Cardiac contractility modulation in patients with heart failure - A review of the literature.

Experimental in vivo and in vitro studies showed that electric currents applied during the absolute refractory period can modulate cardiac contractility. In preclinical studies, cardiac contractility modulation (CCM) was found to improve calcium handling, reverse the foetal myocyte gene programming associated with heart failure (HF), and facilitate reverse remodeling. Randomized control trials and observational studies have provided evidence about the safety and efficacy of CCM in patients with HF. Clinically, CCM therapy is indicated to improve the 6-min hall walk, quality of life, and functional status of HF patients who remain symptomatic despite guideline-directed medical treatment without an indication for cardiac resynchronization therapy (CRT) and have a left ventricular ejection fraction (LVEF) ranging from 25 to 45%. Although there are promising results about the role of CCM in HF patients with preserved LVEF (HFpEF), further studies are needed to elucidate the role of CCM therapy in this population. Late gadolinium enhancement (LGE) assessment before CCM implantation has been proposed for guiding the lead placement. Furthermore, the optimal duration of CCM application needs further investigation. This review aims to present the existing evidence regarding the role of CCM therapy in HF patients and identify gaps and challenges that require further studies.

Contemporary Role of Cardiac Magnetic Resonance in the Management of Patients with Suspected or Known Coronary Artery Disease.

Cardiac magnetic resonance imaging (CMR) is a useful non-invasive radiation-free imaging modality for the management of patients with coronary artery disease (CAD). CMR cine imaging provides the "gold standard" assessment of ventricular function, late gadolinium enhancement (LGE) provides useful data for the diagnosis and extent of myocardial scar and viability, while stress imaging is an established technique for the detection of myocardial perfusion defects indicating ischemia. Beyond its role in the diagnosis of CAD, CMR allows accurate risk stratification of patients with established CAD. This review aims to summarize the data regarding the role of CMR in the contemporary management of patients with suspected or known coronary artery disease.

Anomaly Detection Trusted Hardware Sensors for Critical Infrastructure Legacy Devices.

Critical infrastructures and associated real time Informational systems need some security protection mechanisms that will be able to detect and respond to possible attacks. For this reason, Anomaly Detection Systems (ADS), as part of a Security Information and Event Management (SIEM) system, are needed for constantly monitoring and identifying potential threats inside an Information Technology (IT) system. Typically, ADS collect information from various sources within a CI system using security sensors or agents and correlate that information so as to identify anomaly events. Such sensors though in a CI setting (factories, power plants, remote locations) may be placed in open areas and left unattended, thus becoming targets themselves of security attacks. They can be tampering and malicious manipulated so that they provide false data that may lead an ADS or SIEM system to falsely comprehend the CI current security status. In this paper, we describe existing approaches on security monitoring in critical infrastructures and focus on how to collect security sensor-agent information in a secure and trusted way. We then introduce the concept of hardware assisted security sensor information collection that improves the level of trust (by hardware means) and also increases the responsiveness of the sensor. Thus, we propose a Hardware Security Token (HST) that when connected to a CI host, it acts as a secure anchor for security agent information collection. We describe the HST functionality, its association with a host device, its expected role and its log monitoring mechanism. We also provide information on how security can be established between the host device and the HST. Then, we introduce and describe the necessary host components that need to be established in order to guarantee a high security level and correct HST functionality. We also provide a realization-implementation of the HST overall concept in a FPGA SoC evaluation board and describe how the HST implementation can be controlled. In addition, in the paper, two case studies where the HST has been used in practice and its functionality have been validated (one case study on a real critical infrastructure test site and another where a critical industrial infrastructure was emulated in our lab) are described. Finally, results taken from these two case studies are presented, showing actual measurements for the in-field HST usage.

Total cosine R-to-T for predicting ventricular arrhythmic and mortality outcomes: A systematic review and meta-analysis.

