Role of the Gut Microbiome in the Development of Atherosclerotic Cardiovascular Disease.

Atherosclerotic cardiovascular disease (ASCVD) is the primary cause of death globally, with nine million deaths directly attributable to ischemic heart diseases in 2020. Since the last few decades, great effort has been put toward primary and secondary prevention strategies through identification and treatment of major cardiovascular risk factors, including hypertension, diabetes, dyslipidemia, smoking, and a sedentary lifestyle. Once labelled "the forgotten organ", the gut microbiota has recently been rediscovered and has been found to play key functions in the incidence of ASCVD both directly by contributing to the development of atherosclerosis and indirectly by playing a part in the occurrence of fundamental cardiovascular risk factors. Essential gut metabolites, such as trimethylamine N-oxide (TMAO), secondary bile acids, lipopolysaccharides (LPS), and short-chain fatty acids (SCFAs), have been associated with the extent of ischemic heart diseases. This paper reviews the latest data on the impact of the gut microbiome in the incidence of ASCVD.

Left ventricular ejection fraction using a simplified wall motion score based on mid-parasternal short axis and apical four-chamber views for non-cardiologists.

BACKGROUND: There is a need for a convenient, yet reliable method to assess left ventricular ejection fraction (LVEF) with point-of-care ultrasound study (POCUS). We aim to validate a novel and simplified wall motion score LVEF based on the analysis of a simplified combination of echocardiographic views. METHODS: In this retrospective study, transthoracic echocardiograms of randomly selected patients were analysed by the standard 16-segments wall motion score index (WMSI) to derive the reference semi-quantitative LVEF. To develop our semi-quantitative simplified-views method, a limited combination of imaging views and only 4 segments per view were tested: (1) A combination of the three parasternal short-axis views (PSAX BASE, MID-, APEX); (2) A combination of the three apical views (apical 2-chamber, 3-chamber and 4-chamber) and (3) A more limited combination of PSAX-MID and apical 4-chamber is called the MID-4CH. Global LVEF is obtained by averaging segmental EF based on contractility (normal = 60%, hypokinesia = 40%, and akinesia = 10%). Accuracy of the novel semi-quantitative simplified-views WMS method compared to the reference WMSI was evaluated using Bland-Altman analysis and correlation was assessed in both emergency physicians and cardiologists. RESULTS: In the 46 patients using the 16 segments WMSI method, the mean LVEF was 34 ± 10%. Among the three combinations of the two or three imaging views analysed, the MID-4CH had the best correlation with the reference method (r2 = 0.90) with very good agreement (mean LVEF bias = - 0.2%) and precision (± 3.3%). CONCLUSIONS: Cardiac POCUS by emergency physicians and other non-cardiologists is a decisive therapeutic and prognostic tool. A simplified semi-quantitative WMS method to assess LVEF using the easiest technically achievable combination of mid-parasternal and apical four-chamber views provides a good approximative estimate for both non-cardiologist emergency physicians and cardiologists.

Right ventricular ejection fraction with cardiac magnetic resonance using a wall motion score.

BACKGROUND: The volumetric method in cardiac magnetic resonance (CMR), the reference standard for right ventricular ejection fraction (RVEF), requires expertise because of the complex right ventricular geometry and anatomical landmarks. AIM: The aim of our retrospective study was to describe a new method to evaluate RVEF based on wall motion score index (WMSI) in CMR. METHODS: Visual assessment of wall motion was performed using an eight-segment model (normokinesia=1, hypokinesia=2, akinesia=3). Correlation between WMSI (WMS/8) and the reference volumetric RVEF was analysed. A regression equation was derived to convert the WMSI into RVEF. The accuracy of CMR WMSI-derived RVEF compared with CMR volumetric RVEF was evaluated using Bland-Altman analysis. RESULTS: In the 112 patients using the volumetric method, the mean RVEF was 48±14%. Fifty-nine patients had normal RV kinetics (WMSI=1), which corresponded to a volumetric RVEF of 56% (standard deviation 7%; range 43-76%). CMR WMSI showed a strong correlation with CMR volumetric RVEF (Spearman's Rho=-0.69). A regression equation was created: RVEF=80-22×WMSI. Overall, the WMSI-derived RVEF resulted in good agreement with the CMR volumetric RVEF (mean bias-3%, standard deviation±7.5%). In addition, using a WMSI cut-off of≥1.5 was highly accurate (92%) to predict a reference RVEF of˂45%, an important prognostic indicator in CMR. CONCLUSIONS: Our results suggest that using the WMS in CMR (eight-segment) to estimate RVEF is accurate, and correlates well with the volumetric method. A WMSI≥1.5 is optimal to categorize patients in the higher-risk subset of CMR RVEF˂45%.

Severe bradyarrhythmia linked to left atrial dysfunction in Fabry disease-A cross-sectional study.

