Assessment of myocardial strain patterns in patients with left bundle branch block using cardiac magnetic resonance.

Recently, a classification with four types of septal longitudinal strain patterns was described using echocardiography, suggesting a pathophysiological continuum of left bundle branch block (LBBB)-induced left ventricle (LV) remodeling. The aim of this study was to assess the feasibility of classifying these strain patterns using cardiovascular magnetic resonance (CMR), and to evaluate their association with LV remodeling and myocardial scar. Single center registry included LBBB patients with septal flash (SF) referred to CMR to assess the cause of LV systolic dysfunction. Semi-automated feature-tracking cardiac resonance (FT-CMR) was used to quantify myocardial strain and detect the four strain patterns. A total of 115 patients were studied (age 66 ± 11 years, 57% men, 28% with ischemic heart disease). In longitudinal strain analysis, 23 patients (20%) were classified in stage LBBB-1, 37 (32.1%) in LBBB-2, 25 (21.7%) in LBBB-3, and 30 (26%) in LBBB-4. Patients at higher stages had more prominent septal flash, higher LV volumes, lower LV ejection fraction, and lower absolute strain values (p < 0.05 for all). Late gadolinium enhancement (LGE) was found in 55% of the patients (n = 63). No differences were found between the strain patterns regarding the presence, distribution or location of LGE. Among patients with LBBB, there was a good association between strain patterns assessed by FT-CMR analysis and the degree of LV remodeling and LV dysfunction. This association seems to be independent from the presence and distribution of LGE.

Predictive value of a positive stress single-photon emission computed tomography or stress cardiac magnetic resonance for ruling in obstructive coronary artery disease in a real-world setting.

INTRODUCTION AND OBJECTIVES: Randomized controlled trials comparing stress cardiac magnetic resonance (CMR) and single-photon emission computed tomography (SPECT) suggest similar diagnostic accuracy for detecting obstructive coronary artery disease (CAD). There are few data on whether this remains true in routine clinical practice. The aim of this study was to assess clinical and angiographic characteristics of patients undergoing invasive coronary angiography (ICA) after stress CMR or SPECT, and to compare their positive predictive value with published results from the CE-MARC trial. METHODS: In this retrospective tertiary-center analysis, we included 429 patients undergoing ICA after a positive stress CMR or positive SPECT performed within the previous 12 months. Obstructive CAD was defined as any coronary artery stenosis ≥50% in a vessel compatible with the ischemic territory on stress testing. RESULTS: Of the total 429 patients, 356 (83%) were referred after a positive SPECT, and 73 (17%) after a positive stress CMR. Patients did not differ according to age, cardiovascular risk factors, previous revascularization or left ventricular dysfunction, but patients with SPECT were more frequently male (p=0.046). The prevalence of obstructive CAD was similar in patients with positive SPECT vs. positive stress CMR (76.1% vs. 80.8%, respectively, p=0.385). The positive predictive values of both techniques were similar to those reported in the CE-MARC trial. CONCLUSION: In this tertiary center analysis, stress CMR and SPECT showed similar positive predictive values, comparable to those reported in the CE-MARC trial. This finding supports the emerging adoption of CMR in clinical practice for the diagnosis and management of CAD.

2021/22 Rugby Europe Injury Surveillance Report: SuperCup, Under-20, and Under-18 Championship.

We conducted a prospective cohort study to determine the incidence rate and characterization of the injuries sustained by players during the 2021/22 season of the Rugby Europe SuperCup, Under-20, and Under-18 championships. Team medics reported the injuries, using an online platform. Ethical approval and informed consent were obtained. The overall incidence of injuries ranged from 33.33 (95% CI: 18.97-54.60) in the under-18s to 83.33 (95% CI: 60.34-112.40) in the under-20s, while in the SuperCup it was 41.35 (95% CI: 30.30-55.18) injuries per 1000 player-match-hours. Injury severity (mean days) was higher in the SuperCup (38.33) and lower in the Under-18 tournament (28.50). Lower limb and soft tissue were the most common type of injuries. Tackles caused almost two-thirds of all injuries. Concussion accounted for 10.0% to 25.6% of all injuries. Our data are consistent with previous reports for similar levels of competition and age grades. The injury incidence was higher in the senior competitions (Under-20s and SuperCup). However, for the under-20s, injury rates were higher than in the SuperCup. This might be related to the competition format; however, more studies need to be conducted in the future. Concussion is a common injury and the protocols used at this level seems to be effective to identify it.