BACKGROUND: The total cosine R-to-T (TCRT), a vectorcardiographic marker reflecting the spatial difference between the depolarization and repolarization wavefronts, has been used to predict ventricular tachycardia/fibrillation (VT/VF) and sudden cardiac death (SCD) in different clinical settings. However, its prognostic value has been controversial. OBJECTIVE: This systematic review and meta-analysis evaluated the significance of TRCT in predicting arrhythmic and/or mortality endpoints. METHODS: PubMed and Embase databases were searched through December 31, 2016. RESULTS: Of the 890 studies identified initially, 13 observational studies were included in our meta-analysis. A total of 11,528 patients, mean age 47 years old, 72% male, were followed for 43 ± 6 months. Data from five studies demonstrated lower TCRT values in myocardial infarction patients with adverse events (syncope, ventricular arrhythmias, or sudden cardiac death) compared to those without these events (mean difference = -0.36 ± 0.05, p < .001; I2  = 48%). By contrast, only two studies analyzed outcomes in heart failure, and pooled meta-analysis did not demonstrate significant difference in TCRT between event-positive and event-negative patients (mean difference = -0.01 ± 0.10, p > .05; I2  = 80%). CONCLUSION: TCRT is lower in MI patients at high risk of adverse events when compared to those free from such events. It can provide additional risk stratification beyond the use of clinical parameters and traditional electrocardiogram markers. Its value in other diseases such as heart failure requires further studies.

Pre-loading therapy with statins in patients with angina and acute coronary syndromes undergoing PCI.

Statins constitute the most powerful class of drugs for cardiovascular risk reduction associated to atherosclerosis. Their important pharmacological properties include reduction of serum lipid concentrations and non-lipid related, pleotropic effects such as anti-inflammatory action. Previous largescale randomized studies have demonstrated the beneficial effects of statin loading prior to elective percutaneous coronary intervention (PCI) for the reduction of periprocedural myocardial infarction and prevention of major adverse cardiac events at 30 days. The present review summarizes the data from major randomized trials that evaluated the clinical benefit of statin pretreatment in the setting of PCI resulting in a better understanding of their impact on reduction of interventional complications.

Reversible Stress Cardiomyopathy Secondary to Aneurysmal Subarachnoid Hemorrhage: A Case Report.

BACKGROUND: Acute cerebral incidents have been correlated with cardiac manifestations. Specifically, subarachnoid hemorrhage has been correlated with a syndrome described as neurogenic stress cardiomyopathy and mimics acute coronary syndrome. CASE REPORT: A 55-year-old woman presented at the Emergency Department of our hospital complaining of vomiting and headache of sudden onset. Computed tomography angiography revealed a ruptured aneurysm at the tip of the basilar artery and the patient underwent a successful complete embolism of the sac of the aneurysm. During hospitalization, the patient developed electrocardiographic alterations and elevation of cardiac biomarkers, and echocardiography showed an impairment of left ventricular systolic function. The patient was diagnosed with neurogenic stress cardiomyopathy and she was treated conservatively. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Clinicians should be aware of neurogenic stress cardiomyopathy because early diagnosis and treatment are the cornerstones for achieving a better outcome.

Diagnosis and Treatment of Left-Sided Prosthetic Paravalvular Regurgitation.

Paravalvular leak (PVL) is a complication related to the surgical implantation of left-sided prosthetic valves. The prevalence of paravalvular regurgitation ranges between 5 and 20%. Left-sided prosthetic paravalvular regurgitation presents with a wide constellation of signs and symptoms ranging from asymptomatic murmur to heart failure, hemolysis and cardiac cachexia. Echocardiography plays a key role in imaging the PVL and can help in guiding the closure procedure with both transesophageal and intracardiac probes. Transcatheter closure of paravalvular regurgitations is an appealing prospect.

Heart failure with complete recovery in a patient with systemic lupus erythematosus.

We report the case of a 43-year-old female patient who was admitted to the Cardiology Department from the Rheumatology Clinic where she was being treated for multi-organ serositis, fatigue and mild dyspnoea on exertion. The patient had a known medical history of systemic lupus erythematosus (SLE). Following extensive evaluation with blood tests for immunological and viral culprits, cardiac ultrasound, chest and abdominal computed tomography (CT) and heart magnetic resonance imaging (MRI), the diagnosis of effusive constrictive pericarditis secondary to her SLE was made. Treatment with ß-blockers, diuretics and corticosteroids was given with excellent results, and one year post discharge the patient remains asymptomatic. Systemic lupus erythematosus patients often manifest cardiac complications such as pericarditis. The practising physician should always bear in mind this possibility when treating such patients.

[Régurgitation mitrale sévère due à la sarcoïdose cardiaque : une présentation clinique inhabituelle ; une étude de cas et des recherches antérieures]. / Severe mitral regurgitation due to cardiac sarcoidosis : An unusual clinical presentation ; a case report and review of the literature.

Sarcoidosis is a granulomatous inflammatory disease that may involve multiple organ systems, including the heart. Cardiac manifestations are not rare and include atrial and ventricular arrhythmias, conduction abnormalities, congestive heart failure, valvular dysfunction, pericarditis, and sudden death. Although, cardiac sarcoidosis (CS) remains a diagnostic and therapeutic challenge. This article describes a case of a patient with a history of pulmonary sarcoidosis who presented with congestive heart failure, on the basis of severe mitral regurgitation secondary to cardiac infiltration and summarizes the published evidence regarding CS and mitral regurgitation.

