Transient pacing in pigs with complete heart block via myocardial injection of mRNA coding for the T-box transcription factor 18.

The adenovirus-mediated somatic transfer of the embryonic T-box transcription factor 18 (TBX18) gene can convert chamber cardiomyocytes into induced pacemaker cells. However, the translation of therapeutic TBX18-induced cardiac pacing faces safety challenges. Here we show that the myocardial expression of synthetic TBX18 mRNA in animals generates de novo pacing and limits innate and inflammatory immune responses. In rats, intramyocardially injected mRNA remained localized, whereas direct myocardial injection of an adenovirus carrying a reporter gene resulted in diffuse expression and in substantial spillover to the liver, spleen and lungs. Transient expression of TBX18 mRNA in rats led to de novo automaticity and pacemaker properties and, compared with the injection of adenovirus, to substantial reductions in the expression of inflammatory genes and in activated macrophage populations. In rodent and clinically relevant porcine models of complete heart block, intramyocardially injected TBX18 mRNA provided rate-adaptive cardiac pacing for one month that strongly correlated with the animal's sinus rhythm and physical activity. TBX18 mRNA may aid the development of biological pacemakers.

Outcomes in Patients with Pulmonary Arterial Hypertension Underwent Transcatheter Closure of an Atrial Septal Defect.

Pulmonary arterial hypertension (PAH) related to an atrial septal defect (ASD) poses a challenge to transcatheter closure of an ASD (tcASD). We aimed to determine the predictors for remaining PAH (rPAH) post-tcASD. This retrospective study was conducted at a single tertiary university hospital. Adult patients with an ASD and PAH were divided into three groups according to pulmonary vascular resistance (PVR). Normalization of pulmonary atrial systolic pressure (PASP) was defined as an estimated right ventricular systolic pressure < 40 mmHg and was determined using transthoracic echocardiography. Among 119 patients, 80% showed PAH normalization post-tcASD. Normalization of PAH post-tcASD was observed in 100%, 56.2%, and 28.6% of patients in mild, moderate, and severe PVR groups, respectively. The patients' New York Heart Association functional class improved. Multivariate logistic regression analysis showed that age and high PVR were significant risk factors for rPAH. A receiving operator curve analysis showed a PASP cutoff value > 67.5 mmHg to be predictive of rPAH post-tcASD, with an area under the curve value of 0.944 (sensitivity, 0.922; specificity 0.933). Most patients, including moderate-to-severe PAH patients, improved hemodynamically and clinically with tcASD. Since patients with severe PAH are at a risk of rPAH, tcASD should be performed by selecting the patient carefully based on pre-procedure medication, a vasoreactivity test, and a balloon occlusion test.

In situ diagnosis and simultaneous treatment of cardiac diseases using a single-device platform.

The in situ diagnosis of cardiac activities with simultaneous therapeutic electrical stimulation of the heart is key to preventing cardiac arrhythmia. Here, we present an unconventional single-device platform that enables in situ monitoring even in a wet condition and control of beating heart motions without interferences to the recording signal. This platform consists of the active-matrix array of pressure-sensitive transistors for detecting cardiac beatings, biocompatible, low-impedance electrodes for cardiac stimulations, and an alginate-based hydrogel adhesive for attaching this platform conformally to the epicardium. In contrast to conventional electrophysiological sensing using electrodes, the pressure-sensitive transistors measured mechanophysiological characteristics by monitoring the spatiotemporal distributions of cardiac pressures during heart beating motions. In vivo tests show mechanophysiological readings having good correlation with electrocardiography and negligible interference with the electrical artifacts caused during cardiac stimulations. This platform can therapeutically synchronize the rhythm of abnormal heartbeats through efficient pacing of cardiac arrhythmia.

Cardiovascular events and safety outcomes associated with remdesivir using a World Health Organization international pharmacovigilance database.