Knowledge and Risk Behaviors Regarding Human Immunodeficiency Virus Transmission among Portuguese Healthcare Students.

BACKGROUND: Human immunodeficiency virus (HIV), the agent responsible for acquired immunodeficiency syndrome, remains a worldwide public health problem. Therefore, this study aimed to assess Portuguese healthcare students' knowledge of HIV, identify risk behaviors for HIV transmission, and assess the frequency of HIV testing and its dissemination by general practitioners. METHODS: A cross-sectional observational study was conducted using an anonymous questionnaire published online. The questionnaire was administered to Portuguese healthcare students who voluntarily agreed to participate in the study after clarifying its objectives and procedures. RESULTS: Most students were aware of the three main HIV transmission routes; however, 66.3% were unaware of the level A recommendation for HIV screening in adolescents and adults. In addition, 59.6% of the students were never informed by their general practitioner about HIV screening tests or risk behaviors for HIV transmission. Of the sample, 78.9% had never been tested for HIV infection. Of the 74.6% of sexually active students, 82.0% had or had already had unprotected sex (without a condom). Men showed riskier sexual behaviors than women. None of the inquiries reported intravenous drug use, and most students (69.9%) never shared personal objects. CONCLUSION: General practitioners and awareness campaigns need to alert and disseminate HIV screening tests. Sexual health and risk behaviors should be addressed more frequently in schools to educate this population because prevention is the best strategy against HIV transmission/contraction.

Outcomes of a combined vs non-combined endo-epicardial ventricular tachycardia ablation strategy.

BACKGROUND: Direct comparisons of combined (C-ABL) and non-combined (NC-ABL) endo-epicardial ventricular tachycardia (VT) ablation outcomes are scarce. We aimed to investigate the long-term clinical efficacy and safety of these 2 strategies in ischemic heart disease (IHD) and non-ischemic cardiomyopathy (NICM) populations. METHODS: Multicentric observational registry included 316 consecutive patients who underwent catheter ablation for drug-resistant VT between January 2008 and July 2019. Primary and secondary efficacy endpoints were defined as VT-free survival and all-cause death after ablation. Safety outcomes were defined by 30-day mortality and procedure-related complications. RESULTS: Most of the patients were male (85%), with IHD (67%) and mean age of 63 ± 13 years. During a mean follow-up of 3 ± 2 years, 117 (37%) patients had VT recurrence and 73 (23%) died. Multivariate survival analysis identified electrical storm (ES) at presentation, IHD, left ventricular ejection fraction (LVEF), New York Heart Association (NYHA) functional class III / IV, and C-ABL as independent predictors of VT recurrence. In 135 patients undergoing repeated procedures, only C-ABL and ES were independent predictors of relapse. The identified independent predictors of mortality were C-ABL, ES, LVEF, age, and NYHA class III / IV. C-ABL survival benefit was only seen in patients with a previous ablation (P for interaction = 0.04). Mortality at 30 days was similar between NC-ABL and C-ABL (4% vs. 2%, respectively, P = 0.777), as was complication rate (10.3% vs. 15.1%, respectively, P = 0.336). CONCLUSION: A combined or sequential endo-epicardial VT ablation strategy was associated with lower VT recurrence and lower all-cause death in IHD and NICM patients undergoing repeated procedures. Both approaches seemed equally safe.