When anticoagulation management in atrial fibrillation becomes difficult: Focus on chronic kidney disease, coagulation disorders, and cancer.

Anticoagulation therapy (AT) is fundamental in atrial fibrillation (AF) treatment but poses challenges in implementation, especially in AF populations with elevated thromboembolic and bleeding risks. Current guidelines emphasize the need to estimate and balance thrombosis and bleeding risks for all potential candidates of antithrombotic therapy. However, administering oral AT raises concerns in specific populations, such as those with chronic kidney disease (CKD), coagulation disorders, and cancer due to lack of robust data. These groups, excluded from large direct oral anticoagulants trials, rely on observational studies, prompting physicians to adopt individualized management strategies based on case-specific evaluations. The scarcity of evidence and specific guidelines underline the need for a tailored approach, emphasizing regular reassessment of risk factors and anticoagulation drug doses. This narrative review aims to summarize evidence and recommendations for challenging AF clinical scenarios, particularly in the long-term management of AT for patients with CKD, coagulation disorders, and cancer.

Optimal Anticoagulation on TAVI Patients Based on Thrombotic and Bleeding Risk and the Challenge Beyond: A Systematic Review and Meta-Analysis.

Transcatheter Aortic Valve Replacement (TAVR) has been established as the treatment of choice for symptomatic aortic stenosis, while it is expanding in all risk-related group categories of patients, gaining gradually ground over the surgical approach. However, complications and adverse events are yet to be effectively limited and diminished with thrombotic and hemorrhagic events being rooted as a crucial topic of discussion. Favorable anticoagulation pharmacotherapy options are constantly being revised and tested, whilst guidelines are being modified to meet current clinical evidence. This review aims to systematically assess already existing guidelines on anticoagulation in post-TAVI patients and examine novel regimens for the specific use, like apixaban, rivaroxaban, and other anticoagulants, essentially constructing a holistic point of view on future progress on this matter. The added complexity brought by coagulation-affecting comorbidities such as atrial fibrillation, coronary artery disease, and more contributes to the direct association of the topic to the quality of healthcare as a public service. The literature was systematically searched to examine the effectiveness and safety of various anticoagulation treatments and cross-evaluate them based on the according category of patients that were assigned to. Clinical trials, observational studies and systematic reviews were included and, eventually, conclusive remarks and future considerations were developed and presented. In the category of patients without prior indication to anticoagulation, SAPT was proven safer and still effective, when antiplatelet therapies were compared, while a comparison of antiplatelet versus anticoagulation strategies noted the first one, with limited data, as the optimal one. Lastly, direct oral anticoagulants were shown to be safe substitutes for vitamin K antagonists for patients with prior indication to anticoagulation.

Cardiac Rehabilitation After TAVI -A Systematic Review and Meta-Analysis.

Despite the increasing popularity of Transcatheter aortic valve implantation (TAVI) in patients with high surgical risk, there is no current guideline for the management of patients following the intervention. This systematic review and meta-analysis aims to summarize and analyse all clinical data and evidence regarding the effectiveness and outcomes of CR following TAVI. The first meta-analysis measured the walked distance in the Six-Minute Walk Test (6MWT) and the second meta-analysis included studies that showed the Barthel Index (BI) before and after CR. The mean distance walked prior to CR was 235.88 ± 69.36 m increased to 292.12 ± 54.92 m after rehabilitation, signifying a moderate clinically relevant effect size (0.593 (0.42, 0.76); P=0.00). The mean BI score before CR was 76.6 ± 11.5 which increased to 89.8 ± 5.5 after the programme and similarly demonstrated a significant standardized mean improvement (0.75 (0.57, 0.93); I= 0.00). Exercise-based CR in patients with aortic stenosis treated with TAVI demonstrated a significant improvement in exercise tolerance and functional independence shown by the 6MWT and BI.

Aortic Stiffness: A Major Risk Factor for Multimorbidity in the Elderly.

