Prognostic Importance of Pulmonary Artery Pulsatility Index and Right Ventricular Stroke Work Index in End-Stage Heart Failure Patients.

BACKGROUND: Right ventricular (RV) failure is an important cause of morbidity and mortality in patients with left ventricular (LV) end-stage heart failure (ESHF). Pulmonary artery pulsatility index (PAPi) and RV stroke work index (RVSWI) are invasive parameters related to RV function. This study aimed to investigate the prognostic impact of PAPi and RVSWI in these patients. METHODS AND RESULTS: In this study, 416 patients with ESHF were included. The adverse cardiac event (ACE) was defined as LV assist device implantation, urgent heart transplantation, or cardiac mortality. There were 218 ACE cases and 198 non-ACE cases over a median follow-up of 503.50 days. Patients with ACE had lower PAPi and similar RVSWI compared to those without ACE (3.1 ± 1.9 vs. 3.7 ± 2.3, p = 0.003 and 7.3 ± 4.9 vs. 6.9 ± 4.4, p = 0.422, respectively). According to the results of multivariate analysis, while PAPi (from 2 to 5.65) was associated with ACE, RVSWI (from 3.62 to 9.75) was not associated with ACE (hazard ratio [HR]: 0.75, 95% confidence interval [CI] [0.55-0.95], p = 0.031; HR: 0.79, 95% CI: [0.58-1.09], p = 0.081, respectively). Survival analysis revealed that PAPi ≤2.56 was associated with a higher ACE risk compared to PAPi >2.56 (HR: 1.46, 95% CI: 1.11-1.92, p = 0.006). PAPi ≤2.56 could predict ACE with 56.7% sensitivity and 51.3% specificity at 1 year. Furthermore, the association between RVSWI and ACE was nonlinear (J-curve pattern). Low and high values seem to be associated with higher ACE risk compared to intermediate values. CONCLUSION: The low PAPi was an independent risk for ACE and it had a linear association with it. However, RVSWI seems to be have a nonlinear association with ACE (J-curve pattern).

Speckle-tracking echocardiography can predict atrial fibrillation in patients with supraventricular tachycardia.

PURPOSE: Atrioventricular nodal reentry tachycardia (AVNRT) is the most common supraventriculer arrhythmia in daily clinical practice. Comorbidity of AVNRT and atrial fibrillation (AF) has been well documented in some patients and AF development has been observed more frequently in AVNRT patients during their long-term follow-up. This study was conducted in order to investigate the left atrial two-dimensional-speckle-tracking echocardiographic (STE) parametres as the predictors of the occurence of AF in long-term follow-up in patients with spontaneously developed AF during AVNRT ablation. METHODS: Two hundred and thirty two consecutive AVNRT patients who developed spontaneous AF during ablation procedure were included in the study. The patients were followed up for a mean follow-up period of 6.2 ± 2.1 years. All patients were evaluated using the 2D-STE method. AF was developed in 34 patients during the follow-up period. Cox regression analysis was performed in order to identify the independent predictors of AF occurence. RESULTS: Left atrial LA-res, LA-pump, LA-SRs, LA-SRe, and LA-SRa values were found to be significantly decreased in the group of patients that developed AF during the follow-up period (p < .001 for all aforementioned values). Multivariate cox regression analysis revealed that LA-res (hazard ratio [HR], 0.367; 95% confidence interval [CI], 0.161-0.0.683, p < .001) and SRe (HR, 0.472; 95% CI, 0.346-0.825, p = .006) were independent risk factors associated with the occurrence of AF. CONCLUSION: In conclusion, it was demonstrated for the first time with this study that 2D-STE can effectively predict the development of AF in long-term follow-up in patients with spontaneously developed AF during AVNRT ablation.

The TAPSE/PASP ratio and MELD score in patients with advanced heart failure.

