Detection of Left Ventricular Systolic Dysfunction From Electrocardiographic Images.

BACKGROUND: Left ventricular (LV) systolic dysfunction is associated with a >8-fold increased risk of heart failure and a 2-fold risk of premature death. The use of ECG signals in screening for LV systolic dysfunction is limited by their availability to clinicians. We developed a novel deep learning-based approach that can use ECG images for the screening of LV systolic dysfunction. METHODS: Using 12-lead ECGs plotted in multiple different formats, and corresponding echocardiographic data recorded within 15 days from the Yale New Haven Hospital between 2015 and 2021, we developed a convolutional neural network algorithm to detect an LV ejection fraction <40%. The model was validated within clinical settings at Yale New Haven Hospital and externally on ECG images from Cedars Sinai Medical Center in Los Angeles, CA; Lake Regional Hospital in Osage Beach, MO; Memorial Hermann Southeast Hospital in Houston, TX; and Methodist Cardiology Clinic of San Antonio, TX. In addition, it was validated in the prospective Brazilian Longitudinal Study of Adult Health. Gradient-weighted class activation mapping was used to localize class-discriminating signals on ECG images. RESULTS: Overall, 385 601 ECGs with paired echocardiograms were used for model development. The model demonstrated high discrimination across various ECG image formats and calibrations in internal validation (area under receiving operation characteristics [AUROCs], 0.91; area under precision-recall curve [AUPRC], 0.55); and external sets of ECG images from Cedars Sinai (AUROC, 0.90 and AUPRC, 0.53), outpatient Yale New Haven Hospital clinics (AUROC, 0.94 and AUPRC, 0.77), Lake Regional Hospital (AUROC, 0.90 and AUPRC, 0.88), Memorial Hermann Southeast Hospital (AUROC, 0.91 and AUPRC 0.88), Methodist Cardiology Clinic (AUROC, 0.90 and AUPRC, 0.74), and Brazilian Longitudinal Study of Adult Health cohort (AUROC, 0.95 and AUPRC, 0.45). An ECG suggestive of LV systolic dysfunction portended >27-fold higher odds of LV systolic dysfunction on transthoracic echocardiogram (odds ratio, 27.5 [95% CI, 22.3-33.9] in the held-out set). Class-discriminative patterns localized to the anterior and anteroseptal leads (V2 and V3), corresponding to the left ventricle regardless of the ECG layout. A positive ECG screen in individuals with an LV ejection fraction ≥40% at the time of initial assessment was associated with a 3.9-fold increased risk of developing incident LV systolic dysfunction in the future (hazard ratio, 3.9 [95% CI, 3.3-4.7]; median follow-up, 3.2 years). CONCLUSIONS: We developed and externally validated a deep learning model that identifies LV systolic dysfunction from ECG images. This approach represents an automated and accessible screening strategy for LV systolic dysfunction, particularly in low-resource settings.

A case of left atrial compression secondary to angioedema.

Angioedema due to angiotensin-converting enzyme (ACE) inhibitors is an uncommon, but deadly adverse reaction with an overall incidence of 0.1%-0.2%. Rapid accumulation of interstitial fluid and vasodilation classically involves the mucus membranes of the mouth and face but has the ability to affect other areas. We describe a case of angioedema secondary to ACE inhibitor that affected the esophagus causing left atrial compression and hemodynamic compromise.

When the gold standard is not always golden: The value of invasive hemodynamic assessment to overcome the pitfalls of echocardiography in challenging cases of mitral stenosis.

Mitral stenosis is a uncommon valvular lesion in the developed countries. Noninvasive evaluation is the first-line modality for assessment of mitral stenosis, however the noninvasive methods may have limitations in certain cases. Invasive hemodynamics can be used as adjunct tool for assessment of mitral stenosis in such difficult cases. Mitral valve using three-dimensional planimetry is a promising technique for assessment of mitral stenosis.

Clinical and echocardiographic predictors of new-onset atrial fibrillation in patients admitted with blunt trauma.

