A 40-year-old man with complex congenital heart disease (double-inlet left ventricle with transposition of the great arteries), previously treated with a Blalock-Taussig shunt in infancy and a modified Fontan procedure (including superior vena cava-to-pulmonary artery anastomosis, atriopulmonary connection, and tricuspid valve closure with a Dacron patch), presented to the emergency department with worsening dyspnea and hypoxemia (SpO2 < 80%). Echocardiography suggested a shunt through the tricuspid patch, possibly related to prior atrial flutter ablation. Cardiac catheterization confirmed an approximately 10 mm fenestration in the calcified patch causing a significant bidirectional shunt, along with two fistulae between the innominate vein and the left atrium. The fenestration was successfully closed using a septal occluder via right femoral venous access under transesophageal echocardiographic guidance. The venous collaterals were occluded with vascular plugs via right femoral and left brachial approaches. Technical success of the closure of the intracardiac and the venous shunts was confirmed angiographically at the end of the procedure. Oxygen saturation improved immediately from 72% to 91% and remained stable at the 2-year follow-up. Similarly, NYHA functional class improved from IV to II and episodes of tachycardia became less frequent and better tolerated, with sustained benefit throughout follow-up.

BACKGROUND:Cardiovascular adaptation to pregnancy is more marked in twin than singleton pregnancies and may result in a higher rate of adverse cardiac events in women with heart disease. The objective was to test the hypothesis that women with heart disease and a twin pregnancy have a higher rate of adverse cardiac events. METHODS AND RESULTS:Registry Of Pregnancy And Cardiac disease (ROPAC) is a prospective (2007-2018), global registry of pregnant women with heart disease. Pregnancy outcomes in twin (n=96) were compared with 5643 women with singleton pregnancies. At baseline, twin mothers were older (32.1 vs 29.5 years, p<0.001) and had fewer prior cardiac interventions (43% vs 55.5%, p=0.02). Cardiac diagnosis, New York Heart Association class, modified WHO class, country of origin, prior hypertension, diabetes mellitus, atrial fibrillation and signs of heart failure were similar. The risk of heart failure was significantly higher in twin pregnancies, with 24/96 developing heart failure vs 631/5643 singleton (25 vs 11.2%, p<0.001), but there were no differences in maternal mortality, arrhythmia, endocarditis, thrombosis, dissection, acute coronary syndrome or hospital admission for cardiac reasons. Multivariable analysis of the whole ROPAC population showed that twin pregnancy was a risk factor for heart failure, and that within the twin pregnancies, cardiomyopathy and prior heart failure were risk factors for development of heart failure. Women with valvular or congenital heart disease experienced heart failure during pregnancy, but those with cardiomyopathy experienced it during the peripartum period. Obstetric outcomes were worse in twins. CONCLUSIONS:Women with heart disease and a twin pregnancy have twice the risk of heart failure, particularly in those with a prior diagnosis of cardiomyopathy.

Endovascular techniques are commonly employed for type B aortic dissections and are rarely reported for type A dissections. We present the case of a 78-year-old female diagnosed with a type A aortic dissection, with coronary arteries and supra-aortic vessels perfused from the true lumen and no significant aortic valve dysfunction. Given her recent cardiovascular surgery, the anticipated prolonged recovery, and multiple comorbidities, a percutaneous approach was preferred, with classical surgery available as stand by. The patient underwent endovascular treatment using two self-expandable, double-disc atrial septal defect occlusion devices. Intracardiac echocardiography facilitated device deployment, offering superior visualization compared with transesophageal echocardiography, which can be partially obscured by the left pulmonary artery. To our knowledge, the false lumen-to-true lumen approach in percutaneous management of type A aortic dissection has not been previously described.