INTRODUCTION: The aim of this study was to explore the relationship between the tricuspid annular plane systolic excursion/pulmonary arterial systolic pressure (TAPSE/PASP) ratio and model for end-stage liver disease (MELD) score in patients with advanced heart failure. METHODS: A total of 103 patients with advanced heart failure evaluated for candidacy for heart transplantation were included in this study. TAPSE was measured by M­mode echocardiography and cardiac catheterization was performed. TAPSE/ PASP ratio and MELD score were calculated. RESULTS: The median age of patients was 49 (40.5-54) years and the majority were male (92%). The percentage of patients with ischemic cardiomyopathy was 40%. The mean value of the group's MELD score was 10 ± 3.3 and the median value of TAPSE/PASP 0.24 (0.18-0.34). There was a moderate negative correlation between TAPSE/PASP and MELD score (r: -0.38, p < 0.001). Right atrial pressure (RAP) and left ventricular end-diastolic pressure (LVEDP) were also negatively correlated with TAPSE/PASP (correlation coefficients were r: -0.562 and r: -0.575, respectively). In patients with a lower TAPSE/PASP ratio, MELD score, LVEDP and RAP were higher and tricuspid regurgitation was more severe, but there were no significant differences between cardiac output (CO) and mean aortic pressure (mean BP). The presence of ischemia was found to be an independent predictor for lower values of TAPSE/PASP. CONCLUSION: The lower TAPSE/PASP obtained on echocardiography may be a sign of the multi-organ failure defined as a high MELD score in patients with advanced heart failure.

Effects of atrial electromechanical delay and ventriculoatrial conduction over the atrial functions in patients with frequent extrasystole and preserved ejection fraction.

BACKGROUND: The deterioration of left atrial and ventricular functions was demonstrated in patients with frequent ventricular extrasystole (fVES). The exact pathophysiology of left atrial dysfunction in patients with fVES is unclear. Retrograde ventriculoatrial conduction (VAC) often accompanies fVES, which may contribute to atrial dysfunction. We investigated whether atrial electromechanical delay and VAC are related to these atrial functions in patients with frequent right ventricular outflow tract (RVOT) VES and preserved ejection fraction (pEF). METHODS: This study included 21 patients with pEF (eight males, 48 ± 11 years), who had experienced more than 10 000 RVOT-VES during 24-h Holter monitoring and had undergone electrophysiological study/ablation. The study also included 20 healthy age- and sex-matched control subjects. Transthoracic echocardiography was performed on all of the subjects. Atrial conduction time was obtained by using tissue Doppler imaging. Strain analysis was performed with two-dimensional speckle tracking echocardiography. RESULTS: The peak atrial longitudinal strain was significantly impaired in patients with fVES (P = 0.01). In addition, although the interatrial and left atrial conduction delay times were significantly different between each group (P < 0.001, P < 0.001), the right atrial conduction delay times were similar. When patients with fVES were divided into groups depending on the existence of retrograde VAC, atrial deformation parameters and conduction delay time did not significantly differ between either group. CONCLUSION: Frequent RVOT-VES causes left atrial dysfunction. This information is obtained through strain analyses and recordings of left atrial conduction times in patients with pEF. Regardless, retrograde VAC is not related to atrial dysfunction.

Comparison of 30-Day MACE between Immediate versus Staged Complete Revascularization in Acute Myocardial Infarction with Multivessel Disease, and the Effect of Coronary Lesion Complexity.

Background and objective: In patients with acute myocardial infarction and multivessel disease, the timing of intervention to non-culprit lesions is still a matter of debate, especially in patients without shock. This study aimed to compare the effect of multivessel intervention, performed at index percutaneous coronary intervention (PCI) (MVI-I) or index hospitalization (MVI-S), on the 30-day results of acute myocardial infarction (AMI), and to investigate the effect of coronary lesion complexity assessed by the Syntax (Sx) score on the timing of multivessel intervention. Materials and methods: We enrolled 180 patients with MVI-I, and 425 patients with MVI-S. The major adverse cardiovascular events (MACE) for this study were identified as mortality, nonfatal myocardial infarction, nonfatal stroke, acute heart failure, ischemia driven revascularization, major bleeding, and acute renal failure developed within 30 days. Results: The unadjusted MACE rates at 30 days were 11.2% and 5% among those who underwent MVI-I and MVI-S, respectively (OR 3.02; 95% confidence interval (CI) 1.51⁻6.02; p=0.002). Associations were statistically significant after adjusting for covariates in the penalized multivariable model (adjusted OR 2.06; 95%CI 1.02⁻4.18; p=0.043), propensity score adjusted multivariable model (adjusted OR 2.46; 95%CI 1.19⁻5.07; p=0.015), and IPW (adjusted OR 2.11; 95%CI 1.28⁻3.47; p=0.041). We found that the Syntax score of lesions did not affect the results. Conclusion: MVI-S was associated with a lower incidence of major adverse cardiovascular events within 30 days after discharge.

Prediction of infarct size using two-dimensional speckle tracking echocardiography in acute myocardial infarction.

