BACKGROUND:Left ventricular (LV) interventions in patients with double mechanical valves represent one of the most formidable challenges in contemporary practice. Standard routes are unavailable in these "no-entry LV" scenarios, necessitating alternative access strategies. OBJECTIVES:To evaluate the feasibility, safety, and reproducibility of a novel stylet-driven pacing lead system (SDL) -guided transventricular access technique in patients with double mechanical valves undergoing ventricular tachycardia (VT) ablation or structural interventions. METHODS:This multicenter case series included five consecutive patients (mean age 69 ± 8 years) with mechanical prostheses in both aortic and mitral positions. A SDL, originally designed for left bundle branch area pacing (LBBAP), was used to cross the interventricular septum under electrogram and fluoroscopic guidance. Subsequent interventions included VT ablation in four patients and transcatheter paravalvular leak (PVL) closure in one patient. RESULTS:Transventricular access was successfully established in all patients, with a mean access time of 13.4 ± 4.0 minutes. One patient required re-access which was rapidly re-established. All four VT ablation procedures were completed with acute noninducibility after substrate modification or adjunctive ethanol ablation. In the PVL case, two mitral paravalvular leaks were closed successfully. Postprocedural TTE revealed small ventricular septal shunts (mean size 1.5 ± 0.6 mm), which resolved spontaneously within one week in all patients. No major complications, conduction disturbances, or thromboembolic events occurred. CONCLUSIONS:The SDL -guided transventricular access technique is a feasible, safe, and reproducible method for achieving LV entry, with promising applicability to both electrophysiologic and structural interventions in "no-entry LV" scenarios.

Catheter ablation of ventricular tachycardia (VT) and electrical storm (ES) controls recurrences and improves survival in ischemic cardiomyopathy. Adequate contact of the catheter with the tissue during mapping and ablation is required for successful outcomes. We aimed to determine the acute procedural and long-term outcomes of ablation of the electrical storm or frequent shocks with and without contact force sensing catheters in ischemic cardiomyopathy. The study retrospectively included 110 ischemic cardiomyopathy patients with electrical storm or frequent shocks. Mapping and ablation were performed with contact force sensing catheters in 46 patients (Contact force [CF] group) and without contact force sensing catheters in 64 patients (non-Contact force[non-CF) group). The acute procedural success was not different between groups (p = 0.438). After a median follow-up of 25 months (14–37) for the CF group and 26 months (11–46) for the non-CF group (p = 0.687) VT free survival was 71.74

BACKGROUND:Atrial fibrillation (AF) recurrence remains a significant challenge in heart failure with reduced ejection fraction (HFrEF) patients undergoing cryoballoon ablation (CBA). Sodium-glucose cotransporter-2 inhibitors (SGLT2i) have demonstrated cardiovascular benefits, including antiarrhythmic effects. This study assesses the impact of SGLT2i on AF recurrence and clinical outcomes in HFrEF patients undergoing CBA. METHODS:This retrospective cohort study was conducted on 246 HFrEF patients (LVEF < 40%) undergoing CBA between January 2022 and June 2024. Patients were categorized into two groups: SGLT2i users (n = 71) and nonusers (n = 175). The primary endpoint was AF recurrence (> 30 s post-blanking period). Secondary endpoints included all-cause mortality and heart failure (HF)-related hospitalizations. RESULTS:The median follow-up period was 347 days. AF recurrence was lower in the SGLT2i group (25.4% vs. 39.4%, p = 0.036). Kaplan-Meier analysis demonstrated higher recurrence-free survival in SGLT2i users (74.6% vs. 60.6%, log-rank p < 0.001). Cox regression confirmed SGLT2i as an independent predictor of reduced AF recurrence (HR: 0.546, 95% CI: 0.262-0.874, p = 0.011). Mortality (9.9% vs. 14.9%, p = 0.039) and HF hospitalizations (16.9% vs. 23.4%, p = 0.014) were also significantly lower in SGLT2i users. CONCLUSION:SGLT2i use was independently associated with lower AF recurrence, mortality, and HF-related hospitalizations in HFrEF patients undergoing CBA. These findings highlight the potential of SGLT2i as adjunctive therapy for AF management, necessitating further prospective studies to validate these results and optimize treatment strategies.

