Outcomes of dual-chamber implantable cardioverter defibrillator for left bundle branch area pacing: A systematic review of literature.

OBJECTIVE: This systematic review of literature aimed to evaluate the safety and efficacy of dual-chamber ICDs for LBBAP in patients with left bundle branch block (LBBB). METHODS: Digital databases were searched systematically to identify studies reporting the left bundle branch area pacing (LBBAP) with implantable cardioverter defibrillator (ICD) placement in patients with LBBB. Detailed study and patient-level baseline characteristics including the type of study, sample size, follow-up, number of cases, age, gender, and baseline characteristics were abstracted. RESULTS: In a total of three studies, 34 patients were included in this review. There was a significant improvement reported in QRS duration in all studies. The mean QRS duration at baseline was 170 ± 17.4 ms, whereas the follow-up QRS duration at follow-up was 121 ± 17.3 ms. Two studies reported a significant improvement of 50% in LVEF from baseline. No lead-related complications or arrhythmic events were recorded in any study. The findings of the systematic review suggest that dual-chamber ICD for LBBAP is a promising intervention for patients with heart conditions. CONCLUSION: The procedure offers significant improvements in QRS duration and LVEF, and there were no lead-related complications or arrhythmic events recorded in any of the studies.

Outcomes of European Society of Cardiology 0/1-h algorithm with high-sensitivity cardiac troponin T among patients with coronary artery disease.

OBJECTIVE: The European Society of Cardiology (ESC) 0/1-h Algorithm with high-sensitivity cardiac troponin T (hs-cTnT) has shown promising results in risk stratification and management of patients with coronary artery disease (CAD). However, its outcomes and clinical implications in the context of developing countries remain understudied. METHODS: This cohort study aimed to evaluate the outcomes and clinical significance of the ESC 0/1-h Algorithm in a developing country setting. A total of 3534 patients with CAD were enrolled, with 1125 in the Rule-Out group and 2409 in the Rule-In group. Baseline characteristics, performance metrics, primary and secondary outcomes, and predictors of Rule-In and Rule-Out groups were assessed. RESULTS: The study enrolled 3534 patients with CAD, with 1125 in the Rule-Out group and 2409 in the Rule-In group. The 0/1-h Algorithm with hs-cTnT demonstrated improved performance compared to Troponin T at Presentation. It exhibited higher sensitivity, specificity, negative predictive value, positive predictive value, and area under the curve (AUC) for risk stratification in patients with CAD. Significant differences were observed in baseline characteristics between the Rule-Out and Rule-In groups, including age, gender, and comorbidities. The Rule-In group had a higher incidence of adverse cardiac events and underwent more invasive procedures compared to the Rule-Out group. Age, gender, hypertension, diabetes, and smoking were identified as significant predictors of Rule-In and Rule-Out. These findings highlight the clinical significance of implementing the 0/1-h Algorithm in the management of patients with CAD in a developing country setting. CONCLUSION: The algorithm's performance, along with its ability to identify high-risk patients and predict outcomes, highlights its potential to enhance patient care and outcomes in resource-limited settings.

Coronary artery complications with left bundle branch area pacing: A review of literature.

Left bundle branch area pacing (LBBAP) is an emerging technique in cardiac resynchronization therapy that shows promise in improving ventricular synchrony and clinical outcomes in patients with heart failure. However, the potential risk of coronary artery complications with LBBAP necessitates careful attention and management. This literature review explores the mechanisms, acute coronary events, and clinical implications associated with coronary artery complications in LBBAP. The mechanism of coronary injury with LBBAP involves mechanical trauma, altered coronary blood flow dynamics, and endothelial damage. Acute coronary events such as myocardial ischemia, acute coronary syndromes, and coronary artery dissection can occur during or after LBBAP, leading to significant clinical implications including the need for prompt intervention and potential impact on long-term outcomes. To avoid coronary injury and acute coronary syndrome with LBBAP, specific care strategies are recommended. These include thorough pre-procedural evaluation, expert operator technique, optimization of hemodynamics and ventricular synchrony, close monitoring for ischemic events, collaboration with cardiology specialists, and long-term follow-up. The clinical implications of coronary artery complications with LBBAP necessitate careful patient selection, informed decision-making, and a multidisciplinary approach. Future directions in this field include advancements in procedural techniques, technological innovations, risk stratification strategies, enhanced imaging modalities, research on mechanisms and prevention, and collaboration among stakeholders. By implementing these strategies and focusing on future advancements, healthcare providers can minimize the risk of coronary artery complications with LBBAP and optimize patient outcomes in cardiac resynchronization therapy.

