia are reported.
Background: The antiadrenergic and antifibrillatory effects of cardiac sympathectomy in pathological states such as long QT syndrome are well established. The indications for the procedure have expanded since the videoassisted thoracoscopic approach was first used. However, the procedure is currently largely used in cases where medication has failed to prevent recurrence of symptomatic ventricular arrhythmia, or in cases of medication intolerance, and large randomised controlled trials are thus non-existent in the literature. The aim of this study was to perform a systematic review of the available literature to examine the utility of cardiac denervation in the management of all ventricular arrhythmias. Methods: A total of 17 studies published between 2009 and 2019 were evaluated for bias using the Risk of Bias in Non-Randomised Studies of Interventions (ROBINS-I) tool. In addition the Harbour and Miller Grading System (2001) was used to assess the significance of the evidence in this review. Results: All studies demonstrated a protective effect of sympathectomy against ventricular arrhythmias in both primary and secondary prevention strategies. The following risk of bias was observed: low in 5 studies, moderate in 8 studies, and serious risk in 4 studies. The highest level of evidence observed was 2++ in 3 studies. Conclusion: Cardiac sympathetic denervation provides benefit for patients with ventricular arrhythmias, in cases of refractory disease or in patients who require a primary prevention strategy where first-line therapies are not tolerated.
There was no recommendation in the current guidelines for how long after the pulmonary embolism (PE) attack the patient can fly again safely on an airplane. A 45 years old female was admitted to our hospital because of deep vein thrombosis and acute PE. Due to persistent leg swelling and afraid of recurrent PE for long distance flights, this patient received four weeks anticoagulant therapy before flying. Eventually, she flew back safely. This report describes our preliminary experience for managing this patient with deep vein thrombosis and PE.
Aim: To assess the efficacy of Vitamin K antagonist to maintain stable INR in a tertiary care hospital. Methodology: All the patients who are on Vitamin K antagonists therapy for more than 6 months before the initiation of the study were included. Data, which include demographics, Personal history, medical history, medication history, Dietary habits, laboratory data (INR), and other relevant data, are collected. The laboratory results are further evaluated using the Rosendaal method and Time in Therapeutic Range, which was obtained which is evaluated, for assessing the use of medication, and other correlations were further made. Results and Discussion: The study showed a mean TTR of 25.638%, the mean TTR above and below the therapeutic range is 19.23% (±17.14), 55.11% (±29.64) respectively, this represents that the patients in the sample population are at higher risk of developing a new clot during the therapy with VKA, various chronic conditions such as Diabetes mellitus, the use of NSAIDs, PPI also showed a statistically significant difference on the patients TTR. Conclusion: Despite patients being therapeutically anticoagulated, based on the available data, many patients in the study population are at high risk of developing complications of anticoagulants and also the development of new clots even during the treatment, there are not many reports of TTR measurement in INDIAN population, The use of Vitamin K Antagonist comes with many limitations, many Newer Oral Anticoagulants (NOAC) can be used in patients as they are proven to be providing better control of TTR.