BACKGROUND: This study aimed to determine the myocardial damage (infarct size provided by cardiac single-photon emission tomography) in early stages of the infarction using longitudinal strain and rotational parameters of the left ventricle. METHODS: The study included 66 patients with anterior myocardial infarction (AMI) and 62 patients with inferior myocardial infarction (IMI) who underwent primary percutaneous intervention as well as a control group consisting of 50 healthy subjects. LV rotational parameters based on parasternal short-axis views in basal and apical planes and global longitudinal strain were measured with apical four-chamber, apical two-chamber, and apical long-axis views. RESULTS: There was a significant positive correlation between infarct size and GLPSavg (r=-.55 <.001), GTOR angle (r=-.52, P<.001), apical rotation angle (r=-.40 <.001, and EF (r=-.43, <.001). While cutoff values were GLPSavg: 11.9 (AUC=0.78), GTOR angle: 11.4° (AUC=0.77), apical rotation angle: 7.1° (AUC=0.76) for patients with an infarct size greater than 20%, the cutoff values were GLPSavg: 10.7 (AUC=0.75), GTOR angle: 8.7° (AUC=0.86), apical rotation angle: 4.35° (AUC=0.87) for those with an infarct size greater than 40%. CONCLUSION: GLPSavg, GTOR angle, and apical rotation angle values may be used to determine the extent of infarction in early post-MI period, thereby allowing precautions to be taken for remodeling in early stages.

Evaluation of the effect of cardiac rehabilitation on left atrial and left ventricular function and its relationship with changes in arterial stiffness in patients with acute myocardial infarction.

BACKGROUND: The main aim of this study was to detect the possible early effect of cardiac rehabilitation (CR) on left atrium (LA) and left ventricle (LV) function and relation to aortic stiffness in patients with acute myocardial infarction (AMI). METHODS: Fifty-four patients with AMI were enrolled in this study. Left atrial strain analysis was performed by two-dimensional speckle tracking echocardiography. The deceleration time (DT) was measured by pulsed-wave Doppler. The ratio of E/e' to LA peak strain was used to estimate the LA stiffness (Stiffnessstrain ) Aortic elasticity parameters were calculated using the formulas including aortic systolic and diastolic diameter with M-Mode echocardiography and blood pressure. Anterior wall aortic expansion velocity was measured by tissue Doppler imaging. RESULTS: Left ventricle ejection fraction (EF) and LA functional parameters were significantly better in trained subjects. Also in training group, the LV diastolic functional parameters were better in CR group than the control group. Aortic elasticity parameters were better with CR. CONCLUSIONS: In patients with CR, an increase in LA strain was correlated with increase in aortic strain and improved aortic distensibility, likely indicating favorable LA and aortic interactions with exercise training.

Mean platelet volume levels in patients with cardiac myxoma.

Thromboembolic events such as cerebrovascular stroke are common and serious complications in patients with cardiac myxomas (CMs). Previous studies have reported that a high mean platelet volume (MPV) level reflects an activated platelet function and has been proven to be an independent risk factor for thromboembolic events. The aim of this study was to evaluate the relation between MPV level and CM. We compared the MPV levels between patients with CM and control subjects, and also evaluated the differences in the MPV levels in patients with CM before and after a successful surgical treatment. Furthermore, we compared the MPV levels in patients with and without cerebrovascular embolic symptoms. Fifty-one consecutive patients (13 men, 38 women, mean age 51.1 ± 16.9 years) who underwent excision of CM in our hospital in the last 13 years and 50 normal subjects as the control group were included in this study. The patients with CM were divided into two groups according to the presence or absence of cerebrovascular embolic symptoms. The preoperative and postoperative MPV levels of each CM patient was evaluated. MPV levels were found to be significantly higher in patients with CM than in control subjects (9.86 ± 1.30 fL vs. 7.63 ± 0.78 fL, p < 0.001). Moreover, the MPV levels significantly decreased after the surgical removal of CM (9.86 ± 1.30 fL vs. 8.68 ± 1.20 fL, p < 0.001). We also found that the MPV values were significantly higher in patients with neurological embolic events (10.55 ± 1.29 fL vs. 9.59 ± 0.78 fL, p = 0.016). We conclude that increased MPV levels might be considered as a marker of increased thromboembolic risk in patients with CM.

Does cardiac rehabilitation improve left ventricular diastolic function of patients with acute myocardial infarction?

