Utility of coronary revascularization in patients with ischemic left ventricular dysfunction.

BACKGROUND: Revascularization in patients with left ventricular (LV) dysfunction has been a subject of ongoing uncertainty and conflicting results. This is further complicated by factors including viability, severity of LV dysfunction, and method of revascularization using percutaneous coronary intervention (PCI) versus coronary-artery bypass grafting (CABG). OBJECTIVES: The purpose of this meta-analysis is to evaluate the association of coronary revascularization with outcomes in patients with ischemic LV dysfunction. METHODS: A literature search was conducted for studies reporting on cardiovascular outcomes after revascularization compared to optimal medical therapy (OMT) in patients with ischemic LV dysfunction. RESULTS: A total of 23 studies with 10,110 participants met inclusion criteria. Revascularization was significantly associated with lower all-cause mortality and CV mortality compared to OMT. The association was statistically significant regardless of severity of LV dysfunction or method of revascularization. Subgroup analysis demonstrated that revascularization was significantly associated with lower all-cause and CV mortality compared to OMT for patients with viable myocardium and mixed cohorts with variable viability, but not patients without viable myocardium. Revascularization was not associated with a significant difference in risk of heart failure (HF) hospitalization or acute myocardial infarction (AMI) compared to OMT. CONCLUSIONS: Revascularization in patients with ischemic LV dysfunction is associated with lower risk of all-cause and CV mortality independent of severity of LV dysfunction or method of revascularization. Revascularization is not associated with lower risk of mortality in patients without evidence of viable myocardium and is not associated with lower risk of AMI or HF hospitalization.

The role of structured inpatient lipid protocols in optimizing non-statin lipid lowering therapy: a review and single-center experience.

Dyslipidemia is a leading contributor to atherosclerotic cardiovascular disease (ASCVD). There has been a significant improvement in the treatment of dyslipidemia in the past 10 years with the development of new pharmacotherapies. The intent of this review is help enhance clinicians understanding of non-statin lipid lowering therapies in accordance with the 2022 American College of Cardiology Expert Consensus Clinical Decision Pathway on the Role of Non-statin Therapies for LDL-Cholesterol Lowering. We also present a single-center experience implementing a systematic inpatient protocol for lipid lowering therapy for secondary prevention of ASCVD.

Utility of native T1 mapping and myocardial extracellular volume fraction in patients with nonischemic dilated cardiomyopathy: A systematic review and meta-analysis.

Background: Cardiac magnetic resonance imaging (CMR) based T1 mapping and extracellular volume fraction (ECV) are powerful tools for identifying myocardial fibrosis. This systematic review and meta-analysis aims to characterize the utility of native T1 mapping and ECV in patients with non-ischemic cardiomyopathy (NICM) and to clarify the prognostic significance of elevated values. Methods: A literature search was conducted for studies reporting on use of CMR-based native T1 mapping and ECV measurement in NICM patients and their association with major adverse cardiac events (MACE), ventricular arrhythmias (VAs), and left ventricular reverse remodeling (LVRR). Databases searched included: Ovid MEDLINE, EMBASE, Web of Science, and Google Scholar. The search was not restricted to time or publication status. Results: Native T1 and ECV were significantly higher in NICM patients compared to controls (MD 78.80, 95 % CI 50.00, 107.59; p < 0.01; MD 5.86, 95 % CI 4.55, 7.16; p < 0.01). NICM patients who experienced MACE had higher native T1 and ECV (MD 52.87, 95 % CI 26.59, 79.15; p < 0.01; MD 6.03, 95 % CI 3.79, 8.26; p < 0.01). There was a non-statistically significant trend toward higher native T1 time in NICM patients who experienced VAs. NICM patients who were poor treatment responders had higher baseline native T1 and ECV (MD 40.58, 95 % CI 12.90, 68.25; p < 0.01; MD 3.29, 95 % CI 2.25, 4.33; p < 0.01). Conclusions: CMR-based native T1 and ECV quantification may be useful tools for risk stratification of patients with NICM. They may provide additional diagnostic utility in combination with LGE, which poorly characterizes fibrosis in patients with diffuse myocardial involvement.