Predicting stroke and mortality in mitral stenosis with atrial flutter: A machine learning approach.

BACKGROUND: Our study hypothesized that an intelligent gradient boosting machine (GBM) model can predict cerebrovascular events and all-cause mortality in mitral stenosis (MS) with atrial flutter (AFL) by recognizing comorbidities, electrocardiographic and echocardiographic parameters. METHODS: The machine learning model was used as a statistical analyzer in recognizing the key risk factors and high-risk features with either outcome of cerebrovascular events or mortality. RESULTS: A total of 2184 patients with their chart data and imaging studies were included and the GBM analysis demonstrated mitral valve area (MVA), right ventricular systolic pressure, pulmonary artery pressure (PAP), left ventricular ejection fraction (LVEF), New York Heart Association (NYHA) class, and surgery as the most significant predictors of transient ischemic attack (TIA/stroke). MVA, PAP, LVEF, creatinine, hemoglobin, and diastolic blood pressure were predictors for all-cause mortality. CONCLUSION: The GBM model assimilates clinical data from all diagnostic modalities and significantly improves risk prediction performance and identification of key variables for the outcome of MS with AFL.

Efficacy and safety of cardiac resynchronization therapy in chemotherapy-induced cardiomyopathy: A systematic review.

OBJECTIVE: The aim of the study was to assess the efficacy of cardiac resynchronization therapy (CRT) in patients with chemotherapy-induced cardiomyopathy (CIC). METHODS: With the increasing incidence of CIC, the association of CRT with improvement in clinical outcomes, echocardiographic parameters, and New York Heart Classification (NYHA) class was assessed through this qualitative systematic review. RESULTS: The five studies included a total of 169 patients who underwent CRT after CIC, and of these, 61 (36.1%) patients were males. All studies showed an improvement in left ventricular ejection fraction (LVEF), among other echocardiographic parameters of LV volume. However, these findings are limited by short follow-up periods, small sample sizes, and the absence of a control group. CONCLUSION: CRT was associated with improvement in all patient parameters with CIC.

Outcomes of primary leadless pacemaker implantation: A systematic review.

BACKGROUND: During the last decade, leadless pacemakers (LPMs) have turned into a prevalent alternative to traditional transvenous (TV) pacemakers; however, there is no consolidated data on LPM implantation in emergencies. METHODS: Digital databases were searched for this review and four relevant studies, including 1276 patients were included in this review with procedure duration, fluoroscopic time, major complications, and mortality as primary outcomes and pacing threshold, impedance, sensing of LPM, and hospital stay as secondary outcomes. RESULTS: Gonzales et al. and Marschall et al. showed the duration of the procedure to be 180 ± 45 versus 324.6 ± 92 and 39.9 ± 8.7 versus 54.9 ± 9.8, respectively. Zhang et al. demonstrated the duration of the procedure and fluoroscopy time to be 36 ± 13.4 and 11.1 ± 3.1, respectively. Similarly, Schiavone et al. exhibited intermediate times of implantation at 60 (45-80) versus 50 (40-65) and fluoroscopic times at 6.5 (5-9.7) versus 5.1 (3.1-9). Hospital stay was more with a temp-perm pacemaker as compared to LPM and pacing parameters were not significantly different in all the studies. CONCLUSION: For underlying arrhythmias, whenever appropriate, our review shows that LPMs may be a better option than temporary pacemakers, even as an urgent treatment.

Echocardiography- versus intracardiac electrocardiogram-based optimization of cardiac resynchronization therapy: A systematic review.