OBJECTIVES: We aimed to observe the effect of cardiac rehabilitation (CR) on left ventricular diastolic function in patients with acute myocardial infarction (AMI) and revascularization by percutaneous coronary intervention (PCI). STUDY DESIGN: 82 patients were enrolled the study; 42 who were participating in a CR program, and 40 who did not maintain the program as a control group. Measurements of mitral inflow included the peak early filling (E-wave) and late diastolic filling (A-wave) velocities, the E/A ratio, deceleration time (DT) of early filling velocity and mitral A-wave duration. The early diastolic annular velocity has been expressed as e' with PW tissue Doppler imaging. The mitral inflow E velocity to tissue Doppler e' (E/e') was calculated and isovolumic relaxation time (IVRT) was measured. Measurements of pulmonary venous waveforms included peak systolic (S) velocity, peak anterograde diastolic (D) velocity and the time difference between the duration of the atrial reversal (Ar) and mitral A-wave duration (Ar-A). RESULTS: E/A and septal e' were better with the CR group than the control group. (p=0.048 vs p=0.006 respectively). The difference between E/e' measurements were not statistically significant (p=0.138). The left ventricular diastolic function of patients were partially improved with cardiac rehabilitation. There was no association between infarct-related artery (IRA) and diastolic functional measurements of the left ventricle in the individuals. Only hypertension was found significantly associated with E/A (p=0.000). CONCLUSION: CR improves septal e' and E/A significantly in patients with AMI and revascularized successfully by PCI, especially in those with hypertension.

Early Systolic Lengthening Is Associated with SYNTAX Score in Patients with Non-ST-Elevation Acute Coronary Syndrome.

BACKGROUND: Early systolic lengthening is a echocardiographic strain parameter previously used to determine the lesion severity in patients with stable coronary artery disease. In the present study, we aimed to evaluate the relationship between early systolic lengthening and anatomic SYNTAX score in troponin (-) and (+) groups among patients with non-ST-elevation acute coronary syndrome (ACS). METHODS: A total of 95 patients diagnosed with non-ST-elevation ACS were included in the prospective, non-randomized, single-center study. The patients were categorized into 2 groups as troponin (+) and troponin (-). The patients were evaluated in terms of echocardiographic, clinical, and angiographic parameters. RESULTS: The baseline characteristics, including age (58 ± 13 vs. 60 ± 10 respectively, P =.340), a history of hypertension (67.1% vs. 64%, respectively, P =.479), diabetes (28.6% vs. 32%, respectively, P =.467), global longitudinal strain (-14.37 ± 5.11 vs. -16.42 ± 3.93, respectively, P =.095), left ventricular ejection fraction (58.71 ± 8.73 vs. 57.20 ± 8.70, respectively, P =.263), and E/e' (8.44 ± 2.13 vs. 8.33 ± 1.99, respectively, P =.785), were similar between troponin (+) and troponin (-) groups. Left ventricle end-systolic diameter (3.2 ± 0.78; 3.50 ± 0.74 vs. 3.2 ± 0.78, respectively, P =.031), left ventricle end-systolic volume (55.57 ± 32.17 vs. 38.28 ± 13.63, respectively, P =.013), left ventricle end-diastolic volume (115.31 ± 49.54 vs. 91.23 ± 20.57, respectively, P =.042), the rate of early systolic lengthening (65.7% vs. 28%, respectively, P =.001), the duration of early systolic lengthening (24.02 ± 31 ms vs. 15.56 ± 30.19 ms, respectively, P =.009), and the SYNTAX score (16 ± 11 vs. 10 ± 10, respectively, P =.023) were higher in the troponin (+) group. Furthermore, a significant correlation was found between early systolic lengthening and SYNTAX score (r = 0.43, P <.001). CONCLUSION: The rate and duration of early systolic lengthening were higher in patients in the troponin (+) group. Early systolic lengthening is related to SYNTAX score in patients with non-ST-elevation ACS.

Trends in heart failure between 2016 and 2022 in Türkiye (TRends-HF): a nationwide retrospective cohort study of 85 million individuals across entire population of all ages.