Relação entre Gordura Epicárdica e Fibrilação Atrial Não Pode Ser Totalmente Explicada pela Fibrose Atrial Esquerda / The Relationship between Epicardial Fat and Atrial Fibrillation Cannot Be Fully Explained by Left Atrial Fibrosis

Resumo Fundamento O tecido adiposo epicárdico (TAE) tem sido associado à fibrilação atrial (FA), mas seus mecanismos fisiopatológicos permanecem obscuros. Objetivos Medir a correlação entre TAE e fibrose do átrio esquerdo (AE), e avaliar sua capacidade de prever recidiva após o isolamento da veia pulmonar (IVP). Métodos Pacientes com FA inscritos para um primeiro procedimento de IVP foram submetidos à tomografia computadorizada (TC) cardíaca e ressonância magnética cardíaca (RMC) em menos de 48 horas. Quantificou-se o TAECE em imagens de TC realçadas com contraste no nível do tronco da coronária esquerda. Quantificou-se a fibrose do AE em RMC tridimensional com realce tardio isotrópico de 1,5 mm. Após o isolamento da veia pulmonar (IVP), os pacientes foram submetidos a seguimento para checar a recidiva da FA. A significância estatística foi definida com p<0,05. Resultados A maioria dos 68 pacientes (46 homens, idade 61±12 anos) tinha FA paroxística (71%, n=48). Os pacientes apresentavam volume TAECE mediano de 2,4 cm3/m2 (intervalo interquartil [IIQ] 1,6-3,2 cm3/m2) e um volume médio de fibrose do AE de 8,9 g (IIQ 5-15 g). A correlação entre TAECE e fibrose do AE foi estatisticamente significativa, mas fraca (coeficiente de correlação de postos de Spearman = 0,40, p=0,001). Durante um seguimento médio de 22 meses (IIQ 12-31), 31 pacientes (46%) tiveram recidiva da FA. A análise multivariada produziu dois preditores independentes de recidiva da FA: TAECE (FC 2,05, IC de 95% 1,51-2,79, p<0,001) e FA não paroxística (FC 2,36, IC de 95% 1,08-5,16, p=0,031). Conclusão A correlação fraca entre TAE e AE sugere que a fibrose do AE não é o principal mecanismo que liga o TAE e a FA. O TAE mostrou-se mais fortemente associado à recidiva da FA do que à fibrose do AE, corroborando a existência de outros mediadores mais importantes do TAE e da FA.

Abstract Background Epicardial adipose tissue (EAT) has been associated with atrial fibrillation (AF), but its pathophysiological mechanisms remain unclear. Objectives To measure the correlation between EAT and left atrium (LA) fibrosis, and to assess their ability to predict relapse after pulmonary vein isolation (PVI). Methods Patients with AF enrolled for a first PVI procedure underwent both cardiac computerized tomography (CT) and cardiac magnetic resonance (CMR) imaging within less than 48 hours. EATLMwas quantified on contrast-enhanced CT images at the level of the left main. LA fibrosis was quantified on isotropic 1.5 mm 3D delayed enhancement CMR. After pulmonary vein isolation (PVI), patients were followed up for AF relapse. Statistical significance was set at p<0.05. Results Most of the 68 patients (46 men, age 61±12 years) had paroxysmal AF (71%, n=48). Patients had a median EATLMvolume of 2.4 cm3/m2(interquartile range [IQR] 1.6-3.2 cm3/m2), and a median amount of LA fibrosis of 8.9 g (IQR 5-15 g). The correlation between EATLMand LA fibrosis was statistically significant but weak (Spearman's R=0.40, p=0.001). During a median follow-up of 22 months (IQR 12-31), 31 patients (46%) had AF relapse. Multivariate analysis yielded two independent predictors of AF relapse: EATLM(HR 2.05, 95% CI 1.51-2.79, p<0.001), and non-paroxysmal AF (HR 2.36, 95% CI 1.08-5.16, p=0.031). Conclusion The weak correlation between EAT and LA suggests that LA fibrosis is not the main mechanism linking EAT and AF. EAT was more strongly associated with AF relapse than LA fibrosis, supporting the existence of other more important mediators of EAT and AF.