Parental and health visitor perceptions on growth screening in early childhood: a qualitative study.

BACKGROUND: Growth screening in early childhood can help identify children with a range of medical and psychosocial vulnerabilities. In the UK, childhood growth and development up to age 5 years are assessed through the Healthy Child Programme, delivered by health visitors. However, formal criteria to trigger referrals for onward investigation are unclear. There is a lack of qualitative data on the acceptability and feasibility of formal growth screening programmes. This study aimed to build understanding of the perceptions and motivations of caregivers and health visitors in relation to child growth and growth screening. METHODS: This longitudinal observational study was part of a larger study piloting an automated growth screening algorithm in Tower Hamlets, London. We conducted three separate qualitative focus group interviews with health visitors (n=10), English-speaking parents (n=6), and Sylheti-speaking parents (n=5). Participants were purposively sampled, and written informed consent was obtained. A bilingual researcher facilitated each group, using a semi-structured interview guide. Data were analysed by two researchers using thematic analysis and assessed for intercoder reliability. The interview guide was translated into Sylheti, and data from the Sylheti group were translated into English by the same bilingual researcher. FINDINGS: Findings suggest that parents desire holistic care in which health visitors are empowered to refer to other health professionals and council services. Parents also want easier access to health visitors, frequent visits with the same health-care provider, and advice on raising their children. Health visitors were seen as well positioned to play an essential role in educating parents on health and developmental milestones and in helping them identify when their child might need additional support. Both parents and health visitors stressed that resources need to be in place not only to assess children but also to provide access to services when problems are identified. INTERPRETATION: These findings suggest that implementing growth screening through health visitors is feasible and acceptable, provided health visitors are given the resources and capabilities to refer children to appropriate services. Interpretation is limited by the purposive nature of the sampling and possible response bias. FUNDING: Barts Charity.

Utility of Fractional Flow Reserve Computed Tomography Angiography in Patients With Stable Coronary Artery Disease.

Coronary computed tomography angiography is a modality with high negative predictive value for evaluation of coronary artery disease (CAD). However, its diagnostic accuracy for obstructive CAD is limited by multiple factors. Fractional flow reserve (FFR) computed tomography (FFRCT) is an emerging analysis tool for identifying flow-limiting disease; nonetheless, the prognostic value of FFRCT is not well established. This meta-analysis aims to evaluate the association of FFRCT with clinical outcomes in patients with stable CAD. A literature search was conducted for studies reporting the association between FFRCT measurements and all-cause mortality, major adverse cardiovascular events (MACEs), acute myocardial infarction (AMI), and any need for coronary revascularization. Obstructive disease was defined as a FFR value ≤0.80; nonobstructive disease was defined as an FFR value >0.80. Ten studies were identified to meet the inclusion criteria; mean follow-up was 17 months (range, 3 to 56 months). There was no difference in risk of all-cause mortality between patients with obstructive and those with nonobstructive CAD on FFRCT. However, obstructive lesions were associated with increased risk of MACE, AMI, and any need for revascularization. FFRCT is a useful adjunctive modality for further risk stratification of patients with stable CAD. Obstructive lesions identified by FFRCT are associated with increased risk of MACE, AMI, and any need for revascularization.

Outcomes and Medical Therapy in Myocardial Infarction With Nonobstructive Coronary Arteries: A Systematic Review and Meta-Analysis.