BACKGROUND: Atrial fibrillation (AF) is a common arrhythmia after trauma or burn injury; however, its predisposing factors are not well known. Moreover, little is known about its effect on mortality and other short-term clinical outcomes. OBJECTIVES: This study is aimed at identifying risk factors for new-onset AF in patients admitted with blunt trauma or burn injuries at a Level 1 academic trauma center, and to determine its effects on the short-term clinical outcomes. METHODS: This case-control study compared patients with new-onset AF with a cohort of patients without AF during the hospital stay after trauma or burn injury. Patients with prior AF or lack of transthoracic echocardiogram were excluded. Demographic, clinical factors including injury severity score and echocardiographic parameters were compared in both cohorts. Risks of short-term clinical outcomes, namely persistent AF, new stroke, myocardial infarction, or death, were compared. RESULTS: Older age, sepsis, CHADS2-VASC score >1, larger left atrium (LA) size, left ventricular hypertrophy (LVH), and left ventricular diastolic dysfunction imposed a significant risk for new-onset AF on univariate analysis. On multivariate, independent predictors of new-onset AF were LA dilation and LVH. LA enlargement increased odds of new-onset AF by 23-fold (OR 23; CI: 5.7-92, P < 0.0001) and the presence of LVH increased the odds of new-onset AF more than 20-fold (OR 20.8; CI: 5-87, P < 0.0001). CONCLUSIONS: Dilated LA and LVH are independent predictors of new-onset AF in the patients with blunt trauma or burn. New-onset AF did not confer increased risk for in-hospital mortality.

Outcomes of percutaneous coronary intervention of chronic total saphenous vein graft occlusions in the contemporary era.

BACKGROUND: Percutaneous coronary intervention of a chronic total occlusion to a saphenous vein graft is currently not recommended because the benefit/risk ratio is considered unfavorable. However, there is a patient subset with clinical ischemia, and PCI of the native chronic total occlusion (CTO) is unfavorable. In this setting, PCI to the saphenous vein graft (SVG) may have utility. We reviewed our experience to determine its value in the modern era. METHODS AND RESULTS: This was a single-center retrospective study of all patients undergoing PCI to SVG CTO. Of 161 patients undergoing SVG PCI during the study period, 27 patients underwent 28 SVG CTO PCI, which was technically successful in 79% (22/28). There were 2 intra-procedural Q wave myocardial infarctions. At 30 days there were no adverse events after hospital discharge. Angina relief was significantly better at 30 days in successful (n = 21) vs. unsuccessful (n = 6) PCI(90% vs. 33% P < 0.01). At the last available follow-up (591 ± 407 days), angina improvement persisted (80.1% vs. 33%, P < 0.01). Long-term adverse events were not significantly different between the two groups. CONCLUSION: PCI to SVG CTO is feasible with a reasonable success rate, safety profile, and improvement in angina in contemporary practice. This approach may be considered in highly selected patients where revascularization to the ischemic territory is appropriate and the native CTO is technically difficult to recanalize.

Hypoattenuated Leaflet Thickening-Associated Myocardial Infarction: A Rare Case Report and Literature Review.

Hypoattenuated leaflet thickening (HALT), a potential aftereffect of transcatheter aortic valve replacement (TAVR) procedure, may affect valve performance and clinical outcomes. At this moment we describe an elderly patient who, despite being on prophylactic antiplatelet medication for previous percutaneous intervention (PCI) for coronary artery disease (CAD) and a self-expanding valve in-situ for aortic stenosis (TAVR), presented to the emergency room with non-ST-segment elevation myocardial infarction (NSTEMI), probably as a result of a thromboembolic event from HALT. The case highlights the significance of considering HALT-associated thromboembolism as a potential cause of myocardial infarction (MI) in post-TAVR patients.

Acute Radial Artery Thromboembolic Occlusion During Transcatheter Aortic Valve Replacement: A Case Report and Review of Management Strategies.

Acute limb ischemia requires prompt diagnosis and treatment. Thromboembolic events are common, especially in patients with multiple risk factors. This case report describes a rare complication of transcatheter aortic valve replacement (TAVR) involving thromboembolic occlusion of the radial artery and highlights the risk of embolic complications during TAVR. While TAVR is minimally invasive and preferred for high-risk patients, it carries the risk of complications such as paravalvular leakage and cerebrovascular events. Prompt recognition and management are crucial. Various mechanisms, including catheter manipulation and altered hemodynamics, contribute to embolic risks during TAVR. Awareness and management of rare embolic complications during TAVR are essential. Further research is needed to prevent these complications and improve patient outcomes.

Gut Dysbiosis and Cardiovascular Health: A Comprehensive Review of Mechanisms and Therapeutic Potential.