On October 2020, the US Food and Drug Administration (FDA) approved remdesivir as the first drug for the treatment of coronavirus disease 2019 (COVID-19), increasing remdesivir prescriptions worldwide. However, potential cardiovascular (CV) toxicities associated with remdesivir remain unknown. We aimed to characterize the CV adverse drug reactions (ADRs) associated with remdesivir using VigiBase, an individual case safety report database of the World Health Organization (WHO). Disproportionality analyses of CV-ADRs associated with remdesivir were performed using reported odds ratios and information components. We conducted in vitro experiments using cardiomyocytes derived from human pluripotent stem cell cardiomyocytes (hPSC-CMs) to confirm cardiotoxicity of remdesivir. To distinguish drug-induced CV-ADRs from COVID-19 effects, we restricted analyses to patients with COVID-19 and found that, after adjusting for multiple confounders, cardiac arrest (adjusted odds ratio [aOR]: 1.88, 95% confidence interval [CI]: 1.08-3.29), bradycardia (aOR: 2.09, 95% CI: 1.24-3.53), and hypotension (aOR: 1.67, 95% CI: 1.03-2.73) were associated with remdesivir. In vitro data demonstrated that remdesivir reduced the cell viability of hPSC-CMs in time- and dose-dependent manners. Physicians should be aware of potential CV consequences following remdesivir use and implement adequate CV monitoring to maintain a tolerable safety margin.

Regeneration of infarcted mouse hearts by cardiovascular tissue formed via the direct reprogramming of mouse fibroblasts.

Fibroblasts can be directly reprogrammed into cardiomyocytes, endothelial cells or smooth muscle cells. Here we report the reprogramming of mouse tail-tip fibroblasts simultaneously into cells resembling these three cell types using the microRNA mimic miR-208b-3p, ascorbic acid and bone morphogenetic protein 4, as well as the formation of tissue-like structures formed by the directly reprogrammed cells. Implantation of the formed cardiovascular tissue into the infarcted hearts of mice led to the migration of reprogrammed cells to the injured tissue, reducing regional cardiac strain and improving cardiac function. The migrated endothelial cells and smooth muscle cells contributed to vessel formation, and the migrated cardiomyocytes, which initially displayed immature characteristics, became mature over time and formed gap junctions with host cardiomyocytes. Direct reprogramming of somatic cells to make cardiac tissue may aid the development of applications in cell therapy, disease modelling and drug discovery for cardiovascular diseases.

Early Outcomes of Percutaneous Pulmonary Valve Implantation with Pulsta and Melody Valves: The First Report from Korea.

Percutaneous pulmonary valve implantation (PPVI) is used to treat pulmonary stenosis (PS) or pulmonary regurgitation (PR). We described our experience with PPVI, specifically valve-in-valve transcatheter pulmonary valve replacement using the Melody valve and novel self-expandable systems using the Pulsta valve. We reviewed data from 42 patients undergoing PPVI. Twenty-nine patients had Melody valves in mostly bioprosthetic valves, valved conduits, and homografts in the pulmonary position. Following Melody valve implantation, the peak right ventricle-to-pulmonary artery gradient decreased from 51.3 ± 11.5 to 16.7 ± 3.3 mmHg and right ventricular systolic pressure fell from 70.0 ± 16.8 to 41.3 ± 17.8 mmHg. Thirteen patients with native right ventricular outflow tract (RVOT) lesions and homograft underwent PPVI with the new self-expandable Pulsta valve-a nitinol wire stent mounted with a trileaflet porcine pericardial valve. Following Pulsta valve implantation, cardiac magnetic resonance imaging showed a decreased PR fraction and that the right ventricular end-diastolic volume index decreased from 166.1 ± 11.9 to 123.6 ± 12.4 mL/m2. There were no mortality, severe procedural morbidity, or valve-related complications. At the mean 14.2 month (4-57 months) follow-up, no patients had more than mild PR. PPVI using Melody and Pulsta valves was first shown to provide excellent early outcomes without serious adverse event in most patients with RVOT dysfunction in Korea.

A retrospective study of changes in skin cancer characteristics over 11 years.

