The ganglion cell complex damage in coronary artery disease.

PURPOSE: This study aims to investigate the correlation between macular thickness, retinal nerve fiber layer thickness, ganglion cell complex thickness, and Gensini scores in patients who have undergone coronary angiography, using spectral-domain optical coherence tomography. METHODS: We retrospectively evaluated optical coherence tomography results from patients who had undergone coronary angiography between January 2019 and January 2021 due to coronary artery disease, with angiography performed within one month of the optical coherence tomography examination. Based on their Gensini scores, patients were classified into two groups: mild coronary artery disease (Gensini score ≤ 20, Group 1) and severe coronary artery disease (Gensini score > 20, Group 2). RESULTS: Group 1 comprised 28 patients with an average age of 61.3 ± 10.2, while Group 2 consisted of 25 patients with an average age of 65.4 ± 9.6. While there was no statistically significant difference found in retinal nerve fiber layer and macular thickness between the groups, the ganglion cell complex thickness was significantly thinner in Group 2 in the inner superior temporal (112.55 ± 34.12 µm vs. 99.68 ± 37.81 µm, p = 0.026), inner superior nasal (121.14 ± 32.92 µm vs. 108.36±24.53 µm, p = 0.012), inner inferior nasal (120.81 ± 32.34 µm vs. 108.45 ± 12.53 µm, p = 0.048), and superior (99.11 ± 25.91 µm vs. 88.77 ± 16.75 µm, p = 0.020) regions. Furthermore, a significant negative correlation was observed between the Gensini score and the ganglion cell complex thickness in both the inner superior nasal and superior regions. CONCLUSION: Compared to patients with mild coronary artery disease, those with severe disease exhibited a significant decrease in ganglion cell complex thickness in the superior and inner superior nasal regions.

Noninvasive Investigation of the Presence and Extent of Coronary Artery Disease by the Evaluation of Fingertip-Reactive Hyperemia.

OBJECTIVE: Fingertip-reactive hyperemia-peripheral artery tonometry (RH-PAT) is an emerging novel noninvasive method for evaluating endothelial function. We aimed to evaluate endothelial function with fingertip-reactive hyperemia by RH-PAT in symptomatic patients undergoing elective coronary angiography and to assess the relationship between the degree of endothelial dysfunction (ED) and the presence and the severity of coronary artery disease (CAD). SUBJECTS AND METHODS: We assessed 92 patients. Before coronary angiography, endothelial function was measured by RH-PAT and reactive hyperemia index (RHI) was obtained. For each patient, the Gensini score was calculated according to the coronary angiographic findings to evaluate the severity of CAD. RESULTS: In CAD (+) group, RHI (1.35 ± 0.57 vs. 1.74 ± 0.46, p = 0.001) mean values were lower than CAD (-) group. In multivariate logistic regression analysis, age, high-density lipoprotein, and RHI were found to be independent parameters predicting the presence of CAD. In multivariate linear regression analysis, RHI was found to be an independent predictor associated with the severity of CAD. In receiver operating characteristic curve analysis, RHI achieved an area under the curve of 0.763 (95% confidence interval 0.663-0.846, p = 0.001) for the ability to predict the presence of CAD. A cut-off value of 1.49 for an RHI predicted the presence of CAD with a sensitivity of 75% and a specificity of 72.9%. CONCLUSION: RH-PAT is an objective and highly reproducible test with superior diagnostic accuracy for the evaluation of ED. We found significant correlations between ED and the presence and the severity of CAD.

Cerebral embolic protection devices during transcatheter aortic valve implantation, the current state of the art.

Stroke after transcatheter aortic valve (TAVI) is a devastating adverse event. The majority of these occur in the acute phase following TAVI where cerebral embolic events are frequent. Cerebral embolic protection devices (CEPD) have been developed to minimise the risk of peri-procedural ischaemic stroke during TAVI. CEPD have the potential to lower intraprocedural burden of new silent ischaemic brain injury. Several CEPD have been developed, but their clinical benefit remains unknown. Herein, we aimed to review the impact of the use of CEPD, in patients undergoing TAVI, on the reduction of strokes or the onset of new ischaemic lesions.

Vascular Complications in TAVR: Incidence, Clinical Impact, and Management.

Transcatheter aortic valve replacement (TAVR) has replaced surgical aortic valve replacement as the new gold standard in elderly patients with severe aortic valve stenosis. However, alongside this novel approach, new complications emerged that require swift diagnosis and adequate management. Vascular access marks the first step in a TAVR procedure. There are several possible access sites available for TAVR, including the transfemoral approach as well as transaxillary/subclavian, transcarotid, transapical, and transcaval. Most cases are primarily performed through a transfemoral approach, while other access routes are mainly conducted in patients not suitable for transfemoral TAVR. As vascular access is achieved primarily by large bore sheaths, vascular complications are one of the major concerns during TAVR. With rising numbers of TAVR being performed, the focus on prevention and successful management of vascular complications will be of paramount importance to lower morbidity and mortality of the procedures. Herein, we aimed to review the most common vascular complications associated with TAVR and summarize their diagnosis, management, and prevention of vascular complications in TAVR.

