The role of imaging in infective endocarditis.

Infective endocarditis (IE) poses a large diagnostic and therapeutical challenge. An early diagnosis is necessary for a positive outcome. Echocardiography is initial diagnostic method when there is a possibility of IE presence. TTE and TEE are useful in detection, accurate localisation and estimation of vegetation size, and also in detection of paravalvular spreading of infection. In certain situations, there is a need for usage of complementary methods like CCT and nuclear techniques. This article will outline advantages and limitations of certain diagnostic methods in diagnosis of IE.

The basic heart anatomy and physiology from the cardiologist's perspective: Toward a better understanding of left ventricular mechanics, systolic, and diastolic function.

A comprehensive understanding of the cardiac structure-function relationship is essential for proper clinical cardiac imaging. This review summarizes the basic heart anatomy and physiology from the perspective of a heart imager focused on myocardial mechanics. The main issues analyzed are the left ventricular (LV) architecture, the LV myocardial deformation through the cardiac cycle, the LV diastolic function basic parameters and the basic parameters of the LV deformation used in clinical practice for the LV function assessment.

Multimodality imaging for the management of patients with primary mitral regurgitation.

Advanced cardiac imaging (ACI), including myocardial deformation imaging, 3D echocardiography and cardiac magnetic resonance, overcomes the limitations of conventional echocardiography in the assessment of patients with primary mitral regurgitation (MR). They enable a more precise MR quantification and reveal early changes before advanced and irreversible remodeling with depressed heart function occurs. ACI permits a thorough analysis of mitral valvular anatomy and MR mechanisms (important for planning and guiding percutaneous and surgical procedures) and helps to identify structural and functional changes coupled with a high arrhythmogenic potential, especially the occurrence of atrial fibrillation and heart failure development. The key question is how the data provided by ACI can improve the current management of primary MR.

Role of different echocardiographic modalities in the assessment of microvascular function in women with ischemia and no obstructive coronary arteries.

This review summarizes current knowledge about echocardiographic modalities used to assess microvascular function and left ventricular (LV) systolic function in women with ischemia and no obstructive coronary arteries (INOCA). Although the entire pathophysiological background of this clinical entity still remains elusive, it is primarily linked to microvascular dysfunction which can be assessed by coronary flow velocity reserve. Subtle impairments of LV systolic function in women with INOCA are difficult to assess by interpretation of wall motion abnormalities. LV longitudinal function impairment is considered to be an early marker of subclinical systolic dysfunction and can be assessed by global longitudinal strain quantification.

Gender-specific therapeutic approach in arterial hypertension - Challenges ahead.

Hypertension was thought to be more important cardiovascular risk factor in men than in women. However, studies showed that overall incidence of hypertension-related cardiovascular diseases is higher in women comparing with men and this is particularly valid in menopause when prevalence of hypertension and its complications sharply and suddenly rises. It was also noticed that the effect of various antihypertensive groups was different in women and men. Some medications are prescribed more often in women, but it does not necessary mean that these drugs are more effective in this gender. There are several important reasons that could explain gender-induced differences in blood pressure levels, blood pressure control and antihypertensive treatment. They involve sex hormones, the renin-angiotensin-aldosterone and sympathetic nervous system, and arterial stiffness. However, taking into account many observational studies and trials, there are no consistent data regarding the impact of gender on effect of antihypertensive medications. Longitudinal study focused on gender and current antihypertensive groups would significantly help to understand the impact of gender. This might change therapeutic approach and improve cost-effectiveness in antihypertensive therapy in both genders. A full understanding of the pathophysiological characteristics of variations between genders demands additional research. This review article summarized the current knowledge regarding differences in the prevalence and awareness of arterial hypertension in women and men; alterations in pathophysiological mechanisms of hypertension between sexes; as well as the impact of sex on the effects of main antihypertensive groups of medications.

Risk factors for intraoperative bradycardia during ear, nose, throat and maxillofacial surgery.