The Relationship between Epicardial Fat and Atrial Fibrillation Cannot Be Fully Explained by Left Atrial Fibrosis. / Relação entre Gordura Epicárdica e Fibrilação Atrial Não Pode Ser Totalmente Explicada pela Fibrose Atrial Esquerda.

BACKGROUND: Epicardial adipose tissue (EAT) has been associated with atrial fibrillation (AF), but its pathophysiological mechanisms remain unclear. OBJECTIVES: To measure the correlation between EAT and left atrium (LA) fibrosis, and to assess their ability to predict relapse after pulmonary vein isolation (PVI). METHODS: Patients with AF enrolled for a first PVI procedure underwent both cardiac computerized tomography (CT) and cardiac magnetic resonance (CMR) imaging within less than 48 hours. EATLMwas quantified on contrast-enhanced CT images at the level of the left main. LA fibrosis was quantified on isotropic 1.5 mm 3D delayed enhancement CMR. After pulmonary vein isolation (PVI), patients were followed up for AF relapse. Statistical significance was set at p<0.05. RESULTS: Most of the 68 patients (46 men, age 61±12 years) had paroxysmal AF (71%, n=48). Patients had a median EATLMvolume of 2.4 cm3/m2(interquartile range [IQR] 1.6-3.2 cm3/m2), and a median amount of LA fibrosis of 8.9 g (IQR 5-15 g). The correlation between EATLMand LA fibrosis was statistically significant but weak (Spearman's R=0.40, p=0.001). During a median follow-up of 22 months (IQR 12-31), 31 patients (46%) had AF relapse. Multivariate analysis yielded two independent predictors of AF relapse: EATLM(HR 2.05, 95% CI 1.51-2.79, p<0.001), and non-paroxysmal AF (HR 2.36, 95% CI 1.08-5.16, p=0.031). CONCLUSION: The weak correlation between EAT and LA suggests that LA fibrosis is not the main mechanism linking EAT and AF. EAT was more strongly associated with AF relapse than LA fibrosis, supporting the existence of other more important mediators of EAT and AF.

FUNDAMENTO: O tecido adiposo epicárdico (TAE) tem sido associado à fibrilação atrial (FA), mas seus mecanismos fisiopatológicos permanecem obscuros. OBJETIVOS: Medir a correlação entre TAE e fibrose do átrio esquerdo (AE), e avaliar sua capacidade de prever recidiva após o isolamento da veia pulmonar (IVP). MÉTODOS: Pacientes com FA inscritos para um primeiro procedimento de IVP foram submetidos à tomografia computadorizada (TC) cardíaca e ressonância magnética cardíaca (RMC) em menos de 48 horas. Quantificou-se o TAECE em imagens de TC realçadas com contraste no nível do tronco da coronária esquerda. Quantificou-se a fibrose do AE em RMC tridimensional com realce tardio isotrópico de 1,5 mm. Após o isolamento da veia pulmonar (IVP), os pacientes foram submetidos a seguimento para checar a recidiva da FA. A significância estatística foi definida com p<0,05. RESULTADOS: A maioria dos 68 pacientes (46 homens, idade 61±12 anos) tinha FA paroxística (71%, n=48). Os pacientes apresentavam volume TAECE mediano de 2,4 cm3/m2 (intervalo interquartil [IIQ] 1,6­3,2 cm3/m2) e um volume médio de fibrose do AE de 8,9 g (IIQ 5­15 g). A correlação entre TAECE e fibrose do AE foi estatisticamente significativa, mas fraca (coeficiente de correlação de postos de Spearman = 0,40, p=0,001). Durante um seguimento médio de 22 meses (IIQ 12­31), 31 pacientes (46%) tiveram recidiva da FA. A análise multivariada produziu dois preditores independentes de recidiva da FA: TAECE (FC 2,05, IC de 95% 1,51­2,79, p<0,001) e FA não paroxística (FC 2,36, IC de 95% 1,08­5,16, p=0,031). CONCLUSÃO: A correlação fraca entre TAE e AE sugere que a fibrose do AE não é o principal mecanismo que liga o TAE e a FA. O TAE mostrou-se mais fortemente associado à recidiva da FA do que à fibrose do AE, corroborando a existência de outros mediadores mais importantes do TAE e da FA.