BACKGROUND: Fabry disease (FD) is a lysosomal storage disorder caused by an enzymatic deficiency. Conduction abnormalities and bradyarrhythmias are common and can occur prior to the onset of left ventricular (LV) hypertrophy. We aimed to describe the clinical, electrocardiographic and echocardiographic, including left atrial (LA) function, determinants of bradyarrhythmic events in FD. HYPOTHESIS: Bradyarrhythmic events are frequent in patients with FD and are associated with LA dysfunction. METHODS: We designed a cross-sectional study that includes 53 FD patients (mean age, 45 years; 42% male). Clinical characteristics and electrocardiographic and echocardiographic data were collected. LA function was measured using biplane volumes and 2D speckle-tracking echocardiography. Bradyarrhythmic events were defined as pause of more than 2 seconds (sinus pause or atrioventricular block) recorded on Holter, severe bradycardia (≤ 40 bpm on ECG) or implantation of a permanent pacemaker. RESULTS: Six (11%) patients had installation of a pacemaker, 4 (8%) patients had cardiac pause and 2 (4%) patients had an episode of severe bradycardia. Patients with bradyarrhythmic events were older and had a lower resting heart rate. On echocardiography, a significantly higher LV mass, a lower LV ejection fraction, and a more affected LA reservoir function were found in those with bradyarrhythmic events. Patients also experienced tachyarrhythmias frequently. Atrial fibrillation occurred in 11 (21%) patients and ventricular tachycardia in 4 (8%) patients. CONCLUSIONS: Bradyarrhythmia are common manifestations of cardiac involvement in FD. Age, LV mass, LV ejection fraction and LA reservoir dysfunction can be useful markers associated with bradyarrhythmia.

Impaired Left Atrial Function in Fabry Disease: A Longitudinal Speckle-Tracking Echocardiography Study.

BACKGROUND: Fabry disease (FD) is characterized by the accumulation of sphingolipids in multiple organs, including the left atrium. It is uncertain if the left atrial (LA) reservoir, conduit, and contractile functions evaluated by speckle-tracking echocardiography are affected in Fabry cardiomyopathy and whether enzyme replacement therapy can improve LA function. METHODS: In this retrospective cohort study, LA strain, strain rates, and phasic LA volumes were studied in 50 patients with FD and compared with values in 50 healthy control subjects. RESULTS: All three LA phasic functions were altered. Peak positive strain (reservoir function) was 38.9 ± 14.9% versus 46.5 ± 10.9% (P = .004), and late diastolic strain (contractile function) was 12.6 ± 5.9% versus 15.6 ± 5.3% (P = .010). In 15 patients who started enzyme replacement therapy during the study, most of the LA parameters improved at 1-year follow-up (peak positive strain from 32.0 ± 13.5% to 38.0 ± 13.5%, P = .006), whereas there was a trend toward deterioration in 15 patients who never received treatment (peak positive strain from 47.3 ± 10.8% to 41.3 ± 9.3%, P = .058). Nine patients with FD (21%) experienced new-onset atrial fibrillation or stroke during 4-year follow-up. By univariate analysis, peak positive strain and early diastolic strain demonstrated significant associations with clinical events, surpassing conventional echocardiographic parameters and clinical characteristics. CONCLUSIONS: LA reservoir, conduit, and contractile functions by speckle-tracking echocardiography were all affected in FD. Enzyme replacement therapy improved LA function. LA strain parameters were associated with atrial fibrillation and stroke.

Preoperative Optimization of the Heart Failure Patient Undergoing Cardiac Surgery.

Heart failure patients who undergo cardiac surgery are exposed to significant perioperative complications and high mortality. We herein review the literature concerning preoperative optimization of these patients. Salient findings are that end-organ dysfunction and medication should be optimized before surgery. Specifically: (1) reversible causes of anemia should be treated and a preoperative hemoglobin level of 100 g/L obtained; (2) renal function and volume status should be optimized; (3) liver function must be carefully evaluated; (4) nutritional status should be assessed and cachexia treated to achieve a preoperative albumin level of at least 30 g/L and a body mass index > 20; and (5) medication adjustments performed, such as withholding inhibitors of the renin-angiotensin-aldosterone system before surgery and continuing, but not starting, ß-blockers. Levels of natriuretic peptides (brain natriuretic peptide [BNP] and N-terminal proBNP) provide additional prognostic value and therefore should be measured. In addition, individual patient's risk should be objectively assessed using standard formulas such as the EuroSCORE-II or Society of Thoracic Surgeons risk scores, which are simple and validated for various cardiac surgeries, including left ventricular assist device implantation. When patients are identified as high risk, preoperative hemodynamic optimization might be achieved with the insertion of a pulmonary artery catheter and hemodynamic-based tailored therapy. Finally, a prophylactic intra-aortic balloon pump might be considered in certain circumstances to decrease morbidity and even mortality, like in some high risk heart failure patients who undergo cardiac surgery, whereas routine preoperative inotropes are not recommended and should be reserved for patients in shock, except maybe for levosimendan.

Coronary artery perforation at the level of two-overlapping bioresorbable vascular scaffolds: The importance of vessel sizing and scaffold thickness.

Everolimus-eluting bioresorbable vascular scaffolds (BVS) have emerged as an alternative to conventional metallic stents and have demonstrated favorable outcomes in simple coronary lesions. As the use of BVS increases and extends to more complex lesion subsets, intraprocedural complications are expected to occur. We describe for the first time the occurrence of a free coronary perforation localized at the exact point of overlap of two BVS. This case illustrates the importance of appropriate vessel sizing, especially when BVS overlapping is performed in a small vessel, and potential advantages of scaffold juxtaposition compared to overlapping when implanting BVS in series.