Intraoperative bradycardia (IOB) is one of the most common cardiac arrhythmias observed in clinical anaesthetic practice. Controlled hypotension, as a strategy of lowering patient's blood pressure during anesthesia has been practiced for decades in head and neck surgery. The aim of our study was to determine the incidence and the risk factors for intraoperative bradycardia in maxillofacial, ear, nose and throat surgery, as well as to determine whether controlled hypotension affects the occurrence of IOB. The retrospective study included 2304 patients who underwent maxillofacial, ear, nose or throat surgery. We studied the influence of: sex, age, comorbidity, type of surgery, duration of anesthesia and controlled hypotension on the occurrence of IOB. IOB was registered in 473 patients (20.5%). Patients with controlled hypotension had IOB significantly more often than patients without controlled hypotension (33.9 vs 15.1%) (p = 0.000). The significant predictors of IOB were: age (OR = 1.158; 95% CI = 1.068-1.256; p = 0.000), sex (OR = 0.786; 95% CI = 0.623-0.993; p = 0.043), ischemic heart disease (OR = 2.016; 95% CI = 1.182-3.441; p = 0.010); ear surgery (OR = 1.593; 95% CI = 1.232-2.060; p = 0.000), anesthesia duration, (OR = 1.006; 95% CI = 1.004-1.007; p = 0.000) and controlled hypotension (OR = 2.204; 95% CI = 1.761-2.758; p = 0.000). IOB is common in maxillofacial, ear, nose and throat surgery, particularly in male, older age and patients with ishemic heart disease. The ear surgery, longer anesthesia duration and controlled hypotension raise the risk for occurrence of IOB.

Cardiac mechanics and heart rate variability in patients with systemic sclerosis: the association that we should not miss.

We aimed to determine left ventricular (LV) and right ventricular (RV) structure, function and mechanics, as well as heart rate variability (HRV), and their relationship, in patients with systemic sclerosis (SSc). The study included 41 SSc patients and 30 age-matched healthy volunteers. All the patients underwent clinical examination, serological tests, pulmonary function testing, 24-h Holter monitoring and complete two-dimensional echocardiography including strain analysis. The parameters of LV structure (interventricular septum thickness and LV mass index) and RV structure (RV wall thickness) were significantly higher in SSc patients. LV and RV diastolic function (estimated by mitral and tricuspid E/e' ratio) was significantly impaired in SSc group comparing with the healthy controls. LV and RV longitudinal function was significantly deteriorated in SSc patients. LV circumferential strain was also significantly lower in SSc group, whereas LV radial strain was similar between the observed groups. All parameters of time and frequency domain of HRV were decreased in SSc patients. LV and RV cardiac remodeling parameters, particularly diastolic function and longitudinal strain, were associated with HRV indices without regard to the main demographic or the clinical and echocardiographic characteristics. Rodnan Skin Score was also independently associated with biventricular cardiac remodeling in SSc patients. LV and RV structure, function and mechanics, as well as autonomic nervous function, were significantly impaired in SSc patients. There is the significant association between biventricular cardiac remodeling and autonomic function in these patients, which could be useful for their everyday clinical assessment.

Left Ventricular Mechanics in Untreated Normotensive Patients with Type 2 Diabetes Mellitus: A Two- and Three-dimensional Speckle Tracking Study.