Predictors of pacemaker implantation after TAVI in a registry including self, balloon and mechanical expandable valves.

The need for permanent pacemaker implantation (PPMI) is a burdensome complication of transcatheter aortic valve implantation (TAVI). The aim of our study was to evaluate different anatomical, clinical, electrocardiographic, and procedural variables associated with the development of conduction abnormalities after TAVI across the entire device spectrum. Single-center prospective cohort of consecutive patients who underwent TAVI since March 2017. Final cohort was studied to detect areas of calcium within aortic valve characterized by leaflet sector and region. Membranous septum (MS) length was assessed throughout a modified coronal view. Device selection and positioning were performed according to the operator criteria. Device selection and positioning were performed according to the operator criteria. From the 273 patients included, 57 underwent PPMI (20.8%). Univariate analysis determined right bundle branch block (RBBB), QRS duration, MS length and calcium within LVOT of non-coronary cuspid as independent predictors. After multivariable logistic regression, both RBBB (OR 6.138; 95% CI 1.23-30.73, P = 0.027) and MS length (OR 0.259; 95% CI 0.164-0.399, P < 0.005) emerged as statistically significant. As a model, they could predict PPMI in 88.7%, independently of which valve used. Youden index analysis yielded 7.69 mm as the optimal cut-off with a negative and positive predictive value of 94.7 and 71.9%, respectively. In our experience, both RBBB pattern and short membranous septum (< 8 mm) were strongly and independently associated with new permanent pacemaker implantation, regardless of the device type. Our findings suggest that this simple evolved measure of MS length may guide device selection and implantation technique and facilitate early discharge.

Medication adherence to direct anticoagulants in patients with non-valvular atrial fibrillation - A real world analysis.

INTRODUCTION: Direct oral anticoagulants (DOACs) changed the landscape of atrial fibrillation (AF) treatment, but also brought with them new challenges in terms of accessibility and compliance. The purpose of this study was to assess adherence to DOACs, and its determinants in a population of AF patients. METHODS: Single-center retrospective study including all patients with non-valvular AF treated with a DOAC from the outpatient general cardiology list at a tertiary center, whose first DOAC prescription was between 1 April 2016 and August 2018. The number of pharmacy refills from the day of first prescription to 31 August 2018 was counted (by means of an electronic prescription platform). Medication refill adherence (MRA) was calculated by dividing the total days' supply by the number of days under therapy. Non-compliance was defined as MRA <90%. RESULTS: A total of 264 patients (120 men, mean age 74 ±â€¯12 years) met the inclusion criteria. The median CHA2DS2VASC score was 3 (interquartile range (IQR) 2-5) and the median HAS-BLED was 1 (IQR 1-2). Rivaroxaban, apixaban, dabigatran and edoxaban were prescribed in 45%, 41%, 24% and 13% of patients, respectively. During the study 51 patients (19%) used at least two DOACs .Patients took DOACs for a median period of 439 days (IQR 269-638), during which the included population adhered to therapy 90% of the time (IQR 75-100%). Half of the patients (51%) were classified as non-compliant; therapy duration (adjusted odds ratio 1.06 per month, 95% confidence interval (CI) 1.03-1.08, p<0.001), DOACs twice daily (adjusted OR 1.73, 95%CI 1.08-2.75, p=0.022), and higher out-of-pocket costs (adjusted OR 2.13, 95%CI 1.28-3.45, p=0.003) were independent predictors of non-compliance. CONCLUSION: Half of the patients (51%) were classified as non-compliant (medication refill adherence <90%). Therapy duration, DOACs twice daily and higher out out-of-pocket costs were independent predictors of non-compliance, which could be targets to improve patient adherence.