AIMS:Pathophysiology and prognostic implications of right ventricle (RV) dysfunction in heart failure are complex and incompletely elucidated. Cardiac magnetic resonance imaging (CMR) is the reference standard for RV quantification, but its clinical implications in non-ischaemic cardiomyopathy (NICM), in the context of myocardial fibrosis and functional mitral regurgitation are not well defined. We evaluated predictors, prognostic impact, and thresholds for defining significant RV dysfunction in NICM. METHODS AND RESULTS:NICM patients (n = 624) undergoing CMR assessment during 2002-2017 were retrospectively studied. CMR's quantification of right ventricular ejection fraction (RVEF) was evaluated against the primary outcome of all-cause mortality, heart transplant, and/or left ventricular assist device implantation in threshold and multivariable analyses. Mean RVEF was 43 ± 13%, and factors associated with reduced RVEF were male sex, New York Heart Association (NYHA) class III-IV, right bundle branch block, lower left ventricular ejection fraction, higher mitral regurgitant fraction (MR-RF) and right ventricle size in NICM. RVEF per 5% increase was independently associated with the primary endpoint hazards ratio (95% confidence interval) 0.80 (0.73-0.88), P < 0.001. RVEF ≤40% was the optimal threshold associated with worse prognosis, regardless of late gadolinium enhancement (LGE) or MR-RF quantification. On the other hand, higher LGE was associated with primary endpoint in patients with RVEF ≤ 40% only, while risk associated with MR-RF was significant dampened after adjusting for RVEF. CONCLUSION:RVEF provides powerful risk stratification, with RVEF ≤ 40% defining significant RV dysfunction associated with adverse outcomes in NICM. The integration of quantitative CMR measurements for RVEF, LGE, and MR-RF provides comprehensive NICM risk prognostication.

Despite all the advancements in science, medical knowledge, healthcare, and the healthcare industry, cardiovascular disease (CVD) remains the leading cause of morbidity and mortality worldwide.The main reasons are the inadequacy of preventive health services and delays in diagnosis due to the increasing population, the failure of physicians to apply guide-based treatments, the lack of continuous patient follow-up, and the low compliance of patients with doctors' recommendations.Artificial intelligence (AI)-based clinical decision support systems (CDSSs) are systems that support complex decision-making processes by using AI techniques such as data analysis, foresight, and optimization.Artificial intelligence-based CDSSs play an important role in patient care by providing more accurate and personalized information to healthcare professionals in risk assessment, diagnosis, treatment optimization, and monitoring and early warning of CVD.These are just some examples, and the use of AI for CVD decision support systems is rapidly evolving.However, for these systems to be fully reliable and effective, they need to be trained with accurate data and carefully evaluated by medical professionals.

BACKGROUND:Data regarding mitral regurgitation (MR) in extremely elderly patients are limited. The aim of the present study was to assess symptomatic status, frailty, etiology and outcomes for nonagenarians with severe MR. METHODS:Single-center cohort study of patients ≥90 years of age with at least 3+ MR on echocardiography between September 2010 and August 2018. Out of a total of 11,998 patients with at least 3+ MR, 267 patients were included in the present study. RESULTS:The average age was 93.5 ± 2.6 years, and 57% were female. At baseline, 88% were symptomatic, with mean Charlson co-morbidity index of 6 ± 2 points, and mean frailty score of 2.9 ± 1.4 points. Primary MR was present in 50%, secondary in 47%, and prosthetic valve dysfunction in 3%. Among patients with primary MR, the most common etiology was mitral annular calcification (58%). In comparison, the most common etiology of secondary MR was atrial functional MR (52%). Of all, 95% were treated conservatively, and 5% underwent interventional management. Among 253 patients who had follow-up data with a median follow-up of 14 months (25th-75th interquartile range: 3-31 months), 191 patients (75%) died. Mortality trended higher in the conservative group versus the interventional group (60% vs. 22%, log-rank P = 0.063). CONCLUSIONS:Most nonagenarians with significant MR were symptomatic at presentation, had elevated Charlson co-morbidity index and frailty scores. Etiologies of MR were almost equally distributed between primary and secondary causes. The vast majority of nonagenarians with significant MR were conservatively managed.