BACKGROUND: Our aim was to investigate left ventricular (LV) mechanics estimated by two- (2DE) and three-dimensional echocardiography (3DE) strains in subjects with type 2 diabetes mellitus (DM). METHODS: This cross-sectional study included 50 untreated normotensive DM subjects and 50 healthy controls similar by sex and age. All the subjects underwent adequate laboratory analyses and complete 2DE and 3DE examination. RESULTS: Left ventricular mechanics, assessed by 2DE, was impaired in all three directions. Global longitudinal 3DE strain was significantly decreased in the DM group in comparison with the controls (-17.8 ± 2.5 vs. -19.1 ± 2.7%, P = 0.014). Similar results were found for 3DE global circumferential strain (-18.9 ± 2.9 vs. -20.4 ± 3.2%, P = 0.01), 3DE global radial strain (40.3 ± 6.9 vs. 43.1 ± 7.3%, P = 0.035), and 3DE global area strain (-29.2 ± 3.7 vs. -31 ± 4%, P = 0.024). LV torsion was similar between the DM patients and the controls (2.1 ± 0.6 vs. 1.9 ± 0.5 °/cm, P = 0.073); whereas LV untwisting rate was significantly increased in the DM subjects (-114 ± 26 vs. -96 ±23 °/s, P < 0.001). A multivariate analysis showed that 3DE global longitudinal and area myocardial functions were associated with HbA1c independently of 3DE LV mass index. CONCLUSION: Left ventricular deformation obtained by 3DE is significantly impaired in the type 2 DM patients. HbA1c is independently associated with LV mechanics that implies that early anti-diabetic therapy and normalization of the fasting glucose level and HbA1c could impede further cardiac damage.

The influence of the metabolic syndrome on atrial fibrillation occurrence and outcome after coronary bypass surgery: a 3-year follow-up study.

BACKGROUND: We sought to investigate the influence of the metabolic syndrome (MS) on new-onset postoperative atrial fibrillation (POAF), and occurrence of major adverse cardiovascular and cerebrovascular events (MACCE) in a period of 3 years after isolated coronary artery bypass grafting (CABG) surgery. METHODOLOGY: The study included 460 patients who underwent the first CABG operation without baseline atrial fibrillation. The MS was defined by the presence of three or more Adult Treatment Panel (ATP)-American Heart Association (AHA)- National Heart, Lung, and Blood (NHLB) Institute criteria. POAF was diagnosed by continuous electrocardiographic monitoring during the first 48 to 72 hours after CABG. All the patients were followed up for at least 3 years after surgery. RESULTS: The MS and its criteria were significantly associated with POAF and MACCE occurrence in the 3-year period after isolated CABG surgery. Among the MS risk factors, hypertension, abdominal obesity, and the increased fasting glucose level were independently associated with both POAF and MACCE onset in the observed patients. Individuals with four or five MS criteria have similar risk of POAF or MACCE as individuals with three MS criteria. In the 3-year period of follow-up, the MS was proven to be associated with MACCE occurrence, independently of hypertension, diabetes, and obesity defined by body mass index. CONCLUSIONS: The MS and its criteria significantly increased risk of POAF and MACCE in a 3-year period. The MS, irrespective of hypertension, diabetes, and obesity, was associated with POAF and MACCE in the patients who underwent CABG.

What do we actually know about the relationship between arterial hypertension and atrial fibrillation?

Arterial hypertension and atrial fibrillation (AF) are very prevalent cardiovascular diseases, commonly seen together. Considering the fact that frequency of these medical conditions is constantly increasing due to human life extension, AF will be one of the major risks of cardiovascular morbidity and mortality in the future. Several pathophysiological mechanisms have been proposed to explain the onset of AF in arterial hypertension, and there are numerous theories that explain the protective effect of renin-angiotensin-aldosterone system (RAAS) blockade on new-onset AF. However, the consensus on pathophysiology and the favorable effect of RAAS blockade on AF development is still missing. On the other hand, large clinical trials and meta-analyses demonstrated a positive effect of angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers on AF prevention, which is why these drugs are included in the current guidelines for arterial hypertension, and will probably be better positioned in the new guidelines, which will be published this year. The recent studies have also shown a preventive effect of other antihypertensive drugs on AF occurrence and demonstrated that aggressive approach to hypertensive patients with AF is very important not only for conversion into sinus rhythm, but also for sinus rhythm maintenance.

High-normal blood pressure, functional capacity and left heart mechanics: is there any connection?