Temporal trends in referral patterns for invasive coronary angiography - a multicenter 10-year analysis.

AIM: To assess the temporal trends in the usage pattern of non-invasive testing before invasive coronary angiography (ICA) and its diagnostic yield in patients with suspected coronary artery disease (CAD). METHODS: Cross-sectional observational multicenter study of 4805 consecutive patients (60% male, mean age 66 ± 10 years) with suspected CAD undergoing elective ICA due to angina pectoris in two centers, from 2008 to 2017. The use of noninvasive testing and the proportion of patients with obstructive CAD (defined as the presence of at least one ≥50% stenosis on ICA) were assessed. RESULTS: There were 4038 (84%) patients referred for ICA with positive noninvasive test, mainly SPECT (38%, n = 1828) and exercise ECG (36%, n = 1731). Obstructive CAD was found in 54.5% (n = 2621) of the patients and 37.9% (n = 1822) underwent revascularization. The prevalence of obstructive CAD was higher in patients with vs. without previous noninvasive testing (55.8% vs. 48.1%, respectively, P < 0.001) and tended to decrease during the study period (P for trend <0.001). Both the presence of obstructive CAD and revascularization rate were higher in patients who underwent anatomical evaluation with CCTA compared with noninvasive functional tests (P = 0.001 and P = 0.018, respectively). The number of patients referred after exercise testing and SPECT decreased (p for trend 0.005 and 0.006, respectively) and after CCTA and stress CMR increased (both P for trend <0.001). The proportion of patients referred without previous testing remained stable. CONCLUSION: Nearly half of the patients undergoing ICA for suspected CAD did not have obstructive coronary lesions. This proportion tended to increase over the 10-year span of this study. Better clinical assessment tools and diagnostic pathways for stable CAD are warranted.

Consensus document on magnetic resonance imaging in patients with cardiac implanted electronic devices. / Documento de Consenso sobre a realização de ressonância magnética em doentes com dispositivos cardíacos electrónicos implantados.

Magnetic resonance imaging (MRI) is currently considered an essential complementary method for diagnosis in many conditions. Exponential growth in its use is expected due to the aging population and a broader spectrum of clinical indications. Growth in its use, coupled with an increasing number of pacemaker implants, implantable cardioverter-defibrillators and cardiac resynchronization therapy, has led to a frequent clinical need for this diagnostic modality in patients with cardiac implantable electronic devices (CIED). This clinical need has fueled the development of devices specifically designed and approved for use in a magnetic resonance (MR) environment under certain safety conditions (MR-conditional devices). More than a decade after the introduction of the first MR-conditional pacemaker, there are now several dozen MR-conditional devices with different safety specifications. In recent years, increasing evidence has indicated there is a low risk to MRI use in conventional (so-called non-MR-conditional) CIED patients in the right circumstances. The increasing number, as well as the greater diversity and complexity of implanted devices, justify the need to standardize procedures, by establishing institutional agreements that require close collaboration between cardiologists and radiologists. This consensus document, prepared jointly by the Portuguese Society of Cardiology and the Portuguese Society of Radiology and Nuclear Medicine, provides general guidelines for MRI in patients with CIED, ensuring the safety of patients, health professionals and equipment. In addition to briefly reviewing the potential risks of MRI in patients with CIED and major changes to MRI-conditional devices, this article provides specific recommendations on risk-benefit analysis, informed consent, scheduling, programming strategies, devices, monitoring and modification of MRI sequences. The main purpose of this document is to optimize patient safety and provide legal support to facilitate easy access by CIED patients to a potentially beneficial and irreplaceable diagnostic technique.