Mitral annular calcification (MAC) is a chronic degenerative process often found incidentally on imaging. MAC is associated with elevated risk of atherosclerosis and stroke. The association between MAC and the risk of infective endocarditis (IE) is less well known. Therefore, we conducted this systematic review in order to understand the diagnosis, clinical outcomes, and management of IE associated with MAC. We conducted a systematic review of published data regarding MAC related IE in various databases until November 20, 2019. Case series and cohort studies were included. A total of 8 studies with a cohort of 113 patients were included. Mean age was 69 years with equal gender distribution (50% female). Hypertension (55.8%) was the most common comorbidity seen in this patient population. IE was diagnosed by either antemortem trans esophageal echocardiographic examination (76%) or post-mortem autopsy (24%). Staphylococcus aureus (47%) was the most common pathogen identified. MAC was adjudicated to be moderate-to-severe in 100% of identified cases, with 77.9% of cases presenting with distinct vegetation's. Twenty-six percent of patients (n = 29) underwent surgery. MAC may be associated with development of IE. Echocardiography is the most common non-invasive technique for diagnosis. Due to the difficulties associated with antemortem diagnosis, diagnosis is occasionally made on post-mortem examination. Neurologic complications are frequently encountered, and reported mortality is high in MAC associated IE.

Infective endocarditis (IE) describes the infection of native and prosthetic cardiac valves as well as cardiac implantable electronic devices. Echocardiography is the most widely used imaging technique for evaluation of IE. Due to its reduced sensitivity in detection of prosthetic valve IE and cardiac implantable electronic device related IE and related complications, complementary techniques such as cardiac computed tomography (CT) and 18-flurodeoxyglucose positron emission tomography/CT play an emerging role. Therefore, multiple guidelines recommend the use of multimodality imaging in the diagnosis and management of IE. In this review, we aim to compare the various guidelines and to discuss the role of imaging in the diagnosis, detection of complications, monitoring of treatment response, and prognostication of IE.

BACKGROUND: The severity classification of functional mitral regurgitation (FMR) remains controversial despite adverse prognosis and rapidly evolving interventions. Furthermore, it is unclear if quantitative assessment with cardiac magnetic resonance can provide incremental risk stratification for patients with ischemic cardiomyopathy (ICM) or non-ICM (NICM) in terms of FMR and late gadolinium enhancement (LGE). We evaluated the impact of quantitative cardiac magnetic resonance parameters on event-free survival separately for ICM and NICM, to assess prognostic FMR thresholds and interactions with LGE quantification. METHODS: Patients (n=1414) undergoing cardiac magnetic resonance for cardiomyopathy (ejection fraction<50%) assessment from April 1, 2001 to December 31, 2017 were evaluated. The primary end point was all-cause death, heart transplant, or left ventricular assist device implantation during follow-up. Multivariable Cox analyses were conducted to determine the impact of FMR, LGE, and their interactions with event-free survival. RESULTS: There were 510 primary end points, 395/782 (50.5%) in ICM and 114/632 (18.0%) in NICM. Mitral regurgitation-fraction per 5% increase was independently associated with the primary end point, hazards ratios (95% CIs) of 1.04 (1.01–1.07; P =0.034) in ICM and 1.09 (1.02–1.16; P =0.011) in NICM. Optimal mitral regurgitation-fraction threshold for moderate and severe FMR were ≥20% and ≥35%, respectively, in both ICM and NICM, based on the prediction of the primary outcome. Similarly, optimal LGE thresholds were ≥5% in ICM and ≥2% in NICM. Mitral regurgitation-fraction×LGE emerged as a significant interaction for the primary end point in ICM ( P =0.006), but not in NICM ( P =0.971). CONCLUSIONS: Mitral regurgitation-fraction and LGE are key quantitative cardiac magnetic resonance biomarkers with differential associations with adverse outcomes in ICM and NICM. Optimal prognostic thresholds may provide important clinical risk prognostication and may further facilitate the ability to derive selection criteria to guide therapeutic decision-making.