Background: Data on the burden of heart failure (HF) outside western countries are limited, but available data suggest it may present differently in other countries. The aim of this study was to examine the incidence, prevalence, and survival rates of HF in Türkiye, with a specific focus on how these rates vary according to age, sex, comorbidities, and socioeconomic status (SES). Methods: We harnessed the extensive National Electronic Database of the Turkish Ministry of Health, covering Turkey's entire population from January 1, 2016, to December 31, 2022, to identify 2,722,151 cases of HF and their associated comorbidities using ICD-10 codes. Analyzing the primary endpoint of all-cause mortality, our study utilized anonymized data to examine patient demographics, comorbidities, socioeconomic status, and survival patterns, employing statistical techniques to delve into relationships and trends. The data were segmented by gender, socioeconomic status, and age, involving cross-tabulations and statistical metrics to explore connections, odds ratios, and survival rates. Findings: The estimated prevalence of HF was 2.114% in Türkiye at the end of 2022, with an annual incidence ranging between 3.00 and 6.06 per 1000 person years. Females were older than males (69.8 ± 13.9 years vs. 66.8 ± 13.9 years, respectively). The most common comorbidities were congenital heart diseases and anemia under the age of 20, and hypertension and atherosclerotic cardiovascular disease in the adult population. Only 23.6% (643,159/2,722,151) of patients were treated with any triple guideline-directed medical therapy (GDMT) and 3.6% (96,751/2,722,151) of patients were on quadruple GDMT. The survival rates for patients with HF at 1, 5, and 7 years were 83.3% (95% CI: 83.2-83.3), 61.5% (95% CI: 61.4-61.6), and 57.7% (95% CI: 57.6-57.8) among females, and 82.1% (95% CI: 82.0-82.2), 58.2% (95% CI: 58.1-58.3), and 54.2% (95% CI: 54.0-54.3) among males. Despite a tendency for an increase from the highest to the lowest SES, the prevalence of HF and mortality were paradoxically lowest in the lowest SES region. Interpretation: The prevalence, incidence, and survival rates of HF in Türkiye were comparable to western countries, despite the notable difference of HF onset occurring 8-10 years earlier in the Turkish population. Drug usage statistics indicate there is a need for effective strategies to improve treatment with GDMT. Funding: None.

Characteristics and Gender-Related Differences of Patients Admitted to a Large Intensive Cardiac Care Unit: A Single-Center Experience with over 55 000 Patients.

OBJECTIVE: Parallel to the aging of the world population, the complexity of patients with cardiac problems has increased, especially in intensive cardiology care units, and the importance of multidisciplinary care has become more evident. The aim of this study was to analyze the clinical characteristics and gender-related differences of patients hospitalized in a large intensive cardiology care unit. METHODS: This single-center, retrospective, cross-sectional study includes all hospitalizations in a large intensive cardiology care unit between January 2016 and March 2021. All data were obtained using data collection software and transferred to MEDULLA, Turkey's general database system. RESULTS: Of the 55 737 consecutive patients included in the analysis, 16342 (29%) were women. The mean age of males was 59.71 ± 12 years, and the mean age of females was 63.3 ± 14 years (P <.001). Over a period of 5 years, the most common reason for hospitalization in the intensive cardiac care unit was acute coronary syndrome. The number of acute coronary syndrome patients who underwent coronary angiography was found to be 17 478 (31%), of which 12 878 were males and 26.3% were female. The number of patients who underwent at least 1 stent implantation was 13 952 (80% of coronary angiography procedures), and 2960 (21%) were women. The second cause of hospitalization in the intensive cardiology care unit was arrhythmias (5654 patients [10%]) followed by advanced heart failure (932 patients [1.7%]). During follow-up in the intensive cardiology care unit, the percentage of development of multiorgan failure was found to be approximately 18%. The mortality rate was 7% in women, which was higher than in men (4%). While the most common cause of death was acute coronary syndrome, the highest rate of death was found in patients with advanced heart failure. Among the patients who died, the mean age of females was higher than that of males, and the length of hospital stay was longer. CONCLUSION: Although numerically the highest death rate was observed in male acute coronary syndrome patients, the highest mortality rate was found in patients with advanced heart failure. Due to the elderly population and the increase in the number of patients requiring multidisciplinary treatment, the development of multiorgan failure in intensive cardiology care units seems to be one of the most important causes of death. Although the number of females hospitalized in the intensive cardiology care unit is lower than that of males, the mean age and mortality rate were found to be higher than males.

Relationship between right atrial pressure and the Model for End-Stage Liver Disease (MELD) score in patients with advanced heart failure.