OBJECTIVE: This systematic review aimed to evaluate the performance of echocardiography-based programming in comparison with the intracardiac electrocardiogram (IEGM)-based method for the optimization of cardiac resynchronization therapy (CRT). METHODS: A literature review was conducted using digital databases to systematically identify the studies reporting CRT optimization through echocardiography compared with IEGM. Detailed patient-level study characteristics including the type of study, sample size, therapy, the New York Heart Classification (NYHA) status, lead placement, and other parameters were abstracted. Finally, postprogramming outcomes were extracted for each article. RESULTS: In a total of 11 studies, 919 patients were recruited for the final analysis. Overall, 692 (75.29%) were males. The mean duration of the QRS complex in our study population ranged from 145.2 ± 21.8 ms to 183 ± 19.9 ms. There was an equal improvement in the NYHA class between the two methods while the left ventricular ejection fraction (LVEF) demonstrated an improvement by IEGM. Many studies supported IEGM to increase the 6-minute walk test and left ventricular outflow tract velocity time interval (LVOT VTI) when compared to echocardiography. The mean time for echocardiography-based optimization was 60.15 min while that of IEGM-based optimization was 6.65 min. CONCLUSION: IEGM is an alternative method for CRT optimization in improving the NYHA class, LVEF, and LVOT VTI, and is less time-consuming when compared to the echocardiography-based methods.

Association of gut microbiome dysbiosis with the progression of atrial fibrillation: A systematic review.

OBJECTIVE: Many clinical and preclinical studies have implicated an association between atrial fibrillation (AF) and its progression to imbalances in the gut microbiome composition. The gut microbiome is a diverse and complex ecosystem containing billions of microorganisms that produce biologically active metabolites influencing the host disease development. METHODS: For this review, a literature search was conducted using digital databases to systematically identify the studies reporting the association of gut microbiota with AF progression. RESULTS: In a total of 14 studies, 2479 patients were recruited for the final analysis. More than half (n = 8) of the studies reported alterations in alpha diversity in atrial fibrillation. As for the beta diversity, 10 studies showed significant alterations. Almost all studies that assessed gut microbiota alterations reported major taxa associated with atrial fibrillation. Most studies focused on short-chain fatty acids (SCFAs), whereas three studies evaluated TMAO levels in the blood, which is the breakdown product of dietary l-carnitine, choline, and lecithin. Moreover, an independent cohort study assessed the relationship between phenylacetylglutamine (PAGIn) and AF. CONCLUSION: Intestinal dysbiosis is a modifiable risk factor that might provide newer treatment strategies for AF prevention. Well-designed research and prospective randomized interventional studies are required to target the gut dysbiotic mechanisms and determine the gut dysbiotic-AF relationship.

Predictors of permanent pacemaker insertion after mitral valve replacement: A systematic review.

As the established surgical mitral valve replacement (MVR) expands toward various contemporary techniques and access routes, the predictors and burden of procedure-related complications including the need for permanent pacemaker (PPM) implantation need to be identified. Digital databases were searched systematically to identify studies reporting the incidence of PPM implantation after MVR. Detailed study and patient-level baseline characteristics including the type of study, sample size, follow-up, number of post-MVR PPM implantations, age, gender, and baseline ECG abnormalities were abstracted. A total of 12 studies, recruiting 37,124 patients were included in the final analysis. Overall, 2820 (7.6%) patients required a PPM with the net rate ranging from 1.7% to 10.96%. Post-MVR atrioventricular (AV) block was the most commonly observed indication for PPM, followed by sinoatrial (SA) node dysfunction, and bradycardia. Age, male gender, pre-existing comorbid conditions, prior CABG, history of arrhythmias or using antiarrhythmic drugs, atrial fibrillation ablation, and double valve replacement were predictors of PPM implantation post-MVR. Age, male gender, comorbid conditions like diabetes and renal impairment, prior CABG, double valve replacement, and antiarrhythmic drugs served as positive predictors of PPM implantation in patients undergoing MVR.

Tricuspid regurgitation in His bundle pacing: A systematic review.