Significant aortic regurgitation (AR) leads to left ventricular (LV) remodeling; however, little data exist regarding sex-based differences in LV remodeling in this setting. We sought to compare LV remodeling and AR severity, assessed by echocardiography and cardiovascular magnetic resonance (CMR), to discern sex-based differences. Patients with ≥ moderate chronic AR by echocardiography who underwent CMR within 90 days between December 2005 and October 2015 were included. Nonlinear regression models were built to assess the effect of AR regurgitant fraction (RF) on LV remodeling. A generalized linear model and Bland Altman analyses were constructed to evaluate differences between CMR and echocardiography. Referral for surgical intervention based on symptoms and LV remodeling was evaluated. Of the 243 patients (48.3 ± 16.6 years, 58 (24%) female), 119 (49%) underwent surgical intervention with a primary indication of severe AR, 97 (82%) men, 22 (18%) women. Significant sex differences in LV remodeling emerged on CMR. Women demonstrated significantly smaller LV end-diastolic volume index (LVEDVI) (96.8 ml/m2 vs 125.6 ml/m2, p < 0.001), LV end-systolic volume index (LVESVI) (41.1 vs 54.5 ml/m2, p < 0.001), blunted LV dilation in the setting of increasing AR severity (LVEDVI p value < 0.001, LVESVI p value 0.011), and LV length indexed (8.32 vs 9.69 cm, p < 0.001). On Bland Altman analysis, a significant interaction with sex and LV diameters was evident, demonstrating a significant increase in the difference between CMR and echocardiography measurements as the LV enlarged in women: LVEDVI (p = 0.006), LVESVI (p < 0.001), such that echocardiographic measurements increasingly underestimated LV diameters in women as the LV enlarged. LV length was higher for males with a linear effect from RF (p < 0.001), with LV length increasing at a higher rate with increasing RF for males compared to females (two-way interaction with sex p = 0.005). Sphericity volume index was higher for men after adjusting for a relative wall thickness (p = 0.033). CMR assessment of chronic AR revealed significant sex differences in LV remodeling and significant echocardiographic underestimation of LV dilation, particularly in women. Defining optimal sex-based CMR thresholds for surgical referral should be further developed. Trial registration: NA.

Objective: Although the introduction of radiation therapy for the management of thoracic malignancies has led to a significant improvement in disease-specific survival, this has resulted in the emergence of a new spectrum of cardiovascular disorders induced by radiation injury. Heart rate recovery, as a predictor of cardiovascular events and an indicator of autonomic functions, is measured non-invasively and easily. In the present study, we investigated the effects of mediastinal radiotherapy on heart rate recovery parameters. Methods: Twenty-one patients were included in this study who were planned to receive chest radiotherapy because of lymphoma or lung cancer. Heart rate recovery parameters were evaluated by treadmill exercise before and after radiotherapy. Results: We have found decrease in heart rate recovery parameters (26.05 +/- 12.54 vs. 19.52 +/- 12.28 for HRR1, 39.1 +/- 16.15 vs. 32.86 +/- 14.83 for HRR2, 42.81 +/- 17.66 vs. 38.05 +/- 16.14 for HRR3). The higher doses of mediastinal radiotherapy caused significant changes on heart rate recovery parameters. HRR1 changed from 25.70 +/- 15.12 to 22.00 +/- 14.38 in low dose group and from 26.36 +/- 10.41 to 17.27 +/- 10.10 in high-dose group (P <.05). Attenuation of HRR2 and HRR3 were also more evident in high mediastinal dose group (P <.05). Conclusion: Heart rate recovery parameters were decreased especially in patients who were exposed to more intense mediastinal radiation.

OBJECTIVE:Cardiac resynchronization therapy is the guideline-directed treatment option in selected heart failure with reduced left ventricular ejection fraction patients. Data regarding the contemporary clinical practice of cardiac resynchronization therapy in Turkey have been published recently. This sub-study aims to compare clinical and periprocedural characteristics between cardiac resynchronization therapy upgrade and de novo implantations.METHODS:Turkish arm of the Cardiac Resynchronization Therapy Survey-II was conducted between October 1, 2015, and December 31, 2016, at 16 centers. All consecutive patients who underwent an upgrade to cardiac resynchronization therapy system (n=60) or de novo cardiac resynchronization therapy implantation (n=335) were eligible.RESULTS:Distribution of age, gender, and heart failure etiology were similar in the 2 groups. Atrial fibrillation, valvular heart disease, and chronic kidney disease were more common in cardiac resynchronization therapy upgrade patients. Narrow intrinsic QRS duration and left ventricular ejection fraction being 75% in both groups, and only beta-blockers were prescribed at rates of >90% in both groups.CONCLUSION:Cardiac resynchronization therapy upgrades are performed with high procedural success rates and without excess periprocedural complication risk. Feared complications of cardiac resynchronization therapy upgrades due to the pre-existing device should not delay the procedure if indicated.