Background: This study aims to investigate the association between right atrial pressure and the Model for End-Stage Liver Disease score and to evaluate the ability of this scoring system to accurately predict the value of right atrial pressure. Methods: Between April 2016 and November 2018, a total of 137 patients (118 males, 19 females; median age: 49 years; range, 40 to 54 years) with advanced heart failure who were candidates for left ventricular assist device implantation or heart transplantation were retrospectively analyzed. We developed a formula calculated by using the biochemical and cardiac catheterization parameters of the patients. Results: There was a strong correlation between the right atrial pressure and the scores (r=0.510, p<0.001). The estimated right atrial pressure was calculated as "2 + (0.92 x Model for End-Stage Liver Disease Score)" (unstandardized coefficient 0.920, t value 7.674, p<0.001). The Model for End-Stage Liver Disease score was found to be an independent predictor of high right atrial pressure (odds ratio=1.491, 95% confidence interval: 1.244-1.786, p<0.001). The calculated area under the curve was 0.789 (95% confidence interval: 0.710-0.867, p<0.001) and the cut-off value of the Model for End-Stage Liver Disease score in the prediction of high right atrial pressure was 10.5 with 75% sensitivity and 73% specificity. Conclusion: We define a method to calculate right atrial pressure obtained by using the Model for End-Stage Liver Disease score without the need for cardiac catheterization during the hospitalization and follow-up period of patients with advanced heart failure.

Prognostic Impact of Nutritional Indices in Candidates for Heart Transplantation.

OBJECTIVE: No study has thus far evaluated the association of controlling nutritional status (CO NUT) score and prognostic nutritional index (PNI) with prognosis in candidates listed for heart transplantation (HT). Therefore, in this study, we aimed to investigate the impact of these nutritional indices on prognosis in these candidates. METHODS: In this retrospective study, a total of 195 candidates for HT were included. Over a median follow-up period of 503.5 days, the patients were grouped as survivors (n=121) and non-survivors (n = 74). Malnutrition was defined as CONUT score ≥2 (CONUT-defined malnu trition) and PNI ≤38 (PNI-defined malnutrition). RESULTS: The CONUT-defined malnutrition was observed in 19.8% and 39.2% of the survivors and non-survivors (P = .003), and the PNI-defined malnutrition was observed in 7.4% and 16.2% of the survivors and non-survivors (P = .032). The univariate analysis revealed that the CONUT score from 0 to 2 (hazard ratio [HR]: 1.41, 95% confidence interval [CI]: 1.11-1.79, P =.004) and PNI from 45.5 to 54.5 (HR: 0.78, 95% CI: 0.64-0.95, P = .001), the CONUT-defined malnutrition (HR: 2.48, 95% CI: 1.55-3.97, P < .001) and the PNI-defined malnutrition (HR: 1.97, 95% CI: 1.01-3.86, P = .04) were associated with mortality. In the multivariate adjusted models, the CO NUT-defined malnutrition was an independent predictor of mortality, whereas the PNI-defined malnutrition was not a predictor of mortality (HR: 1.92, 95% CI: 1.12-3.27, P = .001 and HR: 1.64, 95% CI: 0.80-3.40, P = .18). The log-rank test revealed that the CONUT-defined malnutri tion and the PNI-defined malnutrition were associated with decrease in survival rate. CONCLUSION: Although both the CONUT score and the PNI score were associated with prognosis in candidates for HT, the CONUT score was superior to the PNI score in predicting mortality.

Ischaemic versus non-ischaemic: how does heart failure aetiology affect pulmonary arterial capacitance and pulmonary artery pulsatility index in end-stage heart failure?

BACKGROUND: The aetiology of heart failure may have different effects on right ventricular (RV) function, pulmonary pressures and RV afterload. Pulmonary arterial capacitance (PAC) and pulmonary artery pulsatility index (PAPi) are novel haemodynamic indices used in determining RV afterload and RV function, respectively. We aimed to investigate whether there was a difference in PAC and PAPi between ischaemic cardiomyopathy (ICMP) and non-ischaemic cardiomyopathy (NICMP) in patients with end-stage heart failure. METHODS AND RESULTS: A total of 215 subjects undergoing evaluation for heart transplantation or left ventricular (LV) assist device were classified into two groups: ICMP (n = 101) and NICMP (n = 114). The patients with LV ejection fraction ≤ 25% were included in the study. ICMP group had lower PAC and higher PAPi values compared to NICMP group [1.25 (0.82-1.86) vs. 1.58 (1.02-2.21), p = 0.002 and 3.4 (2.2-5.0) vs. 2.5 (1.7-4.0); p = 0.007]. Pulmonary vascular resistance, pulmonary artery systolic and mean pressure were higher in ICMP group compared to NICMP group [3.5 ± 1.8 vs. 2.9 ± 2.3, p = 0.004; 59.0 (42.0-73.0) vs. 46.0 (37.0-59.0), p < 0.001, 35.0 (27.0-46.0) vs. 31.0 (23.0-39.0), p = 0.002]. The patients with ICMP had higher tricuspid annular plane systolic excursion and less RV dilatation. ICMP was an independent risk factor for pulmonary hypertension (OR: 4.02, 95% CI: 1.13-14.24, p = 0.031). CONCLUSION: ICMP was associated with lower PAC and higher PAPi. These results indicated that an ischaemic aetiology is associated with higher RV afterload and better RV function in the end-stage heart failure.