Effects of angiotensin receptor neprilysin inhibition on P-wave dispersion in heart failure with reduced ejection fraction.

BACKGROUND: Angiotensin receptor neprilysin inhibitors (ARNI; sacubitril/valsartan combination) decrease morbidity and mortality in heart failure with reduced ejection fraction (HFrEF). Increased P­wave duration and P­wave dispersion (Pd) reflect prolongation of atrial conduction and correlate with atrial fibrillation. Here, we aimed to assess the effects of switching from valsartan to ARNI treatment on the basis of P­wave indices. METHODS: A total of 28 patients with HFrEF (mean age, 64.8 ± 10.6 years; 18 males, 78.6% ischemic etiology) were included. All patients had New York Heart Association functional class II-III, left ventricular ejection fraction ≤35%, and had been switched from valsartan to ARNI treatment. Standard 12-lead electrocardiograms from patients on valsartan treatment and electrocardiograms 1 month after ARNI treatment were analyzed; heart rate, maximum P­wave duration (Pmax), minimum P­wave duration (Pmin), and Pd were calculated. Minnesota Living with Heart Failure Questionnaire (MLWHFQ) scores and N­terminal pro-brain natriuretic peptide (NT-proBNP) values were recorded. RESULTS: The Pmax (135.6 ± 32.1 ms vs. 116.1 ± 14.1 ms, p = 0.041) and Pd (33.6 ± 7.9 vs. 28.6 ± 5.3, p = 0.006) values were significantly reduced after ARNI treatment. Furthermore, ARNI treatment was associated with an improvement in MLWHFQ scores (31.2 ± 6.2 ms vs. 23.2 ± 7.0 ms, p < 0.001) and with a reduction in NT-proBNP values (1827.3 ± 1287.3 pg/ml vs. 1074.4 ± 692.3 pg/ml, p < 0.001). There were moderately positive correlations between the reduction in Pd and the improvement in MLWHFQ scores (r = 0.408, p = 0.031) and the reduction in NT-proBNP values (r = 0.499, p = 0.007) CONCLUSION: Switching to ARNI treatment alters Pd and Pmax favorably in patients with HFrEF. The reduction in atrial inhomogeneous conduction assessed by Pd was correlated with clinical improvement and reduced NT-proBNP levels in patients with HFrEF.

Echocardiographic assessment in cardiogenic shock.

Echocardiography is the most helpful diagnostic modality in cardiogenic shock, the management of which still remains challenging despite advances in therapeutic options. The presence of cardiogenic shock portends high mortality rates. Therefore, rapid recognition, identification of the underlying cause, and evaluation of the severity of hemodynamic dysfunction are vital for correct management. Whether the cause of shock is unknown, suspected, or established, echocardiography is utilized in its diagnosis and management as well as to monitor progress. It is recommended as the modality of first choice. No other investigative bedside tool can offer comparable diagnostic capability, allowing for exact targeting of the underlying cardiac and hemodynamic problems. Echocardiography can promptly provide an impression of the etiology of shock and the potential line of treatment. Normal left ventricular and right ventricular systolic function, normal cardiac chamber dimensions, absence of any significant valvular pathology, and absence of any pericardial effusion virtually rule out a cardiac cause of shock. This review discusses the role of echocardiography as a decision-making tool in the evaluation and management of cardiogenic shock.

A systematic review on durability and structural valve deterioration in TAVR and surgical AVR.

Mechanical valves and bioprosthetic heart valves are widely used for aortic valve replacement (AVR). Mechanical valves are associated with risk of bleeding because of oral anticoagulation, while the durability and structural valve deterioration (SVD) represent the main limitation of the bioprosthetic heart valves. The implantation of bioprosthetic heart valves is increasing precipitously due aging population, and the widespread use of transcatheter aortic valve replacement (TAVR). TAVR has become the standard treatment for intermediate or high surgical risk patients and a reasonable alternative to surgery for low risk patients with symptomatic severe aortic stenosis. Moreover, TAVR is increasingly being used for younger and lower-risk patients with longer life expectancy; therefore it is important to ensure the valve durability for long-term transcatheter aortic valves. Although the results of mid-term durability of the transcatheter heart valves are encouraging, their long-term durability remains largely unknown. This review summarises the definitions, mechanisms, risk factors and assessment of SVD; overviews available data on surgical bioprosthetic and transcatheter heart valves durability.

Assessment of the relationship between non-dipping phenomenon and heart rate turbulence.