Cardiovascular diseases (CVDs) are a leading cause of mortality worldwide. Recent research has identified gut dysbiosis - an imbalance in the gut microbiota - as a significant factor in the development of CVDs. This complex relationship between gut microbiota and cardiovascular health involves various mechanisms, including the production of metabolites such as trimethylamine N-oxide (TMAO) and short-chain fatty acids (SCFAs). These metabolites influence lipid metabolism, inflammation, and blood pressure regulation. In addition, the gut-brain axis and neurohormonal pathways play crucial roles in cardiovascular function. Epidemiological studies have linked gut dysbiosis to various cardiovascular conditions, highlighting the potential for therapeutic interventions. Dietary changes, probiotics, and prebiotics have shown promise in modulating gut microbiota and reducing cardiovascular risk factors. This underscores the critical role of gut health in preventing and treating CVDs. However, further research is needed to develop targeted therapies that can enhance cardiovascular outcomes.

Early versus delayed percutaneous coronary intervention for patients with non-ST segment elevation acute coronary syndrome: a meta-analysis of randomized controlled clinical trials.

BACKGROUND: Studies assessing the timing of percutaneous coronary interventions (PCI) in patients with Non-ST segment elevation Acute Coronary Syndromes (NSTE-ACS) have failed to generate a consensus on how early PCI should be performed in such patients. PURPOSE: This meta-analysis compares clinical outcomes at 30 days in NSTE-ACS patients undergoing PCI within 24 hours of presentation (early PCI) with those receiving PCI more than 24 hours after presentation (delayed PCI). DATA SOURCES: Data were extracted from searches of MEDLINE (1990-2010) and Google scholar and from scrutiny of abstract booklets from major cardiology meetings (1990-2010). STUDY SELECTION: Randomized clinical trials (RCTs) that included the composite endpoint of death and non-fatal myocardial infarction (MI) at 30 days after PCI were considered. DATA EXTRACTION: Two independent reviewers extracted data using standard forms. The effects of early and delayed PCI were analyzed by calculating pooled estimates for death, non-fatal MI, bleeding, repeat revascularization and the composite endpoint of death or non-fatal MI at 30 days. Univariate analysis of each of these variables was used to create odds ratios. DATA SYNTHESIS: Seven studies with a total of 13,762 patients met the inclusion criteria. There was no significant difference in the odds of the composite endpoint of death or non-fatal MI at 30 days between patients undergoing early PCI and those receiving delayed PCI (OR-0.83, 95%CI 0.62-1.10). Patients receiving delayed PCI experienced a 33% reduction in the odds of repeat revascularization at 30 days compared to those undergoing early PCI (OR-1.33, 95%CI 1.14-1.56, P=0.0004).Conversely, patients undergoing early PCI experienced lower odds of bleeding than those receiving delayed PCI (OR-0.76, 95%CI 0.63-0.91, P = 0.0003). CONCLUSIONS: In NSTE-ACS patients early PCI doesn't reduce the odds of the composite endpoint of death or non-fatal MI at 30 day. This strategy is associated with lower odds of bleeding and higher odds of repeat revascularization at 30 days than a strategy of delayed PCI.

Is Concomitant Mitral Stenosis Associated With Worse Outcomes in Patients Who Underwent TAVR? Insights from a National Database.

Concomitant mitral stenosis (MS) is present in 10% to 15% of all patients who underwent transcatheter aortic valve replacement (TAVR). Our aim is to assess outcomes of TAVR in patients with MS using a national database. The Nationwide Inpatient Sample database was used to identify patients who underwent TAVR from 2015 to 2020. We created 2 groups, patients with and those without MS. We then compared baseline characteristics, demographics, and in-hospital outcomes of the groups. Primary outcomes were in-hospital mortality, acute respiratory failure, and pacemaker placement. Secondary outcomes were length of stay and in-hospital costs. Our study indicates that patients with MS had greater incidence of acute respiratory failure (8.8% vs 4.89%, p = 0.001), complete heart block (13.54% vs 9.36%, p = 0.01), and permanent pacemaker placement (8.03% vs 6.03%, p = 0.05). In-hospital mortality was greater in the MS group; however, it was not statistically significant (1.32% vs 1.53%, p = 0.679).

A Review of the Role of Imaging Modalities in the Evaluation of Viral Myocarditis with a Special Focus on COVID-19-Related Myocarditis.

Viral myocarditis is inflammation of the myocardium secondary to viral infection. The clinical presentation of viral myocarditis is very heterogeneous and can range from nonspecific symptoms of malaise and fatigue in subclinical disease to a more florid presentation, such as acute cardiogenic shock and sudden cardiac death in severe cases. The accurate and prompt diagnosis of viral myocarditis is very challenging. Endomyocardial biopsy is considered to be the gold standard test to confirm viral myocarditis; however, it is an invasive procedure, and the sensitivity is low when myocardial involvement is focal. Cardiac imaging hence plays an essential role in the noninvasive evaluation of viral myocarditis. The current coronavirus disease 2019 (COVID-19) pandemic has generated considerable interest in the use of imaging in the early detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-related myocarditis. This article reviews the role of various cardiac imaging modalities used in the diagnosis and assessment of viral myocarditis, including COVID-19-related myocarditis.