Objective: Despite efforts spent on promotion of gender equity in the academia, the gender gap is feared to have widened after the coronavirus disease 2019 pandemic. Herein, we aimed to compare the distribution of female authorship by Turkish adult cardiologists in journals indexed at PubMed before and after the pandemic. Methods: In this cross-sectional study, an advanced search on PubMed (https://pubmed.ncbi.nlm.nih.gov/) was carried out based on the following criteria: "entrez date" and keywords "Turkey" and "cardiology" to identify papers that entered the online database in AprilSeptember 2019 and April-September 2020. After the study sample was determined, type of the article and details of the author list were recorded. Results: Of 1318 articles screened, 708 met the inclusion criteria. Overall, 85 (12.0%) of first authors and 67 (10.0%) of senior authors were female. Females were less likely to first author original articles, editorials, case reports/series, and papers with international participation (9.5%, P = .012; 33.3%, P = .045; 18.3%, P = .033; 4.8%, P = .032, respectively). A higher proportion of females were in first and corresponding author positions in original articles (73.2%, P = .032; 76.5%, P = .019, respectively) but not in other article types (all P >.05), after emergence of the pandemic. Conclusion: These suggest that significant gender differences exist with regard to authorships of scientific publications that were submitted by Turkish adult cardiologists. Future studies may aim to evaluate the trends across a wider time span and based on a more extensive scientific output follow-up.

Background: Cardiac magnetic resonance imaging (CMR) is the reference standard for right ventricle (RV) quantification, however predictors and prognosis of RV dysfunction in cardiomyopathy patients, including differences between ischemic (ICM) and non-ischemic (NICM) cardiomyopathies, remain not well understood. We evaluated the factors and outcomes associated with CMR-derived reduced RV systolic function, and compared by type of cardiomyopathy. Methods: Adult cardiomyopathy patients undergoing CMR with RV quantified during 2002-2017 were retrospectively studied. Multivariable linear and Cox regression were used to identify factors associated with reduced RV ejection fraction (RVEF) and the primary endpoint (all-cause death, heart transplant or LVAD) during follow-up. Results: Amongst 771 ICM and 624 NICM patients (mean ages 62.3±11.2 and 52.8±15.9 years, 190 (24.6%) and 253 (40.5%) were female respectively), mean RVEFs were 43±14% and 43±13% respectively. The primary endpoint occurred in 455 (59.0%) ICM and 113 (18.1%) NICM patients over mean follow-up of 5.3±4.5 years. Predictors of lower RVEF in ICM were younger age, lower eGFR, lower left ventricular ejection fraction, higher right ventricular end-diastolic volume indexed and higher mitral regurgitant fraction; and in NICM were male sex, NYHA class III-IV, right bundle branch block, lower left ventricular ejection fraction, higher right ventricular end-diastolic volume and higher mitral regurgitation fraction. Reduced RVEF was associated with the primary endpoint in univariable analysis in both ICM and NICM, but only remained so for NICM in multivariable analysis of the primary endpoint as shown in the table. Conclusion: Reduced RVEF is associated with adverse prognosis, however was only independently associated with the primary endpoint in NCIM but not ICM. Key predictors of RV dysfunction in both ICM and NICM were identified, with some similar and some different predictors between them.

Mitral annular calcification (MAC) refers to calcium deposition in the fibrous skeleton of the mitral valve. It has many cardiovascular associations, including mitral valve dysfunction, elevated cardiovascular risk, arrhythmias, and endocarditis. Echocardiography conventionally is the first-line imaging modality for anatomic assessment, and evaluation of mitral valve function. Cardiac computed tomography (CT) has demonstrated importance as an imaging modality for the evaluation and planning of related procedures. It also holds promise in quantitative grading of MAC. Currently, there is no universally accepted definition or classification system of MAC severity. We review the multimodality imaging evaluation of MAC and associated valvular dysfunction and propose a novel classification system based on qualitative and quantitative measurements derived from echocardiography and cardiac CT.