Background: Although less frequently encountered, aortic valve stenosis is associated with complications separate from its hemodynamic burdens, such as infective endocarditis. Case Summary: We report the case of a 77-year-old female patient with regular cardiac follow-up in the setting of an asymptomatic severe aortic stenosis, who presented to the emergency department with signs and symptoms of sepsis and acute decompensated heart failure. Echocardiography revealed two vegetations attached to the tricuspid valve, an abscess of the anterior aortic ring, and a high-velocity ventricular septal defect. The patient was started on adequate antibiotic therapy. Surgical treatment in an urgent manner (within a few days) was decided by the Heart Team, in accordance with the ESC guidelines on the management of infective endocarditis. Whilst awaiting surgery, the patient presented with a sudden hemodynamic deterioration a few days after diagnosis, with cardiopulmonary arrest and subsequent death. Discussion: We hypothesize that the patient developed an infective endocarditis of the degenerated stenotic aortic valve with extension from left to right via a ventricular septal defect, the development of which was facilitated by the high trans-aortic valve gradient. Some reported cases describe a ventricular septal defect as a complication of native aortic valve endocarditis, though not all involve concomitant aortic stenosis. In conclusion, our case illustrates a very rare scenario of infective endocarditis complicating aortic stenosis with fulminant development. This case highlights a rare, albeit severe complication associated with aortic stenosis and therapeutic challenges in managing the dismal evolution of endocarditis in this setting.

End-to-end video classification by transfer learning allows one to categorize left ventricular ejection fraction (LVEF) into reduced EF (rEF), midrange EF (mEF), and preserved EF (pEF) from echocardiographic recordings, avoiding delineation of the LV cavity by a human expert or an AI algorithm. We developed a PyTorch implementation using MoViNet. Classical and PennyLane-based classical-quantum models were created. Fine-tuning involved the top four of the five model blocks. We tested our models on Stanford’s EchoNet dataset with the original train-val-test split. We tuned the models on the validation set. We developed ternary classifiers for distinguishing between rEF, mEF and pEF, and binary classifiers for rEF vs. rest and not pEF vs. rest. We used the output probabilities of all the classifiers as features subjected to a soft-voting ensemble algorithm consisting of random forest, Gaussian naive Bayes, and logistic regression. For the test set, the extension of the receiver operating characteristic (ROC) to one-vs.-rest multiclass showed a micro-averaged ROC AUC score of 0.96. The ROC AUC score and the balanced accuracy were 0.96 and 0.89 for rEF vs. rest, 0.94 and 0.86 for not pEF vs. rest. After optimization of the decision threshold, the sensitivity and specificity of rEF vs. rest and not pEF vs. rest were always above 0.85.

Identifying patients with left ventricular ejection fraction (EF), either reduced [EF < 40% (rEF)], mid-range [EF 40-50% (mEF)], or preserved [EF > 50% (pEF)], is considered of primary clinical importance. An end-to-end video classification using AutoML in Google Vertex AI was applied to echocardiographic recordings. Datasets balanced by majority undersampling, each corresponding to one out of three possible classifications, were obtained from the Standford EchoNet-Dynamic repository. A train-test split of 75/25 was applied. A binary video classification of rEF vs. not rEF demonstrated good performance (test dataset: ROC AUC score 0.939, accuracy 0.863, sensitivity 0.894, specificity 0.831, positive predicting value 0.842). A second binary classification of not pEF vs. pEF was slightly less performing (test dataset: ROC AUC score 0.917, accuracy 0.829, sensitivity 0.761, specificity 0.891, positive predicting value 0.888). A ternary classification was also explored, and lower performance was observed, mainly for the mEF class. A non-AutoML PyTorch implementation in open access confirmed the feasibility of our approach. With this proof of concept, end-to-end video classification based on transfer learning to categorize EF merits consideration for further evaluation in prospective clinical studies.