BACKGROUND: The incidence of skin cancer, which is primarily caused by exposure to ultraviolet radiation, has steadily increased in recent years. The authors of the present study sought to investigate changes in the epidemiology of skin cancer by conducting a retrospective review of patients diagnosed with skin cancer who received related care at a single medical institution.
. METHODS: The present study included patients who were diagnosed with skin cancer and received treatment at Gyeongsang National University Hospital from 2008 to 2018. The site and type of skin cancer, the number of patients with skin cancer each year, the sex and sex ratio of the patients, and changes in patients' age at first diagnosis were examined through retrospective chart reviews.
. RESULTS: The number of patients with skin cancer significantly increased, but statistically significant changes were not found in patients' sex, skin cancer sites, or the types of skin cancer. However, patients' age at the first diagnosis of skin cancer showed a statistically significant decrease starting in 2015.
. CONCLUSION: In this study, the number of patients with skin cancer increased over time. However, patients' age at first diagnosis has decreased since 2015. Therefore, younger patients should take care to prevent skin cancer, and further research on the causes of skin cancer in younger patients is needed.

Velocity Vector Imaging Assessment of Functional Change in the Right Ventricle during Transcatheter Closure of Atrial Septal Defect by Intracardiac Echocardiography.

The functional change of the right ventricle (RV) after atrial septal defect (ASD) via transcatheter closure is well known. We assessed the immediate RV functional change using velocity vector imaging (VVI) with intracardiac echocardiography (ICE). Seventy-four patients who underwent transcatheter closure of an ASD were enrolled. VVI in the "home view" of ICE showing the RV was obtained before and after the procedure. Velocity, strain, strain rate (SR), and longitudinal displacement were analyzed from VVI data, and the changes of these parameters before and after the procedure were compared. The velocity of the RV decreased after ASD transcatheter closure (3.97 ± 1.48 to 3.56 ± 1.4, p = 0.024), especially in the RV inlet and outlet. The average strain decreased (-19.21 ± 5.79 to -16.87 ± 5.03, p = 0.002), as did the average SR (-2.28 ± 0.64 to -2.03 ± 0.61, p = 0.006). The average longitudinal displacement did not differ. With the VVI technique, we could clearly observe RV functional change immediately after transcatheter closure of the ASD. RV functional change with regional difference may reflect the heterogeneity of volume reduction and suggest subclinical RV dysfunction. These findings can enhance our understanding of the physiologic changes in the RV during reverse remodeling.

Prognostic Value of Cystatin C-Derived Estimated Glomerular Filtration Rate in Patients with Acute Heart Failure.

BACKGROUND: Renal function is closely related to cardiac function and an important prognostic marker in heart failure. OBJECTIVE: We aimed to test the prognostic value of cystatin C (cysC)-derived estimated glomerular filtration rates (eGFR) in comparison with eGFRs from creatinine solely based equations in patients with acute heart failure (AHF). METHODS: This study included 262 patients (65.8 ± 14.9 years old, 126 male) with AHF. Prognostic value of the eGFRs, from cysC-based equations chronic kidney disease epidemiology collaboration (CKD-EPI-cysC and CKD-EPI-creatinine [cr]-cysC equations) were compared with eGFRs calculated from serum creatinine levels only (Modification of Diet in Renal Disease [MDRD]-4 and CKD-EPI-cr equations). Prognosis was evaluated with the composite of all-cause mortality and hospitalization for heart failure within 1 year. RESULTS: During the follow-up period (mean follow-up period, 264.0 ± 136.1 days), 67 (25.6%) events occurred. Estimated GFR using CKD-EPI-cysC was the best for predicting 1-year outcome using receiver operating characteristic curve analysis (area under curve 0.585, 0.607, 0.669, and 0.652 for eGFRs from MDRD-4, CKD-EPI-cr, CKD-EPI-cysC, and CKD-EPI-cr-cysC respectively). The Kaplan-Meier survival curve analysis showed that only the eGFRs classification from the equations based on cysC significantly predicted 1-year outcome in patients with AHF. CONCLUSIONS: Estimated GFRs calculated with cysC predicted the prognosis more accurately in patients with AHF than the eGFRs from creatinine only equations.

All-in-One, Wireless, Stretchable Hybrid Electronics for Smart, Connected, and Ambulatory Physiological Monitoring.