COVID-19: the new cause of dyspnoea as a result of reduced lung and peripheral muscle performance.

This study aimed to evaluate the cardiopulmonary function and impairment of exercise endurance in patients with COVID-19 after 3 months of the second wave of the pandemic in Turkey. A total of 51 consecutive COVID-19 survivors, mostly healthcare providers, still working in the emergency room and intensive care units of the hospital after the second wave of Covid 19 pandemia were included in this study. Cardiopulmonary exercise stress test was performed. The median of the exercise time of the COVID-19 survivors, was 10 (4.5-13) minutes and the mean 6.8 ± 1.3 Mets was achieved. The VO2max of the COVID-19 survivors was 24 ± 4.6 ml kg-1min-1which corresponds the 85 ± 10% of the predicted VO2max value. The VO2WRs value which was reported about 8.5-11 ml min-1per watt in healthy individuals as normal was found lower in Covid 19 survivors (5.6 ± 1.4). The percentage of the maximum peak VO2calculated according to the predictable peak VO2of the COVID-19 survivors, was found significantly lower in male patients (92 ± 9.5% vs 80 ± 8.5%,p: 0.000). Also, there was a positive correlation between the percentage of the maximum predicted VO2measurements and age (r: 0.320,p: 0000). The peak VO2values of COVID-19 survivors decreased, and simultaneously, their exercise performance decreased due to peripheral muscle involvement. We believe that COVID-19 significantly affects men and young patients.

Prognostic value of main pulmonary artery diameter to ascending aorta diameter ratio in patients with advanced heart failure.

OBJECTIVES AND BACKGROUND: In this study we assessed the prognostic value of main pulmonary artery diameter and its ratio to ascending aorta diameter (P/Ao ratio) in advanced heart failure patients. METHODS: Patients with advanced heart failure who were candidates for heart transplantation were retrospectively evaluated. The clinical information, cardiac catheterisation results, and computed tomography images were gathered from institutional database system. The observed and predicted probabilities for survival were analysed in a nomogram. RESULTS: The P/Ao ratio was found to be a strong predictor for MACE both in traditional multivariable Cox proportional hazard regression modelling (increase in P/Ao ratio per 2 SD, HR:2.72, 95% CI 1.14-6.48, p = 0.024) and ridge regression analysis (increase in P/Ao ratio per 2SD, HR:3.45, 95% CI 1.53-7.74, p = 0.003). Prediction model showed statistically significant correlation between the observed and predicted probabilities for 1-year survival. CONCLUSION: In patients with advanced heart failure, computed tomography derived P/Ao ratio might be a prognostic predictor during follow up.

How does severe functional mitral regurgitation redefined by European guidelines affect pulmonary vascular resistance and hemodynamics in heart transplant candidates?