A 76-year-old male patient presented to the emergency room with acute decompensated right heart failure and presyncope episodes. Upon admission, his electrocardiogram (ECG) showed sustained monomorphic ventricular tachycardia at 180 bpm, which was electrically cardioverted, and the patient was subsequently admitted to the intensive care unit. The echocardiography showed a very dilated right ventricle (RV) with global systolic dysfunction and akinetic anterior and lateral walls. The coronary angiography was normal. The cardiac magnetic resonance showed signs of fibro-fatty replacement of the RV myocardium. Furthermore, the ECG after cardioversion showed inverted T waves and an epsilon wave in V1–V3 leads and late potentials by signal-averaged ECG. As such, a diagnosis of arrhythmogenic right ventricular cardiomyopathy (ARVC) was suspected. However, he presented no familial history of ARVC, was 76 years of age at the time of diagnosis and was asymptomatic until now. Given these considerations, we performed a right ventricular angiography which showed dilatation of the RV with akinetic/dyskinetic bulging, creating the “pile d’assiettes” image suggestive of ARVC. In the case of this patient, the RV angiography contributed to establish a diagnosis of ARVC with a very late presentation, to our knowledge the latest presentation in terms of age described in the literature.

Atrial fibrillation (AF) and coronary artery disease are frequently associated and, when so, lead to a grim prognosis. Recent studies suggest the presence of interconnected pathophysiological pathways between the 2 conditions that can promote and aggravate each other, igniting a vicious cycle. Notwithstanding, in contrast with the attention dedicated to the management of antithrombotic treatment, research on other aspects of coronary artery disease in AF is only recently gaining traction. The clinical impact of correct assessment of coronary artery stenosis in AF is especially high, due to the antithrombotic therapy imposed by both AF and coronary stenting. Until recently, an in‐depth characterization of coronary microcirculation in AF was lacking. However, contemporary studies indicate that coronary microvascular dysfunction is a frequent encounter in AF, possibly explaining the ischemic symptoms even in the absence of obstructive coronary artery disease and interfering with the use of pressure‐based indices to evaluate the hemodynamic significance of coronary artery stenosis. This comprehensive review addresses our current knowledge on coronary physiology in AF and its repercussion on the invasive management of coronary artery disease in this setting.

Left ventricular aneurysms are outpouchings delineated by a thin myocardial wall, more frequently encountered at the apex of the left ventricle, which is seldom dyskinetic or akinetic. Apart from coronary artery disease, the etiology can be challenging. We report the case of a 30-year-old man with an isolated apical left ventricular aneurysm associated with prominent trabeculations on echocardiography.

Click to increase image sizeClick to decrease image sizeKeywords: Arterial hypertensionaortic coarctationpregnancy Disclosure statementNo potential conflict of interest was reported by the author(s).

IntroductionHeart failure (HF) remains a major cause of mortality, morbidity and poor quality of life. It affects 1–2% of the population in developed countries and approximately 44% of HF patients have an impaired left ventricular ejection fraction (LVEF). Kinocardiography (KCG) technology combines ballistocardiography (BCG) and seismocardiography (SCG). With 12 degrees-of-freedom, it measures the body motion produced by myocardial contraction and blood flow through the cardiac chambers and major vessels by means of a portable device.ObjectiveKino-HF sought to evaluate the potential of KCG to distinguish HF patients with impaired LVEF from a control group.MethodSuccessive patients with HF and impaired LVEF (HF group) were matched and compared to patients with normal LVEF≥50% (control). Cardiac ultrasound was followed by a 60 second KCG acquisition. The kinetic energy from KCG signals was computed in different phases of the cardiac cycle (iK systolic and ΔiK disastolic) as markers of cardiac mechanical function.ResultsIn all, 131 successive patients were recruited. Thirty patients from the HF group (67 [59; 71] years, 87% male) were matched with 30 controls (64.5 [49; 73] years, 87% male). SCG ΔiK disastolic, BCG iK systolic, BCG ΔiK disastolic were different between groups (P<0.05) (Fig. 1).Furthermore, QRS width was significantly larger in the HF group (94.0 [87.5; 102.0] vs. 104 [93.0; 127.0], P=0.02) with more complete bundle brunch block morphology (7% vs. 30%, P=0.01). In these specific patients, SCG iK systolic was higher in the HF group.ConclusionKINO-HF demonstrates that kinocardiography is able to distinguish heart failure patients with impaired systolic function from a control group. iK systolic and ΔiK disastolic make Kinocardiography an interesting tool for screening heart failure with impaired left ventricular ejection fraction.