Myocardial infarction with nonobstructive coronary arteries (MINOCAs) is a disease that has been poorly characterized with unclear clinical and therapeutic outcomes. The association of medical therapy with cardiovascular outcomes in patients with MINOCA has been inadequately assessed. The purpose of this meta-analysis is to evaluate the association of MINOCA at risk of adverse cardiovascular outcomes as compared with myocardial infarction with coronary artery disease (MICAD) and the efficacy of medical therapy in reducing the risk of adverse outcomes. A literature search was conducted for studies reporting on the association of MINOCA at risk of adverse outcomes as compared with MICAD. A literature search was also conducted for studies reporting on the association of medical therapy at risk of adverse outcomes in patients with MINOCA. A total of 29 studies with 893,134 participants met inclusion criteria comparing MINOCA to MICAD. Patients with MINOCA had a significantly lower risk of adverse outcomes as compared with MICAD. Nine studies with 27,731 MINOCA patients met inclusion criteria for evaluating the utility of medical therapy. Medical therapy did not significantly reduce risk of MACE; however, there was a trend toward lower risk in patients treated with ß blockers. In conclusion, our results suggest that MINOCA is associated with a lower risk of in-hospital and long-term adverse outcomes compared with MICAD. Standard medical therapy is not associated with a lower risk of adverse cardiovascular outcomes in patients with MINOCA. Additional high-quality studies are required to evaluate the utility of specific medication classes for the treatment of specific etiologies of MINOCA.

Ultra-broadband Kerr microcomb through soliton spectral translation.

Broadband and low-noise microresonator frequency combs (microcombs) are critical for deployable optical frequency measurements. Here we expand the bandwidth of a microcomb far beyond its anomalous dispersion region on both sides of its spectrum through spectral translation mediated by mixing of a dissipative Kerr soliton and a secondary pump. We introduce the concept of synthetic dispersion to qualitatively capture the system's key physical behavior, in which the second pump enables spectral translation through four-wave mixing Bragg scattering. Experimentally, we pump a silicon nitride microring at 1063 nm and 1557 nm to enable soliton spectral translation, resulting in a total bandwidth of 1.6 octaves (137-407 THz). We examine the comb's low-noise characteristics, through heterodyne beat note measurements across its spectrum, measurements of the comb tooth spacing in its primary and spectrally translated portions, and their relative noise. These ultra-broadband microcombs provide new opportunities for optical frequency synthesis, optical atomic clocks, and reaching previously unattainable wavelengths.

Streptococcus oralis MitraClip endocarditis following a dental procedure: a case report.

BACKGROUND: Transcatheter edge-to-edge mitral valve repair using the MitraClip device is increasingly used for high surgical risk patients with severe mitral regurgitation (MR). Previous guidelines for infective endocarditis prophylaxis prior to dental procedures focused on high-risk patients, but without explicit recommendation for MitraClip recipients. We believe this could be the first reported case to identify Streptococcus oralis as the causative organism. CASE PRESENTATION: An 87-year-old male with severe MR treated with two MitraClip devices three months prior to index admission, presented with worsening malaise and intermittent chills on a background of multiple comorbid conditions. The patient had dental work a month prior to presentation, including a root canal procedure, without antibiotic prophylaxis. Vitals were significant for fever and hypotension. On physical examination, there was a holosystolic murmur at the apex radiating to the axilla, bilateral pitting edema in the lower extremities, and elevated jugular venous pulsation. A transthoracic echocardiogram showed severe MR with a possible echodensity on the mitral valve, prompting a transesophageal echocardiogram, which demonstrated a pedunculated, mobile mass on the posterior leaflet of the mitral valve. Five blood cultures grew gram positive cocci in pairs and chains, later identified as Streptococcus oralis, with minimum inhibitory concentration to penicillin 0.06 mg/L. Initial empiric antibiotics were switched to ceftriaxone 2 gr daily and subsequent blood cultures remained negative. However, the patient developed pulmonary edema and worsening hemodynamic instability requiring vasopressors. As surgical risk for re-operation was considered prohibitive, the decision was made to continue medical management and comfort-directed care. The patient died a week later. CONCLUSIONS: Despite low incidence, infective endocarditis should be included in the differential among MitraClip recipients. The explicit inclusion of this growing patient population in the group requiring prophylaxis prior to dental procedures in the 2020 ACC/AHA valvular heart disease guidelines is an important step forward.