OBJECTIVE: This systematic review aimed to explore an association of new TR and its quantification in patients undergoing His bundle pacing (HBP). METHODS: A literature review was conducted using Mesh terms (His bundle pacing, tricuspid regurgitation, tricuspid valve incompetence, etc.) in PubMed, EMBASE, Web of science CINAHL, and the Cochrane Library till October 2021. Relevant studies evaluating tricuspid regurgitation in HBP were included and information regarding TR and its related factors (ejection fraction (EF) and New York Heart Association (NYHA) class) were retrieved from the eligible studies. RESULTS: Out of 196 articles, 10 studies met the inclusion criteria, which consisted of 546 patients with HBP. The mean age of the patients ranged between 61.2 ± 12.3 and 75.1 ± 7.9 years with 54.1% males. The overall implant success rate was 79.2%. Only one study reported a 5% incidence of TR, while 9 studies reported no new TR after HBP. Four studies reported overall decrease in TR by 1 grade and 3 studies demonstrated increased TR from baseline. Two studies showed no change from baseline TR. CONCLUSION: HBP causes improvement in TR grade after HBP for cardiac resynchronization therapy (CRT) as well as atrioventricular block (AVB). Further studies in the form of randomized controlled trials are required to further evaluate the effect of HBP on tricuspid valve functioning.

Myocardial blush grade: a determinant of left ventricular ejection fraction and adverse outcomes in STEMI.

BACKGROUND AND AIMS: Despite restoration of blood flow, subtle microvascular obstruction can occur. This obstruction can be graded using myocardial blush grade. We aimed to investigate the role of myocardial blush grade in ejection fraction and adverse outcomes, after percutaneous intervention. METHODS: A prospective, observational study was conducted at our institute with a calculated sample size. Variables such as age, gender, and ejection fraction were noted before the intervention. The patients were followed for 3 months to determine the outcomes. The data was analyzed using IBM SPSS software version 26.0. P-value of less than 0.05 was considered significant for the statistical tests. RESULTS: There were 74 male and 36 female participants in the study. The mean age was 52.20 ± 10.02 years. The most common adverse outcome was heart failure (18%). There was a significant Pearson's correlation between myocardial blush grade and improvement in ejection fraction (p < 0.05). Improvement in myocardial blush grade was significantly related to a decrease in adverse outcomes (p < 0.05). Regression analysis proved myocardial blush grade and diabetes status as independent predictors of percentage increase in ejection fraction (p < 0.05). CONCLUSION: High myocardial blush grade is one of the independent predictors of better outcomes in ST-elevation myocardial infarction.

Optical coherence tomography: assessment of coronary artery disease and guide to percutaneous coronary intervention.

BACKGROUND AND AIMS: Angiographic guidance for percutaneous coronary intervention (PCI) has significant limitations in interpretation. The superior spatial resolution of optical coherence tomography (OCT) can provide meaningful clinical benefits, although limited data is available on Asian populations. This study aimed to determine whether OCT can provide additional advantages and useful clinical information beyond that obtained by angiography alone in decision making for PCI. METHODS: This was an observational study based on a single tertiary cardiac center in Pakistan, which includes 67 patients who underwent coronary angiogram and stenting. Their pre and post stenting OCT findings were recorded. Any additional intervention was also recorded. The data were analysed using IBM SPSS software version 26.0. RESULTS: The mean age was 55.00 ± 9.00 years. Majority of the patients were males (65.7%). On angiography, there was an equal number of stable and ruptured plaques (38.8%). Post stenting results showed 29.9% under deployed stents and 34.3% were either undersized or mal-apposed. Out of 67 patients, 50 (74.6%) needed re-intervention after PCI. Among different procedures, post-dilatation was most common. CONCLUSION: The main OCT benefit is in borderline lesions on CA, in whom OCT identifies significant coronary stenosis and leads to PCI indication in patients. In the post-PCI context, OCT leads to an indication of PCI optimisation in half of the coronary lesions.

Fondaparinux-associated Thrombocytopenia.

Heparin-induced thrombocytopenia (HIT) is an immune-mediated condition causing thrombocytopenia and paradoxical thrombosis after exposure to heparin or low-molecular-weight heparin. It has been rarely reported by Fondaparinux, an artificial pentasaccharide similar to heparin. This manuscript presents a case of HIT associated with fondaparinux use.

Atrial myopathy.