Multimorbidity, the coexistence of multiple health conditions in an individual, has emerged as one of the greatest challenges facing health services, and this crisis is partly driven by the aging population. Aging is associated with increased aortic stiffness (AoStiff), which in turn is linked with several morbidities frequently affecting and having disastrous consequences for the elderly. These include hypertension, ischemic heart disease, heart failure, atrial fibrillation, chronic kidney disease, anemia, ischemic stroke, and dementia. Two or more of these disorders (multimorbidity) often coexist in the same elderly patient and the specific multimorbidity pattern depends on several factors including sex, ethnicity, common morbidity routes, morbidity interactions, and genomics. Regular exercise, salt restriction, statins in patients at high atherosclerotic risk, and stringent blood pressure control are interventions that delay progression of AoStiff and most likely decrease multimorbidity in the elderly.

Study Level Meta-Analysis of Transcatheter Aortic Valve Implantation With the ACURATE neo Self-Expanding Transcatheter Heart Valve.

The ACURATE neo transcatheter aortic valve is a self-expanding device. Several studies have investigated safety and efficacy, but meta-analysis and pooled data are lacking. We aimed to provide a comprehensive systematic review and meta-analysis on the clinical outcomes of transcatheter aortic valve implantation with the ACURATE neo valve. A systematic literature search for eligible records was conducted. The primary endpoint was device success as designated by Valve Academic Research Consortium-2 criteria. The secondary endpoints (time frame: 30 days) were all-cause mortality, stroke, myocardial infarction, need for new permanent pacemaker, major vascular complications, major bleeding, acute kidney injury stage II or III, and paravalvular regurgitation grade moderate or severe (II or III). Our search yielded a total of 355 records, 20 of those (n = 5858 ACURATE neo receivers) were included in our meta-analysis. Device success was achieved in 94.5% (95% confidence interval [CI], 91.4-96.5%) of the patients. The 30-day all-cause mortality incidence proportion was 1.8% (95% CI, 1.3-2.4%). New pacemaker implantation was required in 7.7% (95% CI, 6.4-9.2%) of the patients, stroke occurred in 1.9% (95% CI, 1.6-2.3%), myocardial infarction in 0.5% (95% CI, 0.3-0.7%), major bleeding in 5.0% (95% CI, 3.9-6.5%), major vascular complication in 5.6% (95% CI, 4.0-7.8%), acute kidney injury stage ≥2 in 2.5% (95% CI, 1.8-3.4%), and paravalvular leak grade ≥moderate was observed in 4.3% (95% CI, 3.0-6.2%). Balloon predilatation and postdilatation incidence was 93.9% (95% CI, 87.0-97.3%) and 43.2% (95% CI, 37.9-48.6%), respectively. ACURATE neo appears to be safe and effective in our analysis with high device success incidence, low mortality, and low new pacemaker implantations.

Visualization of the intracavitary blood flow in systemic ventricles of Fontan patients by contrast echocardiography using particle image velocimetry.

BACKGROUND: Flow patterns in univentricular hearts may have clinical value. Therefore, it is our objective to asses and characterize vortex flow patterns with Fontan circulation in comparison with healthy controls. METHODS: Twenty-three patients (8 Fontan and 15 normal patients) underwent echocardiography with intravenous contrast agent (Sonovue®) administration. Dedicated software was used to perform particle image velocimetry (PIV) and to visualize intracavitary flow in the systemic ventricles of the patients. Vortex parameters including vortex depth, length, width, and sphericity index were measured. Vortex pulsatility parameters including relative strength, vortex relative strength, and vortex pulsation correlation were also measured. RESULTS: The data from this study show that it is feasible to perform particle velocimetry in Fontan patients. Vortex length (VL) was significantly lower (0.51 ± 0.09 vs 0.65 ± 0.12, P = 0.010) and vortex width (VW) (0.32 ± 0.06 vs 0.27 ± 0.04, p = 0.014), vortex pulsation correlation (VPC) (0.26 ± 0.25 vs -0.22 ± 0.87, p = 0.05) were significantly higher in Fontan patients. Sphericity index (SI) (1.66 ± 0.48 vs 2.42 ± 0.62, p = 0.005), relative strength (RS) (0.77 ± 0.33 vs 1.90 ± 0.47, p = 0.0001), vortex relative strength (VRS) (0.18 ± 0.13 vs 0.43 ± 0.14, p = 0.0001) were significantly lower in the Fontan patients group. CONCLUSIONS: PIV using contrast echocardiography is feasible in Fontan patients. Fontan patients had aberrant flow patterns as compared to normal hearts in terms of position, shape and sphericity of the main vortices. The vortex from the Fontan group was consistently shorter, wider and rounder than in controls. Whether vortex characteristics are related with clinical outcome is subject to further investigation.

Severe tricuspid regurgitation and isolated right heart failure due to thyrotoxicosis.