Commercially available health monitors rely on rigid electronic housing coupled with aggressive adhesives and conductive gels, causing discomfort and inducing skin damage. Also, research-level skin-wearable devices, while excelling in some aspects, fall short as concept-only presentations due to the fundamental challenges of active wireless communication and integration as a single device platform. Here, an all-in-one, wireless, stretchable hybrid electronics with key capabilities for real-time physiological monitoring, automatic detection of signal abnormality via deep-learning, and a long-range wireless connectivity (up to 15 m) is introduced. The strategic integration of thin-film electronic layers with hyperelastic elastomers allows the overall device to adhere and deform naturally with the human body while maintaining the functionalities of the on-board electronics. The stretchable electrodes with optimized structures for intimate skin contact are capable of generating clinical-grade electrocardiograms and accurate analysis of heart and respiratory rates while the motion sensor assesses physical activities. Implementation of convolutional neural networks for real-time physiological classifications demonstrates the feasibility of multifaceted analysis with a high clinical relevance. Finally, in vivo demonstrations with animals and human subjects in various scenarios reveal the versatility of the device as both a health monitor and a viable research tool.

Convolutional Recurrent Neural Network-Based Event Detection in Tunnels Using Multiple Microphones.

This paper proposes a sound event detection (SED) method in tunnels to prevent further uncontrollable accidents. Tunnel accidents are accompanied by crashes and tire skids, which usually produce abnormal sounds. Since the tunnel environment always has a severe level of noise, the detection accuracy can be greatly reduced in the existing methods. To deal with the noise issue in the tunnel environment, the proposed method involves the preprocessing of tunnel acoustic signals and a classifier for detecting acoustic events in tunnels. For preprocessing, a non-negative tensor factorization (NTF) technique is used to separate the acoustic event signal from the noisy signal in the tunnel. In particular, the NTF technique developed in this paper consists of source separation and online noise learning. In other words, the noise basis is adapted by an online noise learning technique for enhancement in adverse noise conditions. Next, a convolutional recurrent neural network (CRNN) is extended to accommodate the contributions of the separated event signal and noise to the event detection; thus, the proposed CRNN is composed of event convolution layers and noise convolution layers in parallel followed by recurrent layers and the output layer. Here, a set of mel-filterbank feature parameters is used as the input features. Evaluations of the proposed method are conducted on two datasets: a publicly available road audio events dataset and a tunnel audio dataset recorded in a real traffic tunnel for six months. In the first evaluation where the background noise is low, the proposed CRNN-based SED method with online noise learning reduces the relative recognition error rate by 56.25% when compared to the conventional CRNN-based method with noise. In the second evaluation, where the tunnel background noise is more severe than in the first evaluation, the proposed CRNN-based SED method yields superior performance when compared to the conventional methods. In particular, it is shown that among all of the compared methods, the proposed method with the online noise learning provides the best recognition rate of 91.07% and reduces the recognition error rates by 47.40% and 28.56% when compared to the Gaussian mixture model (GMM)-hidden Markov model (HMM)-based and conventional CRNN-based SED methods, respectively. The computational complexity measurements also show that the proposed CRNN-based SED method requires a processing time of 599 ms for both the NTF-based source separation with online noise learning and CRNN classification when the tunnel noisy signal is one second long, which implies that the proposed method detects events in real-time.

A rat model of complete atrioventricular block recapitulates clinical indices of bradycardia and provides a platform to test disease-modifying therapies.