Despite the current use of fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) in evaluating coronary stenosis in patients with atrial fibrillation (AF), to date, there are no studies investigating these coronary physiologic indexes in guiding coronary revascularization in this population. We aimed to compare the risk of major adverse cardiac events (MACE) in patients with AF and intermediate coronary artery stenosis, depending on the coronary revascularization approach used: FFR, iFR, or traditional angiography. In parallel, we evaluated the same outcomes in a population of patients in sinus rhythm (SR) as the control.

Pintea Bentea, Georgiana; Berdaoui, Brahim; Samyn, Sophie; Morissens, Marielle; van de Borne, Philippe; Castro Rodriguez, Jose Author Information

Left ventricular aneurysms are outpouchings delineated by a thin myocardial wall, more frequently encountered at the apex of the left ventricle, which is seldom dyskinetic or akinetic. Apart from coronary artery disease, the etiology can be challenging. We report the case of a 30-year-old man with an isolated apical left ventricular aneurysm associated with prominent trabeculations on echocardiography.

Background:Heart failure (HF) remains a major cause of mortality, morbidity, and poor quality of life. 44% of HF patients present impaired left ventricular ejection fraction (LVEF). Kinocardiography (KCG) technology combines ballistocardiography (BCG) and seismocardiography (SCG). It estimates myocardial contraction and blood flow through the cardiac chambers and major vessels through a wearable device. Kino-HF sought to evaluate the potential of KCG to distinguish HF patients with impaired LVEF from a control group. Methods:Successive patients with HF and impaired LVEF (iLVEF group) were matched and compared to patients with normal LVEF ≥ 50% (control). A 60 s KCG acquisition followed cardiac ultrasound. The kinetic energy from KCG signals was computed in different phases of the cardiac cycle (iKsystolic;ΔiKdiastolic) as markers of cardiac mechanical function. Results:Thirty HF patients (67 [59; 71] years, 87% male) were matched with 30 controls (64.5 [49; 73] years, 87% male). SCG ΔiKdiastolic, BCG iKsystolic, BCG ΔiKdiastolic were lower in HF than controls (p < 0.05), while SCG iKsystolic was similar. Furthermore, a lower SCG iKsystolic was associated with an increased mortality risk during follow-up. Conclusions:KINO-HF demonstrates that KCG can distinguish HF patients with impaired systolic function from a control group. These favorable results warrant further research on the diagnostic and prognostic capabilities of KCG in HF with impaired LVEF.Clinical Trial Registration: NCT03157115.

Primary cardiac tumours are rare entities with an estimated prevalence of 0.02% according to 22 series of autopsies on more than 700,000 patients [1]. Three quarters of these tumours are benign, with myxoma accounting for half of them and haemangioma for about 2% [2]. As a rare phenomenon, cardiac haemangioma suffers from a scarce literature. Long considered a curiosity in the autopsy, the latter has been better characterised since the advent of angiography and cardiac surgery in the 1970s. The clinical presentation is diverse and dependent on the anatomical position. Asymptomatic in most cases, dyspnoea or arrhythmia remain possible revelations [3]. Tetralogy of Fallot (TOF) is the most common cyanogenic heart defect at birth. Described in 1888 by the French anatomopathologist Etienne-Louis Arthur Fallot [4], its prevalence is 4–5 per 10,000 live births [5]. It groups together four anomalies: deviation of the conal septum inducing a dextroposition of the aorta, ventricular septal defect (VSD) and pulmonary stenosis with secondary right ventricular hypertrophy. We report here the case of a young 17-year-old patient with a history of TOF operated on in childhood who presented with a rapidly growing left intraventricular haemangioma with an atypical location, discovered during his annual follow-up. This text discusses about the clinical and iconographic description, surgical management, and diagnostic confirmation with regard to histological data.