We describe the case of a patient presented with isolated right heart failure with atrial fibrillation and severe tricuspid regurgitation due to hyperthyroidism. Treatment of the thyroid disease resulted in the disappearance of signs of right heart failure and resolution of the valve incompetence and normalization of the heart rhythm. Although thyrotoxicosis may be associated with congestive heart failure, isolated right heart failure with marked tricuspid regurgitation is rarely seen.

Artificial intelligence supporting cancer patients across Europe-The ASCAPE project.

INTRODUCTION: Breast and prostate cancer survivors can experience impaired quality of life (QoL) in several QoL domains. The current strategy to support cancer survivors with impaired QoL is suboptimal, leading to unmet patient needs. ASCAPE aims to provide personalized- and artificial intelligence (AI)-based predictions for QoL issues in breast- and prostate cancer patients as well as to suggest potential interventions to their physicians to offer a more modern and holistic approach on cancer rehabilitation. METHODS AND ANALYSES: An AI-based platform aiming to predict QoL issues and suggest appropriate interventions to clinicians will be built based on patient data gathered through medical records, questionnaires, apps, and wearables. This platform will be prospectively evaluated through a longitudinal study where breast and prostate cancer survivors from four different study sites across the Europe will be enrolled. The evaluation of the AI-based follow-up strategy through the ASCAPE platform will be based on patients' experience, engagement, and potential improvement in QoL during the study as well as on clinicians' view on how ASCAPE platform impacts their clinical practice and doctor-patient relationship, and their experience in using the platform. ETHICS AND DISSEMINATION: ASCAPE is the first research project that will prospectively investigate an AI-based approach for an individualized follow-up strategy for patients with breast- or prostate cancer focusing on patients' QoL issues. ASCAPE represents a paradigm shift both in terms of a more individualized approach for follow-up based on QoL issues, which is an unmet need for cancer survivors, and in terms of how to use Big Data in cancer care through democratizing the knowledge and the access to AI and Big Data related innovations. TRIAL REGISTRATION: Trial Registration on clinicaltrials.gov: NCT04879563.

Dual wire technique for aortic coarctation stent placement.

A young adult presented for percutaneous treatment of a narrow aortic coarctation. A very large left subclavian artery originated immediately proximal to the coarctation. In order not to exclude or jail the left subclavian artery with a stent, a double wire technique was used. From a femoral approach, two guide wires were positioned, one in the aortic arch and another in the subclavian artery. A stent crimped over a 16-mm balloon and a 4-Fr catheter was advanced over the two wires within a 14-Fr long introducer sheath. The stent was successfully deployed and molded within the bifurcation by a kissing balloon technique, relieving the obstruction and leaving a guaranteed passage to the subclavian artery. The double wire technique is an elegant way to deliver a stent safely across a narrowing with guaranteed access to important side branches.

The outcome of Eisenmenger patients with trisomy 21 does not differ from patients without trisomy 21.

OBJECTIVE: Several patients with trisomy 21 developed the Eisenmenger syndrome (ES) because the underlying congenital heart defect was not corrected. However, little is known about their prognosis.This study aimed at (1) identifying risk factors for worse prognosis in ES patients, and (2) evaluating whether outcome of ES patients with trisomy 21 differs from ES patients without trisomy 21. DESIGN: Data on all Eisenmenger patients in follow-up at the paediatric and adult congenital heart disease clinic of the University Hospitals Leuven were collected for retrospective analysis. Regression analysis was performed where applicable and survival rate was compared between patients with and without trisomy 21. RESULTS: One hundred thirty-four patients (mean age at latest follow-up 33.2 +/- 13.6 years, 41.8% male, 44.8% trisomy 21) were included in the study. Complex lesions, right heart failure, impaired renal function, lower transcutaneous saturation and lower body mass index were predictive of impaired outcome. Mean survival of the global ES group was 44.9 +/- 2.2 years. However, long-term survival of trisomy 21 patients was not statistically different from patients without trisomy 21 (mean survival 44.5 +/- 2.6 years vs 44.5 +/- 2.9 years, respectively, P = 0.80, log rank test). CONCLUSION: Long-term survival is markedly reduced in Eisenmenger patients. Complex lesions, right heart failure, impaired renal function, lower transcutaneous saturation and lower body mass index were related to worse prognosis. However, survival of trisomy 21 patients did not differ from patients without trisomy 21.

Current issues on simultaneous TAVR (Transcatheter Aortic Valve Replacement) and EVAR (Endovascular Aneurysm Repair).

Simultaneous EVAR and TAVR is technically feasible and is a reliable option in high-risk patients.