Complete atrioventricular block (CAVB) is a life-threatening arrhythmia. A small animal model of chronic CAVB that properly reflects clinical indices of bradycardia would accelerate the understanding of disease progression and pathophysiology, and the development of therapeutic strategies. We sought to develop a surgical model of CAVB in adult rats, which could recapitulate structural remodeling and arrhythmogenicity expected in chronic CAVB. Upon right thoracotomy, we delivered electrosurgical energy subepicardially via a thin needle into the atrioventricular node (AVN) region of adult rats to create complete AV block. The chronic CAVB animals developed dilated and hypertrophied ventricles with preserved systolic functions due to compensatory hemodynamic remodeling. Ventricular tachyarrhythmias, which are difficult to induce in the healthy rodent heart, could be induced upon programmed electrical stimulation in chronic CAVB rats and worsened when combined with ß-adrenergic stimulation. Focal somatic gene transfer of TBX18 to the left ventricular apex in the CAVB rats resulted in ectopic ventricular beats within days, achieving a de novo ventricular rate faster than the slow atrioventricular (AV) junctional escape rhythm observed in control CAVB animals. The model offers new opportunities to test therapeutic approaches to treat chronic and severe CAVB which have previously only been testable in large animal models.

Serum levels of carbohydrate antigen 125 in combination with N-terminal pro-brain natriuretic peptide in patients with acute decompensated heart failure.

BACKGROUND/AIMS: Carbohydrate antigen 125 (CA-125) is an emerging prognostic biomarker for heart failure. We aimed to test the long-term prognostic value of CA-125 in combination with N-terminal pro-brain natriuretic peptide (NT-proBNP) in patients with acute decompensated heart failure (ADHF). METHODS: This observational study included a total of 413 patients (64.1 ± 15.6 yearold, 214 men) with ADHF. All-cause mortality during the 2-year follow-up was investigated for the prognosis. RESULTS: During the follow-up (mean follow-up, 591 ± 233 days), 109 deaths (26.0%) were recorded. In the multivariable analysis model, CA-125 was an independent factor associated with all-cause mortality (log CA-125: hazard ratio, 1.23; 95% confidence interval, 1.02 to 1.48; p = 0.030) together with age, sex, New York Heart Association class, ß-blocker, and NT-proBNP. The Kaplan-Meier survival analysis demonstrated that the group with both low marker levels showed the best 2-year survival (87.9%) followed by the group with low NT-proBNP and high CA-125 (76.1%), high NT-proBNP and low CA-125 (64.7%) and high NT-proBNP and high CA-125 levels (54.3%) (p < 0.001). Addition of CA-125 in combination with NT-proBNP and established risk factors further increased the predictive power for mortality in patients with ADHF. CONCLUSION: CA-125 was an independent factor associated with all-cause mortality in patients with ADHF. Combination of CA-125 with NT-proBNP significantly improved the prediction of mortality in patients with ADHF.

Impact of Flow Differentials According to Cardiac and Respiratory Cycles on Three Types of Fontan Operation.

Few hemodynamic comparison studies on various types of Fontan operation have been reported. The objective of this study was to perform hemodynamic comparisons for flow size and volume in three types of Fontan operation: atriopulmonary connection (APC), lateral tunnel (LT), and extracardiac conduit (ECC). Forty patients with Fontan operation (8 with APC Fontan, 22 with LT Fontan, and 10 with ECC Fontan) were enrolled. Velocity time integral (VTI) and average peak velocity (APV) were assessed according to cardiac and respiratory cycles in SVC, IVC, hepatic vein, conduit, LPA, and RPA using direct intravenous Doppler echocardiography. During each cardiac cycle in APC, VTI and APV between inspiration and expiration did not show significant differences in SVC, IVC, HV, LPA, or RPA. During each cardiac cycle in LT and ECC, VTI and APV between inspiration and expiration showed significant differences in all native vessels. The gap between S and D wave in APC was the highest, followed by that in LT. It was the lowest in ECC regardless of inspiration or expiration. Hepatic reverse VTI and APV in APC showed significant decreases compared to those in VC and PA during inspiration and expiration. Flow size and volume in APC were more influenced by cardiac cycle. Those in LT were moderately influenced by both respiratory cycle and cardiac cycle while those in ECC were more influenced by respiratory cycle. APC Fontan has hemodynamic inefficiency with prominent reverse flow. However, total cavopulmonary connection (TCPC) Fontan has more hemodynamic efficiency without prominent reverse flows.

A stepwise approach to conduit puncture for electrophysiological procedures in patients with Fontan circulation.