Men are from mars, women are from venus: Factors responsible for gender differences in outcomes after surgical and trans-catheter aortic valve replacement.

Females suffer higher operative (30-day) mortality than males after surgical aortic valve replacement (SAVR). In contrast, outcomes after trans-catheter aortic valve replacement (TAVR) seem to favor females, both in terms of procedural mortality, and more prominently, medium to long-term survival. With an ever-greater number of TAVR procedures being performed, an understanding of factors responsible for gender differences in outcomes after the two AVR modalities is critical for better patient selection. Current evidence suggests that this gender difference in outcomes after SAVR and TAVR stems from differences in baseline risk profiles, as well as inherent anatomic/physiological differences between genders. This review attempts to examine these clinical and physiological factors, with a goal of guiding better patient selection for each AVR modality, and to highlight areas that beg further investigation.

Chest X-Ray to Predict Difficult Right Transradial Cardiac Catheterization Due to Vascular Tortuosity: A Retrospective Study.

Tortuous brachiocephalic artery may lead to procedural difficulties among patients undergoing right transradial cardiac catheterization. By prospectively identifying patients with this anatomic barrier, operators may choose an alternate catheterization site to avoid complications from switching midway. To assess brachiocephalic artery tortuosity, 23 patients who underwent challenging diagnostic coronary angiography by right transradial access were compared to a control group of 29 patients who lacked brachiocephalic artery tortuosity. Preprocedural, plain chest x-rays were analyzed for measurable anatomic parameters and assessed for statistical significance between groups. The vertebrocarinal distance-the distance in centimeters between the spinous process of the first thoracic vertebra (T1) and the most caudal point of tracheal bifurcation, measured at and parallel to the midline-was the most reliable and statistically significant radiographic predictor of brachiocephalic artery tortuosity. Using this novel concept reduces procedure duration and radiation exposure by decreasing transradial cardiac catheterization failure rates.

Antiplatelet therapy for stroke prevention in atrial fibrillation.

Warfarin has been the cornerstone therapy for stroke prevention in non-valvular atrial fibrillation (NVAF), particularly in patients at high risk of ischemic stroke or thromboembolism. Warfarin use in NVAF results in a 64% relative reduction in the incidence of ischemic stroke and several trials have demonstrated warfarin to be superior to aspirin alone (relative risk reduction-22%). However, anticoagulation with warfarin is associated with increased bleeding, especially in the elderly population. Anticoagaulation with warfarin requires close monitoring of the international standardized ratio (INR), which can be inconvenient to patients. Additionally, large numbers of patients on coumadin have a subtherapeutic INR level, which increases the risk of thromboembolic episodes. In part due to the above mentioned reasons, anticoagulation with warfarin is underutilized for stroke prevention.

The Impact of Marijuana on the Cardiovascular System: A Review of the Most Common Cardiovascular Events Associated with Marijuana Use.

With the expanded legalization of marijuana, its medical and recreational use have sharply increased over the past decade. A wide array of new forms of cannabis is available on the market today, and the potencies are ten times those of forms previously tested, meaning that the true impact of marijuana on the cardiovascular system remains unclear. Cannabis mainly exerts its effects via the sympathetic and parasympathetic nervous systems, with different doses affecting different cannabinoids receptors. Studies have shown that marijuana plays a role in thrombosis, inflammation, and atherosclerosis. Case reports have linked marijuana use to myocardial infarction, cardiac arrythmias, cardiomyopathies, stroke, and arteritis. Most patients are young, healthy men with no cardiovascular risk factors; however, the patient population is expected to change to include older individuals in the future. The widespread public perception of safety accompanying marijuana use has contributed to its increased use among the elderly, who are the most at risk population for acute cardiovascular events. In this review, we aim to provide a basic understanding of the physiological effects of marijuana on the cardiovascular system and to review the current literature regarding cardiovascular diseases linked to marijuana use in adults.

Outcomes of Percutaneous Antegrade Intraluminal Coronary Intervention of Chronic Total Occlusion With Remote Surgical Backup.