This paper delves into the progressive concept of atrial myopathy, shedding light on its development and its impact on atrial characteristics. It extensively explores the intricate connections between atrial myopathy, atrial fibrillation (AF), and strokes. Researchers have sought additional contributors to AF-related strokes due to the absence of a clear timing correlation between paroxysmal AF episodes and strokes in patients with cardiac implantable electronic devices. Through various animal models and human investigations, a close interrelation among aging, inflammation, oxidative stress, and stretching mechanisms has been identified. These mechanisms contribute to fibrosis, alterations in electrical properties, autonomic remodeling, and a heightened pro-thrombotic state. These interconnected factors establish a detrimental cycle, exacerbating atrial myopathy and elevating the risk of sustained AF and strokes. By emphasizing the significance of atrial myopathy and the risk of strokes that are distinct from AF, the paper also discusses methods for identifying patients with atrial myopathy. Moreover, it proposes an approach to incorporate the concept of atrial myopathy into clinical practice to guide anticoagulation decisions in individuals with AF.

Postcardiac Injury Syndrome After Cardiac Surgery: An Evidence-Based Review.

Postcardiac injury syndrome (PCIS) serves as a comprehensive term encompassing a spectrum of conditions, namely postpericardiotomy syndrome, postmyocardial infarction (MI) related pericarditis (Dressler syndrome), and post-traumatic pericarditis stemming from procedures like percutaneous coronary intervention or cardiac implantable electronic device placement. These conditions collectively give rise to PCIS, triggered by cardiac injury affecting pericardial or pleural mesothelial cells, leading to subsequent inflammation syndromes spanning from uncomplicated pericarditis to substantial pleural effusion. A thorough literature search conducted on MEDLINE/PubMed utilizing search terms including "postacute cardiac injury syndrome," "postcardiac injury syndrome," "postcardiotomy syndrome," "postpericardiotomy syndrome," and "post-MI pericarditis" was instrumental in collating pertinent studies. To encapsulate the amassed evidence, relevant full-text materials were meticulously selected and amalgamated narratively. The pathophysiology of PCIS is proposed to manifest through an autoimmune-mediated process, particularly in predisposed individuals. This process involves the development of anti-actin and antimyosin antibodies after a cascade of cardiac injuries in diverse forms. Treatment strategies aimed at preventing recurrent PCIS episodes have shown efficacy, with colchicine and nonsteroidal anti-inflammatory drugs, including ibuprofen, demonstrating positive outcomes. Conversely, corticosteroids have exhibited no discernible benefit concerning prognosis or recurrence rates for this ailment. In summary, PCIS serves as a unifying term encompassing a spectrum of cardiac injury-related syndromes. A comprehensive review of relevant literature underscores the autoimmune-mediated pathophysiology in susceptible individuals. The therapeutic landscape involves the proficient use of colchicine and Nonsteroidal anti-inflammatory drugs to deter recurrent PCIS episodes, while corticosteroids do not appear to contribute to improved prognosis or reduced recurrence rates. This nuanced understanding contributes to an enhanced comprehension of PCIS and its multifaceted clinical manifestations, potentially refining its diagnosis and management.

Physicians' Perspective on Percutaneous Left Atrial Appendage Closure in Patients with Atrial Fibrillation and Chronic Kidney Disease in Pakistan.

This study, conducted in Pakistan, examines the perspectives of 1200 physicians across diverse specialties regarding Left Atrial Appendage Occlusion (LAAO) procedures for atrial fibrillation (AF) patients with chronic kidney disease (CKD). Using a random sampling approach, physicians participated in a survey that assessed their familiarity with LAAO, views on its effectiveness and safety, experience levels, and encountered challenges. The results unveil a spectrum of knowledge levels among physicians, reinforcing the need for tailored medical education and training programs. The majority of respondents were between 30 and 49 years old (59.8 %). A notable proportion, 33.3 %, had limited or no knowledge of LAAO, with 16.7 % having never heard of the procedure, and 16.7 % having limited knowledge but no experience. About 36.2 % of physicians believed LAAO was moderately to extremely effective in reducing stroke risk, with 23.3 % considering it very effective and 25.4 % believing it to be extremely effective. The most commonly cited clinical indications were a history of recurrent strokes despite anticoagulation (34.6 %) and a high CHA2DS2-VASc score (27.3 %). Renal considerations played a significant role, with 33.1 % considering LAAO for CKD stage 4 or 5 patients with elevated stroke risk. Patient preferences, such as a desire to avoid long-term anticoagulant use, were important for 28.7 % of physicians. Identified challenges encompass limited equipment access, training gaps, patient reluctance, and administrative complexities. Furthermore, the study underscores the pivotal role of shared decision-making in healthcare delivery. These findings lay essential groundwork for improving LAAO utilization and patient-centered care in Pakistan's healthcare system.