Aims: In patients with Fontan circulation, the conduit may be punctured for electrophysiological procedures. We evaluated the feasibility and safety of a stepwise approach to conduit puncture in adults who have undergone Fontan operation. Methods and results: We included 13 consecutive patients with lateral tunnel or extracardiac conduit Fontan circulation [median age (interquartile range), 24.0 (16.0-25.0) years; seven men] who had undergone electrophysiological procedures. We performed a stepwise approach to conduit puncture: 1st, Brockenbrough needle; 2nd, Brockenbrough needle with snare; 3rd, extra-steep Brockenbrough needle with/without snare; 4th radiofrequency transseptal needle with/without snare; 5th, wiring through the puncture; 6th, conduit dilation with angioplasty balloon; 7th, non-compliant or cutting balloon; and 8th, Inoue dilator. In 12 patients, conduit puncture was successful. In two, one, and two patients with a lateral tunnel made of the pericardium or right atrial wall, conduit puncture was performed by steps 1st, 2nd, and 4th, respectively. In one, three, two, and one patient with the Goretex lateral tunnel or extracardiac conduit, conduit puncture was performed by steps 1st, 6th, 7th, and 8th, respectively. Puncture time was significantly longer in patients with Goretex conduits than with pericardial conduits [62.0 (50.0-120.0) and 11.5 (10.0-14.8) min, respectively; P < 0.001]. A snare was necessary in patients with angles ≤ 35° between the conduit wall and vertical line. Conclusion: A stepwise conduit puncture approach is feasible and safe in patients with lateral tunnel and extracardiac conduit Fontan circulation. Goretex conduit puncture was more difficult than pericardial conduit puncture.

Changes in Strain Pattern and Exercise Capacity after Transcatheter Closure of Atrial Septal Defects.

BACKGROUND AND OBJECTIVES: Assessment of left ventricle (LV) function by using strain and strain rate is popular in the clinical setting. However, the use of these echocardiographic tools in assessing right ventricle (RV) failure, and the manner in which they both reflect the functional capacity of the patient, remains poorly understood. This study aimed to investigate the change in exercise capacity and strain between before and (1 month) after the transcatheter closure of atrial septal defects (ASDs). SUBJECTS AND METHODS: Thirty patients who underwent transcatheter closure of ASD between May 2014 and June 2015 at the Division of Pediatric Cardiology, Severance Cardiovascular Hospital, were enrolled. We compared and analyzed the results of the following examinations, before and (1 month) after the procedure: echocardiography, cardiopulmonary exercise test (CPET), and N-terminal pro-brain natriuretic peptide level. RESULTS: There were no mortalities, and the male-to-female ratio was 1:2. The mean defect size was 22.3±4.9 mm; the mean Qp/Qs ratio, 2.1±0.5; and the mean device size, 22.3±4.9 mm. Changes in global RV longitudinal (GRVL) strain and LV torsion were measured echocardiographically. Exercise capacity improved from 7.7±1.2 to 8.7±1.8 metabolic equivalents (p=0.001). These findings correlated to the change in GRVL strain (p=0.03). CONCLUSION: The average exercise capacity increased after device closure of ASD. The change in strain was evident on echocardiography, especially for GRVL strain and LV torsion. Further studies comparing CPET and strain in various patients may show increased exercise capacity in patients with improved RV function.

Video-Assisted Thoracoscopic Left Cardiac Sympathetic Denervation in Patients with Hereditary Ventricular Arrhythmias.