Percutaneous coronary intervention (PCI) of chronic total occlusion (CTO) is not favored in facilities without on-site surgical backup. We reviewed outcomes of patients who had CTO intervention with remote surgical backup in our institution. All patients who underwent attempted antegrade intraluminal CTO PCI from January 2013 to July 2017 were analyzed. Twenty cases (18 patients, 58.1 ± 7.0 years, 70% males) were identified. Procedure was successful in 85% (17 of 20). There were 2 nonflow limiting dissections and 1 wire perforation. Two patients had post-PCI myocardial infarction. There was no cardiac death, myocardial infarction, target vessel revascularization, or stroke at 30 days and at mean follow-up of 19.5 ± 13.7 months. There were 4 rehospitalizations for angina requiring repeat angiogram in 3 cases: 2 without intervention, and 1 referred for coronary artery bypass grafting. Careful attempt at antegrade intraluminal CTO intervention done at a center with remote surgical backup is feasible in selected patients.

Vascular functions of the plasminogen activation system.

The plasminogen activator (PA) system, which controls the formation and activity of plasmin, plays a key role in modulating hemostasis, thrombosis, and several other biological processes. While a great deal is known about the function of the PA system, it remains a focus of intensive investigation, and the list of biological pathways and human diseases that are modulated by normal and pathologic function of its components continues to lengthen. Because of remarkable advances in molecular genetics, the laboratory mouse has become the most useful animal system to study the normal and pathologic functions of the PA system. The purpose of this review is to summarize studies that have used genetically modified mice to examine the functions of the PA system in hemostasis and thrombosis, intimal hyperplasia after vascular injury, and atherosclerosis. Particular emphasis is placed on the vascular functions of PA inhibitor-1, a key regulator of the PA system, and the multiple variables that appear to account for the complex role of PA inhibitor-1 in regulating vascular remodeling. Lastly, the strengths and limitations of using mice to model human vascular disease processes are discussed.

Peri-procedural antibiotic prophylaxis in ventricular septal defect: a case study to re-visit guidelines.

The current American Heart Association (AHA)/American College of Cardiology (ACC) guidelines do not recommend antibiotic prophylaxis for infective endocarditis (IE) in patients with acyanotic congenital valvular heart disease due to lack of any proven benefit and potential harm associated with antibiotics. As recognized by the guidelines, some acyanotic congenital heart disease, such as ventricular septal defects (VSDs), are associated with a high velocity jet and pose a greater risk of peri-procedural endocarditis. We suggest that an acyanotic congenital heart disease with high velocity jet should be considered for antibiotic prophylaxis for IE.

Hyperlipidemia: Management with Proprotein Convertase Subtilisin/Kexin Type 9 (PCSK9) Inhibitors.

Coronary artery disease is the leading cause of death in United States. Hyperlipidemia is an independent and potentially reversible risk factor for coronary artery disease. The 3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitors, collectively known as statins, have been the mainstay of pharmacologic therapy. Their availability, ease of administration, low cost, and strong evidence behind safety and efficacy makes them one of the most widely prescribed lipid-lowering agents. However, some patients may be intolerant to statins, and few others suffer from very high serum levels of cholesterol in which statin therapy alone or in combination with other cholesterol-lowering agents is insufficient in reducing serum lipid levels to achieve desired levels. In 2015, the Food and Drug Administration approved a new family of lipid-lowering agents, collectively known as proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors.PCSK9 inhibitors are biologically active molecules that decrease serum low-density lipoprotein cholesterol compared with statin therapy alone. They serve as an alternative to statins for patients who are intolerant to statin or as supplemental therapy in those patients for whom lower levels in serum low-density lipoprotein cholesterol are not achieved by statins alone. This article discusses PCSK9 inhibitors, their mechanism of action, indications, efficacy, safety, costs and limitations.

Double conduction through the atrioventricular node following acute medullary infarction: a case report.

Lateral medullary syndrome (LMS), also known as Wallenberg's syndrome, PICA syndrome, results from occlusion of the posterior inferior cerebellar artery, with associated infarction of parts of medulla oblongata, and cerebellum on the ipsilateral side. It often manifests as various patterns of sensory, motor, and autonomic deficits. While sensorimotor dysfunction presents as a predicted pattern of clinical signs and symptoms, autonomic dysfunction is usually less clinically apparent, and can be easily mistaken as a concomitant pathology in the end organ it affects. In this case, we present a case of an unusual pattern of cardiac arrhythmia as the first objective finding of LMS, caused by autonomic instability following infarction of vagus nerve nuclei in the medulla.