OBJECTIVE: To evaluate the relationship between functional capacity and left ventricular (LV) and left atrial (LA) myocardial deformation, assessed by two- and three-dimensional (2DE and 3DE) strain analysis, in subjects with high-normal blood pressure (BP). METHODS: This cross-sectional study included 64 subjects with optimal BP and 75 subjects with high-normal BP of similar gender and age. All the subjects underwent a complete 2DE and 3DE examination and cardiopulmonary exercise testing. RESULTS: 3DE global longitudinal strain was significantly lower in the group with high-normal BP than in the optimal BP group (- 20.1 ± 2.4 vs - 18.5 ± 2.3%, p < 0.001). Similar results were obtained for 3DE global circumferential strain (- 21.8 ± 2.6 vs - 19.3 ± 2.4%, p < 0.001), as well as for 3DE global radial strain (45.1 ± 8.8 vs 42.3 ± 7.2%, p = 0.042), and 3DE global area strain (- 30.1 ± 4.2 vs - 28.1 ± 3.8%, p < 0.001). LV twist was similar between the observed groups, whereas untwisting rate was significantly decreased in the subjects with high-normal BP (- 123 ± 30 vs - 112 ± 26°/s, p = 0.023). Peak VO2 was significantly lower in the high-normal BP group (30.8 ± 4 vs 28.3 ± 3.7 ml/kg/min, p < 0.001). 2DE LV ejection fraction (ß = 0.38, p = 0.014), 2DE global longitudinal strain (ß = 0.35, p = 0.019) and 3DE global longitudinal strain (ß = 0.27, p = 0.042) were independently associated with peak VO2. CONCLUSION: LV and LA mechanics, as well as functional capacity are significantly impaired in the subjects with high-normal BP. LV and LA myocardial deformations are associated with peak oxygen uptake.

Left atrial phasic function and mechanics in women with subclinical hypothyroidism: the effects of levothyroxine therapy.

BACKGROUND: Left atrial (LA) mechanics has been poorly investigated in women with subclinical hypothyroidism (SHT), and the effect of levothyroxine therapy on LA deformation and function is unknown. AIM: To investigate LA phasic function and mechanics assessed by two-dimensional echocardiography (2DE) and speckle tracking in women with SHT, and to estimate the influence of levothyroxine therapy on LA remodeling. METHODS: We included 48 untreated women with SHT and 38 healthy control women of the same age. All the SHT patients received levothyroxine therapy and were followed for 1 year after euthyroid status was achieved. All the participants underwent laboratory analyses and complete 2DE examination. RESULTS: Left atrial total emptying fraction was significantly lower in the SHT patients at the baseline in comparison with the controls. LA passive emptying fraction gradually decreased from the controls, throughout the treated SHT patients, to the untreated SHT patients. LA active emptying fraction was lower in the controls than in the untreated and the treated SHT participants. 2DE LA longitudinal strain and systolic strain rate gradually decreased from the controls to the untreated SHT patients, whereas LA early diastolic strain rate significantly increased in the same direction. Late diastolic LA strain was lower in the controls than in the untreated and the treated SHT patients. CONCLUSION: Subclinical hypothyroidism significantly affects LA mechanics. Reservoir, conduit, and booster pump LA functions are all impacted by SHT. A 1-year levothyroxine therapy significantly improves, but does not completely restore LA phasic function and mechanics in the SHT patients.

The impact of metabolic syndrome, recently diagnosed diabetes and hypertension on right ventricular remodeling. Is there difference between risk factors?