BACKGROUND: Left cardiac sympathetic denervation (LCSD) has been underutilized in patients with hereditary ventricular arrhythmia syndromes such as congenital long QT syndrome (LQTS) and catecholaminergic polymorphic ventricular tachycardia (CPVT). The purpose of this study was to investigate the safety and efficacy of video-assisted thoracoscopic (VATS) LCSD in such patients. METHODS: Fifteen patients (four men, 24.6 ± 10.5 years old) who underwent VATS-LCSD between November 2010 and January 2015 for hereditary ventricular arrhythmia syndromes at Kyungpook National University Hospital were enrolled in this study. The safety and efficacy of VATS-LCSD were evaluated by periprocedural epinephrine tests and assessing the development of complications and cardiac events during follow-up. RESULTS: Fourteen patients with LQTS and one patient with CPVT underwent VATS-LCSD. Six and one patients developed ventricular tachyarrhythmia during preprocedural and postprocedural epinephrine test, respectively (P = 0.063). No serious complications such as Horner syndrome, pneumothorax, or bleeding developed after LCSD. Mean hospital stay after VATS-LCSD was 3.7 ± 1.5 days. During a mean follow-up of 927 ± 350 days, one LQTS patient and one CPVT patient, neither of whom manifested tachyarrhythmia during post-LCSD epinephrine test, developed torsades de pointes and syncope, respectively. The annual event rates of six patients who were symptomatic during the period preceding LCSD decreased from 0.97 to 0.19 events/year (P = 0.045). CONCLUSIONS: VATS-LCSD was a safe, and effective procedure for patients with hereditary ventricular tachycardia syndrome, with no serious adverse events and with short hospital stay.

Difference in the Prognostic Impact of Left Ventricular Global Longitudinal Strain between Anterior and Nonanterior Myocardial Infarction.

BACKGROUND: Speckle tracking-derived global longitudinal strain (GLS) of left ventricle is a potent prognostic marker for patients with ST-segment elevation myocardial infarction (STEMI). The purpose of this study was to investigate the difference of prognostic impact of GLS between anterior and nonanterior myocardial infarction. METHODS: This study included 686 patients who underwent primary percutaneous coronary intervention for their first STEMI between November 2007 and April 2012. Differences in the prognostic impact of GLS between anterior MI group and nonanterior MI group were evaluated. The composite of all-cause mortality and hospitalization for heart failure in 2 years was investigated for outcome. RESULTS: During the follow-up period, 77 (11.2%) adverse events occurred. The anterior and nonanterior MI groups included 339 and 347 patients, respectively. Among patients with anterior MI, GLS significantly predicted 2-year outcome in an adjusted model (adjusted hazard ratio [HR] 1.186; 95% confidence interval [CI] 1.071-1.314, P = 0.001), whereas the association between GLS and mortality was weaker in the nonanterior MI group (adjusted HR 0.977; 95% CI 0.884-1.081, P = 0.657). The interaction between the infarction territory and GLS was significant (P for interaction = 0.018), indicating that GLS was a more sensitive predictor of mortality in patients with anterior MI than that in those with nonanterior MI. CONCLUSIONS: Speckle tracking-derived GLS of left ventricle more sensitively predicted clinical outcome in patients with anterior MI than in those with nonanterior MI.

Extracorporeal life support can be a first-line treatment in children with acute fulminant myocarditis.

OBJECTIVES: The clinical outcome of children with severe acute myocarditis who require mechanical circulatory support is not well known. Therefore, we studied the survival and clinical courses of patients with acute fulminant myocarditis supported by extracorporeal life support (ECLS). METHODS: We performed a retrospective chart review of 13 consecutive children with acute fulminant myocarditis who were treated with ECLS between April 2013 and April 2015. Demographics, initial symptoms, laboratory results, management, clinical courses and last follow-up status were investigated. RESULTS: The median age was 25.8 months (range, 2.9 months to 11.5 years) and the median body weight was 10.3 kg (range, 5.3-47.5 kg). All patients received the ECLS procedure via peripheral approach (right neck). The median ECLS duration was 140 h (range, 51-425 h). The median intensive care unit stay was 16 days (range, 4-44 days). Viral pathogens were detected in 7 patients. Six patients underwent left-heart decompression using a catheter-based technique, which was performed using atrial septostomy and leaving a left atrial venting cannula. Eleven patients recovered from ventricular dysfunction, and 2 patients underwent successful orthotopic heart transplantation. Ultimately, 12 patients (92.3%) survived to discharge. The deceased patient succumbed to unrestored brain function due to enterovirus encephalitis, and the patient's parents chose to donate other organs. CONCLUSIONS: Mechanical circulatory support using ECLS can be a first-line treatment that confers excellent clinical outcomes for children with acute fulminant myocarditis.