BACKGROUND: The aim of this cross-sectional study was to evaluate cardiac autonomic function by heart rate turbulence (HRT) indices in normotensive and hypertensive individuals with either non-dipper or dipper type circadian rhythm of blood pressure (BP). METHODS: A total of 122 patients were allocated into four groups: normotensive/dipper, n = 33; normotensive/non-dipper, n = 31; hypertensive/dipper, n = 29; and hypertensive/non-dipper, n = 29. HRT indices (turbulence slope [TS] and turbulence onset [TO]) were calculated from 24-h ambulatory electrocardiographic recordings. RESULTS: TS values were higher (TS = 10.0 ± 3.4 vs 8.0 ± 1.5, p = 0.004) and TO values were lower (TO = -2.9 [-3.6, -2.2] vs -2.0 [-2.3, -1.9], p = 0.037) in the dipper subgroup of normotensive cases than in the non-dipper subgroup of normotensive cases. Similarly, TS values were higher (TS = 8.4 ± 3.5 vs 6.2 ± 2.9, p = 0.012) and TO values were lower (TO = -2.1 [-3.4, -2.0] vs -1.6 [-1.9, -0.2], p = 0.003) in the dipper subgroup of hypertensive cases than in the non-dipper subgroup of hypertensive cases. Spearman's correlation analyses revealed a high positive correlation between percentage of dipping and TS (r = 0.600, p = 0.001) and a higher negative correlation between percentage of dipping and TO (r = -0.653, p = 0.001). CONCLUSIONS: Blunting of the nocturnal fall in BP is associated with impaired HRT indices in both normotensive and hypertensive groups.

The relationship between circadian blood pressure pattern and ventricular repolarization dynamics assessed by QT dynamicity.

OBJECTIVE: The aim of the present cross-sectional study was to evaluate ventricular repolarization dynamics by QT dynamicity in normotensive and hypertensive individuals with either a non-dipper-type or a dipper-type circadian rhythm of blood pressure (BP). METHODS: A total of 103 patients were allocated into four groups as follows: (i) normotensive/dipper, n=28; (ii) normotensive/nondipper, n=26; (iii) hypertensive/dipper, n=25; and (iv) hypertensive/nondipper, n=24. The linear regression slopes of the QT interval measured to the apex and to the end of the T wave plotted against R-R intervals (QTapex/R-R and QTend/R-R slopes, respectively) were calculated from 24-h ambulatory ECG recordings using a dedicated algorithm. RESULTS: QTapex/R-R and QTend/R-R slopes were higher in the nondipper subgroup of normotensive cases with respect to the dipper subgroup of normotensive cases (QTapex/R-R=0.171±0.017 vs. 0.127±0.023, P=0.001; QTend/R-R=0.159±0.015 vs. 0.133±0.025, P=0.001). QTapex/R-R and QTend/R-R slopes were higher in the nondipper subgroup of hypertensive cases with respect to the dipper subgroup of hypertensive cases (QTapex/R-R=0.187±0.019 vs. 0.133±0.019, P=0.001; QTend/R-R=0.183±0.018 vs. 0.147±0.022, P=0.001). Pearson's correlation analyses revealed a higher negative correlation between night-time decline in BP and QTapex/R-R (r=-0.638, P=0.001). There was also a moderate negative correlation between night-time decline in BP and QTend/R-R (r=-0.504, P=0.001). The correlation coefficients for degree of night-time dipping and QT dynamicity indices were higher in hypertensive groups than in the normotensive groups. CONCLUSION: Blunting of the nocturnal fall in BP associates with impaired QT dynamicity indices in both normotensive and hypertensive groups.

Improvement in right ventricular systolic function after cardiac resynchronization therapy correlates with left ventricular reverse remodeling.

BACKGROUND: Cardiac resynchronization therapy (CRT) improves left ventricular (LV) systolic function in heart failure (HF). However, the effects of CRT on right ventricular (RV) systolic function are not fully understood. OBJECTIVE: We aimed to determine echocardiographic correlates of improvement in RV systolic function after CRT. METHODS: Fifty-four patients (61.9 ± 10.5 years; 43 men; LV ejection fraction 24.6 ± 4.0%; QRS duration > 120 ms) with HF were enrolled. Standard echocardiography, strain rate (SR), and tissue Doppler imaging were performed in all patients before and 6 months after CRT. Pulsed-wave TDI-derived systolic indices of RV included systolic (RV(S) ) and isovolumic velocity (RV(IVV)) and isovolumic acceleration (RV(IVA)). Response to CRT was defined as decline in LV end-systolic volume (LVESV) ≥ 10%. RESULTS: When indices of RV systolic function were assessed between responders and nonresponders, in responders (38 patients, 70.4%) RV end-diastolic diameters (RVD1-3), mid-RV strain, and mid-RV SR improved significantly (P < 0.01, for all). RV(S) (10.77 ± 4.29 vs 12.62 ± 4.10 cm/sec, P = 0.005), RV(IVV) (14.71 ± 5.88 vs 18.52 ± 6.62 cm/sec, P < 0.001), and RV(IVA) (1.69 ± 0.70 vs 2.39 ± 0.77 m/sec(2) , P < 0.001) significantly increased among responders. There was no significant change in these parameters among nonresponders. Pearson's analyses revealed moderate positive correlations between reduction of LVESV and ΔRV(IVV) (r = 0.467, P = 0.001) and ΔRV(IVA) (r = 0.473, P = 0.001), respectively. CONCLUSIONS: RV diameters and systolic indices after CRT improved only in the responder group. Improvement in RV systolic performance after CRT is correlated with the reduction of LVESV.