The aim of this study was to compare the right ventricular (RV) structure and diastolic function between normotensive and non-diabetic subjects with metabolic syndrome (MS), and new diagnosed diabetic and hypertensive patients. Study included 89 normotensive and non-diabetic subjects with MS which was defined by the presence ≥3 ATP-NCEP-III criteria, 45 diabetic and 117 hypertensive patients, as well as 76 controls with no MS criteria, matched for age and sex. All subjects underwent laboratory blood tests and complete two-dimensional echocardiography including pulsed and tissue Doppler. RV free wall thickness was similar between MS and diabetic patients, but significantly lower than in hypertensive patients (4.6 ± 0.8 versus 4.3 ± 0.7 versus 4.9 ± 0.9 mm; p < 0.01). Tricuspid E/e' ratio was similar between observed groups (5.3 ± 1.2 versus 5.2 ± 1.1 versus 5.7 ± 1.2, p > 0.05). RV systolic function evaluated by tissue Doppler (st) was similar between MS and diabetic participants, but still worse than in hypertensive patients (13.1 ± 2.2 versus 13.5 ± 2.5 versus 12.5 ± 2.4, p < 0.05). Global RV function estimated by Tei index was similar among MS and diabetic patients, and most impaired in hypertensive patients (0.47 ± 0.09 versus 0.45 ± 0.08 versus 0.52 ± 0.1, p < 0.01). Increased fasting glucose level, abdominal obesity and hypertension were independent predictors of biventricular hypertrophy, diastolic dysfunction and global dysfunction in whole population. RV structure and function gradually deteriorated from diabetic patients, across MS subject, to hypertensive patients. Normotensive and non-diabetic subjects with MS had similar level of RV impairment as diabetic patients which emphasize the synergic effects of MS components on cardiac damage.

When does low normal blood pressure become too low? The J-curve phenomenon.

The J-shaped relationship between blood pressure lowering and cardiovascular morbidity and mortality has been the topic of debates in the last three decades, especially because it has been shown that this relationship is not the same in different populations of hypertensive patients. This phenomenon is very important from a clinical point of view because it determines blood pressure cut-off values in patients with different comorbidities (diabetes, coronary artery disease, kidney disease, previous stroke). There is still no consensus about the J-shaped relationship. However, the number of studies supporting the existence of the inverse relationship between blood pressure reduction, especially diastolic pressure lowering, and cardiovascular morbidity and mortality, is increasing each year. The aim of this review is to summarize current knowledge about the J curve in a different population of hypertensive patients.

Imaging in Infective Endocarditis-Current Opinions and Trends in Cardiac Computed Tomography.

Infective endocarditis is a rare disease with an increasing incidence and an unaltered high mortality rate, despite medical development. Imaging plays an integrative part in the diagnosis of infective endocarditis, with echocardiography as the initial diagnostic test. Research data in the utility of cardiac computed tomography (CCT) in the diagnostic algorithm of IE are rising, which indicates its importance in detection of IE-related lesion along with the exclusion of coronary artery disease. The latest 2023 European Society of Cardiology Guidelines in the management of IE classified CCT as class of recommendation I and level of evidence B in detection of both valvular and paravalvular lesions in native and prosthetic valve endocarditis. This review article provides a comprehensive and contemporary review of the role of CCT in the diagnosis of IE, the optimization of acquisition protocols, the morphology characteristics of IE-related lesions, the published data of the diagnostic performance of CCT in comparison to echocardiography as the state-of-art method, as well as the limitations and future possibilities.

Left and right ventricular structure and function in subclinical hypothyroidism: the effects of one-year levothyroxine treatment.

BACKGROUND: The aim of this study was to investigate left ventricular (LV) and right ventricular (RV) structure, function, and mechanics in patients with subclinical hypothyroidism (SHT), and to evaluate the effect of a 1-year levothyroxine treatment. MATERIAL AND METHODS: We compared 45 untreated women with subclinical hypothyroidism and 35 healthy control women matched by age. All the subjects underwent laboratory analyses, which included a thyroid hormone levels (free T3, free T4, and TSH) test, and a complete 2-dimensional echocardiographic study. All the SHT patients received levothyroxine therapy and were followed for a year after euthyroid state was achieved. RESULTS: The LV mass index in the SHT participants before and after replacement therapy was significantly higher than in controls. In the SHT patients before the treatment, LV diastolic function and global function estimated by the Tei index were significantly impaired, whereas the LV systolic function was decreased. The results show that LV mechanics was significantly impaired in the SHT patients at baseline. Additionally, the SHT participants before levothyroxine substitution had increased RV wall thickness and significantly impaired RV diastolic and global function in comparison with the controls or the SHT subjects after the treatment. Furthermore, RV mechanics was also significantly deteriorated in the SHT patients before the treatment. CONCLUSIONS: Subclinical hypothyroidism significantly affected LV and RV structure, systolic, diastolic and global function, and LV and RV mechanics. Levothyroxine replacement therapy significantly improved cardiac structure, function, and mechanics in the SHT patients.