OBJECTIVE: Increased pulmonary artery pressure (PAP) and pulmonary vascular resistance (PVR) are important prognostic factors in patients with heart transplantation (HT). It is well known that severe mitral regurgitation increases pulmonary pressures. However, the European Society of Cardiology and the 6th World Symposium of pulmonary hypertension (PH) task force redefined severe functional mitral regurgitation (FMR) and PH, respectively. We aimed to investigate the effect of severe FMR on PAP and PVR based on these major redefinitions in patients with HT. METHODS: A total of 212 patients with HT were divided into 2 groups: those with severe FMR (n=70) and without severe FMR (n=142). Severe FMR was defined as effective orifice regurgitation area ≥20 mm2 and regurgitation volume ≥30 mL where the mitral valve was morphologically normal. A mean PAP of >20 mm Hg was accepted as PH. Patients with left ventricular ejection fraction ≤25% were included in the study. RESULTS: The systolic PAP, mean PAP, and PVR were higher in patients with severe FMR than in those without severe FMR [58.5 (48.0-70.2) versus 45.0 (36.0-64.0), p<0.001; 38.0 (30.2-46.6) versus 31.0 (23.0-39.5), p=0.004; 4.0 (2.3-6.8) versus 2.6 (1.2-4.3), p=0.001, respectively]. Univariate analysis revealed that the severe FMR is a risk factor for PVR ≥3 and 5 WU [odds ratio (OR): 2.0, 95% confidence interval (CI): 1.1-3.6, p=0.009; and OR: 3.2, 95% CI: 1.5-6.7, p=0.002]. The multivariate regression analysis results revealed that presence of severe FMR is an independent risk factor for PVR ≥3 WU and presence of combined pre-post-capillary PH (OR: 2.23, 95% CI: 1.30-3.82, p=0.003 and OR: 2.30, 95% CI: 1.25-4.26, p=0.008). CONCLUSION: Even in the updated definition of FMR with a lower threshold, severe FMR is associated with higher PVR, systolic PAP, and mean PAP and appears to have an unfavorable effect on pulmonary hemodynamics in patients with HT.

The association of left ventricular end-diastolic pressure with global longitudinal strain and scintigraphic infarct size in ST-elevation myocardial infarction patients undergoing primary percutaneous coronary intervention.

Left ventricular end-diastolic pressure (LVEDP) is an independent predictor for prognosis in ST-elevation myocardial infarction (STEMI) patients. We aimed to investigate the relationship of admission LVEDP measured after a successful primary percutaneous coronary intervention (pPCI) with scintigraphic infarct size (IS) and global longitudinal strain (GLS), a strong predictor of IS, in STEMI patients. A total of 62 consecutive patients with STEMI were enrolled in the study. LVEDP measurements were performed after pPCI in patients who had TIMI-3 flow. Echocardiography was performed 24 h after pPCI and repeated 3 months later. GLS was calculated as an average peak strain from the 3 apical projections. IS was evaluated at the third month by technetium 99m sestamibi. The mean age was 56 ± 8 years in the study population. The mean LVEDP was found 19.4 ± 4.4 mmHg. Median IS was 4% (0-11.7 IQR).The mean GLS at the 24th hour and the third month were found to be - 15.4 ± 2.8 and - 16.7 ± 2.5 respectively. There was a moderate negative correlation between LVEDP and GLS (24th-hour p < 0.001 r = - 0.485 and third-month p < 0.001 r = - 0.489). LVEDP had a moderate positive correlation with scintigraphic IS (p < 0.001 r = 0.545). In the multivariable model, we found that LVEDP was significantly associated with scintigraphic IS (ß coefficient = 0.570, p = 0.008) but was not associated with the 24th hour (ß coefficient = 0.092, p = 0.171) and third month GLS (ß coefficient = 0.037, p = 0.531). This study demonstrated that there was a statistically significant relationship between LVEDP and scintigraphic IS, and IS was increased with high LVEDP values. However, there was not a relationship between LVEDP and GLS.

Current clinician perspective on non-vitamin K antagonist oral anticoagulant use in challenging clinical cases.

OBJECTIVE: The evolution of non-vitamin K antagonist anticoagulants (NOACs) has changed the horizon of stroke prevention in atrial fibrillation (SPAF). All 4 NOACs have been tested against dose-adjusted warfarin in well-designed, pivotal, phase III, randomized, controlled trials (RCTs) and were approved by regulatory authorities for an SPAF indication. However, as traditional RCTs, these trials have important weaknesses, largely related to their complex structure and patient participation, which was limited by strict inclusion and extensive exclusion criteria. In the real world, however, clinicians are often faced with complex, multimorbid patients who are underrepresented in these RCTs. This article is based on a meeting report authored by 12 scientists studying atrial fibrillation (AF) in diverse ways who discussed the management of challenging AF cases that are underrepresented in pivotal NOAC trials. METHODS: An advisory board panel was convened to confer on management strategies for challenging AF cases. The article is derived from a summary of case presentations and the collaborative discussions at the meeting. CONCLUSION: This expert consensus of cardiologists aimed to define management strategies for challenging cases with patients who underrepresented in pivotal trials using case examples from their routine practice. Although strong evidence is lacking, exploratory subgroup analysis of phase III pivotal trials partially informs the management of these patients. Clinical trials with higher external validity are needed to clarify areas of uncertainty. The lack of clear evidence about complex AF cases has pushed clinicians to manage patients based on clinical experience, including rare situations of off-label prescriptions.