Background:Symptoms suggestive of myocardial ischemia are frequently encountered in patients with atrial fibrillation (AF) even in the absence of obstructive coronary artery disease. Nevertheless, an in-depth characterisation of coronary physiology in patients with AF is currently lacking.Objectives:We aim to provide an insight into the characteristics of coronary physiology in AF, by performing simultaneous invasive measurements of coronary flow- and pressure- indices in a real-life population of patients with AF and indication of coronary angiography.Methods:This is a prospective open label study including patients with permanent or persistent AF and indication of coronary angiography showing intermediate coronary stenosis requiring routine physiological assessment (n = 18 vessels from 14 patients). We measured FFR (fractional flow reserve), and Doppler-derived coronary flow indices, including CFR (coronary flow reserve) and HMR (hyperaemic microvascular resistance).Results:From the analysed vessels, 18/18 vessels (100%) presented a pathological CFR (<2.5), indicative of coronary microvascular dysfunction (CMD), and 3/18 (17%) demonstrated obstructive epicardial coronary disease (FFR ≤ 0.8). A large proportion of vessels (15/18; 83%) showed discordant FFR/CFR with preserved FFR and low CFR. 47% of the coronary arteries in patients with AF and non-obstructive epicardial coronary disease presented structural CMD (HMR ≥ 2.5 mmHg/cm/s), and were associated with high BMR and an impaired response to adenosine. Conversely, vessels from patients with AF and non-obstructive epicardial coronary disease with functional CMD (HMR < 2.5 mmHg/cm/s) showed higher bAPV. The permanent AF subpopulation presented increased values of HMR and BMR compared to persistent AF, while structural CMD was more often associated with persistent symptoms at 3 months, taking into account the limited sample size of our study.Conclusion:Our findings highlight a systematically impaired CFR in patients with AF even in the absence of obstructive epicardial coronary disease, indicative of CMD. In addition, patients with AF presented more prevalent structural CMD (HMR ≥ 2.5 mmHg/cm/s), characterized by reduced hyperaemic responses to adenosine, possibly interfering with the FFR assessment.

Background: At the beginning of the COVID-19 pandemic, professionals in charge of particularly vulnerable populations, such as adult congenital heart disease (ACHD) patients, were confronted with difficult decision-making. We aimed to assess changes in risk stratification and outcomes of ACHD patients suffering from COVID-19 between March 2020 and April 2021.Methods and results: Risk stratification among ACHD experts (before and after the first outcome data were available) was assessed by means of questionnaires. In addition, COVID-19 cases and the corresponding patient characteristics were recorded among participating centres. Predictors for the outcome of interest (complicated disease course) were assessed by means of multivariable logistic regression models calculated with cluster-robust standard errors. When assessing the importance of general and ACHD specific risk factors for a complicated disease course, their overall importance and the corresponding risk perception among ACHD experts decreased over time. Overall, 638 patients (n = 168 during the first wave and n = 470 during the subsequent waves) were included (median age 34 years, 52% women). Main independent predictors for a complicated disease course were male sex, increasing age, a BMI >25 kg/m2, having >= 2 comorbidities, suffering from a cyanotic heart disease or having suffered COVID-19 in the first wave vs. subsequent waves.Conclusions: Apart from cyanotic heart disease, general risk factors for poor outcome in case of COVID-19 reported in the general population are equally important among ACHD patients. Risk perception among ACHD experts decreased during the course of the pandemic.

Transcatheter aortic valve implantation (TAVI) is a new minimally invasive procedure for symptomatic patients with severe aortic stenosis and surgical high-risk. Numerous technical improvements have been developed to simplify the procedure and reduce the incidence of complications. Temporary pacing of the right ventricle remains mandatory to ensure transient hypotension and low cardiac output while performing predilation of the aortic annulus and accurately position and deploy the valve. Temporary pacing is also crucial as a backup pacing device if complete atrioventricular block develops after TAVI. Implanting a temporary pacing wire requires additional venous vascular access and a pacing lead, both of which may generate complications. Cardiac tamponade during TAVI is a rare complication. We present the case of a cardiac tamponade during TAVI probably due to right ventricular perforation associated with pacing. We report some measures to avoid such complications and improve the TAVI procedure.