Association of transportation noise with cardiovascular diseases.

This comprehensive article delves into the intricate and multifaceted issue of noise pollution, shedding light on its diverse sources, profound health implications, and the economic burden it imposes on societies. Noise pollution is an increasingly prevalent environmental challenge, impacting millions of people worldwide, often without their full awareness of its adverse effects. Drawing from a wealth of scientific research, the article underscores the well-established links between noise pollution and a spectrum of health issues, including cardiovascular diseases, sleep disturbances, and psychological stress. While exploring the sources and consequences of noise pollution, the article highlights the urgent need for a holistic and collaborative approach to mitigate its impact. This entails a combination of regulatory measures, technological innovations, urban planning strategies, and public education campaigns. It is increasingly evident that the detrimental effects of noise pollution extend beyond physical health, encompassing mental and social well-being. The article also addresses the synergistic relationship between noise pollution and other environmental stressors, emphasizing the importance of considering noise in conjunction with factors like air pollution and access to green spaces. It examines the potential of green spaces to mitigate the effects of noise pollution and enhance overall health.

Cardiovascular risk assessment in inflammatory bowel disease with coronary calcium score.

The interplay between inflammatory bowel disease (IBD) and atherosclerotic cardiovascular disease (ASCVD) underscores the intricate connections between chronic inflammation and cardiovascular health. This review explores the multifaceted relationship between these conditions, highlighting the emerging significance of the coronary calcium score as a pivotal tool in risk assessment and management. Chronic inflammation, a hallmark of IBD, has far-reaching systemic effects that extend to the cardiovascular system. Shared risk factors and mechanisms, such as endothelial dysfunction, lipid dysfunction, and microbiome dysregulation, contribute to the elevated ASCVD risk observed in individuals with IBD. Amidst this landscape, the coronary calcium score emerges as a means to quantify calcified plaque within coronary arteries, offering insights into atherosclerotic burden and potential risk stratification. The integration of the coronary calcium score refines cardiovascular risk assessment, enabling tailored preventive strategies for individuals with IBD. By identifying those at elevated risk, healthcare providers can guide interventions, fostering informed shared decision-making. Research gaps persist, prompting further investigation into mechanisms linking IBD and ASCVD, particularly in the context of intermediate mechanisms and early atherosclerotic changes. The potential of the coronary calcium score extends beyond risk assessment-it holds promise for targeted interventions. Randomized trials exploring the impact of IBD-modifying therapies on ASCVD risk reduction can revolutionize preventive strategies. As precision medicine gains prominence, the coronary calcium score becomes a beacon of insight, illuminating the path toward personalized cardiovascular care for individuals living with IBD. Through interdisciplinary collaboration and rigorous research, we embark on a journey to transform the paradigm of preventive medicine and enhance the well-being of this patient population.

Association of burnout and harassment among cardiology trainees: Pakistan's perspective.

OBJECTIVE: This study explores the relationship between sexual harassment and burnout among cardiology trainees, shedding light on the prevalence and impact of these experiences in medical practice. METHODS: A cross-sectional online survey was conducted among 518 respondents, with 420 responding to the Sexual Experience Questionnaire (SEQ). The survey measured harassment experiences and their impact on burnout, especially among female physicians. Correlations were analyzed to understand the association between these variables. RESULTS: Out of 1,375 invitees, we received 671 (48.8 %) responses. The study population was divided into two main groups: males (359) and females (312). The study identified a high prevalence of sexual harassment experiences among female physicians, with incidents occurring primarily during training. Moderate to large correlations were observed between SEQ subscales related to colleagues and patients and their families. While sexual harassment was not significantly related to burnout, this study suggests the need for interventions to create a safer medical workplace. Approximately 22 % of male participants (n = 359) reported career-related inappropriate sexual incidents, with 28 % of male physicians experiencing weekly burnout. Among female participants (n = 312), around 37 % reported inappropriate incidents, while 42 % of female physicians felt weekly burnout. CONCLUSION: Sexual harassment in medicine is a pervasive issue with potential implications for physician well-being. Initiatives aimed at changing the organizational response and fostering a more equitable environment are warranted to address this critical concern.