Risk factors for intraoperative hypotension during thyroid surgery.

BACKGROUND: Hypotension is a common adverse effect of IV anaesthetics, especially during the induction of anaesthesia. The aim of our study was to determine the incidence and risk factors for intraoperative hypotension (IOH) in thyroid surgery, as well as to determine whether and to what extent IOH affects the occurrence of postoperative hypotension. MATERIAL AND METHODS: The study included 1252 euthyroid patients, ASA 2 and ASA 3 status (American Society of Anesthesiologists physical status classification), who had thyroid surgery between 2007 and 2011. IOH was defined as a decrease in systolic blood pressure of >20% of baseline values. We studied the influence of demographic characteristics (sex, age, body mass index-BMI), comorbidity, type and duration of surgery, and anaesthesia on the occurrence of IOH. Univariate and multivariate logistic regression were used to determine predictors of occurrence of IOH. RESULTS: IOH was registered in 6.5% of patients. The most common operation was thyroidectomy. Patients with IOH were younger, had lower BMI, and significantly less often had hypertension as a coexisting disease. The multivariate regression model identified BMI and the absence of hypertension as a coexisting disease, and as independent predictors of occurrence of IOH. Significantly more patients with IOH had postoperative hypotension (9.9% vs. 2.4%, p=0.000). CONCLUSIONS: IOH is common, even during operations of short duration and with minimal bleeding. It is necessary to pay special attention to these patients, given that many of these patients remained hypotensive during the postoperative period.

Is gender responsible for everything? The relationship between sex and right ventricular remodeling in metabolic syndrome.

BACKGROUND: The aim of this study was to examine the impact of metabolic syndrome (MS) on right ventricular (RV) remodeling in different genders. METHODS: The study included 341 subjects (216 subjects with MS and 125 controls). MS was defined by the presence of ≥ 3 ATP-NCEP-III criteria. All subjects underwent complete two-dimensional echocardiography. RESULTS: RV structure, diastolic, and global function were significantly impaired in MS subjects, in both genders. The multiple regression analysis of MS parameters showed that systolic blood pressure (BP) and waist circumference were independently associated with RV wall thickness in women, whereas the only independent predictor in men was systolic BP. The multivariate logistic regression analysis revealed that increased BP, impaired fasting glucose, and dyslipidemia were a combination of MS risk factors related with RV hypertrophy solely in women. Increased systolic BP, impaired fasting glucose, and abdominal obesity were independently associated with tricuspid E/e' in women, whereas increased systolic BP was the only independent predictor in men. Impaired fasting glucose, abdominal obesity, and dyslipidemia were a combination of MS criteria, which was independently associated with RV diastolic dysfunction only in women. CONCLUSIONS: Different parameters of MS are responsible for RV remodeling in women and men. The metabolic parameters of MS are more important for RV remodeling in women.

Do nondipping pattern and metabolic syndrome impact left ventricular geometry and global function in hypertensive patients?

The aim of this study was to investigate the impact of nondipping arterial blood pressure pattern and the metabolic syndrome (MS), as well as their interaction, on left ventricular (LV) structural and function remodeling. The study included 352 never-treated hypertensive patients with and without MS. Nondipping pattern and MS, separately, as well as their interaction, significantly impacted LV structure, LV geometry pattern, systolic, diastolic and global function in hypertensive patients. Abdominal obesity was the only MS criterion which was simultaneously associated with LV hypertrophy, LV diastolic dysfunction and, LV global dysfunction.